Valerie M. Vaughn, MD, MSc; Scott A. Flanders, MD; Ashley Snyder, MS; Anna Conlon, PhD; Mary A.M. Rogers, PhD, MS; Anurag N. Malani, MD; Elizabeth McLaughlin, MS, RN; Sarah Bloemers, MPH; Arjun Srinivasan, MD; Jerod Nagel, PharmD, BCPS; Scott Kaatz, DO; Danielle Osterholzer, MD; Rama Thyagarajan, MD; Lama Hsaiky, PharmD, BCPS; Vineet Chopra, MD, MSc; Tejal N. Gandhi, MD
Disclaimer: The views expressed in this article are those of the authors and do not necessarily reflect those of the Centers for Disease Control and Prevention or the position or policy of the Department of Veterans Affairs.
Financial Support: Support for the Michigan Hospital Medicine Safety Consortium is provided by Blue Cross Blue Shield of Michigan (BCBSM) and Blue Care Network as part of the BCBSM Value Partnerships program.
Disclosures: Dr. Flanders reports personal fees for expert testimony, grants from Blue Cross Blue Shield of Michigan and the Agency for Healthcare Research and Quality, and personal fees from Wiley Publishing outside the submitted work. Dr. Chopra reports grants from Blue Cross Blue Shield of Michigan during the conduct of the study and royalties from Wolters Kluwer Publishing and Oxford University Press, personal fees from universities and medical centers for visiting professorships, and personal fees for serving as an expert witness outside the submitted work. Authors not named here have disclosed no conflicts of interest. Disclosures can also be viewed at www.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum=M18-3640.
Editors' Disclosures: Christine Laine, MD, MPH, Editor in Chief, reports that her spouse has stock options/holdings with Targeted Diagnostics and Therapeutics. Darren B. Taichman, MD, PhD, Executive Editor, reports that he has no financial relationships or interests to disclose. Cynthia D. Mulrow, MD, MSc, Senior Deputy Editor, reports that she has no relationships or interests to disclose. Jaya K. Rao, MD, MHS, Deputy Editor, reports that she has stock holdings/options in Eli Lilly and Pfizer. Catharine B. Stack, PhD, MS, Deputy Editor, Statistics, reports that she has stock holdings in Pfizer, Johnson & Johnson, and Colgate-Palmolive. Christina C. Wee, MD, MPH, Deputy Editor, reports employment with Beth Israel Deaconess Medical Center. Sankey V. Williams, MD, Deputy Editor, reports that he has no financial relationships or interests to disclose. Yu-Xiao Yang, MD, MSCE, Deputy Editor, reports that he has no financial relationships or interest to disclose.
Reproducible Research Statement: Study protocol: Available from Dr. Vaughn (e-mail, firstname.lastname@example.org). Statistical code: Available from Ms. Snyder (e-mail, email@example.com). Data set: Not available.
Corresponding Author: Valerie M. Vaughn, MD, MSc, Assistant Professor of Medicine, Division of Hospital Medicine, Michigan Medicine, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 472C, Ann Arbor, MI 48109-2800; e-mail, firstname.lastname@example.org.
Current Author Addresses: Dr. Vaughn: Assistant Professor of Medicine, Division of Hospital Medicine, Michigan Medicine, North Campus Research Complex, 2800 Plymouth Road, Building 16, Room 472C, Ann Arbor, MI 48109-2800.
Dr. Flanders: Professor of Medicine, Chief Clinical Strategy Officer, University of Michigan, 2800 Plymouth Road, Ann Arbor, MI 48109.
Drs. Flanders, Conlon, Rogers, Chopra, and Gandhi; Ms. Snyder; Ms. McLaughlin; and Ms. Bloemers: Department of Internal Medicine, University of Michigan Medical School, 3110 Taubman Center, SPC 5368, 1500 East Medical Center Drive, Ann Arbor, MI 48109.
Dr. Malani: St. Joseph Mercy Health System, IHA Infectious Diseases Consultants, 5333 McAuley Drive, Suite 6109, Ypsilanti, MI 48197.
Dr. Srinivasan: Division of Healthcare Quality Promotion, Centers for Disease Control and Prevention, 1600 Clifton Road, MS H16-2, Atlanta, GA 30306.
Dr. Nagel: Michigan Medicine, 1111 East Catherine Street, Ann Arbor, MI 48109.
Dr. Kaatz: Henry Ford Hospital, OFP 413, 2799 West Grand Boulevard, Detroit, MI 48202.
Dr. Osterholzer: Hurley Medical Center, 2 Hurley Plaza, Suite 212, Flint, MI 48503.
Dr. Thyagarajan: Beaumont Infectious Disease – Dearborn, 18181 Oakwood Boulevard, Pharmacy Administration – Dearborn, Suite 101, Dearborn, MI 48124.
Dr. Hsaiky: Beaumont Infectious Disease – Dearborn, 18101 Oakwood Boulevard, Pharmacy Administration – Dearborn, Suite 101, Dearborn, MI 48124.
Author Contributions: Conception and design: V.M. Vaughn, S.A. Flanders, A.N. Malani, J. Nagel, L. Hsaiky, V. Chopra, T.N. Gandhi.
Analysis and interpretation of the data: V.M. Vaughn, A. Snyder, A. Conlon, A.N. Malani, J. Nagel, S. Kaatz, V. Chopra, T.N. Gandhi.
Drafting of the article: V.M. Vaughn, A.N. Malani, J. Nagel, V. Chopra.
Critical revision of the article for important intellectual content: V.M. Vaughn, S.A. Flanders, M.A.M. Rogers, A.N. Malani, A. Srinivasan, S. Kaatz, D. Osterholzer, R. Thyagarajan, L. Hsaiky, V. Chopra, T.N. Gandhi.
Final approval of the article: V.M. Vaughn, S.A. Flanders, A. Snyder, A. Conlon, M.A.M. Rogers, A.N. Malani, E. McLaughlin, S. Bloemers, A. Srinivasan, J. Nagel, S. Kaatz, D. Osterholzer, R. Thyagarajan, L. Hsaiky, V. Chopra, T.N. Gandhi.
Statistical expertise: V.M. Vaughn, A. Snyder, A. Conlon, M.A.M. Rogers.
Obtaining of funding: S.A. Flanders, V. Chopra.
Administrative, technical, or logistic support: E. McLaughlin, S. Bloemers, A. Srinivasan, J. Nagel.
Collection and assembly of data: V.M. Vaughn, A. Conlon, E. McLaughlin, V. Chopra, T.N. Gandhi.
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.
Vaughn VM, Flanders SA, Snyder A, et al. Excess Antibiotic Treatment Duration and Adverse Events in Patients Hospitalized With Pneumonia: A Multihospital Cohort Study. Ann Intern Med. 2019;171:153–163. [Epub ahead of print 9 July 2019]. doi: https://doi.org/10.7326/M18-3640
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Published: Ann Intern Med. 2019;171(3):153-163.
Published at www.annals.org on 9 July 2019
High Value Care, Hospital Medicine, Infectious Disease, Pneumonia, Pulmonary/Critical Care.
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Copyright © 2019 American College of Physicians. All Rights Reserved.
Print ISSN: 0003-4819 | Online ISSN: 1539-3704
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