Effect of a 3-Step Critical Pathway to Reduce Duration of Intravenous Antibiotic Therapy and Length of Stay in Community-Acquired Pneumonia：A Randomized Controlled Trial

Jordi Carratalà, MD; Carolina Garcia-Vidal, MD; Lucía Ortega, MD; Núria Fernández-Sabé, MD; Mercedes Clemente, MD; Ginesa Albero, MSc; Marta López, MD; Xavier Castellsagué, MD; Jordi Dorca, MD; Ricard Verdaguer, MD; Joaquín Martínez-Montauti, MD; Frederic Manresa, MD; Francesc Gudiol, MD

Arch Intern Med. 2012;172(12):922-928. doi:10.1001/archinternmed.2012.1690.

ABSTRACT.

Background  The length of hospital stay (LOS) for community-acquired pneumonia (CAP) varies considerably, even though this factor has a major impact on the cost of care. We aimed to determine whether the use of a 3-step critical pathway is safe and effective in reducing duration of intravenous antibiotic therapy and length of stay in hospitalized patients with CAP.

Methods  We randomly assigned 401 adults who required hospitalization for CAP to follow a 3-step critical pathway including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge or usual care. The primary end point was LOS. Secondary end points were the duration of intravenous antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patients' satisfaction.

Results  Median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (difference, −2.1 days; 95% CI, −2.7 to −1.7; P < .001). Median duration of intravenous antibiotic therapy was 2.0 days in the 3-step group and 4.0 days in the usual care group (difference, −2.0 days; 95% CI, −2.0 to −1.0; P < .001). More patients assigned to usual care experienced adverse drug reactions (4.5% vs 15.9% [difference, −11.4 percentage points; 95% CI, −17.2 to −5.6 percentage points; P < .001]). No significant differences were observed regarding subsequent readmissions, case fatality rate, and patients' satisfaction with care.

Conclusions  The use of a 3-step critical pathway was safe and effective in reducing the duration of intravenous antibiotic therapy and LOS for CAP and did not adversely affect patient outcomes. Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced.