TORONTO — Adherence to guidelines that recommend early use of antibiotics may lead to inaccurate diagnosis of community-acquired pneumonia and inappropriate use of antibiotics, according to a study presented at the annual meeting of the Infectious Diseases Society of America.
The IDSA guidelines for community-acquired pneumonia (CAP), published in November 2003, recommend the initiation of antibiotics within 4 hours of hospitalization—an indicator that has been linked to incentive compensation of third-party payers to hospitals, said Dr. Manreet K. Kanwar of St. John Hospital and Medical Center in Detroit.
Given the potential for providing less than optimal care by promoting compliance with the current CAP quality indicator, a more feasible target should be established, Dr. Kanwar suggested. “It's possible that prolonging the antibiotic window to 6 hours may be enough time to better evaluate a patient.”
To determine the effect of this recommendation on the diagnosis of CAP and associated antibiotic utilization, Dr. Kanwar and colleagues reviewed the charts for 518 patients older than age 21 years who were admitted to their institution through the emergency department both prior to (January through June 2003) and following (January through June 2005) the publication of the guidelines. They collected data on clinical signs and symptoms at presentation, as well as chest x-ray findings, preantibiotic blood cultures, time to antibiotic administration data, Pneumonia Severity Index (PSI) scores, intensive care unit (ICU) transfer rates, and mortality data.
There were no significant differences between the 199 patients in the preguideline group and the 319 in the postguideline group in age, gender, PSI score, ICU transfer rates, or mortality. In the postguideline group, 66% of patients received antibiotics within 4 hours of triage, compared with 54% of the preguideline patients. The percentage of blood cultures prior to antibiotic administration was higher (70%) in the 2005 group compared with 47% in the 2003 group. But the final diagnosis of CAP dropped significantly, from about 76% in 2003 to 59% in 2005, and the mean antibiotic utilization per patient increased significantly, Dr. Kanwar reported in a poster presentation.
The increases in both the misdiagnosis in CAP and inappropriate antibiotic use as a result of compliance with the 4-hour antibiotic rule suggest that many patients received antibiotics for noninfectious processes. The increase in blood cultures obtained without indication suggests potential antibiotic use for contaminant-related positive cultures.
Dr. Kanwar reported having no financial disclosures related to this presentation.