Excess antibiotic duration in patients hospitalized with pneumonia: Amulti-hospital cohort study
Vaughn VM, Flanders S, Chopra V, Conlon A, Malani AN, Srinivasan A, Nagel J, Kaatz S, Osterholzer D, Thyagarajan R, Hsaiky L, and Gandhi T. Excess antibiotic duration in patients hospitalized with pneumonia: Amulti-hospital cohort study. J Gen Intern Med 2018; 33(2):188-189
J Gen Intern Med
Background: Despite national guidelines, patients with pneumonia often receive antibiotics for longer than recommended. Factors that influence excess treatment are unknown. Methods: Retrospective cohort study of patients with pneumonia at 48 hospitals participating in the Michigan Hospital Medicine Safety consortium from December 2015 through July 2017. Adult patients were included if they were admitted to a non-ICU medicine service with pneumonia (diagnosis confirmed by symptoms, antibiotic receipt, and radiographs). Patients who were pregnant or had severe immune-compromise, concomitant infections, or conditions requiring a longer antibiotic course were excluded. Patient data were abstracted from the medical record by trained nurses and appropriate antibiotic duration was calculated for each patient based on national guidelines. Ongoing stewardship activities were assessed via survey to stewardship teams. Factors associated with excess duration antibiotic therapy were evaluated using multivariable logistic generalized estimate equations models, adjusting for hospital clustering. Results: Of 5179 eligible patients, 3776 (72.9%) met inclusion criteria. 68.5% (2586/3776) received an excess duration of antibiotic therapy. Antibiotics prescribed at hospital discharge accounted for 94.3% (9055/9603 additional days) of excess duration. Factors associated with excess duration included: identification of a bacterial pathogen (OR 1.90, 95% CI 1.32, 2.75), more signs of pneumonia (hypoxemia, abnormal temperature, auscultator findings, leukocytosis; OR 1.18, 95% CI 1.06 to 1.31 per additional sign), and uncomplicated pneumonia (vs. complicated pneumonia [OR 0.38, 95% CI 0.28 to 0.50] or healthcare-associated pneumonia [0.44, 95% CI 0.33, 0.57]). Hospitals that incorporated stewardship recommendations into their order-entry systems (89.6%, 43/48) had fewer patients receive excess duration (69.7% vs. 81.4%, P< 0.001). Variation in excess antibiotic duration varied across the 48 hospitals (Figure), with no hospital performing well. Conclusions: Most hospitalized patients with pneumonia received an excess duration of antibiotic treatment. Although incorporating stewardship guidelines into order-entry may be one countermeasure, substantial improvement will require specifically targeting excessive antibiotic prescribing at hospital discharge.