1. Home>
2. Specialties>
3. Infectious Diseases>
4. Summary and Comment

Treatment of Pneumonia: Is Timing of Antibiotics a Quality Indicator?

For patients with atypical symptoms, pressure to start therapy for pneumonia within 4 hours after admission could promote inappropriate use of antibiotics.

Several recent studies have shown that delayed administration of appropriate antibiotic therapy for severe infections adversely affects outcome. Current recommendations — for example, those of the U.S. National Pneumonia Project — promote initiation of antibiotics within 4 hours after hospital admission for pneumonia. Recently, this 4-hour time frame has been (ab)used as a marker for quality of care, with payers sometimes instituting "pay-for-performance" programs to ensure compliance. Now, two groups of researchers have analyzed factors associated with delayed initiation of antibiotics for pneumonia.

Waterer and colleagues studied 451 patients hospitalized with community-acquired pneumonia (CAP). The mortality rate was 8% overall and 11% in patients aged 65. Fifty-one percent did not receive antibiotics within 4 hours. On univariate analysis, a >4-hour delay was associated with increased mortality. However, altered mental state (P=0.001), absence of fever (P=0.025), absence of hypoxia (P=0.022), and older age (P=0.038) were significant predictors of delayed antibiotic administration. On multivariate logistic regression analysis of these parameters, altered mental state and absence of fever were significantly associated with mortality, but delayed antibiotic therapy was not. In patients aged 65, the only significant predictor of mortality was altered mental state.

Metersky and colleagues analyzed 86 pneumonia cases in Medicare patients for factors associated with delayed initiation of antibiotics. Experts reviewed the charts and x-rays and agreed that in 19 patients (22%), diagnostic uncertainty could appropriately have precluded antibiotic administration within 4 hours. Absence of rales, normal pulse oximetry findings, and absence of infiltrates on chest radiographs were significantly associated with diagnostic uncertainty. Time to administration of antibiotics was insignificantly longer in these 19 patients than in the 67 patients with no diagnostic uncertainty.

Comment: An editorialist concludes that the 4-hour time frame for initiating antibiotics should be applied only to patients aged 65 with radiographically confirmed pneumonia (i.e., the population from which this performance measure was derived), not to all cases. Unfortunately, neither patients nor doctors are perfect; in patients with atypical symptoms, establishing the diagnosis of pneumonia requires more time and effort. Lowering the target to 75% or 80% of pneumonia patients treated appropriately within 4 hours, or lengthening the time frame (e.g., to 6 hours), would allow for diagnostic uncertainty and minimize inappropriate antibiotic use.

— Thomas Glück, MD

Published in Journal Watch Infectious Diseases August 23, 2006

Citation(s):

Waterer GW et al. Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia. Chest 2006 Jul; 130:11-5.

• Original article (Subscription may be required)
• Medline abstract (Free)

Metersky ML et al. Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: Is it reasonable to expect all patients to receive antibiotics within 4 hours? Chest 2006 Jul; 130:16-21.

• Original article (Subscription may be required)
• Medline abstract (Free)

Houck PM. Antibiotics and pneumonia: Is timing everything or just a cause of more problems? Chest 2006 Jul; 130:1-3.

• Original article (Subscription may be required)
• Medline abstract (Free)