An analysis today of patients treated for community-onset pneumonia has found that more than two-thirds receive antibiotics for longer than necessary, researchers reported in the Annals of Internal Medicine. More than 90% of the excess antibiotics were prescribed at discharge.
The analysis, conducted by researchers with the University of Michigan, the Centers for Disease Control and Prevention (CDC), and elsewhere, also found that while excess antibiotic treatment was not associated with better outcomes in the patients, it was linked to increased risk of adverse events.
The findings add to a growing body of literature that suggests that community-onset pneumonia is being overtreated by clinicians, that shorter antibiotics courses are just as effective as longer ones, and that longer antibiotic treatment is both unnecessary and potentially harmful. The study's authors say they hope it encourages hospitals to rethink how they're treating pneumonia patients.
"What we're hoping this [study] shows is that it really is not only safe to do short-course therapy, but it's actually better for patients," lead study author Valerie Vaughn, MD, a hospitalist at the University of Michigan's academic medical center, told CIDRAP News.
Results no surprise
For the study, Vaughn and her colleagues looked at the medical records of nearly 6,500 patients who received treatment for community-onset pneumonia at 43 Michigan hospitals and conducted follow-up interviews with 60% of those patients within a month of their hospital stay. The hospitals belong to the Michigan Hospital Medicine Safety Consortium (HMS), a statewide quality initiative that aims to improve care for hospitalized patients at risk of adverse events.
Pneumonia, an illness for which more than a million US patients seek hospital care each year, is a particular focus for HMS. It's the most common reason for antibiotic prescribing in hospitals, and a frequent source of antibiotic overuse.
"If you think about trying to improve care for patients, pneumonia's an important disease," Vaughn said. "If you think about trying to improve antibiotic use, pneumonia's a really important disease."
The current clinical guidelines for community-acquired pneumonia (CAP) and healthcare-associated pneumonia (HCAP) call for antibiotic treatment durations of at least 5 and 7 days, respectively, as along as patients have been without a fever for 48 to 72 hours and are clinically stable. But several studies in recent years have found that antibiotic courses for these two types of community-onset pneumonia tend to last longer. Furthermore, several randomized clinical trials and systematic reviews in the past 5 years have shown that shorter antibiotic courses for community-onset pneumonia are just as effective as longer courses, and may be safer.
"Ten years ago, people thought that if you didn't prescribe long courses of antibiotics, patients would develop resistance, they would have more bad side effects, their infection would come back," Vaughn said. "What we've found is it's kind of the reverse—if you treat people with excess durations, there are more problems. So there's been a change."
But many clinicians, Vaughn noted, remain uncomfortable with short-course durations. That's why the results of the study didn't surprise her.
More than 2 extra days per patient
Among the 6,481 patients included in the analysis, 4,747 (73.2%) had CAP and 1,734 (26.8%) had HCAP (involving either nursing home residence, hospitalization in the previous 90 days, intravenous chemotherapy, home wound care, or long-term hemodialysis). The median age of the patients was 70.2 years, and more than half (57.4%) had a severe case of pneumonia. More than 86% of the patients improved quickly, however, and were discharged from the hospital by day 5.
Still, the analysis found that 67.8% of the patients received antibiotics for longer than the shortest effective duration consistent with guidelines, with 71.8% of CAP and 56.5% of HCAP patients receiving excess treatment. The median antibiotic duration was 8 days overall—8 for CAP and 9 for HCAP. The median excess duration was 2 days overall—2 days for CAP and 1 day for HCAP. There were 2,526 excess days of treatment per 1,000 patients.
"There are certain patients who, if they're still doing poorly, might need longer or more aggressive courses, but the vast majority of patients in our study got better quickly, and really didn't need these longer courses," Vaughn said.
Excess treatment varied at the hospitals, but even at its lowest, more than a third of pneumonia patients at participating hospitals were receiving antibiotics for longer than necessary. In some hospitals, more than 90% of pneumonia patients were being treated for longer than necessary.
Excess prescribing at discharge
Notably, antibiotics prescribed to patients when they were leaving the hospital accounted for 93.2% of the excess duration. The most common durations prescribed for both CAP and HCAP patients upon discharge were 5 and 7 days, even though the vast majority of patients should have received 0 to 2 days' worth of antibiotics, according to guidelines.
What appears to be happening, Vaughn and her colleagues suggest, is that clinicians are "restarting the clock" and not factoring in how many days the patients have already been on antibiotics.
"What you really see is the habits that doctors get into," Vaughn explained. "I think a lot of times, when we're taking care of patients, we discount what's happened in the hospital and that 5-day number…it restarts at discharge."
The most common antibiotics patients were sent home with were fluoroquinolones, which accounted for 39.3% of excess days of treatment. That's a concern given worries that fluoroquinolones promote antibiotic resistance, increase the risk of Clostridoides difficile infection, and have been linked to tendon and aorta ruptures.
Multivariable analysis found that patients who had longer hospital stays, high-risk antibiotic use within the prior 90 days, and respiratory cultures or non-culture diagnostic tests were more likely to receive excess antibiotic treatment.
Longer antibiotic courses were not associated with any improvement in patient outcome, including mortality, readmission, emergency department visit, or C difficile infection. But among the patients who were contacted by telephone, each day of excessive treatment was linked to 5% increase odds of an adverse event. Diarrhea, gastrointestinal distress, and yeast infections were the most commonly reported side effects.
Call for changing guidelines
In an accompanying editorial, Brad Spellberg, MD, of the Los Angeles County-University of Southern California Medical Center and Louis Rice, MD, of Rhode Island Hospital argue that the findings from the study provide further evidence to bolster the "shorter is better" mantra, and that it's time for clinicians—and the wider healthcare system—to adapt.
"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 write. "It is time for regulatory agencies, payers, and professional societies to align themselves with the overwhelming data and assist in converting practice patterns to short-course therapy."
Vaughn and her colleagues suggest that one part of the solution, based on their findings, is an increased focus on discharge stewardship to curtail unnecessary antibiotic use.
One strategy involves pharmacists meeting with prescribers when a patient is discharged to review antibiotic duration and make sure that the total duration is written down on the discharge summary. This forces prescribers to think about how long the patient has already been on antibiotics, so they can calculate how many more days of treatment are truly needed.
They also suggest the next update of clinical guidelines for community-onset pneumonia should explicitly recommend—rather than suggest—that clinicians not prescribe more than the shortest effective duration. The Infectious Diseases Society of America/American Thoracic Society guidelines were last updated in 2007. The next update is expected to be published this fall.
"I definitely hope the guidelines are more prescriptive when they come out," Vaughn said.
See also:
Jul 9 Ann Intern Med study
Jul 9 Ann Intern Med editorial
