Duration of Antibiotics Remains Excessive for Many Hospitalized with Pneumonia

Patients hospitalized with pneumonia often receive excess antibiotic treatment, with detrimental outcomes, according to a new study that examined prescribing practices at 43 hospitals in Michigan.

The retrospective cohort study, published in Annals of Internal Medicine, determined excess days of antibiotic treatment by comparing actual treatment with the shortest expected effective treatment based on time to clinical stability, pathogen, and whether the pneumonia was community-acquired or health care-associated.

“After looking at more than 6000 patients hospitalized with community-onset pneumonia, we found two-thirds received longer antibiotic courses than necessary,” lead author Valerie Vaughn MD, MSc, assistant professor of medicine and hospitalist at Veterans Affairs Ann Arbor Healthcare System and University of Michigan Medical School, told Contagion^®. “These long antibiotic courses were harmful: patients were more likely to have side effects for every extra day of antibiotics they received.”

The vast majority (93.2%) of excess antibiotics were those prescribed at discharge, and these excess antibiotics didn’t improve outcomes including death, readmission, emergency department visit, or Clostridioides difficile infection. Odds of adverse effects increased by 5% for each extra day of antibiotics, and patients may have been more likely to seek additional medical care for associated adverse events.

Most patients with community-acquired pneumonia (86.7%) stabilized quickly and were candidates for 5 days of antibiotic treatment, but fewer than 24.7% received such duration of treatment. More research is needed to further examine the association between antibiotic duration and adverse events.

“We often don’t think about antibiotics as patients are discharged and this showed us that we all really need to stop and think about the length of antibiotic prescriptions as patients leave the hospital,” Vaughn said. “Second, we found that patients were less likely to receive excess therapy if physicians documented the antibiotic duration in the medical record. This is an exciting finding, as it suggests that a simple intervention—improving documentation—may also improve patient care.”

The study, which was primarily funded by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program, is the second study the investigators have published showing the prevalence of antibiotic overuse as patients are discharged. Funding from the Association for Professionals in Infection Control and Epidemiology is supporting an ongoing antibiotic “timeout” study during which pharmacists and physicians pause prior to discharge to discuss appropriate antibiotic prescribing.

“The study is ongoing, but we’ve already seen big improvements—half of the timeouts result in better prescribing,” Vaughn said. “These conversations may be the way forward in the future.”

Vaughn said providers can start making changes now to improve antibiotic stewardship for future generations.

“Most patients with community-onset pneumonia only need 5 days of antibiotics,” she said. “More than that may be harmful. That’s a change we can all start making now to improve patient care.”

Antibiotic resistance is a growing public health concern and overprescribing of antibiotics continues despite efforts to contain it. A recent analysis of European hospitals found that the main cause of resistance to carbapenems was acquisition of the drugs, with hospitals being the key facilitators of transmission of carbapenem-resistant Klebsiella pneumoniae.

Antimicrobial stewardship programs began gaining prominence in 2007, and efforts have continued to evolve. Integrating infection prevention programs with antimicrobial stewardship programs may help optimize these efforts, a recent report suggests.

Developing new treatments is another important effort in the fight against pathogens, The US Food and Drug Administration recently approved lefamulin (Xenleta) for the treatment of community-acquired bacterial pneumonia.