Factors Influencing Length of Stay, Time to Resolution of Morbidity, and Cost of Patient Care: A Comparative Retrospective Study of Short-Stay and Long-Stay Patients Hospitalized for Simple Pneumonia (DRG 89 and 90):

Evidence-based emergency medicine/critically appraised topic. Evidence behind the 4-hour rule for initiation of antibiotic therapy in community-acquired pneumonia

STUDY OBJECTIVE

US regulatory authorities mandate delivery of antibiotics within 4 hours of arrival for patients being admitted to the hospital with community-acquired pneumonia. This evidence-based emergency medicine review examines the scientific evidence pertaining to this requirement.

METHODS

We searched MEDLINE, EMBASE, the Cochrane Library, other databases, and bibliographies. We selected articles allowing comparison of inpatient or 30-day mortality among patients receiving early versus delayed antibiotics. We prospectively categorized studies according to whether they were retrospective or prospective and whether they adjusted for severity with the Pneumonia Severity Index. We evaluated the precision with which the interval to initiation of antibiotic therapy was defined and the compliance of retrospective studies with standard reporting criteria for chart reviews.

RESULTS

We identified 13 observational studies reporting comparative outcomes in patients receiving early versus delayed antibiotic initiation, of which 10 allowed calculation of our primary outcome. Of the 4 prospective studies, 1 allowed severity adjustment using the Pneumonia Severity Index score. Among the retrospective studies, definition of time to antibiotic therapy was frequently imprecisely defined, and compliance with standard reporting criteria for chart review was scanty in the subgroup lacking severity adjustment. Odds ratios (ORs) for mortality varied widely. One methodologically weak study reported a large benefit of early antibiotics (OR for mortality antibiotics <4 hours versus >4 hours 0.24; 95% confidence interval [CI] 0.08 to 0.71). The one study that used prospective enrollment and severity adjustment using the Pneumonia Severity Index observed a contrary result (adjusted OR for mortality, antibiotics <4 hours versus >4 hours 1.99; 95% CI 1.22 to 13.45). Results from studies reporting an 8-hour cutoff also varied in magnitude and direction of effect.

CONCLUSION

Evidence from observational studies fails to confirm decreased mortality with early administration of antibiotics in stable patients with community-acquired pneumonia. Although timely administration of antibiotics to patients with confirmed community-acquired pneumonia should be encouraged, an inflated sense of priority of the 4-hour time frame is not justified by the evidence.

Management of community-acquired pneumonia: a focus on conversion from hospital to the ambulatory setting

Patients with community-acquired pneumonia (CAP) are treated in hospital or in the ambulatory care setting depending on the severity of illness. Despite numerous guidelines proposed, there is no agreement on specific criteria for hospitalization other than the clinicians' experience. The purpose of this review is to discuss the importance of the appropriate choice and timely administration of antibacterial agents, either in the hospital or in the outpatient setting. Since a high proportion of CAP patients will not have an etiologic agent identified at the time of initiation of treatment, the choice of antibacterial therapy is usually empiric. Antibacterial agents with activity against pneumococci and atypical pathogens causing pneumonia are the preferred choices. Macrolides, doxycycline, or respiratory fluoroquinolones have been recommended by various guidelines committees in North America for the treatment of pneumonia in patients with or without underlying comorbidities. Because of the increasing resistance to beta-lactams as well other antibacterial agents such as macrolides, doxycycline, and sulfamethoxazole/trimethoprim (cotrimoxazole), it is important that clinicians are aware of local statistics on resistance to Streptococcus pneumoniae, as infection with this bacterium is associated with high rates of morbidity and mortality. More recently, fluoroquinolone resistance has been reported, but the percentage of pneumococcal strains resistant to this agent is relatively low compared with the other antibacterial agents. Switch (intravenous to oral) therapy is recommended for hospitalized patients with CAP to facilitate early discharge, which has been shown to improve patient satisfaction and reduce hospital costs. Early conversion to oral therapy has not been shown to be associated with increased complications or higher mortality. Following prompt intravenous therapy and stabilization, patients with CAP should be treated with oral therapy in the ambulatory setting.