New research from the Centers for Disease Control and Prevention (CDC) indicates that more than two thirds of adult US patients hospitalized for uncomplicated community-acquired pneumonia (CAP) are on antibiotics longer than necessary.
In a study today in Clinical Infectious Diseases, researchers with the CDC's Division of Healthcare Quality Promotion found that the median length of antibiotic therapy (LOT) for more than 150,000 patients hospitalized for CAP in 2012 and 2013 was just under 10 days—nearly 3 days longer than recommended. That excess treatment was driven mainly by outpatient antibiotic therapy, with more than 70% of patients exceeding the recommended duration of antibiotics after being discharged from the hospital. Nearly 60% of the total LOT consisted of outpatient antibiotic therapy.
Guidelines issued in 2007 by the Infectious Diseases Society of America and the American Thoracic Society recommend that patients with uncomplicated CAP should be treated for a minimum of 5 days, with antibiotic durations of more than 7 days "rarely necessary" to achieve clinical stability. While previous studies have shown that the average length of antibiotic therapy for CAP patients in the United States exceeds those recommendations, the authors of the current study say those studies haven't been generalizable to the US population.
Better stewardship at discharge
For the study, the CDC researchers analyzed the medical records of patients hospitalized for CAP in 2012-2013, stratifying the patients into two demographic cohorts: Patients 18 to 64 years with private insurance and those 65 and older with Medicare. Patients include in the study were limited to those who had been hospitalized for 2 to10 days, discharged home with self-care, and not re-hospitalized within 3 days of discharge.
The primary measures of interest were the total LOT—a combination of the inpatient hospital days and outpatient days of treatment—and the proportion of patients who had more than 3 days of outpatient antibiotic therapy following hospital discharge. The determination that more than 3 days of outpatient antibiotics exceeded recommended LOT was based on using hospital discharge as a surrogate for clinical stability.
Inclusion criteria were met for 22,128 patients 18 to 64 years in 2,100 hospitals and 130,746 patients over 65 in 3,227 hospitals. The median total LOT was 9.5 days in the younger cohort and 9.5 days in the over-65 cohort, with 69% and 67% of patients exceeding 7 total days of treatment, respectively. The estimated median inpatient LOT was 3.4 days and 4.3 days, respectively.
When the researchers looked at outpatient treatment, they found that the median outpatient LOT was 6 days for the younger cohort and 5 days for the over-65 cohort, with 71% and 74% of patients exceeding the recommended outpatient LOT of 3 days, respectively. The researchers calculated that the more than 70% of patients receiving excessive antibiotic treatment translated to 71,474 unnecessary days of treatment for the 18-to-64 cohort, and 375,289 of unnecessary days for patients over 65.
The authors of the study say that reducing LOT for hospitalized CAP patients may require addressing antibiotic prescribing at time of discharge.
"These findings suggest prolonged and potentially excessive antibiotic treatment among patients hospitalized with uncomplicated CAP, and stewardship at the time of discharge may be an important target for antibiotic stewardship programs," the authors write.
Nov 6 Clin Infect Dis abstract