Overuse of Antibiotics in Treatment of Community-Acquired Pneumonia Requiring Hospitalization

Community-acquired pneumonia (CAP) continues to be a significant cause of morbidity and mortality with a major impact upon health care costs. It is the third most common cause of death on a global basis and is the eighth most common cause of death in the United States.1,2 The mortality rates among outpatients is usually less than 5%, whereas among those hospitalized for CAP treatment, the rate can range from 12% to 40% depending on the site of care in the hospital (eg, non–intensive care unit vs intensive care unit). The usual pathogens are Streptococcus pneumoniae and atypicals such as Mycoplasma pneumoniae or Legionella species. Viruses have been found in up to one third of patients, but if not the influenza virus, it is not always possible to determine if the virus is the etiologic pathogen, a copathogen, or simply a colonizer. For treatment of hospitalized patients with CAP, additional pathogens including Staphylococcus aureus and gram-negative rods including Pseudomonas aeruginosa must be taken into account depending on risk factors identified with each patient. Evidence-based national guidelines are available to help in the selection of antimicrobials, and adherence to such guidelines results in improved patient outcomes.3,4 Despite advances in the diagnosis and treatment of CAP, there is still debate and questions regarding optimal treatment. For example, issues such as the potential advantages of a macrolide-containing regimen, optimal duration of treatment, and the role of adjuvant measures. A number of studies have shown that prolonged treatment of uncomplicated CAP is not required, and even when treating hospital-acquired pneumonia, therapy does not usually need to exceed 7 days.5–8 Reasonable data also exist to support an early switch from intravenous to oral antimicrobial therapy in patients who have achieved stability.9,10 In the area of adjuvant measures, some studies now support the role of steroids in serious cases of CAP.11,12 A retrospective analysis of all patients 18 years or older with a diagnosis of CAP admitted to 2 hospitals in Pennsylvania was published in this journal.13 The primary objective was to assess the appropriateness of treatment duration with antibiotics for patients with uncomplicated infection. Secondary outcome measures including duration of intravenous antibiotic therapy, inpatient length of stay, and pneumonia-related rehospitalisation within 30 days of discharge were also assessed. Patients with health care–associated pneumonia were excluded. A total of 98 patients were in the final evaluation, and the results showed mean values of 10.0 and 4.9 days for the total duration of treatment and intravenous duration of treatment, respectively. There were 26.5% of patients who were given 7 days or less of treatment and 38.8% more than 10 days; 9.2% of patients were readmitted for pneumonia-related issues. The most commonly isolated pathogen was S. pneumoniae, and the most common treatment regimens were azithromycin and ceftriaxone for inpatients and an oral respiratory fluoroquinolone for outpatients. Given the existing data in the medical literature and the recommendations of national societies, the results presented by Walsh and colleagues are surprising and disconcerting.14 The authors mention that a limitation of the study is the fact that only uncomplicated CAP was studied. In fact, I think this is actually a strength of the study as it emphasizes just how extensive the problem of antibiotic misuse is. Focusing on the uncomplicated cases helps to drive home the fact that their hospitals and likely many others as well use antibiotics inappropriately for treatment of pneumonia. The inappropriate use of antibiotics can be manifested in a number of ways, for example, using drugs with an inadequate spectrum of activity or poor pharmacokinetic/pharmacodynamic properties, or appropriate drugs that are started too late or given for too long a time. In the Walsh paper, the focus is primarily on duration including total length of treatment, number of days of intravenous therapy before conversion to oral therapy, and number of days in hospital. It is well recognized that with prolonged overuse of antibiotics, a number of difficulties can result including an increase in number of adverse drug reactions, incidence of Clostridium difficile diarrhea, antimicrobial resistance, and direct and indirect costs. Prolonged length of stay can result in an increase risk of superinfection. As the authors point out, there are some limitations to the study, and some obvious questions and concerns arise. It is a retrospective analysis and we were not given a sense of the severity of illness as no grading system or predictive rules such as pneumonia severity index or CURB-65 are reported. From the point of view of diagnosis, invasive samples such as broncho alveolar lavage are not even routinely required for hospital-acquired pneumonia/ventilator acquired pneumonia cases, yet here 14% of patients underwent this procedure.8 As far as the antibiotic regimens themselves, azithromycin and ceftriaxone are certainly reasonable but in situations in which an antipseudomonal β-lactam was used, did the patients have known risk factors for this pathogen? In addition, what prompted the use of vancomycin and linezolid in 30.6% of the patients? Given the aggressive nature of diagnostic testing and the prolonged use of antibiotics in many cases, it is surprising that in 4% of patients, azithromycin monotherapy was used. This is generally not a recommended approach for uncomplicated hospitalized CAP. This article is interesting and significant in that it highlights a problem that is very likely more common than we know and has yet to be resolved. The issue of inappropriate antibiotic use in terms of overall length of treatment and duration of intravenous treatment before conversion to oral therapy continues despite significant amounts of data explaining proper use. The key questions are why does this continue and what can be done? The authors have taken an important first step to try to correct this by introducing a bundle initiative, which hopefully will improve the management of patients with CAP admitted to their hospitals.

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