Pneumonia is one of the most prevalent infections seen in Canadian hospitals.

According to the
Canadian Institute for Health Information (CIHI), pneumonia was the number one visit diagnosis
at emergency departments in 2017-2018, with more than 1 in 4 of these patients requiring
hospital admission (1). In Canada, the total number of reported inpatient hospitalizations from all
causes of pneumonia in 2017-2018 was 70,149 patients (2), who averaged a length of stay of 6.7
days. The average cost of a patient admission for bacterial pneumonia was $9,649 (3). Alberta
had an admission of 6,987 inpatient hospitalizations from all causes of pneumonia with an
average length of stay on par with the national average of 6.7 days (2). However, there was a
striking difference reported in the average cost of admission for bacterial pneumonia; Alberta
had the second-highest provincial cost, reporting an average cost of $14,470 per patient (3).

Increased prevalence and cost is driven by Canada's aging population and population growth, as
well as the increasing costs of running a healthcare system (4). The Conference Board of Canada
has provided a briefing (2017) which examines the future economic burden of pneumonia in
individuals 65 years of age and older in greater detail (4). This briefing found that Canada's total
direct health care cost attributed to those 65 years of age and older with pneumonia is forecasted
to double from a $216.2 million spent in 2010, to a $532.2 million spend in 2025 (4). The
incidence of pneumonia is higher in our elderly population, and therefore, with an aging society,
cases of pneumonia will continue to rise, necessitating a focus on fiscally responsible prescribing
practices, including concordant evidence-based guideline therapy (4).

The most recent community-acquired pneumonia (CAP) clinical practice guidelines from The
American Thoracic Society (ATS) and Infectious Disease Society of America (IDSA) (2019)
recommend initial antibiotic therapy for non-severe (non-ICU admission) inpatient without risk
factors for MRSA and p. aeruginosa of 1) β-lactam plus a macrolide, or 2) monotherapy with a
respiratory fluoroquinolone (5). An alternative option of a β-lactam plus doxycycline is reserved
for those whom have contraindications to both macrolides and fluoroquinolones (5). When
stepping down from intravenous therapy to oral therapy, guidelines recommend either the same
agent or the same drug class to be used (5). For most patients with non-severe CAP, without risk
factors of MRSA/p. aeruginosa, a minimum 5-day course of antibiotic therapy will be
appropriate, as most of these patients achieve clinical stability within the first 48-72 hours of
therapy (5).

The new ATS/IDSA guidelines state, "When assessment of clinical stability has been introduced
into clinical practice, patients have shorter durations of antibiotic therapy without adverse impact
on outcome. All clinicians should, therefore, use an assessment of clinical stability as part of
routine care of patients with CAP (5)." Halm et al. validated clinical stability criteria in CAP
inpatients, which was used in numerous studies (8-11) in switching patients from intravenous to
oral antibiotic therapy. These criteria include resolution of heart rate, blood pressure, respiratory
rate, oxygen saturation, and temperature, as well as the ability to eat and return to baseline
mental status (9).

A 2008 meta-analysis, evaluated the early switch from intravenous route (after 2-4 days of
treatment) to oral route in patients with moderate to severe CAP (6). The findings support an
early conversion to oral antibiotic treatment. The analysis found that there was no difference in
treatment success between the early switch to oral treatment and the intravenous only group, nor
any difference in mortality and recurrence of CAP (6). It also found that the duration of
hospitalization was shorter in the early switch group, and adverse drug-related events were less
in the early switch group (6). This meta-analysis demonstrates the importance of evaluating the
route of administration daily and ensuring patients are on a route of administration concordant to
their clinical stability.

Recent Canadian data regarding the use of guideline-concordant antibiotic route of

administration in CAP hospital treatment is lacking. As the prevalence of pneumonia will
continue to rise (4), it will be very beneficial to collect baseline information in Alberta of current
inpatient practices to determine if there is a need for development of further protocols or
interventions. This study will review antibiotic therapy in inpatients treated for CAP from the
past four years at Red Deer Regional Hospital Centre (RDRHC), a facility that serves a
population of over 450,000 central Albertans (7). From this local data, prescribing practices can
be examined to determine if the route of administration (i.e., intravenous or oral) is concordant
with the patient's clinical stability.