MAJOR ARTICLE

Use of Indicators to Evaluate

the Quality of Community-Acquired
Pneumonia Management
Dilip Nathwani,1 Fiona Williams,3 John Winter,2 Janet Winter,2 Simon Ogston,3 and Peter Davey1
1
Infection and Immunodeficiency and 2Respiratory Units, Tayside University Hospitals Trust, and 3Department of Epidemiology,
University of Dundee, Dundee, United Kingdom

Quality-assessment indicators for community-acquired pneumonia (CAP) founded on health care structure,
process, and outcome have been recommended as a potential audit tool to evaluate the delivery of care. We
prospectively audited the treatment of 205 patients admitted with CAP to 2 hospitals in Dundee against some
of these key standards. Patients with severe CAP were more likely to die (mortality rate, 42% versus 7%) and
to receive antibiotics by the intravenous route (relative risk [RR], 1.81; 95% confidence interval [CI], 1.382.37)
and within 4 hours of admission to the hospital (RR, 1.22; 95% CI, 0.921.62). There was a lack of uniformity
regarding the amount of oxygen prescribed, with evidence of poor case record and drug prescription chart
documentation related to oxygen therapy. Adherence to the recommended antibiotic policy was associated
with reduced risk of death or readmission to the hospital (RR, 0.58; 95% CI, 0.341.00). However, in a
multivariate analysis, severity of pneumonia was the strongest predictor of death or readmission (P p .004),
and adherence to the antibiotic policy was not statistically significant (P p .154 ). Our study has confirmed
the value of quality indicators in evaluating our CAP management and has stimulated the development and
implementation of a local hospitalbased integrated care pathway.

Community-acquired pneumonia (CAP) remains a sig-
nificant cause of morbidity, mortality, and economic
burden [1, 2]. Many guidelines from around the world
have recognized the importance of CAP [3]. In the
United Kingdom, written guidelines for antibiotic ther-
apy for CAP exist in most hospitals [4]; most broadly
follow the 1993 guidelines of the British Thoracic So-
ciety (BTS) [5].
The aim of these best-practice guidelines is to reduce
variation in key aspects of care and, by doing so, to
improve the efficiency and effectiveness of health care
Received 28 February 2001; revised 15 August 2001; electronically published
13 December 2001.
Reprints or correspondence: Dr. Dilip Nathwani, Consultant Physician, Infection
Ward (Ward 42), East Block, Ninewells Hospital, Tayside University Hospitals,
Dundee, United Kingdom (nathwani@globalnet.co.uk).
Clinical Infectious Diseases 2002; 34:31823
 2002 by the Infectious Diseases Society of America. All rights reserved.
1058-4838/2002/3403-0004$03.00
[6]. We recently reviewed the current evidence for the
clinical and cost effectiveness of CAP guidelines [7].
For guidelines to influence outcome, there should be
evidence that links process to outcome and evidence
that there are potentially important variations in the
process of routine care [7, 8]. The key supposition of
many guidelines or care pathways is that a number of
processes are linked to outcome. Where there is an as-
sociation between variations in process and variations
in outcome, the implication is that improving the pro-
cess of care will improve outcome [9]. For CAP, a num-
ber of such processes have been identified. These in-
clude assessment of severity at the time of presentation
[1013]; time to administration of first antibiotic [14
18], the prescription of appropriate antibiotic (choice
and route according to the guideline or protocol [19,
20]); the prescription of an antibiotic by the iv route,
for patients with severe pneumonia [21, 22]; the mea-
surement and administration of appropriate amounts
of oxygen [11, 13, 15, 23]; and the obtaining of blood

318 CID 2002:34 (1 February) Nathwani et al.

samples for culture prior to therapy [15, 2427]. The link be-
tween obtaining blood samples for culture and outcome is one
process measure that does not appear to be supported by a
number of validity criteria that assess whether an association
can be judged as cause and effect [28]. However, the timely
delivery of antibiotics does meet these criteria and appears to
be biologically plausible, in that there is experimental [29] and
clinical evidence [30] to support the assertion that early anti-
biotic treatment is more effective than delayed treatment. Sim-
ilarly, timely measurement of oxygen saturation with subse-
quent appropriate treatment is crucial, because hypoxemia at
presentation is independently associated with short-term mor-
tality [11, 13]. In a study we published elsewhere [7], these and
other criteria are recommended as potential audit criteria of
CAP management. Some of these parameters for audit are out-
lined in table 1. The aim of the present analysis was to assess
the quality of CAP management in the Dundee cohort against
these audit criteria.
MATERIALS AND METHODS
Ascertainment of cases. A research nurse prospectively iden-
tified patients in the 2 hospitals in Dundee who had acute
medical emergencies and who were admitted to the hospital
from October 1999 through March 2000. The acute receiving
ward was visited on weekdays. The following case definition
was used to enter patients into the study: patients who received
an antibiotic for a presumed chest infection and had a docu-
mented abnormality on a chest radiograph (new infiltrate on
chest radiograph) consistent with pneumonia or those who
received an antibiotic for whom the diagnosis of pneumonia
had been made and noted in the case notes by a consultant or
specialist registrar (fellow) in medicine.
Names of patients who received an antibiotic for a chest
infection or pneumonia were collected prospectively, and one-
third of these were randomly selected for detailed audit on
discharge, depending on the availability of complete case re-
cords. Of the 640 patients admitted with the presumptive di-
agnosis of lower respiratory tract infection, 205 were selected
for audit and had case records available.
Assessment of severity. The following information for each
patient was recorded: demographic characteristics; initial
(within 24 h of admission) assessment of severity (defined by
use of the extended BTS criterion [5], in which severe is
defined by the presence of 2 of the following characteristics:
respiratory rate of 130 beats/min, diastolic blood pressure of
!60 mm Hg, urea of 17 mmol/L, and confusion [new onset]
at the time of initial assessment); the presence of comorbid
illness; and the process of management (investigations, oxy-
genation, and antibiotic therapy). The patients clinical out-
come (discharge home, discharge to intensive care unit [ICU],
death, or readmission within 2 weeks of discharge with the
same problem) were also recorded.
Adherence to the local antibiotic policy. The local policy
recommends a combination of a b-lactam and a macrolide
antibiotic for treatment of CAP, which is in line with current
British Thoracic Guidelines. The recommended antibiotics are
amoxicillin with or without a macrolide, for patients hospi-
talized with mild to moderate CAP, and iv cefuroxime (or)
coamoxiclav with or without a macrolide, for patients with
severe CAP. For the purposes of the audit, we allowed ceftriax-
one to be included instead of cefuroxime. Although this is not
part of our current protocol, ceftriaxone had been included in
the previous edition of the antibiotic policy. However, pre-
scription of ceftazidime for CAP was not allowed. Flucloxacillin
could be added for patients with severe cases if indicated. Ad-
herence was assessed solely by the choice of antibiotic on the
protocol; we did not include route of administration in the
assessment of adherence.
Statistical analysis. RRs and the corresponding 95% CIs
were calculated by use of EpiInfo, version 5.0 (Centers for
Disease Control and Prevention and World Health Organiza-
tion). We used multiple logistic regression analysis (SPSS for
Windows, Advanced Statistics Release 6.0 [SPSS]) to determine
the effect on outcome of adherence to the local antibiotic policy,
adjusted for severity of pneumonia.
Ethics approval. Audit of case records supervised by the
consultants responsible for their inpatient management does
not require approval by the Tayside Research Ethics committee.
RESULTS
Of the 205 patients in the study, 105 (51%) were male and 100
(49%) were female; 74 (36%) were aged 60 years, 43 (21%)
were aged 6175 years, and 88 (43%) were aged 175 years. The
time of admission was accurately recorded for 170 patients
(83%); the time of admission was between 8:00 a.m. and 4:00
p.m. for 82 patients (48%), 4:00 p.m. and midnight for 71
(42%), and after midnight for the remaining 17 (10%). We
were able to compare our performance against 11 of 17 quality
indicators, which we identified from a recent review of the
literature (table 1).
Compliance with protocol and process of treatment. We
had complete information on antibiotic therapy for 196 of the
205 patients. The median durations of iv and oral therapy,
respectively, were 3 days and 9 days. The median duration of
antibiotic treatment was 4.6 days. Only 102 (52%) of 196 of
patients received antibiotics within 4 h of admission. Of these
patients, those with severe CAP were more likely to receive
antibiotics promptly and via the iv route during the first 24 h
of hospitalization than were the others (table 2). The time of
admission did not influence the proportion of patients who
CAP Management CID 2002:34 (1 February) 319
Table 1. Suggested quality indicators for hospitalized patients with community-acquired pneumonia (CAP; adapted from [7]).
Quality or outcome indicator
Processes that are likely to improve the outcome of CAP
Posterior-anterior chest radiograph performed within 24 h of admission
Proven indicators of severity of CAP documented in the medical case records
Brief interval between admission to hospital and initiation of appropriate
antibiotic therapy
Receipt of an antibiotic regimen active against all of the likely causative pathogens
Receipt of iv antibiotics for severe pneumonia
Receipt of adequate oxygenation and respiratory support for severe pneumonia
Receipt of adequate fluid replacement for severe pneumonia
Brief median interval between diagnosis of respiratory failure and transfer
to the intensive care unit
Processes that are likely to increase the costs of management of CAP
Admission to the hospital for patients at low risk
Receipt of unnecessarily intensive or expensive antibiotic treatment
Failure to switch from iv to oral therapy, according to existing criteria
and clinical stability
Discharge at 124 h after switching to oral therapy
a
Outcome indicators
Duration of hospital stay, median days
Requirement of intensive care unit admission, %
30-day mortality rate, %
Readmission within 30 days of hospital discharge with an associated illness
Cost of care
a
One would need to identify the presence of comorbid illness and severity indicators in all patients.
received antibiotics within 4 h of admission. During the 3 ad-
mission time frames of 8:00 a.m. to 4:00 p.m., 4:00 p.m. to
midnight, and midnight to 8:00 a.m., similar percentages of
patients received antibiotics within 4 h (44 [54%] of 82, 44
[62%] of 71, and 10 [61%] of 17, respectively; x2, 1.02 with 2
degrees of freedom; P p .594).
The antibiotic choice was correct according to the local pro-
tocol in 138 (70%) of the 196 patients in whom this could be
assessed. Failure to use a macrolide or combination of anti-
biotics without activity against atypical organisms accounted
for 40 cases (69%) of noncompliance with the protocol. The
proportion of patients who received antibiotics that are active
against atypical bacteria was not related to severity of pneu-
monia (38 [79%] of 48 patients with severe cases vs. 118 [80%]
of 148 patients with nonsevere cases). Only in a very small
number of cases (10 of 58) was noncompliance the result of
treatment with such agents as ceftazidime, doxycycline, or quin-
olones. Compliance with the recommended antibiotic policy
was associated with reduced risk of death or readmission to
hospital (RR, 0.58; 95% CI, 0.341.00; table 2). However, in
the multivariate analysis (table 3), severity of pneumonia was
the strongest predictor of death or readmission (P p .004), and
320 CID 2002:34 (1 February) Nathwani et al.
Data collected in Dundee during the study period
80%
82% of patients with severe pneumonia; 48% of patients with non-
severe pneumonia with all 4 severity indicators documented
52% of patients received antibiotics within 4 h of admission
72%
71% (within 24 h of admission)
82% of all patients received oxygen therapy prescribed; 98%
of those in the severe group received oxygen therapy
Not measured
Not measured
Not measured
17%
Not measured
Not measured
7
2
14.6
7.2% admitted within 2 weeks of discharge
Not measured
adherence to the antibiotic policy was not statistically significant
(P p .154).
Data about oxygenation were available for all 205 patients
audited. According to either medical or nursing notes, 82% of
the patients received oxygen therapy. Only 70% of the patients
in this group had oxygen prescribed in the drug prescription
chart. The concentration of oxygen administered varied con-
siderably, from 24% to 100%, but this did not appear to be
guided by initial oximetry or blood gas levels. Overall, 170
(83%) of 205 of patients had oxygen saturations performed
within 24 h of admission, but patients with severe pneumonia
were no more likely than other patients to have oxygen satu-
rations performed or repeated within the first 24 h of admission
(table 2).
DISCUSSION
Our data confirm that patients with cases stratified as severe,
according to the BTS criteria [5], are significantly more likely
to die (irrespective of the presence of comorbid illness) or to
remain in the hospital for a longer period of time. These pa-
tients should be treated in a high-dependency unit or ICU. The
Table 2. Comparison of process and outcome measures for management of community-acquired pneumonia (CAP) in patients with
severe or nonsevere CAP.

Relation to
antibiotic protocol
Patients with Patients with Outside Within
severe CAP nonsevere CAP protocol protocol
Characteristic (n p 48) (n p 148) (n p 58) (n p 146) RR (95% CI)
Process or outcome of CAP management
Died 20 (42) 10 (7) 6.17 (3.1112.24)
Received antibiotics within 4 h of hospital admission 29 (61) 73 (49) 1.22 (0.921.62)
Received iv antibiotics within 24 h of hospital
admission 34 (71) 58 (39) 1.81 (1.382.37)
Blood gas levels determined within 24 h
of hospital admission 44 (92) 126 (85) 1.08 (0.971.20)
Blood gases or O2 saturation repeated within 24 h
of hospital admission, n/N (%) 29/44 (66) 80/126 (63) 1.12 (0.851.47)
Antibiotic therapy in relation to protocol
Patient died or was readmitted to the hospital 17 (29) 25 (17) 0.58 (0.341.00)

NOTE. Data are no. (%) of patients, unless otherwise indicated.

low mortality rate in the patients with nonsevere pneumonia
confirms increasing evidence [17] that many patients currently
admitted to the hospital with pneumonia can be managed in
the ambulatory or outpatient setting by use of well-validated
risk stratification criteria [5, 1821].
Compliance with the choice of antibiotics recommended by
the BTS was associated with reduced risk of death and of read-
mission within 2 weeks of hospital discharge. However, the
association was not statistically significant after adjustment for
severity of pneumonia. Nonetheless, our results are consistent
with those of a number of studies that have supported the
potential positive effect of guidelines or protocols on the out-
come of patients who are hospitalized with CAP [7]. Simple
cohort studies are always subject to confounding and bias.
However, randomized trials of organizational interventions in
hospitals present considerable methodological challenges, be-
cause, by necessity, they require the participation of several
hospitals, given that the unit of randomization is the hospital,
not the patient. [31] The Cochrane Effective Practice and Or-
ganisation of Care (EPOC) group recommends the following
2 quasi experimental study designs as alternatives to random-
ized trials: controlled before-and-after studies and interrupted
Table 3. Multiple logistic regression of the relationship be-
tween adherence to antibiotic protocol or severity of pneumonia
and outcome (death or readmission).
Variable b SE Wald Exp (b)
Protocol 0.530 0.372 2.032 1.699
Severity 1.286 0.446 8.297 3.617
Constant 0.630 0.302 4.336 1.877
NOTE. Exp (b), exponential function (logistic regression coefficient).
time-series analyses. Unfortunately, the published literature on
quality improvement interventions in CAP consists of uncon-
trolled before-and-after studies [7], which would not meet the
quality criteria for inclusion in an EPOC systematic review
(see the Data Collection Checklist at www.abdn.ac.uk/public_
health/hsru/epoc/). It is important that future studies are de-
signed to meet the EPOC quality criteria.
Some recent evidence [32] has suggested that antibiotic
choice may be particularly important for elderly patients. This
may have influenced the guidelines developed by the Infectious
Disease Society for CAP [33], in which a new 4-fluoroquinolone
has been introduced as an alternative regimen to a macrolide
combined with either cefuroxime or ceftriaxone for hospitalized
patients. The use of a 4-fluoroquinolone is thought to be par-
ticularly of importance in the elderly and nursing home pop-
ulations [34].
Good compliance with our protocol is encouraging, because
it provides some measurable evidence of our success in im-
plementation of such protocols through posters and a contin-
uing education program. Although compliance may not result
directly in improved health outcome, it shows that clinicians
are supporting good practice by reducing the use of unnecessary
agents [35] or combinations. There is growing concern about
inappropriate use of these agentsin particular, extended-spec-
trum cephalosporins, which are important drivers of antibiotic
resistance [36]and the occurrence of Clostridium difficile in-
P
fections [37].
.154 Although it was encouraging that patients with severe pneu-
.004 monia were more likely to receive antibiotics by the iv route
.037 and within 4 h of admission, there is still plenty of room for
improvement, because 39% of the patients with severe pneu-

CAP Management CID 2002:34 (1 February) 321

monia did not receive prompt appropriate treatment (table 2).
This may indicate a lack of appreciation of the factors that
should stimulate iv therapy, despite the fact that these are clearly
outlined in our empiric sepsis-management protocol, which is
prominently displayed in all the medical units. The use of oral
therapy in the patients with severe pneumonia may also reflect
confidence in oral therapy for patients with severe cases [38],
which many may argue is appropriate [21] in patients with
uncomplicated cases. In fact, decisions regarding the use of the
iv route are largely made on the basis of the theoretical ad-
vantage that high serum levels of antibiotics have for thera-
peutic cure, a fact that may be relevant in intravascular infec-
tions or cases in which there are barriers to penetration, such
as necrotizing pneumonia; however, this would appear to be
less relevant in patients with pneumonia, given that the lung
is a vascular structure and that penetration is excellent [39].
Nonetheless, the existing evidence in favor of oral therapy
comes from studies with a low proportion of severe cases [38].
The median duration of iv therapy in our study (3 days) was
consistent with that in studies published elsewhere [19, 39].
It was reassuring that 92% of the patients with severe pneu-
monia had oxygen saturations performed with 24 h of admis-
sion. However, only 66% of the patients in the severe group
had an additional assessment performed after another 24 h, as
recommended in our protocol. Furthermore, only 18% of the
patients who received oxygen therapy had any documentation
of this treatment in the medical or nursing case notes, despite
the legal requirement that oxygen prescriptions be written in
the notes. The fact that only 62% of the patients had oxygen
prescribed in the drug prescription chart is also a cause of
concern. Even when oxygen treatment was documented, the
amount of oxygen therapy (e.g., concentrations of 35%, 60%,
or 100%) was not adequately noted or justified in the case
notes. We have identified similar evidence of poor case record
documentation in the management of respiratory tract infec-
tion and other infections elsewhere [40]. An improvement in
the process of administering oxygen therapy by implementing
a multidisciplinary multimethod pathway can lead to changes
in oxygen prescription behavior, but this has been found to be
time consuming and costly, and it has not led to changes in
patient outcome. [41]. Despite this, we need to encourage
more-careful documentation of oxygen therapy in our practice
and to ensure that patients with severe pneumonia have ad-
ditional assessments of their oxygenation when appropriate.
Regular evaluation of clinical performance through audit and
feedback of information to stakeholders as a means of pro-
moting change is now encouraged as part of the quality im-
proving agenda of Clinical Governance within the United King-
dom [42]. The emphasis is on implementation and evaluation
of clinical care. Identification of a champion for managing CAP
effectively is a first important step toward realizing this goal.
322 CID 2002:34 (1 February) Nathwani et al.
This may be a physician or specialist nurse who may potentially
also be involved in the care of several patients with other ill-
nesses that require antibiotics. The benefit, for example, of use
of a nurse practitioner for providing ambulatory-care paren-
teral antibiotic therapy in our infection service has already been
shown [43]. We aim to complete the audit loop by introducing
a care pathway for CAP [4446] in 1 of our hospitals, reauditing
our practice in 1824 months. The effect of this intervention
on outcome will be assessed by use of a controlled before-and-
after study design.
References
1. Woodhead MA, McFarlane JT, McCraken JS, Rose DH, Finch RG.
Prospective study of the aetiology and outcome of pneumonia in the
community. Lancet 1987; 1:6714.
2. Guest JF, Morris A. Community acquired pneumonia: the annual cost
to the National Health Service in the United Kingdom. Eur Respir J
1997; 10:15304.
3. Woodhead M. Community-acquired pneumonia guidelinesan in-
ternational comparison: a view from Europe. Chest 1998; 113:183S7S.
4. Woodhead M, McFarlane J, for the BTS CAP Guideline Committee.
Local antibiotic guidelines for adult community acquired pneumonia
(CAP): a survey of UK hospital practice in 1999. J Antimicrob Chemo-
ther 2000; 46:1413.
5. British Thoracic Society. Guidelines for the management of community
acquired pneumonia in adults admitted to hospital. Br J Hosp Med
1993; 49:34650.
6. Miller J, Petrie J. Development of practice guidelines. Lancet 2000;
355:823.
7. Nathwani D, Rubenstein E, Barlow G, Davey P. Do guidelines for
community acquired pneumonia improve the cost-effectiveness of hos-
pital care? Clin Infect Dis 2001; 32:72841.
8. Thomson R, Lavender M, Madhok R. How to ensure that guidelines
are effective. BMJ 1995; 311:23742.
9. Kahn KL, Rogers WH, Rubenstein TV, et al. Measuring quality of care
with explicit process criteria before and after implementation of the
DRG-based prospective payment system. JAMA 1990; 264:196973.
10. Atlas SJ, Benzer TI, Borowsky LH, et al. Safely increasing the proportion
of patients with community-acquired pneumonia treated as outpa-
tients: an interventional trial. Arch Intern Med 1998; 158:13506.
11. Fine MJ, Auble TE, Yealy DM, et al. A prediction rule to identify low-
risk patients with community acquired pneumonia. N Engl J Med
1997; 336:24350.
12. Fine MJ, Hanusa BH, Lave JT, et al. Comparison of disease specific
and a generic severity illness measure of patients with community
acquired pneumonia. J Gen Intern Med 1995; 10:35968.
13. Neill AM, Martin IR, Weir R, et al. Community acquired pneumonia:
aetiology and usefulness of severity criteria on admission. Thorax
1996; 51:10106.
14. Kahn KL, Rogers WH, Rubenstein LV, et al. Measuring quality of care
with explicit process criteria before and after implementation of the
DRG-based prospective payment system. JAMA 1990; 264:196973.
15. Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process,
and outcomes in elderly patients with pneumonia. JAMA 1997; 278:
20804.
16. Gleason PP, Meehan TP, Fine MJ, Galusha DH, Fine MJ. Associations
between initial antimicrobial therapy and medical outcomes for hos-
pitalized elderly patients with pneumonia. Arch Intern Med 1999; 159:
256272.
17. Stahl JE, Barza M, DesJardin J, Martin R, Eckman MH. Effect of
macrolides as part of initial empiric therapy on length of stay in patients
 hospitalized with community-acquired pneumonia. Arch Intern Med
1999; 159:257680.
18. McGarvey RN, Harper JJ. Pneumonia mortality reduction and quality
improvement in a community hospital. QRB Qual Rev Bull 1993; 19:
12430.
19. Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients
hospitalized with community-acquired pneumonia: implications for
practice guidelines. JAMA 1998; 279:14527.
20. Davis D, OBrien MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-
Vaisey A. Impact of formal continuing medical education: do confer-
ences, workshops, rounds, and other traditional continuing education
activities change physician behaviour or health care outcomes? JAMA
1999; 282:86774.
21. Chan R, Hemeryck L, ORegan M, Clancy L, Feely J. Oral versus
intravenous antibiotics for community acquired lower respiratory tract
infection in a general hospital: open, randomised controlled trial. BMJ
1995; 310:13602.
22. MacGregor RR, Grazianni AL. Oral administration of antibiotics: a
rational alternative to the parenteral route. Clin Infect Dis 1997; 24:
45767.
23. Fulmer JD, Snider GL. American College of Chest Physicians/National
Heart, Lung and Blood Institute National Conference on Oxygen Ther-
apy. Heart Lung 1984; 13:55062.
24. Arbo MD, Snydman DR. Influence of blood culture results on anti-
biotic choice in the treatment of bacteremia. Arch Intern Med 1994;
154:26415.
25. Bryan CS. Clinical implications of positive blood cultures. Clin Mi-
crobiol Rev 1989; 2:32953.
26. Rintala E, Kairisto V, Eerola E, Nikoskelainen J, Lehtonen O-P. An-
timicrobial therapy of septicaemic patients in intensive care units before
and after blood culture reporting. Scand J Infect Dis 1991; 23:3416.
27. Schonheyder HC, Hojbjerg T. The impact of the first notification of
positive blood cultures on antibiotic therapy: a one-year survey. APMIS
1995; 103:3744.
28. Hennekens CH, Buring JE. Statistical association and cause-effect re-
lationships. In: Mayrent SL, ed. Epidemiology in medicine, first ed.
Toronto: Little, Brown and Company, 1987:3053.
29. Davey PG, Barza M, Stuart M. Dose response of experimental Pseu-
domonas endophthalmitis to ciprofloxacin, gentamicin and imipenem:
evidence for resistance to late treatment of infections. J Infect Dis
1987; 155:51823.
30. Fine MJ, Medsger AR, Stone RA, et al. The hospital discharge decision
for patients with community-acquired pneumonia: results from the
Pneumonia Patient Outcomes Research Team cohort study. Arch Intern
Med 1997; 157:4756.
31. Ukoumunne C, Gulliford MC, Chinn S, Sterne JA, Burney PG, Donner
A. Methods in health service research: evaluation of health interven-
tions at area and organisation level. BMJ 1999; 319:3769.
32. Gleason PP, Meehan TP, Fine JM, et al. Associations between initial
antimicrobial therapy and medical outcomes for hospitalised elderly
patients with pneumonia. Arch Intern Med 1999; 159:256272.
33. Bartlett JG, Breiman RF, Mandell LA, File TM. Community-acquired
pneumonia in adults: guidelines for management. Clin Infect Dis
1998; 26:81138.
34. Marrie TJ. Community-acquired pneumonia in the elderly. Clin Infect
Dis 2000; 31:106678.
35. Department of Health Advisory Committee Sub-Group on Antimi-
crobial Resistance. The path of least resistance. London, United King-
dom: Department of Health, 1999.
36. John JF, Fishman NO. Programmatic role of the infectious diseases
physician in controlling antimicrobial costs in the hospital. Clin Infect
Dis 1997; 24:47185.
37. Zadik PM, Moore AP. Antimicrobial associations of an outbreak of
diarrhoea due to Clostridium difficile. J Hosp Infect 1998; 40:115.
38. Bartlett JG. Impact of new oral antibiotics on the treatment of infec-
tious diseases. Infect Dis Clin Pract 1994; 2:40513.
39. Siegel RE. How long a stay in hospital is needed for patients with
community acquired pneumonia. Am J Med 2000; 109:4346.
40. Seaton RA, Nathwani D, Philips G, Millar R, Davey P. Clinical record
keeping in patients receiving antibiotics in hospital. Health Bull
1999; 57:12833.
41. Wong C, Visram F, Cook D, et al. Development, dissemination, im-
plementation and evaluation of a clinical pathway for oxygen therapy.
CMAJ 2000; 162:2933.
42. Scally J, Donaldson LJ. Clinical governance and drive for quality im-
provement in the new NHS in England. BMJ 1998; 317:615.
43. Nathwani D, Morrison J, Seaton R, et al. Outpatient and home par-
enteral antibiotic therapy (OHPAT): evaluation and impact of one years
experience in Tayside. Health Bull 1999; 57:3327.
44. Marrie TJ, Lau CY, Wheeler SL, Wong CJ, Vandervoort MK, Feagan
BG. A controlled trial of a critical pathway for treatment of community-
acquired pneumonia. CAPITAL Study Investigators. Community-Ac-
quired Pneumonia Intervention Trial Assessing Levofloxacin. JAMA
2000; 283:74955.
45. Al-Eidan FA, McElnay JC, Scott MG, Kearney MP, Corrigan J, Mc-
Connell JB. Use of a treatment protocol in the management of com-
munity-acquired lower respiratory infection. J Antimicrob Chemother
2000; 45:38794.
46. Fine MJ, Pratt HM, Oborsky S, et al. Relation between length of hos-
pital stay and cost of care for patients with community acquired pneu-
monia. Am J Med 2000; 109:37885.
CAP Management CID 2002:34 (1 February) 323