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Revised Empiric Treatment IDSA/ATS Guidelines for CAP
By Carol Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases, Santa Clara Valley Medical Center. Dr. Kemper reports no financial relationship relevant to this field of study.
This article originally appeared in the May 2005 issue of Infectious Disease Alert. It was edited by Stan Deresinski, MD, FACP, and peer reviewed by Connie Price, MD. Dr. Deresinski is Clinical Professor of Medicine, Stanford University; Associate Chief of Infectious Diseases, Santa Clara Valley Medical Center, and Dr. Price is Assistant Professor, University of Colorado School of Medicine. Dr. Deresinski serves on the speaker's bureau for Merck, Pharmacia, GlaxoSmithKline, Pfizer, Bayer, and Wyeth, and does research for Merck. Dr. Price reports no financial relationships relevant to this field of study.
Sources: Mandell LA, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44:S27-S72; Pines JM. Measuring antibiotic timing for pneumonia in the emergency department: Another nail in the coffin. Ann Emerg Med. 2007;49:561-563
Since the publication of the initial IDSA Guidelines for the Management of Community-Acquired Pneumonia in 2003, and their implementation by JHACO and the Centers for Medicare and Medicaid Services (CMS) in 2004 as a "quality standard" for hospital care and reimbursement, hospital administrators have been scrambling to improve their numbers. Notably, the 2003 Guideline advocated the administration of appropriate antibiotics within 4 hours of arrival to the emergency department (ED) for patients with possible CAP. For reimbursement, hospitals were required by the Joint Hospital Commission and CMS to attain > 90% compliance with these measures. "Non-compliance" (ie, less than 90% compliance) resulted in a "low score" for the hospital which, to the horror of our hospital administrators, was published on the Internet. This score had no relevance to clinical data or the actual number of patients who received appropriate care. To improve their performance, some ED physicians received financial incentives for speedier diagnosis and treatment, and those physicians that failed to prescribe one of the 4 specified beta-lactams, or perhaps gave an extra antibiotic for poorly documented reasons, were considered "non-compliant."
As a result, some hospitals have moved toward the blanket administration of a specified antibiotic for any individual walking into the ED with possible CAP. Administrators at one of our hospitals altered the computer ordering system so that ED physicians were given one, and only one, choice of initial empiric therapy, ceftriaxone, and azithromycin. One administrator was overheard to say of the ED physicians "I don't want them to think, I just want them to order the antibiotic."
Clinicians and researchers are increasingly concerned about this misguided and potentially dangerous intrusion of government bodies into health care decision-making. Strict adherence to guidelines can have unintended and adverse consequences for patient care, including the inappropriate administration overuse of antibiotics, an increase in health care costs, adverse outcomes and medication reactions, and increased antibacterial resistance. Imagine the consequences for antibacterial resistance if every ED used levofloxacin for every person walking through the ER with cough and fever. In addition, evidence suggests that the all too frequent administration of quinolones has contributed to the rise of MRSA.
The basis for the initial recommendation (that antibiotics be administered within 4 hours) grew from a general impression that patients, especially those that are ill, probably do better the sooner they receive antibiotic therapy. However, there is notably little clinical data to support this impression. Two retrospective studies found an association between the administration of antibiotics within 8 hours of presentation and severity-adjusted outcomes; subsequent analyses found that < 4 hours was associated with a lower mortality. But retrospective data can readily be confounded by other factors, both studies actually found that patients who received antibiotics within 0-2 hours did worse, and the degree of survival benefit was small. Other studies have shown that atypical presentations of pneumonia, which may lack initial radiographic evidence of an infiltrate, resulting in possible delays in treatment, were associated with twice the mortality. But these are the very patients to which the de facto 4-hour rule might fail to apply.
Good guidelines are useful tools, and their appropriate use may result in improved outcomes. A large 5-year clinical trial found that the use of guidelines in the treatment of CAP in 28,700 patients resulted in a 3.2% lower 30-day mortality rate. However, no study has demonstrated that the implementation of a single set of "rules" in the ED has improved outcomes. For this reason, the latest IDSA guideline states "CAP guidelines should address a comprehensive set of elements in the process of care." Deviations from the guidelines are natural, and by the very nature of medicine, should occur 5% to 20% of the time. The 2007 modified recommendations for initial empiric antibacterial treatment include:
Infectious disease and infection control personnel have a responsibility to encourage the thoughtful implementation of the revised 2007 IDSA/ATS guidelines for the majority of patients with CAP, and thwart the use of a simple "one-size fits all" approach to patient care.