Study Questions Antibiotic Guideline for Treatment of Pneumonia

Many people arriving at emergency rooms don't have the condition, researchers say

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Study Questions Antibiotic Guideline for Treatment of Pneumonia

By
HealthDay Reporter

FRIDAY, March 9, 2007 (HealthDay News) -- Many patients arriving at U.S. hospital emergency rooms who receive antibiotics based on a federal guideline to treat pneumonia don't need the drugs, a new study contends.

That means the guideline may not be feasible and may be contributing to the growing problem of antibiotic resistance, the study authors said.

The researchers were studying a 2004 guideline that stipulates that emergency-room doctors administer antibiotics within four hours to adult patients displaying symptoms of pneumonia.

The Centers for Medicare and Medicaid Services (CMS) and the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) established the guideline as a core measure of hospital performance. Earlier studies had shown that administering antibiotics within this time window was associated with a small decrease in death rates.

The University HealthSystem Consortium has a goal of achieving 90 percent compliance with the guideline. At the University of California, San Francisco, where the study was done, non-physician staff bonuses are dependent upon this performance.

The study, conducted in 2005, followed a group of 152 emergency room patients who met eligibility criteria for receiving antibiotics. Of this group, 65.1 percent received antibiotics within four hours of arriving at the hospital. The remaining 34.9 percent were identified as "outliers," and more than half (58.5 percent) of the outliers did not have a final diagnosis of pneumonia. And 43 percent of the outliers had an abnormal chest X-ray, compared with 95 percent of those who received antibiotics.

The findings are published in the March issue of Annals of Emergency Medicine.

"It was not possible in many of the cases to actually have given them antibiotics because a lot of them didn't actually have pneumonia or got a diagnosis later," said Dr. Jesse Pines, author of an accompany editorial in the journal, and an attending physician in the department of emergency medicine at the Hospital of the University of Pennsylvania. He supports the study findings.

The authors concluded that it may not be feasible to identify 90 percent of emergency department patients admitted with pneumonia using the current JCAHO/CMS case definitions. Either the goal or the case definitions need to be changed, the researchers said.

Pneumonia is the leading cause of visits to an emergency room, Pines said.

Many experts are critical of the guideline and the studies on which they were based.

"I think it is extremely problematic and controversial when CMS and Joint Commission create national performance standards based on retrospective, clinically non-validated retrospective studies," said Dr. Tareg Bey, professor of emergency medicine and director of international emergency medicine at the University of California, Irvine. "I could easily imagine that this program would increase antibiotic-resistance of pneumonia bacteria just because physicians prescribe antibiotics earlier and more often to meet the goals of the CMS program.

"Performance-based medicine is principally a good thing, but it has to be based on very powerful scientific data," Bey added. "Retrospective studies alone, and not recognizing the complex interdependencies of our extremely stressed health-care delivery system, are not good enough to link a four-hour rule to a performance for payment program."

Pines said the guideline may not even address the main underlying problem, which is emergency-room crowding.

"Because emergency rooms are so crowded, getting a chest X-ray and doing all the things that go into getting a rapid diagnosis of pneumonia is not possible," he said. "What's happening with the performance measure is that patients with suspected pneumonia end up getting antibiotics before they have a diagnosis in order to meet the government-mandated standard."

More information

For advice on when antibiotic use is appropriate, visit the American Academy of Family Physicians.

SOURCES: Jesse M. Pines, M.D., attending physician, department of emergency medicine, Hospital of the University of Pennsylvania, Philadelphia; Tareg Bey, M.D., professor, emergency medicine, and director, International Emergency Medicine, Department of Emergency Medicine, University of California, Irvine; March 2007 Annals of Emergency Medicine

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