The Unintended, Negative Consequences of the Door-to-Antibiotic Measure for Pneumonia

Potential Financial Conflicts of Interest: None disclosed.

TO THE EDITOR:

I work at a tertiary community geriatric and neurologic hospital specializing in acute, subacute, and rehabilitation care. I fully agree with Wachter and colleagues' critique (1) of the flawed scientific basis of defining a time window for antibiotic administration for CAP in hospitalized patients. In 2006 and 2007, there were 40 428 inpatients with CAP in Lower Saxony (Germany). Forty-four patients were treated at my hospital. Data derived from the quality measurement tool for hospitalized patients with CAP found no association between time to first antibiotic administration and death. Because our patients have had higher CURB-65 (confusion, respiratory rate, blood pressure, and age 65 years or older) scores, were older, more often came from other hospitals or rehabilitation units, were more often bedridden, and were cognitively impaired, we add more data to the growing evidence that questions the sense of shorter door-to-antibiotic time. In a time when some physicians treat guidelines as gospel truth, it seems necessary to cite the most recent U.S. guideline (2): “ … [T]he first antibiotic dose should be administered while still in the ED [emergency department]” is judged only as a “[m]oderate recommendation; level III evidence,” but “[f]or these and other reasons, the committee did not feel that a specific time window for delivery of the first antibiotic dose should be recommended. However, the committee does feel that therapy should be administered as soon as possible after the diagnosis is considered likely.” We hope that randomized, controlled trials will lead us to more reasonable quality measurement tools in future.