Rethink antibiotics before discharging pneumonia patients, researchers say

By Will Boggs MD

NEW YORK (Reuters Health) - 9/7/2019

Patients hospitalized with pneumonia who receive antibiotic treatment longer than recommended durations have increased odds of reporting antibiotic-associated adverse events after discharge, according to a retrospective study.

Antibiotics prescribed at discharge played an important role in the outcomes, researchers found.

"As a result of this study, we've already started making changes at the University of Michigan," Dr. Valerie M. Vaughn from University of Michigan Medical School and VA Ann Arbor Health System, Ann Arbor, told Reuters Health by email. "We now have pharmacists on our hospital medicine service discuss antibiotic duration and treatment with the physicians before patients leave the hospital. As a result, we've already started to see improvement in prescribing. Hopefully, we'll start to see a reduction in antibiotic side effects as well."

Numerous studies have shown that shorter antibiotic therapy is safe and equally effective for most patients with pneumonia and that longer treatment places them at risk for antibiotic-associated adverse events.

Dr. Vaughn and colleagues in the Michigan Hospital Medicine Safety Consortium used data from an ongoing study of medical patients hospitalized with community-acquired pneumonia (CAP) or health care-associated pneumonia (HCAP) to quantify excess antibiotic treatment duration, determine the factors associated with it, and evaluate its relationship with outcomes.

Most of the 6481 patients included in the study (86.7%) were clinically stable or discharged by day 5.

Two thirds of patients received antibiotics for longer than the shortest effective duration consistent with guidelines, including 71.8% of those with CAP and 56.6% of those with HCAP, with a median excess duration of 2 days overall (2 days for CAP and 1 day for HCAP), the authors reported online July 8 in Annals of Internal Medicine.

Antibiotics prescribed at discharge accounted for half of the total days with antibiotic therapy and 93.2% of the excess days.

"We focus so much on improving prescribing during hospitalization, I think a lot of us missed that over-prescribing can happen at hospital discharge," Dr. Vaughn said.

Factors associated with higher rates of excess treatment included having a respiratory culture or a non-culture diagnostic test, a longer hospital stay, high-risk antibiotic use in the prior 90 days, and CAP and not having total treatment duration documented in the discharge summary.

Excess treatment duration was not associated with 30-day mortality, readmission, or emergency department visit, but the odds of a patient-reported adverse event were 5% greater for each excess day of treatment.

"As an inpatient physician, I didn't think about some of the side effects these antibiotics can cause," Dr. Vaughn said. "In our study, we found patients who received longer treatment reported more side effects. These are often the side effects I never see. Patients aren't hospitalized with yeast infections. And, they often don't see their primary care doctors about them either. So, we're probably under-capturing a lot of the harm we're causing. That's made me really stop and double-think when I prescribe antibiotics."

"Rethink the antibiotic prescriptions you're writing at discharge," she said. "Before you discharge a patient on antibiotics, ask first: do they need this antibiotic? If not, stop it. If they need the antibiotic, make sure it's written for the shortest duration necessary. And then document your planned treatment!"

Dr. Brad Spellberg from Los Angeles County-University of Southern California Medical Center, who co-authored an editorial related to this report, told Reuters Health by email, "The importance of the results is that it reaffirms that giving patients antibiotics for more than a week for pneumonia not only doesn't improve cure or mortality, but actually causes harm to patients. Doctors have been grossly over-treating for pneumonia, as for many other types of infections, for many years. These data support the 'Shorter Is Better' movement for antibiotic prescribing."

"We've been talking about short course therapy for well over a decade and most doctors still don't know about it," he said. "We need doctors to learn that more than 45 randomized controlled trials have shown that shorter courses of antibiotics are as effective as longer courses for many types of infections, including pneumonia (both community and nosocomial), skin infections, complicated urinary and abdominal infections, Gram negative bacteremia, septic joints and osteomyelitis, and even neutropenic fever."

SOURCE: http://bit.ly/2XvD3LP

Ann Intern Med 2019;171:153-163.

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