Julian Harris

Julian is a basic physician trainee working in Cairns Hospital. Originally hailing from South East Queensland and having misguided early career aspirations in mathematics, he now spends his time off exploring the natural wonders of Far North Queensland with occasional breaks feigning preparation for the RACP Written Exam.

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Community Acquired Pneumonia in Far North Queensland : A Retrospective Clinical Audit

Aim: To evaluate the assessment, investigation and management of adults admitted with a provisional diagnosis of CAP in Cairns Hospital and compare current practice with established guidelines.

Methods: A list of admissions to Cairns Hospital with a clinical code of pneumonia or lower respiratory tract infection in the 2017 calendar year was collected. Relevant information was extracted from patient medical records and a SMART-COP1 risk stratification score was calculated.

Results: 1,136 episodes of care were examined, with 201 episodes from 196 unique patients meeting inclusion criteria. The median age was 66 (Range 18 to 99) with 1:1 male to female ratio. 72 (30.5%) episodes had documented severity scoring tool. Using SMART-COP, 17 (8.5%)  episodes were high or very high risk of requiring intensive respiratory or vasopressor support. Blood cultures were performed in 105 (53%), sputum cultures in 82 (42%), urinary bacterial antigens for Streptococcus pneumoniae and Legionella pneumophila in 76 (38%), respiratory virus PCR in 62 (31%) and serology for atypical organisms in 33 (17%). There were 24 different antimicrobial regimes prescribed. Of 201 patient episodes, 75 were prescribed benzylpenicillin and doxycycline (39%), 32 ceftriaxone and doxycycline (16%) and 15 ceftriaxone with azithromycin (8%). In 67 (34%) episodes prescriptions were either consistent with those recommended in therapeutic guidelines or had any documented rationale for choice of antimicrobial.

Conclusion: Investigation ordering was inconsistent, without clear correlation with risk status or provisional aetiology in the studied cohort.
Antimicrobial prescribing was highly variable and adherence with current management guidelines was low. Further examination of our data and more investigation is required to elucidate reasons for observed heterogeneity in practice.

References:
1. Charles PG, Wolfe R, Whitby M, Fine MJ, Fuller AJ, Stirling R, et al. SMART-COP: a tool for predicting the need for intensive respiratory or vasopressor support in community-acquired pneumonia. Clin Infect Dis. 2008 Aug 1;47(3):375-84.