Standardized Prospective Intervention in Hospitalized Patients with Bacterial Pneumonia.

Background

Community-acquired pneumonia (CAP) remains one of the leading causes of infectious mortality worldwide. Variability in diagnosis and management can significantly influence outcomes.

Objective

To assess the association between the implementation of a standardized hospital protocol and clinical outcomes in patients hospitalized for bacterial CAP and to identify factors associated with in-hospital and 30-day mortality.

Methods

An ambispective before-after study was conducted at Hospital San Juan de Dios del Aljarafe (Seville, Spain), including a retrospective phase (2019) and a prospective intervention period (2022-2023). The intervention consisted of a standardized clinical protocol supported by training sessions and a 9-item checklist. Adults (≥18 years) with clinically and radiologically confirmed bacterial CAP were included. Mortality, length of stay, and empirical and targeted antibiotic adequacy were compared between periods. In the prospective cohort (n = 169), mortality-associated factors were analyzed using multivariate logistic regression.

Results

A total of 1610 patients were analyzed: 634 in the pre-intervention period and 976 during the intervention period. Hospital mortality was lower during the intervention (11.3% [95% CI 9.3-13.2] vs. 16.6%; [95% CI 13.7-19.5] p = 0.002) with an absolute risk difference of 5.3%, corresponding to an approximate number needed to treat (NNT) of 19. Median length of stay decreased slightly (8.1 vs. 7.9 days; p < 0.001). In the prospective cohort, in-hospital mortality was 7.7% and 30-day mortality 16.6%. The therapeutic effort limitation (aOR 9.10, 95% CI 1.36-121.57; p = 0.021) and lower SaO2/FiO2 (aOR per unit 0.98, 95% CI 0.97-0.99; p < 0.001) were independently associated with in-hospital mortality. The ARDS (aOR 4.29, 95% CI 1.05-19.93; p = 0.043), lower SaO2/FiO2 (aOR 0.99 per unit, 95% CI 0.98-1.00; p = 0.005), older age (aOR 1.06 per year, 95% CI 1.02-1.12; p = 0.005), and lower Barthel Index (aOR 0.97 per point, 95% CI 0.94-0.99; p < 0.001) were associated with higher 30-day mortality.

Conclusions

Implementation of a standardized CAP protocol was associated with lower mortality and high antibiotic adequacy in the intervention cohort. While causal inference is limited by the non-contemporaneous before-after design, these findings support the integration of structured, multidisciplinary, protocol-driven strategies-together with periodic audit and feedback cycles-to strengthen CAP management in community hospital settings.