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Background  Antipseudomonal antibiotics should be restricted to patients at risk of  Pseudomonas aeruginosa  infection. However, the indications in different guidelines on community-acquired pneumonia (CAP) are discordant. Our objectives were to assess the prevalence of antipseudomonal antibiotic prescriptions and to identify determinants of empirical antibiotic choices in the emergency department.    Methods  Observational, retrospective, one-year cohort study in hospitalized adults with pneumonia. Antibiotic choices and clinical and demographic data were recorded on a standardized form. Antibiotics with antipseudomonal activity were classified into two groups: a) β-lactam antipseudomonals (β-APS), including carbapenems, piperacillin / tazobactam or cefepime (in monotherapy or combination) and b) monotherapy with antipseudomonal quinolones.    Results  Data were recorded from 549 adults with pneumonia, with  Pseudomonas aeruginosa  being isolated in only nine (1.6%). Most (85%) prescriptions were compliant with SEPAR guidelines and 207 (37%) patients received antibiotics with antipseudomonal activity (14% β-APS and 23% levofloxacin). The use of β-APS was independently associated with ICU admission (OR 8.16 95% CI 3.69–18.06) and prior hospitalization (OR 6.76 95% CI 3.02–15.15), while levofloxacin was associated with negative pneumococcal urine antigen tests (OR 3.41 95% CI 1.70–6.85) but negatively associated with ICU admission (OR 0.26 95% CI 0.08–0.86). None of these factors were associated with  P aeruginosa  episodes. In univariate analysis, prior  P aeruginosa  infection/colonization (2/9 vs 6/372,  p  = 0.013), severe COPD (3/9 vs 26/372,  p  = 0.024), multilobar involvement (7/9 vs 119/372,  p  = 0.007) and prior antibiotic (6/9 vs 109/372,  p  = 0.025) were significantly associated with  P aeruginosa  episodes.    Conclusions  Antipseudomonal prescriptions were common, in spite of the very low incidence of  Pseudomonas aeruginosa . The rationale for prescription was influenced by both severity-of-illness and pneumococcal urine antigen test (levofloxacin) and prior hospitalization and ICU admission (β-APS). However, these factors were not associated with  P aeruginosa  episodes. Only prior  P aeruginosa  infection/colonization and severe COPD seem to be reliable indicators in clinical practice.

Determinants of empirical antipseudomonal antibiotic prescription for adults with pneumonia in the emergency department