Treatment and Outcomes for Patients With Bacteremic Pneumococcal Pneumonia

Abstract

Delayed time to antibiotic administration has been linked with higher mortality for patients with community-acquired pneumonia, but the impact of antibiotic resistance on clinical outcomes has been controversial. In the current study we assess the combined impact of antibiotic resistance and antibiotic timing on outcomes, including inhospital mortality, complications, length of stay, and time to stability, for patients hospitalized with community-acquired bacteremic pneumococcal pneumonia. We conducted a retrospective cohort study in 43 hospitals in the Southeastern Pennsylvania region from 2001 to 2004. Eligible adult patients had pneumococcal bacteremia and radiographic evidence of pneumonia. Outcomes were assessed based on medical record review. Multivariable regression was used to adjust for severity of illness and sequentially assess the impact of antibiotic resistance and time to active antibiotic therapy. The overall inhospital mortality was 10%. Overall, levels of macrolide, cephalosporin, and fluoroquinolone resistance were low and did not adversely impact the time to administration of active antibiotic therapy. Receipt of at least 1 active antibiotic within 4 hours was associated with reduced mortality (odds ratio [OR], 0.47; 95% confidence interval [CI], 0.2-1.0) and shortened length of stay (OR, 0.77; CI, 0.6-1.0) but did not reduce the risk of other adverse outcomes. We conclude that early antibiotic administration reduces the risks of mortality in patients with bacteremic pneumococcal pneumonia. Current patterns of drug resistance did not lead to delays in administration of active antimicrobial therapy.

The impact of an early chest radiograph on outcome in patients hospitalised with community-acquired pneumonia

“…[4][5][6] In recent years controversy has surrounded the prognostic benefit conferred by early antibiotic treatment of CAP on arrival to hospital. A short time to first antibiotic dose (TFA) for patients hospitalised with CAP was initially suggested to decrease mortality 7,8 and later hospital length of stay (LOS), [9][10][11] findings which have since been vigorously disputed. [12][13][14][15][16][17][18] A number of reports have also been published showing an increase in both the CAP misdiagnosis rate and the proportion of patients inappropriately administered antibiotics following the introduction of clinical care pathways advocating a short TFA in all patients with suspected CAP.…”

Community‐Acquired Pneumonia

“…[26] The observational studies found evidence of benefit with early rather than delayed antibiotics in people with severe disease. Categorisation of prompt administration of antibiotics in people admitted to intensive care with community-acquired pneumonia (improved outcomes compared with delayed antibiotic treatment) unchanged (Likely to be beneficial).…”

“…[26] Cohort study Further information on studies [25] The remaining 5 cohort studies included people of varying disease severity, two were retrospective cohorts and three prospective cohorts, and three studies adjusted results for disease severity. One cohort found a significant reduction in mortality with antibiotics before 4 hours compared with after 4 hours, three cohorts found no significant difference between groups in mortality after disease severity adjustment, while one cohort found an increase in mortality with antibiotics before 4 hours.…”

“…Quality point deducted for incomplete reporting of results Very low 0 0 0 -1 2 Prompt versus delayed antibiotic treatment Mortality 3 (988) [25] [26] We initially allocate 4 points to evidence from RCTs, and 2 points to evidence from observational studies. To attain the final GRADE score for a given comparison, points are deducted or added from this initial score based on preset criteria relating to the categories of quality, directness, consistency, and effect size.…”

“…[26] The review (search date 2006) identified retrospective and prospective observational studies reporting on outcomes relating to the timing of antibiotic treatment in people with community-acquired pneumonia. The review included no RCTs.…”