Community-Acquired Pneumonia - 4-hour Rule

12/19/2007

Question:  What evidence supports the 4-hour rule mandating antibiotics within four hours of admission for patients suspected of community-acquired pneumonia?

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<1>

Unique Identifier [PMID]: 17913298

Authors: Pines JM. Localio AR. Hollander JE. Baxt WG. Lee H. Phillips C. Metlay JP.

Institution: Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu

Title: The impact of emergency department crowding measures on time to antibiotics for patients with community-acquired pneumonia.[see comment].

Source: Annals of Emergency Medicine. 50(5):510-6, 2007 Nov.

Abstract: STUDY OBJECTIVE: We seek to determine the impact of emergency department (ED) crowding on delays in antibiotic administration for patients with community-acquired pneumonia. METHODS: We performed a retrospective cohort study of adult patients admitted with community-acquired pneumonia from January 1, 2003, to April 31, 2005, at a single, urban academic ED. The main outcome was a delay (>4 hours from arrival) or nonreceipt of antibiotics in the ED. Eight ED crowding measures were assigned at triage. Multivariable regression and bootstrapping were used to test the adjusted impact of ED crowding measures of delayed (or no) antibiotics. Predicted probabilities were then calculated to assess the magnitude of the impact of ED crowding on the probability of delayed (or no) antibiotics. RESULTS: In 694 patients, 44% (95% confidence interval [CI] 40% to 48%) received antibiotics within 4 hours and 92% (95% CI 90% to 94%) received antibiotics in the ED. Increasing levels of ED crowding were associated with delayed (or no) antibiotics, including waiting room number (odds ratio [OR] 1.05 for each additional waiting room patient [95% CI 1.01 to 1.10]) and recent ED length of stay for admitted patients (OR 1.14 for each additional hour [95% CI 1.04 to 1.25]). When the waiting room and recent length of stay were both at the lowest quartiles (ie, not crowded), the predicted probability of delayed (or no) antibiotics within 4 hours was 31% (95% CI 21% to 42%); when both were at the highest quartiles, the predicted probability was 72% (95% CI 61% to 81%). CONCLUSION: ED crowding is associated with delayed and nonreceipt of antibiotics in the ED for patients admitted with community-acquired pneumonia.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 17426609

Authors: Drake DE. Cohen A. Cohn J.

Institution: Albert Einstein Healthcare Network, Philadelphia, PA 19141, USA. DrakeD@einstein.edu

Title: National hospital antibiotic timing measures for pneumonia and antibiotic overuse.

Source: Quality Management in Health Care. 16(2):113-22, 2007 Apr-Jun.

Abstract: The development of drug-resistant bacteria from the overuse of antibiotics is a serious problem, with overutilization threatening to disarm caregivers and their patients even as together they face increasingly virulent strains of microbes. On the other hand, the speedy treatment of pneumonia with antibiotics is a firmly established, evidence-based practice, enshrined in Joint Commission on Accreditation for Healthcare Organizations Core Measures used in hospital accrediting and public reporting, and in Centers for Medicare and Medicaid Services (CMS) public-reporting and pay-for-performance hospital measures. This sets the stage for a potential conflict between (a) not doing the wrong thing by overprescribing antibiotics and (b) prescribing antibiotics on time for pneumonia. In November 2005, pneumonia antibiotic timing results were announced for the 133 top-performing hospitals in the first year of the 3-year CMS Hospital Quality Incentive Demonstration (HQID) pay-for-performance project, conducted in collaboration with Premier Inc, a hospital purchasing and informatics alliance. Premier client hospitals participating in the HQID also submit drug utilization and other comparative data to Premier for client access for benchmarking purposes; this makes it possible to see how the antibiotics specified for pneumonia are used by Premier hospitals for other conditions. In this study we look at where increased success in meeting the HQID pneumonia antibiotic timing measure is tied to an increase in antibiotic use for conditions where antibiotics are unwarranted--with the potential for promoting antibiotic resistance.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 17656730

Authors: Mitchiner JC. Hutto SL.

Institution: Michigan Peer Review Organization, 22670 Haggerty Rd, Ste 100, Farmington Hills, MI 48335-2611, USA. jmitchin@mpro.org

Title: The effect of selected hospital characteristics on the timeliness of antibiotic administration for pneumonia.

Source: American Journal of Medical Quality. 22(4):259-64, 2007 Jul-Aug.

Abstract: In this study, we compared large urban teaching hospitals (group 1) with small nonurban nonteaching hospitals (group 2) in terms of administering antibiotics to patients admitted with pneumonia within 4 hours of hospital arrival. The following 2 independent data sets were used: hospital-reported data (comprising 22 193 patients with pneumonia discharged from Michigan hospitals in 2003) and hospital surveillance data (comprising 1053 randomly selected patients with pneumonia in Michigan from 2002 to 2004, reviewed by a central data abstraction center). Using hospital-reported data, the mean antibiotic timeliness rates were 65.9% (95% confidence interval [CI], 61.5%-70.2%) for group 1 and 79.5% (95% CI, 76.8%-80.2%) for group 2 (P<.001). Using hospital surveillance data, the mean antibiotic timeliness rates were 58.2% (95% CI, 52.9%-63.5%) for group 1 and 70.1% (95% CI, 63.7%-76.6%) for group 2 (P = .01). These results support efforts to reduce logistical barriers to pneumonia antibiotic timeliness at large hospitals.

Publication Type: Comparative Study. Journal Article. Research Support, Non-U.S. Gov't. Research Support, U.S. Gov't, Non-P.H.S..

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Unique Identifier [PMID]: 17643863

Authors: Fee C. Weber EJ. Sharpe BA. Quon T.

Title: When is a scarlet letter really a red badge of courage?: the paradox of percentage of pneumonia patients receiving antibiotics within 4 hours in accordance with JCAHO and CMS core measures.

Source: Annals of Emergency Medicine. 50(2):205-6, 2007 Aug.

Publication Type: Letter.

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Unique Identifier [PMID]: 17470905

Authors: Pines JM. Hollander JE. Lee H. Everett WW. Uscher-Pines L. Metlay JP.

Institution: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu

Title: Emergency department operational changes in response to pay-for-performance and antibiotic timing in pneumonia.

Source: Academic Emergency Medicine. 14(6):545-8, 2007 Jun.

Abstract: BACKGROUND: The percentage of adult patients admitted with pneumonia who receive antibiotics within four hours of hospital arrival is publicly reported as a quality and pay-for-performance measure by the Department of Health and Human Services and is called PN-5b. OBJECTIVES: To determine attitudes among physician leaders at emergency medicine training programs toward using PN-5b as a quality measure for pay for performance, and to determine what operational changes academic emergency departments (EDs) have made to ensure early antibiotic administration for patients with pneumonia. METHODS: The authors administered an online questionnaire to 129 chairpersons and medical directors of 135 academic ED training programs in the United States on attitudes toward performance measurement in pneumonia and changes that academic EDs have made in response to PN-5b; one response was sought from each institution. Respondents were identified through the Society for Academic Emergency Medicine Web site and e-mailed five times to maximize survey participation. RESULTS: Ninety chairpersons and medical directors (70%) completed the survey; 47% were medical directors, 51% were chairpersons, and 2% were medical directors and chairpersons. Forty-five (50%) did not agree that PN-5b was an accurate quality measure, and 61 (69%) did not agree that pay for performance targeting this measure would lead to improved pneumonia care. The most common strategy to address PN-5b was to provide information to providers on the importance of early treatment with antibiotics (n = 63; 70%). For patients with suspected pneumonia, 46 (51%) automate chest radiograph (CXR) ordering at triage, 37 (41%) prioritize patients with suspected pneumonia, and 33 (37%) administer antibiotics before obtaining CXR results. Overall ED changes include improved turnaround time for CXR (n = 33; 37%), prioritized CXRs over other radiographs (n = 13; 14%), and improved inpatient bed availability (n = 12; 13%). Of 13 strategies identified to improve PN-5b, the median number that programs have implemented is five (interquartile range, 5-7). All sites reported engaging in at least three operational changes to address PN-5b. CONCLUSIONS: All EDs in this study have addressed early antibiotic administration with multiple operational changes despite mixed sentiment that these changes will improve care. Future research is needed to measure the impact of pay-for-performance initiatives.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 17210202

Authors: Fee C. Weber EJ.

Institution: Division of Emergency Medicine, Department of Medicine, University of California, San Francisco Medical Center, San Francisco, CA 94143, USA. christopher.fee@ucsfmedctr.org

Title: Identification of 90% of patients ultimately diagnosed with community-acquired pneumonia within four hours of emergency department arrival may not be feasible.[see comment].

Source: Annals of Emergency Medicine. 49(5):553-9, 2007 May.

Abstract: STUDY OBJECTIVE: We determine whether it is feasible to identify 90% of emergency department (ED) patients who subsequently receive a hospital discharge diagnosis of community-acquired pneumonia using the current Joint Commission on Accreditation of Healthcare Organizations (JCAHO)/Centers for Medicare and Medicaid Services (CMS) community-acquired pneumonia core measures criteria. METHODS: This was a retrospective case series in a university tertiary care ED. From a random sample of patients discharged from the hospital between January and December 2005 who were eligible for JCAHO/CMS community-acquired pneumonia antibiotic timing measure PN-5b, we identified the proportion of patients admitted through the ED who received antibiotics more than 4 hours after hospital arrival (outliers). Medical records of outliers were reviewed to determine whether they received a final ED community-acquired pneumonia diagnosis. Presenting characteristics of outliers with and without final ED community-acquired pneumonia diagnoses were compared to determine feature(s) that might explain failure to diagnose community-acquired pneumonia in the ED. RESULTS: Of 152 eligible ED community-acquired pneumonia patients, 53 (34.9%) were identified as outliers. Thirty-one of the outliers did not have a final ED community-acquired pneumonia diagnosis. Thus, at least 20.4% (95% confidence interval [CI] 14.3% to 27.7%) of all ED community-acquired pneumonia patients did not have an ED community-acquired pneumonia diagnosis. Of outliers without an ED community-acquired pneumonia diagnosis, 43.3% had an abnormal chest radiograph compared with 95% with an ED community-acquired pneumonia diagnosis (odds ratio 24.8; 95% CI 3.63 to infinity). CONCLUSION: It may not be possible to identify 90% of hospitalized patients with a discharge diagnosis of community-acquired pneumonia during their ED assessment by using the current JCAHO/CMS criteria. It may therefore be unrealistic to expect that 90% of such patients will have antibiotics delivered within 4 hours of hospital presentation. A more realistic performance standard for antibiotic administration should be established or case definitions modified to include only patients with a final ED community-acquired pneumonia diagnosis or objective clinical and radiographic evidence.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16928714

Authors: Barlow G. Nathwani D. Williams F. Ogston S. Winter J. Jones M. Slane P. Myers E. Sullivan F. Stevens N. Duffey R. Lowden K. Davey P.

Institution: Ninewells Hospital and Medical School, Dundee, Scotland, UK. gavin.barlow@hey.nhs.uk

Title: Reducing door-to-antibiotic time in community-acquired pneumonia: Controlled before-and-after evaluation and cost-effectiveness analysis.

Source: Thorax. 62(1):67-74, 2007 Jan.

Abstract: BACKGROUND: Practice guidelines suggest that all patients hospitalised with community-acquired pneumonia (CAP) should receive antibiotics within 4 h of admission. An audit at our hospital during 1999-2000 showed that this target was achieved in less than two thirds of patients with severe CAP. METHODS: An experienced multidisciplinary steering group designed a management pathway to improve the early delivery of appropriate antibiotics to patients with CAP. This was implemented using a multifaceted strategy. The effect of implementation was evaluated using a controlled before-and-after study design over two winter seasons (November-April 2001-2 and 2002-3). Cost-effectiveness analyses were performed from the hospital's perspective. RESULTS: The proportion of patients receiving appropriate antibiotics within 4 h of admission to hospital increased from 33% to 56% at the intervention site, and from 32% to 36% at the control site (absolute change adjusted for differences in severity of illness 17%, p = 0.035). The cost per additional patient receiving appropriate antibiotics within 4 h was 132 pound with no post-implementation evaluation, and 456 pound for a limited post-implementation evaluation. Simple modelling from the results of a large observational study suggests that the cost per death prevented could be 3003 pound with no post-implementation evaluation, or 16,632 pound with a limited post-implementation evaluation. CONCLUSIONS: The intervention markedly improved door-to-antibiotic time, albeit at considerable cost. It might still be a cost-effective strategy, however, to reduce mortality in CAP. Uncertainty about the cost effectiveness of such interventions is likely to be resolved only by a well-designed, cluster randomised trial.

Publication Type: Controlled Clinical Trial. Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 16825671

Authors: Pines JM. Morton MJ. Datner EM. Hollander JE.

Institution: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA. pinesjes@uphs.upenn.edu

Title: Systematic delays in antibiotic administration in the emergency department for adult patients admitted with pneumonia.

Source: Academic Emergency Medicine. 13(9):939-45, 2006 Sep.

Abstract: OBJECTIVES: The authors sought to determine the contribution of delays in care on time to antibiotics for patients admitted from the emergency department (ED) with pneumonia and to identify patients at risk for delayed antibiotics. METHODS: This was a retrospective cohort study of patients admitted to the Hospital of the University of Pennsylvania (HUP) and to Pennsylvania Presbyterian Hospital (Presbyterian) with an admission diagnosis of pneumonia in 2004. RESULTS: A total of 393 patients were included. Ninety percent had antibiotics documented as given in the ED. Eighty-three (43%) of 209 at HUP and 104 (64%) of 161 patients at Presbyterian received antibiotics within four hours. Patients who received antibiotics more than four hours after ED arrival experienced longer waits for radiograph orders (HUP, 54 min [95% confidence interval {CI} = 33 to 76 min]; Presbyterian, 43 min [95% CI = 29 to 58 min]), for radiograph performance (HUP, 21 min [95% CI = 4 to 39 min], Presbyterian, 24 min [95% CI = 8 to 47 min]), for antibiotic orders (HUP, 56 min [95% CI = 38 to 95 min]; Presbyterian, 67 min [95% CI = 33 to 103 min]), and for antibiotic administration (HUP, 28 min [95% CI = 17 to 39 min]; Presbyterian, 30 min [95% CI = 21 to 38 min]). Patients with lower severity scores (p = 0.005) and patients with nonclassic clinical presentations for pneumonia were at increased risk for delayed antibiotics (odds ratio, 2.2; 95% CI = 1.1 to 4.4). CONCLUSIONS: Antibiotic delays for patients admitted with pneumonia occur across multiple care processes. Less severely ill patients and patients with nonclassic presentations are at higher risk for delayed antibiotic administration. Hospitals should consider performing a similar analysis to evaluate hospital-specific and patient-specific care delays.

Publication Type: Journal Article.

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Unique Identifier [PMID]: 16766743

Authors: Pines JM. Hollander JE. Localio AR. Metlay JP.

Institution: Department of Emergency Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA. pinesjes@uphs.upenn.edu

Title: The association between emergency department crowding and hospital performance on antibiotic timing for pneumonia and percutaneous intervention for myocardial infarction.

Source: Academic Emergency Medicine. 13(8):873-8, 2006 Aug.

Abstract: BACKGROUND: Antibiotics within four hours of arrival for patients with pneumonia and percutaneous intervention (PCI) within two hours for patients with acute myocardial infarction (AMI) are standard measures of emergency department (ED) quality. OBJECTIVES: To assess the institutional-level association between measures of ED crowding and process measures for pneumonia and AMI. METHODS: The authors used summary data from 24 academic hospitals in the University Health Consortium. Analysis included the 2004 ED cycle time survey and performance data from January to December 2004 regarding the Joint Commission for Accreditation of Healthcare Organizations' PN-5b (initial antibiotic administration within four hours) for pneumonia and AMI-8a (PCI received within 120 minutes). Spearman correlation coefficients were used to determine associations between crowding and performance measures. RESULTS: Across all institutions, 59% (range 43%-77%) of pneumonia patients received antibiotics within four hours, and 57% (range 22%-95%) of AMI patients received PCI within two hours. An increase in overall ED length of stay (-0.44, p = 0.04) and for admitted patients (-0.37, p = 0.08) was associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. An increase in chest x-ray turnaround time (-0.83, p < 0.001) and an increase in the left-without-being-seen rate (-0.51, p = 0.01) were also associated with a decrease in the proportion of pneumonia patients receiving antibiotics within four hours. No measures of crowding exhibited an association with time to PCI for AMI patients. CONCLUSIONS: Administrative measures of ED crowding showed an association with poorer performance on pneumonia quality of care measures but not with AMI quality of care measures. Hospitals might consider improving ED throughput, reducing boarding times for admitted patients, and reducing chest x-ray turnaround times to improve pneumonia care.

Publication Type: Comparative Study. Journal Article.

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Unique Identifier [PMID]: 16840377

Authors: Metersky ML. Sweeney TA. Getzow MB. Siddiqui F. Nsa W. Bratzler DW.

Institution: Division of Pulmonary and Critical Care, University of Connecticut School of Medicine, Farmington, CT, USA. Metersky@nso.uchc.edu

Title: Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?[see comment].

Source: Chest. 130(1):16-21, 2006 Jul.

Abstract: BACKGROUND: Many organizations, including the Centers for Medicare & Medicaid Services, measure the percentage of patients hospitalized with pneumonia who receive antibiotics within 4 h of presentation. Because the diagnosis of pneumonia can be delayed in patients with an atypical presentation, there are concerns that attempts to achieve a performance target of 100% may encourage inappropriate antibiotic usage and the diversion of limited resources from seriously ill patients. This study was performed to determine how frequently Medicare patients with a hospital discharge diagnosis of pneumonia present in a manner that could potentially lead to diagnostic uncertainty and a resulting appropriate delay in antibiotic administration. METHODS: Randomly selected charts of hospitalized Medicare patients who have received diagnoses of pneumonia were reviewed independently by three reviewers to determine whether there was a potential reason for a delay of antibiotic administration other than quality of care. Antibiotic administration timing, patient demographic, and clinical characteristics were also abstracted. RESULTS: Nineteen of 86 patients (22%; 95% confidence interval, 13.7 to 32.2) presented in a manner that had the potential to result in delayed antibiotic treatment due to diagnostic uncertainty. Diagnostic uncertainty was significantly associated with the lack of rales, normal pulse oximetry findings, and lack of an infiltrate seen on the chest radiograph. There was a nonsignificant trend toward a longer time until antibiotic treatment in patients with diagnostic uncertainty. CONCLUSIONS: Many Medicare patients in whom pneumonia has been diagnosed present in an atypical manner. Delivering antibiotic treatment within 4 h for all patients would necessitate the treatment of many patients before a firm diagnosis can be made.

Publication Type: Journal Article. Research Support, U.S. Gov't, Non-P.H.S..

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Unique Identifier [PMID]: 16840376

Authors: Waterer GW. Kessler LA. Wunderink RG.

Institution: University of Western Australia, School of Medicine and Pharmacology, 4th Floor MRF Building, Royal Perth Hospital, GPO Box X2213, Perth, WA, Australia 6847. waterer@cyllene.uwa.edu.au

Title: Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.[see comment].

Source: Chest. 130(1):11-5, 2006 Jul.

Abstract: OBJECTIVES: The time to the first antibiotic dose (TFAD) has been adopted as a measure of quality of care in patients with community-acquired pneumonia (CAP) based on two retrospective studies of large Medicare databases. The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to understand given the historical data regarding how long it takes for antibiotics to influence outcome. We investigated the factors that predict a prolonged TFAD and their association with mortality. DESIGN: Prospective cohort study. SETTING: A large tertiary hospital. PATIENTS: Immunocompetent adults admitted to the hospital with CAP. RESULTS: A total of 451 patients with CAP were studied. A TFAD of > 4 h was associated with increased mortality (p = 0.017). Altered mental state (p = 0.001), absence of fever (p = 0.02), absence of hypoxia (p = 0.025), and increasing age (p = 0.038) were significant predictors of a TFAD of > 4 h. After adjusting for these factors, the association between TFAD and mortality was not statistically significant (p = 0.131). Similar findings were observed in patients who were > or = 65 years. CONCLUSIONS: A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis. TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome. Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 16840371

Authors: Houck PM.

Title: Antibiotics and pneumonia: is timing everything or just a cause of more problems?[comment].

Source: Chest. 130(1):1-3, 2006 Jul.

Publication Type: Comment. Editorial.

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Unique Identifier [PMID]: 16490912

Authors: Lindenauer PK. Behal R. Murray CK. Nsa W. Houck PM. Bratzler DW.

Institution: Division of Healthcare Quality, Baystate Medical Center, Springfield, Massachusetts 01199, USA. Peter.Lindenauer@bhs.org

Title: Volume, quality of care, and outcome in pneumonia.

Source: Annals of Internal Medicine. 144(4):262-9, 2006 Feb 21.

Abstract: BACKGROUND: The establishment of minimum volume thresholds has been proposed as a means of improving outcomes for patients with various medical and surgical conditions. OBJECTIVE: To determine whether volume is associated with either quality of care or outcome in the treatment of pneumonia. DESIGN: Retrospective cohort study. SETTING: 3243 hospitals participating in the National Pneumonia Quality Improvement Project in 1998 and 1999. PATIENTS: 13,480 patients with pneumonia cared for by 9741 physicians. MEASUREMENTS: The association between the annual pneumonia caseload of physicians and hospitals and adherence to quality-of-care measures and severity-adjusted in-hospital and 30-day mortality rates. RESULTS: Physician volume was unrelated to the timeliness of administration of antibiotics and the obtainment of blood cultures; however, physicians in the highest-volume quartile had lower rates of screening for and administration of influenza (21%, 19%, 20%, and 12% for quartiles 1 through 4, respectively; P < 0.01) and pneumococcal (16%, 13%, 13%, and 9% for quartiles 1 through 4, respectively; P < 0.01) vaccines. Among hospitals, the percentage of patients who received antibiotics within 4 hours of hospital arrival was inversely related to pneumonia volume (72%, 64%, 60%, and 56% for quartiles 1 through 4, respectively; P < 0.01), while selection of antibiotic, obtainment of blood cultures, and rates of immunization were similar. Physician volume was not associated with in-hospital or 30-day mortality rates. Odds ratios for in-hospital mortality rates rose with increasing hospital volume (1.14 [95% CI, 0.87 to 1.49], 1.34 [CI, 1.03 to 1.75], and 1.32 [CI, 0.97 to 1.80] for quartiles 2 to 4, respectively); however, odds ratios for 30-day mortality rates were similar. LIMITATIONS: This study was limited to Medicare beneficiaries 65 years of age and older. Ascertainment of some measures of the quality of care and severity of illness depended on the documentation practices of the physician. CONCLUSION: Among both physicians and hospitals, higher pneumonia volume is associated with reduced adherence to selected guideline recommendations and no measurable improvement in patient outcomes.

Publication Type: Journal Article. Research Support, U.S. Gov't, Non-P.H.S.. Research Support, U.S. Gov't, P.H.S..

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Unique Identifier [PMID]: 15832463

Authors: Golub JE. Bur S. Cronin WA. Gange S. Sterling TR. Oden B. Baruch N. Comstock GW. Chaisson RE.

Institution: School of Medicine, Johns Hopkins University, Baltimore, Maryland 21231, USA. jgolub@jhmi.edu

Title: Impact of empiric antibiotics and chest radiograph on delays in the diagnosis of tuberculosis.[see comment].

Source: International Journal of Tuberculosis & Lung Disease. 9(4):392-7, 2005 Apr.

Abstract: SETTING: Maryland Department of Health and Mental Hygiene, Division of Tuberculosis (TB) Control. OBJECTIVES: To assess the implications of antibiotic treatment of presumed community-acquired pneumonia (CAP) on delays in the diagnosis of TB, and to assess the frequency with which chest radiographs (CXRs) were utilized before a diagnosis of pneumonia or pulmonary TB was made. DESIGN: A nested case-control study within a prospective study conducted to assess factors associated with delays in the diagnosis of TB. RESULTS: Cases (n = 85; 54%) were patients who received antibiotics for non-TB diagnoses/indications prior to TB diagnosis, and controls (n = 73; 46%) were patients who had initially received TB therapy. Median health care delay for cases was 39 days vs. 15 days (P < 0.01) for controls. Median antibiotic delay was similar among all antibiotic classes. Of 54 patients who did not have a CXR at their first health care visit, 41 (79%) received empiric antibiotics, compared to 44/105 (42%) who had a CXR (P < 0.01). Only 31/54 (57%) patients initially diagnosed with CAP had a CXR at the time of diagnosis. CONCLUSION: More widespread use of CXR when diagnosing CAP should reduce delays in diagnosing TB, and the unnecessary use of antibiotics.

Publication Type: Comparative Study. Journal Article. Research Support, N.I.H., Extramural. Research Support, U.S. Gov't, P.H.S..

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Unique Identifier [PMID]: 15037492

Authors: Houck PM. Bratzler DW. Nsa W. Ma A. Bartlett JG.

Institution: Centers for Medicare & Medicaid Services, Seattle, WA 98121, USA. phouck@cms.hhs.gov

Title: Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia.

Source: Archives of Internal Medicine. 164(6):637-44, 2004 Mar 22.

Abstract: BACKGROUND: Pneumonia accounts for more than 600 000 Medicare hospitalizations yearly. Guidelines have recommended antibiotic treatment within 8 hours of arrival at the hospital. METHODS: We performed a retrospective study using medical records from a national random sample of 18 209 Medicare patients older than 65 years who were hospitalized with community-acquired pneumonia from July 1998 through March 1999. Outcomes were severity-adjusted mortality, readmission within 30 days of discharge, and length of stay (LOS). RESULTS: Among 13 771 (75.6%) patients who had not received outpatient antibiotic agents, antibiotic administration within 4 hours of arrival at the hospital was associated with reduced in-hospital mortality (6.8% vs 7.4%; adjusted odds ratio [AOR], 0.85; 95% confidence interval [CI], 0.74-0.98), mortality within 30 days of admission (11.6% vs 12.7%; AOR, 0.85; 95% CI, 0.76-0.95), and LOS exceeding the 5-day median (42.1% vs 45.1%; AOR, 0.90; 95% CI, 0.83-0.96). Mean LOS was 0.4 days shorter with antibiotic administration within 4 hours than with later administration. Timing was not associated with readmission. Antibiotic administration within 4 hours of arrival was documented for 60.9% of all patients and for more than 50% of patients regardless of hospital characteristics. CONCLUSIONS: Antibiotic administration within 4 hours of arrival was associated with decreased mortality and LOS among a random sample of older inpatients with community-acquired pneumonia who had not received antibiotics as outpatients. Administration within 4 hours can prevent deaths in the Medicare population, offers cost savings for hospitals, and is feasible for most inpatients.

Publication Type: Journal Article. Research Support, U.S. Gov't, P.H.S..

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Unique Identifier [PMID]: 14605051

Authors: Silber SH. Garrett C. Singh R. Sweeney A. Rosenberg C. Parachiv D. Okafo T.

Institution: Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA. sts9005@nyp.org

Title: Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia.[see comment].

Source: Chest. 124(5):1798-804, 2003 Nov.

Abstract: STUDY OBJECTIVE: To determine if there is a statistically significant difference in the time to clinical stability (TCS) between those patients with moderate-to-severe (MTS) community-acquired pneumonia (CAP) who received their antibiotics within 4 h and those who received their antibiotics after 4 h. DESIGN: Prospective observational study. SETTING: A large metropolitan teaching institution with 62,000 annual emergency department visits from May 1999 through January 2001. PATIENTS: Patients were > or = 21 year with MTS CAP as defined by the Pneumonia Patient Outcomes Research Team (PORT). INTERVENTIONS: Triage-to-needle time (group 1, 0 to 240 min; group 2, 241 to 480 min; and group 3, > 480 min) was the independent variable, and TCS was the dependent variable. Our hypothesis was that door-to-needle time < 4 h would result in TCS reduction of 0.5 days. MEASUREMENTS: Statistical analysis was performed using the two-tailed Student t test, analysis of variance, and multiple linear regression; p < 0.05 was considered significant. RESULTS: Four hundred nine patients with MTS CAP achieved clinical stability during their hospital stay. Fifty-four percent of patients received antibiotics within 4 h. The mean time to receiving antibiotics was 131.46 min (2.19 h) in group 1, 335.52 min (5.59 h) in group 2, and 783.98 min (13.07 h) in group 3. Mean TCS was 3.19 days in group 1, 3.16 days in group 2, and 3.29 days in group 3. There were no statistically significant differences in TCS between the study groups. CONCLUSION: The administration of antibiotics within 4 h does not reduce the TCS in adult patients with MTS-CAP, as defined by the PORT group. Future studies using other physiologic parameters should be explored.

Publication Type: Clinical Trial. Controlled Clinical Trial. Journal Article.

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Unique Identifier [PMID]: 16840376

Authors: Waterer GW. Kessler LA. Wunderink RG.

Institution: University of Western Australia, School of Medicine and Pharmacology, 4th Floor MRF Building, Royal Perth Hospital, GPO Box X2213, Perth, WA, Australia 6847. waterer@cyllene.uwa.edu.au

Title: Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.[see comment].

Source: Chest. 130(1):11-5, 2006 Jul.

Abstract: OBJECTIVES: The time to the first antibiotic dose (TFAD) has been adopted as a measure of quality of care in patients with community-acquired pneumonia (CAP) based on two retrospective studies of large Medicare databases. The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to understand given the historical data regarding how long it takes for antibiotics to influence outcome. We investigated the factors that predict a prolonged TFAD and their association with mortality. DESIGN: Prospective cohort study. SETTING: A large tertiary hospital. PATIENTS: Immunocompetent adults admitted to the hospital with CAP. RESULTS: A total of 451 patients with CAP were studied. A TFAD of > 4 h was associated with increased mortality (p = 0.017). Altered mental state (p = 0.001), absence of fever (p = 0.02), absence of hypoxia (p = 0.025), and increasing age (p = 0.038) were significant predictors of a TFAD of > 4 h. After adjusting for these factors, the association between TFAD and mortality was not statistically significant (p = 0.131). Similar findings were observed in patients who were > or = 65 years. CONCLUSIONS: A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis. TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome. Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.

Publication Type: Journal Article. Research Support, Non-U.S. Gov't.

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Unique Identifier [PMID]: 9403422

Authors: Meehan TP. Fine MJ. Krumholz HM. Scinto JD. Galusha DH. Mockalis JT. Weber GF. Petrillo MK. Houck PM. Fine JM.

Institution: Connecticut Peer Review Organization, Middletown, USA. ctpro.tmeehan@sdps.org

Title: Quality of care, process, and outcomes in elderly patients with pneumonia.[see comment].

Source: JAMA. 278(23):2080-4, 1997 Dec 17.

Abstract: CONTEXT: Pneumonia is a frequent cause of hospitalization and death among elderly patients, but the relationships between processes of care for pneumonia and outcomes are uncertain, making quality improvement a challenge. OBJECTIVES: To assess quality of care for Medicare patients hospitalized with pneumonia and to determine whether process of care performance is associated with lower 30-day mortality. DESIGN: Multicenter retrospective cohort study with medical record review. SETTING: A total of 3555 acute care hospitals throughout the United States. PATIENTS: A total of 14069 patients at least 65 years old hospitalized with pneumonia. MAIN OUTCOME MEASURES: Four processes of care: time from hospital arrival to initial antibiotic administration; blood culture collection before initial hospital antibiotics; blood culture collection within 24 hours of hospital arrival; and oxygenation assessment within 24 hours of hospital arrival. Associations between processes of care and 30-day mortality were determined with logistic regression analysis. RESULTS: National estimates of process-of-care performance were antibiotic administration within 8 hours of hospital arrival, 75.5% (95% confidence interval [CI], 73.1-77.9); blood cultures before antibiotics, 57.3% (95% CI, 54.5-60.1); initial blood culture collection, 68.7% (95% CI, 66.2-71.2); and initial oxygenation assessment, 89.3% (95% CI, 87.5-90.9). Lower 30-day mortality was associated with antibiotic administration within 8 hours of hospital arrival (odds ratio [OR], 0.85; 95% CI, 0.75-0.96) and blood culture collection within 24 hours of arrival (OR, 0.90; 95% CI, 0.81-1.00). State and territory performance estimates varied from 49.0% to 89.7% for antibiotics given within 8 hours and from 45.6% to 82.6% for blood cultures drawn within 24 hours. CONCLUSIONS: Administering antibiotics within 8 hours of hospital arrival and collecting blood cultures within 24 hours were associated with improved survival. The fact that states varied widely in the performance of these measures suggests that opportunities exist to improve hospital care of elderly patients with pneumonia.

Publication Type: Journal Article. Multicenter Study. Research Support, U.S. Gov't, P.H.S..