Should Physicians Hold Off Longer on Initiating CAP Treatment?

Key Point

Researchers suggest that guideline recommendations for treating community-acquired pneumonia within four hours of hospitalization may result in less than optimal care.

According to Infectious Diseases Society of America (IDSA) guidelines updated in November 2003, treatment for suspected community-acquired pneumonia (CAP) should be initiated within four hours of hospitalization—a quality indicator Medicare and Medicaid Services has linked to incentive compensation, noted Manreet Kanwar, MD, of St. John Hospital and Medical Center in Detroit, and colleagues in the June Chest.

Yet, in their study, “compliance with the four-hour antibiotic–administration rule led to an increase in the misdiagnosis of CAP, and subsequently to greater utilization of inappropriate antibiotics.” They suggested that use of a six-hour window for antibiotic administration instead of the four-hour window would improve patient outcomes by providing physicians more time to evaluate patients.

In their retrospective study, 518 patients 21 or older admitted to the emergency department (ED) with a primary or secondary diagnosis of pneumonia were included in the analysis. Of these patients, 199 were treated in 2003 (before publication of the IDSA guidelines) and 319 were treated in 2005 (one year after publication).

In 2003 and 2005, a total of 53.8% and 65.8% of patients, respectively, received antibiotics within four hours of triage, and the mean number of antibiotics used per patient increased from 1.39 in 2003 to 1.66 in 2005. However, despite the increase in medication use, 20.6% and 28.5% of patients who had no radiographic abnormalities received a hospital diagnosis of CAP—nearly a 60% increase over time, the researchers noted. The percentage of patients with a final diagnosis of CAP dropped from 75.9% in 2003 to 58.9% in 2005. There were no between-year differences in mortality, the number of transfers to the ICU, or average hospital length of stay.

“Evaluating the accuracy of the diagnosis on hospital admission and linking it to performance may provide an incentive to physicians to work on achieving the correct diagnosis in the ED,” the researchers contended. Recent IDSA/American Thoracic Society guidelines recommend initiating antibiotic treatment in the ED, but with no specific time window, they noted.           

—Adriene Marshall

Reference
Kanwar M, Brar N, Khatib R, Fakih MG. Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics: side effects of the 4-h antibiotic administration rule. Chest. 2007;131(6):1865-1869.
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44(suppl 2):S27-S72.

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