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Medline ® Abstracts for References 77,78,83

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

Time to first antibiotic and mortality in adults hospitalised with community-acquired pneumonia: a matched-propensity analysis.
Daniel P, Rodrigo C, Mckeever TM, Woodhead M, Welham S, Lim WS, British Thoracic Society
Thorax. 2016 Jun;71(6):568-70. Epub 2015 Nov 11.
A matched-propensity analysis of national data from the British Thoracic Society community-acquired pneumonia audit was conducted (n=13 725). Overall, time to first antibiotic (TFA) was≤4 h in 63%. Adjusted 30-day inpatient (IP) mortality was lower for adults with TFA≤4 h compared with TFA>4 h (adjusted OR 0.84, 95% CI 0.74 to 0.94; p=0.003). Increasing TFA was associated with greater OR of 30-day IP mortality (p value for trend=0.001), but no TFA threshold was evident. Although we found an association between TFA and mortality, we cannot say whether this is causal or whether TFA might just be a quality measure for overall or other processes of care.
Department of Respiratory Medicine, Nottingham University Hospitals NHS Trust, Nottingham, UK.
Early administration of antibiotics does not shorten time to clinical stability in patients with moderate-to-severe community-acquired pneumonia.
Silber SH, Garrett C, Singh R, Sweeney A, Rosenberg C, Parachiv D, Okafo T
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.
Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY 11215, USA. sts9005@nyp.org
Time to clinical stability in patients hospitalized with community-acquired pneumonia: implications for practice guidelines.
Halm EA, Fine MJ, Marrie TJ, Coley CM, Kapoor WN, Obrosky DS, Singer DE
JAMA. 1998;279(18):1452.
CONTEXT: Many groups have developed guidelines to shorten hospital length of stay in pneumonia in order to decrease costs, but the length of time until a patient hospitalized with pneumonia becomes clinically stable has not been established.
OBJECTIVE: To describe the time to resolution of abnormalities in vital signs, ability to eat, and mental status in patients with community-acquired pneumonia and assess clinical outcomes after achieving stability.
DESIGN: Prospective, multicenter, observational cohort study.
SETTING: Three university and 1 community teaching hospital in Boston, Mass, Pittsburgh, Pa, and Halifax, Nova Scotia.
PATIENTS: Six hundred eighty-six adults hospitalized with community-acquired pneumonia.
MAIN OUTCOME MEASURES: Time to resolution of vital signs, ability to eat, mental status, hospital length of stay, and admission to an intensive care, coronary care, or telemetry unit.
RESULTS: The median time to stability was 2 days for heart rate (<or =100 beats/min) and systolic blood pressure (>or =90 mm Hg), and 3 days for respiratory rate (<or =24 breaths/min), oxygen saturation (>or =90%), and temperature (<or =37.2 degrees C [99 degrees F]). The median time to overall clinical stability was 3 days for the most lenient definition of stability and 7 days for the most conservative definition. Patients with more severe cases of pneumonia at presentation took longer to reach stability. Once stability was achieved, clinical deterioration requiring intensive care, coronary care, or telemetry monitoring occurred in 1% of cases or fewer. Between 65% to 86% of patients stayed in the hospital more than 1 day after reaching stability, and fewer than 29% to 46% were converted to oral antibiotics within 1 day of stability, depending on the definition of stability.
CONCLUSIONS: Our estimates of time to stability in pneumonia and explicit criteria for defining stability can provide an evidence-based estimate of optimal length of stay, and outline a clinically sensible approach to improving the efficiency of inpatient management.
Department of Health Policy, Mount Sinai School of Medicine, New York, NY 10029, USA. ethanvhalm@smtplink.mssm.edu