Table 5.

Summary of management practices in relation to IDSA/ATS guideline recommendations.

IDSA Recommendation	Study cohort	Assessment	Strategy to improve antibiotic and health care resource utilization
Use severity of illness score (e.g., CURB-65) to assist in decision to admit	66% had CURB-65 score of 0 or 1; 27% had score of 0 or 1 and absence of hypoxemia	Frequent hospitalization of low-risk patients	Emergency department provider education and implementation of CURB- 65 score as adjunct in site of care decision
Perform sputum gram stain and culture only if good-quality specimen can be obtained and processed appropriately; obtain prior to antibiotic therapy	When ordered, adequate sputum sample obtained in 45% of cases and yield of pathogen in 16% Median time to sputum collection 11 hours after antibiotic initiation	Low-yield test due to inadequate samples and time delay	Target use to ICU cases and those with risk of multi-drug resistant pathogen. Engage nursing, respiratory therapy, and microbiology laboratory to improve sample collection, processing, and timing.
Obtain pretreatment blood cultures in selected cases	Blood cultures obtained in 81% of non-ICU cases; 12 of 21 (57%) positive results were false-positive	Blood cultures obtained routinely rather than selectively in non-ICU cases with a high proportion of false-positive results	Limit blood cultures in non-ICU to those with risk for multi-drug resistant pathogens. Engage nursing and phlebotomy to reduce blood culture contamination rate.
Empirically treat with a respiratory fluoroquinolone or a β-lactam plus macrolide in non-ICU cases	>90% of non-ICU cases treated with guideline-recommended therapy	Excellent adherence to empiric antibiotic selection guidance	Promote ongoing adherence to guideline- concordant empiric therapy
For CA-MRSA infection, add vancomycin or linezolid	MRSA cultured from respiratory specimens in 3 cases; 53 (25%) treated with vancomycin	Empiric therapy against MRSA common	Educate providers regarding local incidence of CA-MRSA pneumonia and provide specific guidance on when to consider empiric MRSA therapy
When switching to oral antibiotics, either the same agent as the intravenous antibiotic or the same drug class should be used*	66% of patients initially treated with ceftriaxone and azithromycin discharged on a new drug class, most often a fluoroquinolone	Unnecessary exposure to a third drug class and contribution to fluoroquinolone overuse	Provide institution-specific recommendations for oral step-down therapy consistent with IDSA/ATS guidance
Treat until afebrile and clinically stable (5 days minimum). Most patients become clinically stable in 3–7 days, so longer durations rarely necessary	Duration of therapy ≥10 days in 56% of cases	Prolonged treatment durations the norm in both non-ICU and ICU cases	Promote short-course therapy (5–7 days) in uncomplicated, clinically responding cases.

^*macrolide alone suggested for those treated with intravenous β-lactam plus macrolide combination