According to results of an observational study published in Annals of Internal Medicine, approximately two-thirds of patients hospitalized with pneumonia received excessive antibiotic treatment. Antibiotics prescribed at discharge accounted for most of this excessive use.
Antibiotic stewardship programs advocate that patients be treated with the shortest effective course of antibiotics. Historically, longer courses of antibiotics were used to manage pneumonia, but more recent data have shown that shorter courses are safe and effective for most patients.
Researchers conducted a retrospective, cohort study to assess predictors and outcomes of excess antibiotic treatment in patients hospitalized with pneumonia. They gathered data from 43 hospitals in the Michigan Hospital Medicine Safety Consortium, which included information on 6,481 patients hospitalized with either community-acquired pneumonia ([CAP] n = 4,747) or health care–associated pneumonia ([HCAP] n = 1,734). All patients were managed on a general care unit (i.e., not the ICU), had at least 4 days of antibiotic treatment, had received antibiotics on day 1 or 2 of hospitalization (to exclude hospital-acquired pneumonia), and were discharged between January 2017 and April 2018.
Patients' median age was 70.2 years, 51.2% were women, and most had severe pneumonia as defined by a pneumonia severity index class IV or V (57.4%). Approximately two-thirds of patients (67.8%) had received antibiotics that exceeded the shortest effective course per recommended guidelines (71.8% of those with CAP and 56.6% of those with HCAP). The median duration of antibiotic use was 8 days overall, with an excess duration of 2 days overall for the entire cohort (i.e., 2 days for CAP and 1 day for HCAP). This led to 2,526 excess days of treatment per 1,000 patients hospitalized with pneumonia. Antibiotics prescribed at the time of discharge was the most common reason for excessive antibiotic treatment among the cohort (i.e., 93.2% of excess days). No difference in outcomes was observed with excess treatment such as death, readmissions, emergency department visits, or Clostridium difficile infection. However, each day of excess treatment led to a 5% increase in the risk of antibiotic-associated adverse events reported by patients after discharge.
The authors noted that their results support an urgent and unmet need for 'discharge stewardship,' or coordinated interventions to improve antibiotic prescribing at the time of discharge. Current data support antibiotic treatment regimens of at least 5 days for those with CAP (longer for those with clinical instability) and 7 days for those with HCAP. However, most patients in this study received longer durations of therapy without added benefits. The authors wrote, “This adds to growing literature that short-course therapy in pneumonia is safe and that longer durations are not just unnecessary but potentially harmful. Therefore, reducing excess treatment durations should be a top priority for antibiotic stewardship nationally." The Infectious Diseases Society of America (IDSA) has not updated practice guidelines on management of CAP since 2007, but a revision currently in progress is expected to address management of HCAP.
In an accompanying editorial titled “shorter is better,” these authors noted that short-course antibiotic regimens remain underused by clinicians. They wrote, “The cumulative evidence indicates that each day of antibiotic therapy beyond the first confers a decreasing additional benefit to clinical cure while increasing the burden of harm in the form of adverse effects, superinfections, and selection of antibiotic resistance.” They advocated that it is time for regulatory agencies, payers, and professional societies to align themselves to help convert practice to shorter courses of antibiotics.
Inform patients with pneumonia that they should receive a short course of antibiotics to manage their infection. Tell them that antibiotics prescribed at the time of discharge should only be enough to complete the course of therapy started in the hospital. Encourage patients to complete antibiotic courses and to report any signs of continuing infection or antibiotic-associated adverse effects (e.g., diarrhea, rash) to their health care provider.
Vaughn VM, et al. Excess antibiotic treatment duration and adverse events in patients hospitalized with pneumonia: a multihospital cohort study. Ann Intern Med. 2019;[Epub ahead of print].
Spellberg B. Et al. Duration of antibiotic therapy: shorter is better. Ann Intern Med. 2019;[Epub ahead of print].
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