Authors: Michael Remmel, PharmD; Memar Ayalew, PharmD, BCIDP, AAHIVP
Objectives: Evaluate the impact of provider education and an ED-specific outpatient order set on guideline-concordant antibiotic prescribing for CAP, characterize drivers of non-adherence, and assess associated clinical outcomes and adverse drug reactions.
Background: Community-acquired pneumonia (CAP) is a common cause of emergency department (ED) visits, and antibiotic prescribing often deviates from guideline selection, dose, and duration of therapy. This study evaluated whether an order set intervention improved adherence to local CAP guidelines.
Methods: This retrospective, , pre-post intervention quasi-experimental quality improvement study evaluated CAP management at Walter Reed National Military Medical Center ED. Patients were included if >/= 18 years of age, diagnosed with CAP in the ED and received oral antibiotics upon discharge between July 1, 2025 and January 31, 2026 October 16, 2025, used as the pre- and post-intervention cutoff. Prescribing trends were compared before and after intervention which included provider education, implementation of an emergency department-specific updated outpatient protocol and creating a corresponding order set in the electronic medical record (EMR)Patients with recent oral or intravenous antibiotic exposure, recent hospitalization or ED visits, concurrent infections, no discharge antibiotic, or poor demographic data were excluded. The primary outcome was rate of local guideline-concordant antibiotic therapy selection ; secondary outcomes included regimen selection, dose, frequency, duration, and treatment outcomes. Descriptive statistics were used to summarize prescribing patterns and outcomes.
Results: Of 111 screened patients, 82 patients met inclusion criteria, including 28 pre-intervention and 54 post-intervention. Guideline-concordant antibiotic selection increased from 10.7% in the pre-intervention period to 22.2% post-intervention period. Prescriptions for 3- to 5-day treatment durations increased from 35.7% to 53.7%, while durations of at least 6 days decreased from 64.3% to 46.3%. Use of non-preferred antibiotic regimens categorized as “other” decreased from 50.0% to 25.9%. Common drivers of nonadherence were medication selection (36.0% vs 40.5%), duration (24.0% vs 21.4%), and multiple discordant components (36.0% vs 35.7%).
Conclusion: Education and outpatient CAP order set implementation were associated with improved guideline-concordant prescribing in the ED, particularly for antibiotic selection and shortening durations of therapy. These findings support continuing antimicrobial stewardship efforts in the ED and further order set refinement to improve discharge prescribing quality.
