Medline ® Abstracts for References 60-63

of 'Treatment of community-acquired pneumonia in adults who require hospitalization'

60
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Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia.
AU
Silber SH, Garrett C, Singh R, Sweeney A, Rosenberg C, Parachiv D, Okafo T
SO
Chest. 2003;124(5):1798.
 
STUDY OBJECTIVE: To determine if there is a statistically significant difference in the time to clinical stability (TCS) between those patients with moderate-to-severe (MTS) community-acquired pneumonia (CAP) who received their antibiotics within 4 h and those who received their antibiotics after 4 h.
DESIGN: Prospective observational study.
SETTING: A large metropolitan teaching institution with 62,000 annual emergency department visits from May 1999 through January 2001.
PATIENTS: Patients were>or = 21 year with MTS CAP as defined by the Pneumonia Patient Outcomes Research Team (PORT).
INTERVENTIONS: Triage-to-needle time (group 1, 0 to 240 min; group 2, 241 to 480 min; and group 3,>480 min) was the independent variable, and TCS was the dependent variable. Our hypothesis was that door-to-needle time<4 h would result in TCS reduction of 0.5 days.
MEASUREMENTS: Statistical analysis was performed using the two-tailed Student t test, analysis of variance, and multiple linear regression; p<0.05 was considered significant.
RESULTS: Four hundred nine patients with MTS CAP achieved clinical stability during their hospital stay. Fifty-four percent of patients received antibiotics within 4 h. The mean time to receiving antibiotics was 131.46 min (2.19 h) in group 1, 335.52 min (5.59 h) in group 2, and 783.98 min (13.07 h) in group 3. Mean TCS was 3.19 days in group 1, 3.16 days in group 2, and 3.29 days in group 3. There were no statistically significant differences in TCS between the study groups.
CONCLUSION: The administration of antibiotics within 4 h does not reduce the TCS in adult patients with MTS-CAP, as defined by the PORT group. Future studies using other physiologic parameters should be explored.
AD
Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA. sts9005@nyp.org
PMID
61
TI
Delayed administration of antibiotics and atypical presentation in community-acquired pneumonia.
AU
Waterer GW, Kessler LA, Wunderink RG
SO
Chest. 2006;130(1):11.
 
OBJECTIVES: The time to the first antibiotic dose (TFAD) has been adopted as a measure of quality of care in patients with community-acquired pneumonia (CAP) based on two retrospective studies of large Medicare databases. The mechanism by which a difference of a few hours in receiving antibiotics can be deleterious is difficult to understand given the historical data regarding how long it takes for antibiotics to influence outcome. We investigated the factors that predict a prolonged TFAD and their association with mortality.
DESIGN: Prospective cohort study.
SETTING: A large tertiary hospital.
PATIENTS: Immunocompetent adults admitted to the hospital with CAP.
RESULTS: A total of 451 patients with CAP were studied. A TFAD of>4 h was associated with increased mortality (p = 0.017).Altered mental state (p = 0.001), absence of fever (p = 0.02), absence of hypoxia (p = 0.025), and increasing age (p = 0.038) were significant predictors of a TFAD of>4 h. After adjusting for these factors, the association between TFAD and mortality was not statistically significant (p = 0.131). Similar findings were observed in patients who were>or = 65 years.
CONCLUSIONS: A delay in administering antibiotics in patients with CAP is more common in patients who present with an altered mental state or minimal signs of sepsis. TFAD is likely to be a marker of comorbidities driving both an atypical presentation and mortality rather than directly contributing to outcome. Using TFAD as an indicator of quality of care in patients with CAP without significant additional clinical information is potentially misleading as the relationships among TFAD, comorbidities, and outcome are complex.
AD
University of Western Australia, School of Medicine and Pharmacology, 4th Floor MRF Building, Royal Perth Hospital, GPO Box X2213, Perth, WA, Australia 6847. waterer@cyllene.uwa.edu.au
PMID
62
TI
Antibiotic timing and diagnostic uncertainty in Medicare patients with pneumonia: is it reasonable to expect all patients to receive antibiotics within 4 hours?
AU
Metersky ML, Sweeney TA, Getzow MB, Siddiqui F, Nsa W, Bratzler DW
SO
Chest. 2006;130(1):16.
 
BACKGROUND: Many organizations, including the Centers for Medicare&Medicaid Services, measure the percentage of patients hospitalized with pneumonia who receive antibiotics within 4 h of presentation. Because the diagnosis of pneumonia can be delayed in patients with an atypical presentation, there are concerns that attempts to achieve a performance target of 100% may encourage inappropriate antibiotic usage and the diversion of limited resources from seriously ill patients. This study was performed to determine how frequently Medicare patients with a hospital discharge diagnosis of pneumonia present in a manner that could potentially lead to diagnostic uncertainty and a resulting appropriate delay in antibiotic administration.
METHODS: Randomly selected charts of hospitalized Medicare patients who have received diagnoses of pneumonia were reviewed independently by three reviewers to determine whether there was a potential reason for a delay of antibiotic administration other than quality of care. Antibiotic administration timing, patient demographic, and clinical characteristics were also abstracted.
RESULTS: Nineteen of 86 patients (22%; 95% confidence interval, 13.7 to 32.2) presented in a manner that had the potential to result in delayed antibiotic treatment due to diagnostic uncertainty. Diagnostic uncertainty was significantly associated with the lack of rales, normal pulse oximetry findings, and lack of an infiltrate seen on the chest radiograph. There was a nonsignificant trend toward a longer time until antibiotic treatment in patients with diagnostic uncertainty.
CONCLUSIONS: Many Medicare patients in whom pneumonia has been diagnosed present in an atypical manner. Delivering antibiotic treatment within 4 h for all patients would necessitate the treatment of many patients before a firm diagnosis can be made.
AD
Division of Pulmonary and Critical Care, University of Connecticut School of Medicine, Farmington, CT, USA. Metersky@nso.uchc.edu
PMID
63
TI
Antibiotic timing and errors in diagnosing pneumonia.
AU
Welker JA, Huston M, McCue JD
SO
Arch Intern Med. 2008;168(4):351.
 
BACKGROUND: The percentage of patients with community-acquired pneumonia (CAP) whose time to first antibiotic dose (TFAD) is less than 4 hours of presentation to the emergency department (ED) has been made a core quality measure, and public reporting has been instituted. We asked whether these time pressures might also have negative effects on the accuracy of diagnosis of pneumonia.
METHODS: We performed a retrospective review of adult admissions for CAP for 2 periods: group 1, when the core quality measure was a TFAD of less than 8 hours; and group 2, when the TFAD was lowered to less than 4 hours. We examined the accuracy of diagnosis of CAP by ED physicians.
RESULTS: A total of 548 patients diagnosed as having CAP were studied (255 in group 1 and 293 in group 2). At admission, group 2 patients were 39.0% less likely to meet predefined diagnostic criteria for CAP than were group 1 patients (odds ratio, 0.61; 95% confidence interval, 0.42-0.86) (P = .004). At discharge, there was agreement between the ED physician's diagnosis and the predefined criteria for CAP in 62.0% of group 1 and 53.9% of group 2 patients (P = .06) and between the ED physician's admitting diagnosis and that of the discharging physician in 74.5% of group 1 and 66.9% of group 2 patients (P = .05). The mean (SD) TFAD was similar in group 1 (167.0 [118.6]minutes) and group 2 (157.8 [96.3]minutes).
CONCLUSION: Reduction in the required TFAD from 8 to 4 hours seems to reduce the accuracy by which ED physicians diagnose pneumonia, while failing to reduce the actual TFAD achieved for patients.
AD
Department of Medicine, University of Maryland School of Medicine, and Franklin Square Clinical Research Center, Franklin Square Hospital Center, Baltimore, MD 21237, USA. jimwelker@hotmail.com
PMID