65) support this
mandate, but some clinicians believe that it oversimplifies treatment
decisions.
The mandate for early antibiotic administration raises concerns.
A
widely adopted quality-assurance measure calls for hospitals to
administer antibiotics to pneumonia patients within 4 hours of
arrival. Mortality statistics derived from older pneumonia patients
(age,
65) support this
mandate, but some clinicians believe that it oversimplifies treatment
decisions.
Researchers prospectively reviewed treatment outcomes in 451 patients with community-acquired pneumonia who were admitted to a single Tennessee hospital during a 30-month period. Mean age was 58; immunocompromised patients and nonambulatory nursing home residents were excluded. About 50% of patients received antibiotics within 4 hours. Eight percent of patients died. Longer time to antibiotic administration correlated with higher risk for mortality, but, in a multivariate analysis, only altered mental state and absence of fever were significant predictors. The authors suggest that delay in antibiotic administration might simply be a marker for comorbidities that are the true correlates of mortality.
In a retrospective analysis of 86 hospitalized pneumonia patients (mean age, 79), three independent chart reviewers concluded that, in 19 cases (22%), considerable diagnostic uncertainty justified delays in initial treatment to beyond the 4-hour window.
Comment: These studies both suggest that delay in treating pneumonia patients might reflect reasonable diagnostic uncertainty, rather than poor hospital care. An editorialist, one of the leaders in the National Pneumonia Project of the Centers of Medicare and Medicaid Services, disagrees with this assertion and points out that both studies are small in comparison to the vast Medicare database used to create the rule, that a direct correlation with mortality is valid in older patients, and that ongoing reevaluation of standards is part of any quality assurance project.
— Abigail Zuger, MD
Published in Journal Watch August 29, 2006
Citation(s):
Waterer GW et al. Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia. Chest 2006 Jul; 130:11-5.