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Giving Antibiotics Within 4 Hours Improves Outcomes in CAP

Patients who received antibiotics within a window of 2-4 hours after hospital arrival had significantly lower mortality rates and shorter lengths of stay than those who received antibiotics later.

Antibiotic administration within 8 hours of hospital arrival is recommended for patients with community-acquired pneumonia (CAP). These authors assessed whether earlier administration improves outcomes. Using the large Medicare database, the authors retrospectively identified nearly 14,000 patients from 3463 hospitals in all 50 states who had been discharged with diagnoses of pneumonia and who had not taken antibiotics before admission.

Antibiotics were administered within 2 hours after arrival (at the emergency department or on the hospital floor) to 26% of patients, within 4 hours to 61%, within 8 hours to 86%, and within 12 hours to 92%. After controlling for patient risk, the authors found that patients who had received antibiotics within 4 hours had significantly reduced mortality rates in the hospital and for 30 days after admission and had shorter lengths of stay compared with patients who had received antibiotics later. These benefits were seen only in patients who had received antibiotics between 2 and 4 hours; patients who had received antibiotic treatment very early (0-2 hours) presumably were sicker and therefore less responsive to treatment. Of interest, antibiotics were given to more than half the eligible patients within 4 hours at 76% of smaller hospitals (fewer than 200 beds) but at only 55% of larger hospitals (more than 500 beds).

Comment: This study is a worthwhile contribution to the "benefit of time-to-treatment" literature. Further study of the database should address two issues of particular interest to emergency physicians -- whether the benefit was derived predominately from patients admitted through the EDs and whether the delay in larger hospitals was confined to teaching hospitals. In any case, the message is pretty clear: A "golden hour" (or golden 4 hours) exists for CAP, analogous to that for trauma, and ED quality programs should address this issue.

— J. Stephen Bohan, MS, MD, FACP, FACEP

Published in Journal Watch Emergency Medicine May 12, 2004

Citation(s):

Houck PM et al. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med 2004 Mar 22; 164:637-44.

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