While shorter antibiotic duration is safe and effective for general medicine patients admitted with pneumonia, excess treatment is common, especially at discharge, a retrospective cohort study found.
Researchers used data from 43 hospitals in the Michigan Hospital Medicine Safety Consortium to assess the rate of excess antibiotic treatment duration (excess days per 30-day period) in 6,481 adult general medicine patients (median age, 70.2 years; 51.2% women) hospitalized with community-acquired pneumonia (CAP; 73.2% of cohort) or health care–associated pneumonia (HCAP; 26.8% of cohort). Eligible patients had a discharge diagnostic code for pneumonia, symptoms and radiographs consistent with pneumonia, receipt of at least four days of antibiotic treatment, and receipt of antibiotics on hospital day one or two (to exclude hospital-acquired pneumonia). Study participants were discharged between January 2017 and April 2018.
Excess days of antibiotics were calculated by subtracting each patient's shortest effective treatment duration (as was expected based on time to clinical stability, pathogen, and pneumonia classification) from the actual duration. Patients with CAP were expected to have a treatment duration of at least five days (lengthier if time to clinical stability was longer), whereas patients with HCAP, Staphylococcus aureus, or a nonfermenting gram-negative bacillus were expected to have a treatment duration of at least seven days. At 30 days, researchers assessed patient outcomes through medical records and telephone follow-up. Results were published online on July 9 by Annals of Internal Medicine.
Overall, 4,391 (67.8%) patients received excess antibiotic therapy, 71.8% (3,410 of 4,747) of those with CAP and 56.6% (981 of 1,734) of those with HCAP. Antibiotics prescribed at discharge accounted for 93.2% of excess days of therapy. While 99.6% of patients had an expected therapy duration of five or fewer days at discharge, five days was the most common discharge prescription. “This highlights an urgent and unmet need for ‘discharge stewardship,’ or coordinated interventions to improve antibiotic prescribing at discharge,” the study authors wrote.
Patients who were more likely to receive excess treatment included those who had respiratory cultures or nonculture diagnostic testing, had a longer stay, had received a high-risk antibiotic in the prior 90 days, had CAP, or did not have a total antibiotic treatment duration documented at discharge. Excess treatment was not associated with lower rates of adverse outcomes, including death, readmission, or ED visit. Furthermore, each excess day of antibiotic treatment was associated with a 5% increase in the odds of related adverse events reported by patients after discharge, most often diarrhea, gastrointestinal distress, and mucosal candidiasis.
Limitations of the study include its retrospective design and the fact that patient-reported adverse events are subject to recall bias and inaccurate reporting, the study authors noted. “Together, these findings provide evidence that reducing excessive antibiotic treatment durations, especially in patients with CAP via discharge stewardship, is safe and may improve patient care,” they wrote.
The study results add to a considerable body of evidence supporting the antibiotic mantra “shorter is better” for not only pneumonia but also acute exacerbation of chronic bronchitis and sinusitis, complicated urinary and intra-abdominal infections, gram-negative bacteremia, acute bacterial skin infections, osteomyelitis and septic arthritis, and even neutropenic fever, an accompanying editorial noted. More than 45 randomized controlled trials and two meta-analyses have found no difference in efficacy between shorter and traditional courses of antibiotic therapy for these diseases, the editorialists said.
“Change is scary, and medicine is a conservative profession. … Nevertheless, to live up to the expectations that our patients have for us and that we have for one another, we must overcome inertia and tradition and change practice when compelling evidence becomes available,” they wrote.