Evaluation of antibiotic prescription appropriateness for patients with pneumonia in the emergency department

Inappropriate antibiotic prescribing in the emergency department (ED) contributes substantially to antimicrobial resistance, particularly in low- and middle-income countries. Evidence on antibiotic appropriateness for pneumonia in Indian ED settings remains limited. To evaluate the appropriateness of empirical antibiotic prescriptions for pneumonia patients presenting to the ED and to assess door-to-antibiotic time and microbiological culture yield. This prospective observational study was conducted over three months in the ED of a tertiary care academic hospital in India. Adult patients presenting with pneumonia were consecutively enrolled. Antibiotic prescriptions were assessed for appropriateness using predefined domains—indication, empirical choice, dose, route, and timing—based on IDSA/ATS guidelines. Prescriptions were classified as appropriate or partially appropriate. Pneumonia severity, door-to-antibiotic time, and culture positivity were analyzed. Ninety-nine patients were included (mean age 48.3 ± 17.0 years). Antibiotics were administered to all patients, with a median door-to-antibiotic time of 45 minutes; 80.8% received antibiotics within one hour. Overall, 50.5% of prescriptions were appropriate. Appropriateness was significantly higher in severe pneumonia compared with non-severe cases (69.6% vs 44.7%, p = 0.037). No prescriptions were classified as inappropriate. Blood cultures were positive in 11.1% of patients, with clinically significant pathogens identified in 7.1%, predominantly gram-negative organisms. Antibiotic prescribing in the ED demonstrated better guideline concordance in severe pneumonia, while over-broad empirical therapy was common in non-severe cases. These findings highlight the need for ED-adapted antimicrobial stewardship strategies focused on risk stratification rather than routine escalation.