Local guidelines for management of adult community acquired pneumonia: a survey of UK hospitals.

RESULTS The response rate was 60% (n = 152); 92% of hospitals (n = 140) had locally written CAP guidelines (although in only 100 were policies being used in the emergency department as well as the medical department), 5% (n = 7) used the national BTS CAP guidelines and 3% (n = 5) had no guideline. Sixtyeight guidelines (49%) had been updated in the previous year and 88% (n = 123) had been updated since the BTS 2004 CAP guideline. Self-reported concerns over healthcare acquired infections influenced local guidelines in 57 hospitals (Clostridium difficile (n = 57), meticillin-resistant Staphylococcus aureus (MRSA) (n = 22)). Other influences included the BTS 2004 guideline (n = 96), cost of antibiotics (n = 26) and local antibiotic profiles (n = 15). Using severity assessment for planning management was recommended in 94% of guidelines (n = 131/140) including CURB65 tools in 76% (n = 106), CURB in 18, other tools in 9 and clinical judgement only in 9. First-line antibiotic recommendations for non-severe and severe CAP as stated in local CAP guidelines are shown in table 1. For managing non-severe CAP, 61% of hospitals (n = 85) recommended amoxicillin plus macrolide and 24% (n = 34) recommended amoxicillin alone. For severe CAP, recommended first-line antibiotics were consistent with BTS recommendations in 87% of guidelines (113/130; no data from 10 hospitals) including a b-lactamase stable b-lactam plus a macrolide in 101 and the alternative BTS recommendation of a quinolone and blactam in 12. A simple b-lactam, such as amoxicillin or penicillin, plus a macrolide was recommended in 12 guidelines and other antibiotic choices in 5. In hospitals with C difficile concerns, cephalosporins were less commonly recommended as preferred treatment for CAP than in other hospitals (26% vs 47%, p = 0.01). As alternative therapy for severe CAP, 19% of hospitals (n = 27) recommended b-lactamase stable b-lactam plus macrolide combinations and 36% (n = 51) recommended quinolones (most commonly levofloxacin (n = 33), ciprofloxacin (n = 11) and moxifloxacin (n = 4)), mostly as combination therapy (n = 27). In 35 guidelines no alternative regime was stated, 6 recommended microbiology advice and 21 recommended other choices.