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Although the Infectious Diseases Society of America (IDSA) guidelines recommend treating patients with community-acquired pneumonia (CAP) for 5 days (NEJM JW Infect Dis Jun 2007 and Clin Infect Dis 2007; 44:Suppl 2:S27) and those with healthcare-associated pneumonia (HCAP) for 8 days in uncomplicated cases (NEJM JW Infect Dis Apr 2005 and Am J Respir Crit Care Med 2005; 171:388), a large proportion of such patients still receive inappropriately extended therapy. In this study from 30 Veterans Affairs hospitals, researchers retrospectively assessed antibiotic duration in 1739 randomly selected, hospitalized patients with uncomplicated pneumonia. As many as 3 days of antibiotics beyond the recommended minimum number of days for CAP or HCAP was considered to be concordant with guidelines. Complicated pneumonia, hospital-acquired pneumonia, and pneumonia where culture sensitivities were discordant with initial antimicrobial selection were excluded.
Guideline-concordant antibiotic therapy duration was seen in only 7% of CAP patients and in only 29% of HCAP patients. Patients with either guideline-concordant or guideline-excessive duration had similar mortality and similar rates of hospital readmissions and Clostridium difficile infections. Eighty-three percent of guideline-excessive courses were prescribed at hospital discharge.
Madaras-Kelly KJ et al. Total duration of antimicrobial therapy in veterans hospitalized with uncomplicated pneumonia: Results of a national medication utilization evaluation. J Hosp Med 2016 Dec; 11:832. (http://dx.doi.org/10.1002/jhm.2648)
Comment
This study demonstrates clinical practice and systems of care lagging behind study evidence and guideline recommendations. Guidelines offer some flexibility to extend antibiotic duration for pneumonia, and this study also allowed for as many as 3 additional days beyond recommended durations (as many as 8 days for uncomplicated CAP and 11 days for uncomplicated HCAP) even for patients who achieved clinical stability. Nevertheless, practice remains outside the expected maximum range. Because much of the antibiotic excess occurs when patients are sent home on unnecessary additional oral therapy, the discharge transition is the most obvious point for healthcare systems and clinicians to target for reducing unnecessary antibiotic prescribing and achieving guideline-concordant pneumonia care.