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.
“It's possible that prolonging the antibiotic window to 6 hours may be enough time to better evaluate a patient,” Dr. Kanwar suggested.
To determine the effect of this recommendation on CAP diagnosis and associated antibiotic utilization, Dr. Kanwar and colleagues reviewed the charts for 518 patients older than age 21 years 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, 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% 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.
Increases in the misdiagnosis of 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.
Dr. Kanwar reported having no related financial disclosures.