Pneumonia: excess antibiotics tied to poorer outcomes

  • Vaughn VM et al
  • Ann Intern Med

  • International Clinical Digest
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Takeaway

  • Two-thirds of hospitalised patients with community-acquired pneumonia (CAP) receive excessive duration of antibiotics.
  • Discharge antibiotics accounted for 93.2% of excess duration.

Why this matters

  • Consider prescribing ~5 days antibiotic treatment for hospitalised CAP, with a conservative approach to discharge scripts.

Key results

  • 6481 patients, 73.2% (4747) with CAP, 26.8% (1734) with healthcare-associated pneumonia (HCAP).
  • 67.8% received antibiotics for longer than shortest recommended duration; median duration, 8 (interquartile range [IQR], 7-11) days.
  • Overall median excess duration, 2 (IQR, 0-4) days for CAP, 1 (IQR, 0-3) day for HCAP.
  • Prescriptions at discharge accounted for 49.5% (28,947) of total days of antibiotic therapy (fluoroquinolones, 34.3%; azithromycin/amoxicillin-clavulanate, 39.3%).
  • Multivariate (longer antibiotic duration):
    • Respiratory culture/nonculture test, negative: 2.5+ days; adjusted rate ratio [aRR], 1.15 (95% CI, 1.09-1.23); positive: 3.2 days; aRR, 1.49 (95% CI, 1.33-1.68).
    • Longer hospital stay: 0.2 days; aRR, 1.02 (95% CI, 1.02-1.02; P<.001>
    • High-risk antibiotic in prior 90 days: 2.9 days; aRR, 1.17 (95% CI, 1.10-1.25).
    • Pneumonia: CAP, 3.2 days; aRR, 1.43 (95% CI, 1.32-1.55).
  • Odds of adverse events rose by 5% (95% CI, 2%-8%) per excess day.

Study design

  • Retrospective cohort study quantifying excess antibiotic duration, associated factors/outcomes in hospitalised CAP/HCAP patients.
  • Funding: Blue Cross Blue Shield of Michigan.

Limitations

  • Observational.
  • Underestimated excess duration.
  • Guidelines moving away from HCAP.
  • Recall bias.

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