Excess treatment with antibiotics for pneumonia is common and may lead to harm

Reference

Vaughn VM, Flanders SA, Snyder A, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia. Ann Intern Med 2019 Jul 9. doi: 10.7326/M18-3640. [Epub ahead of print]

Synopsis

Using data obtained from 43 hospitals in the Michigan Hospital Medicine Safety Consortium, these investigators identified 6481 patients hospitalized on general medicine wards with either community-acquired pneumonia (CAP) or the now defunct category of health care–associated pneumonia (HCAP). Patients were excluded if they required care in an intensive care unit, were being treated for an additional infection not related to pneumonia, were severely immunocompromised, or were admitted under comfort care. The median age of the cohort was 70 years and 57% were classified as having severe pneumonia. Overall, most patients improved quickly, with 87% clinically stable or discharged by day 5. The primary outcome was the rate of excess antibiotic treatment duration. The expected treatment duration for CAP was 5 days, with longer courses expected if time to clinical stability was longer. The expected treatment duration for patients with HCAP or pneumonia due to Staphylococcus aureus or Pseudomonas aeruginosa was 7 days. An impressive 68% of the cohort received antibiotics for longer than the shortest effective duration. The median duration was 8 days for CAP and 9 days for HCAP. Overall, there were 2526 excess days of antibiotic treatment per 1000 patients hospitalized with pneumonia. Antibiotics prescribed at discharge accounted for 93% of the excess days, commonly prescribed for an additional 5, 7, or 10 days. Although excess treatment was not associated with decreased mortality, readmission rates, or emergency department visits, it was associated with an increased number of patient-reported adverse events. Factors associated with excess treatment included patients with longer hospital stays, those who received diagnostic testing with either a sputum culture or a nonculture test, those who had received high-risk antibiotics in the past 90 days, and those who did not have antibiotic treatment duration documented in the discharge summary. Such documentation only occurred 32% of the time, but was associated with a lower rate of excess antibiotics (2.3 days vs 2.9 days).