Three-step clinical pathway for CAP reduces length of hospital stay

By Stephanie Leveene

A three-step pathway helps to reduce the duration of intravenous (IV) antibiotic treatment in hospitalized patients with community-acquired pneumonia (CAP), show study findings published in the Archives of Internal Medicine.

Hospitalization costs for patients with CAP have greatly increased in the United States and Europe over the last few years. Length of stay (LOS) is a major factor in these cost increases, and how long a patient is given IV antibiotic therapy determines their time spent in the hospital. Therefore, the sooner a patient is stabilized and switched over to oral antibiotics the faster they can be discharged.

Jordi Carratalà (Hospital Universitari de Bellvitge, Barcelona, Spain) and colleagues hypothesized that a three-step critical pathway consisting of early mobilization, use of objective criteria for switching to oral antibiotic therapy (including stable vital signs and absence of major comorbidities), and use of predefined criteria for deciding when to discharge might have greater efficacy than usual care, allowing for shorter durations of IV therapy while maintaining patient safety.

The investigators enrolled 401 immunocompetent adults diagnosed with CAP in the emergency department, who were then randomized to receive usual care or the three-step pathway.

The median LOS was 3.9 days in the three-step group and 6.0 days in the usual care group. While the time to initiate IV antibiotic therapy was about the same for each group, those on the three-step pathway were on IV therapy for a median duration of 2.0 days versus 4.0 days for those given usual care. More patients in the usual care group experienced adverse drug reactions, particularly phlebitis, but mortality rates were comparable between groups.

Previous studies have found all three individual components of the critical pathway to be effective in reducing LOS. Carratalà and colleagues noted some limitations with their study, including that it was not powered to detect a survival difference or the efficacy of the individual components.

However, they conclude that "in a population of immunocompetent adults with CAP requiring hospitalization, the use of a 3-step critical pathway was safe and effective in reducing the duration of IV antibiotic therapy and LOS and did not adversely affect patient outcomes."

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