University of Michigan Medical School and VA Ann Arbor Health System, Ann Arbor, Michigan (V.M.V., M.A.R., V.C.).
University of Michigan Medical School, Ann Arbor, Michigan (S.A.F., A.S., A.C., E.M., S.B., T.N.G.).
Ann Intern Med. 2019 Aug 6;171(3):153-163. doi: 10.7326/M18-3640. Epub 2019 Jul 9.
Randomized trials demonstrate no benefit from antibiotic treatment exceeding the shortest effective duration.
To examine predictors and outcomes associated with excess duration of antibiotic treatment.
Retrospective cohort study.
43 hospitals in the Michigan Hospital Medicine Safety Consortium.
6481 general care medical patients with pneumonia.
The primary outcome was the rate of excess antibiotic treatment duration (excess days per 30-day period). Excess days were calculated by subtracting each patient's shortest effective (expected) treatment duration (based on time to clinical stability, pathogen, and pneumonia classification [community-acquired vs. health care-associated]) from the actual duration. Negative binomial generalized estimating equations (GEEs) were used to calculate rate ratios to assess predictors of 30-day rates of excess duration. Patient outcomes, assessed at 30 days via the medical record and telephone calls, were evaluated using logit GEEs that adjusted for patient characteristics and probability of treatment.
Two thirds (67.8% [4391 of 6481]) of patients received excess antibiotic therapy. Antibiotics prescribed at discharge accounted for 93.2% of excess duration. Patients who had respiratory cultures or nonculture diagnostic testing, had a longer stay, received a high-risk antibiotic in the prior 90 days, had community-acquired pneumonia, or did not have a total antibiotic treatment duration documented at discharge were more likely to receive excess treatment. Excess treatment was not associated with lower rates of any adverse outcomes, including death, readmission, emergency department visit, or Clostridioides difficile infection. Each excess day of treatment was associated with a 5% increase in the odds of antibiotic-associated adverse events reported by patients after discharge.
Retrospective design; not all patients could be contacted to report 30-day outcomes.
Patients hospitalized with pneumonia often receive excess antibiotic therapy. Excess antibiotic treatment was associated with patient-reported adverse events. Future interventions should focus on whether reducing excess treatment and improving documentation at discharge improves outcomes.
Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.
随机试验表明，抗生素治疗的持续时间超过最短有效时间并无益处。
研究与抗生素治疗时间过长相关的预测因素和结局。
回顾性队列研究。
密歇根医院医学安全联盟的 43 家医院。
6481 例肺炎普通科住院患者。
主要结局是抗生素治疗时间过长（每 30 天期间多余天数）的发生率。多余天数通过从每位患者最短有效（预期）治疗时间（基于临床稳定时间、病原体和肺炎分类[社区获得性与医疗保健相关性]）中减去每位患者的实际治疗时间来计算。采用负二项式广义估计方程（GEE）计算率比，以评估 30 天内治疗时间过长发生率的预测因素。通过病历和电话在 30 天内评估患者结局，并使用对数 GEE 进行调整，以调整患者特征和治疗可能性。
三分之二（67.8%[6481 例中的 4391 例]）的患者接受了抗生素治疗时间过长。出院时开具的抗生素占抗生素治疗时间过长的 93.2%。进行了呼吸道培养或非培养诊断性检查、住院时间较长、在过去 90 天内使用了高风险抗生素、患有社区获得性肺炎或未在出院时记录总抗生素治疗时间的患者更有可能接受过长的治疗。过长的治疗与任何不良结局的发生率较低无关，包括死亡、再入院、急诊就诊或艰难梭菌感染。治疗每增加一天，患者出院后报告的抗生素相关不良事件的几率就会增加 5%。
回顾性设计；并非所有患者都能联系以报告 30 天结局。
患有肺炎的住院患者经常接受抗生素治疗时间过长。过长的抗生素治疗与患者报告的不良事件相关。未来的干预措施应重点关注减少过长的治疗和改善出院时的记录是否能改善结局。
密歇根蓝十字蓝盾协会（BCBSM）和蓝保健网络，作为 BCBSM 价值伙伴计划的一部分。
