Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study
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Visual Abstract. Excess Antibiotic Use in Patients Hospitalized With Pneumonia
Randomized trials have demonstrated the safety of shorter courses of antibiotic treatment for pneumonia, but how often excess treatment durations are prescribed is not known. This large multicenter cohort study assessed how often patients hospitalized with pneumonia received excess durations of antibiotic treatment and whether this was associated with harm.
Abstract
Background:
Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration.
Objective:
To examine predictors and outcomes associated with excess duration of antibiotic treatment.
Design:
Retrospective cohort study.
Setting:
43 hospitals in the Michigan Hospital Medicine Safety Consortium.
Patients:
6481 general care medical patients with pneumonia.
Measurements:
The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care–associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment.
Results:
Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge.
Limitation:
Retrospective design; not all patients could be contacted to report 30-day outcomes.
Conclusion:
Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes.
Primary Funding Source:
Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.
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Published In
Annals of Internal Medicine
Volume 171 • Number 3 • 6 August 2019
Pages: 153 - 163
History
Published online: 9 July 2019
Published in issue: 6 August 2019
Keywords
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© 2019 American College of Physicians.
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Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study. Ann Intern Med.2019;171:153-163. [Epub 9 July 2019]. doi:10.7326/M18-3640
Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study. Ann Intern Med.2019;171:153-163. [Epub 9 July 2019]. doi:10.7326/M18-3640
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Comments on "Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia."
In this study, the authors reported that a respiratory culture was associated with higher rates of excess treatment. The present study did not insist on a causal relationship owing to its retrospective design and the authors discussed that sputum testing may reflect greater concern regarding severe disease. Nevertheless, it should be explicitly stated that disease severity could be a critical confounding factor and the above-mentioned association does not deny the importance of sputum culture testing.
Previous studies have suggested the clinical usefulness of gram staining and sputum cultures for the identification of pathogens, thereby, may optimize diagnosis and treatment2). Despite its low sensitivity, sputum culture is clinically useful, particularly for infectious diseases caused by S.pneumoniae and H.influenzae3). De-escalation of broad-spectrum antibiotics based on culture results might reduce the risk of infection with drug-resistant organisms and drug-related adverse events including Clostridium difficile infection4).
We hope that further studies on adequate antibiotic treatment duration will be conducted considering the clinical usefulness of respiratory cultures.
1. Vaughn, V. M., Flanders, S. A., Snyder, A., et al. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia. Annals of Internal Medicine, 43. https://doi.org/10.7326/M18-3640
2. Strålin K. Usefulness of aetiological tests for guiding antibiotic therapy in community-acquired pneumonia. Int J Antimicrob Agents. 2008;31(1):3-11. doi:10.1016/j.ijantimicag.2007.06.037
3. Miyashita N, Shimizu H, Ouchi K, et al. Assessment of the usefulness of sputum Gram stain and culture for diagnosis of community-acquired pneumonia requiring hospitalization. Med Sci Monit. 2008;14(4):CR171-6. http://www.ncbi.nlm.nih.gov/pubmed/18376343.
4. Rac H, Haggard E, Mediwala KN, et al. Role of Early De-escalation of Antimicrobial Therapy on Risk of Clostridioides difficile Infection following Enterobacteriaceae Bloodstream Infections. Clinical Infectious Diseases, Volume 69, Issue 3, 1 August 2019, Pages 414-420, https://doi.org/10.1093/cid/ciy863
Disclosures: None declared.