Harvard Pilgrim Health Care Institute, Department of Population Medicine, Harvard Medical School, Boston, Massachusetts.
Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
JAMA Netw Open. 2020 Jul 1;3(7):e2010700. doi: 10.1001/jamanetworkopen.2020.10700.
Antibiotics are frequently prescribed for suspected pneumonia, but overdiagnosis is common and fixed regimens are often used despite randomized trials suggesting it is safe to stop antibiotics once clinical signs are normalizing.
To quantify potential excess antibiotic prescribing by characterizing antibiotic use relative to patients' initial clinical signs and subsequent trajectories.
DESIGN, SETTING, AND PARTICIPANTS: An observational cohort study was conducted in 2 tertiary and 2 community hospitals in Eastern Massachusetts. All nonventilated adult patients admitted between May 1, 2017, and July 1, 2018 (194 521 hospitalizations), were included.
Identification of all antibiotic starts for possible community-acquired pneumonia (CAP) or hospital-acquired pneumonia (HAP) per clinicians' stated indications. Potential excess antibiotic prescribing was quantified by characterizing the frequency of patients in whom all clinical signs were within reference ranges on the first day of antibiotic therapy and by how long antibiotic therapy was continued after all clinical signs were normal, including postdischarge antibiotics.
Among 194 521 hospitalizations, 9540 patients were treated for possible CAP (4574 [48.0%] women; mean [SD] age, 67.6 [17.0] years) and 2733 for possible HAP (1211 [44.3%] women; mean [SD] age, 66.7 [16.2] years). Temperature, respiratory rate, oxygen saturation, and white blood cell count were all within reference ranges on the first day of antibiotics in 1779 of 9540 (18.6%) episodes of CAP and 370 of 2733 (13.5%) episodes of HAP. Antibiotics were continued for 3 days or longer after all clinical signs were normal in 3322 of 9540 (34.8%) episodes of CAP and 1050 of 2733 (38.4%) episodes of HAP. Up to 24 978 of 71 706 (34.8%) antibiotic-days prescribed for possible pneumonia may have been unnecessary.
In this study, almost one-fifth of hospitalized patients treated for pneumonia did not have any of the cardinal signs of pneumonia on the first day of treatment and antibiotics were continued for 3 days or longer after all signs were normal in more than a third of patients. These observations suggest substantial opportunities to improve antibiotic prescribing.
抗生素常被用于治疗疑似肺炎，但过度诊断很常见，尽管随机试验表明，一旦临床症状正常化，停止使用抗生素是安全的，但仍常使用固定疗程。
通过描述抗生素的使用与患者初始临床症状及后续病程的关系，定量评估潜在的抗生素过度使用情况。
设计、环境和参与者：这是一项在马萨诸塞州东部的 3 家三级医院和 2 家社区医院进行的观察性队列研究。纳入 2017 年 5 月 1 日至 2018 年 7 月 1 日期间所有非机械通气的成年住院患者（共 194521 例住院患者）。
根据临床医生的说明，确定所有可能的社区获得性肺炎（CAP）或医院获得性肺炎（HAP）的抗生素起始治疗。通过描述抗生素治疗第一天所有临床症状均在参考范围内的患者比例，以及所有临床症状正常后（包括出院后抗生素）继续使用抗生素的时间，定量评估潜在的抗生素过度使用情况。
在 194521 例住院患者中，9540 例（48.0%为女性；平均[SD]年龄 67.6[17.0]岁）被诊断为可能患有 CAP，2733 例（1211 例为女性；平均[SD]年龄 66.7[16.2]岁）被诊断为可能患有 HAP。在 9540 例 CAP 患者中，1779 例（18.6%）和 2733 例 HAP 患者中 370 例（13.5%）在开始抗生素治疗的第一天，体温、呼吸频率、氧饱和度和白细胞计数均在参考范围内。在 9540 例 CAP 患者中，3322 例（34.8%）和 2733 例 HAP 患者中 1050 例（38.4%）在所有临床症状正常后，抗生素使用时间超过 3 天。在可能患有肺炎的 71706 例抗生素治疗患者中，高达 24978 例（34.8%）的抗生素使用可能是不必要的。
在这项研究中，近五分之一接受肺炎治疗的住院患者在治疗的第一天没有任何肺炎的主要症状，超过三分之一的患者在所有症状正常后抗生素使用时间超过 3 天。这些观察结果表明，有很大的机会可以改善抗生素的使用情况。
