Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics - Side effects of the 4-h antibiotic administration rule
Misdiagnosis of community-acquired pneumonia and inappropriate utilization of antibiotics - Side effects of the 4-h antibiotic administration rule
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DOI：
10.1378/chest.07-0164
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发表时间：
2007-06-01
期刊：
影响因子：
9.6
通讯作者：
Fakih, Mohamad G.
中科院分区：
文献类型：
--
作者：
Kanwar, Manreet;Brar, Navkiranjot;Fakih, Mohamad G.
背景资料：2003年美国传染病学会社区获得性肺炎（CAP）指南建议在住院后4小时内开始抗生素治疗。这一质量指标已与第三方支付者对医院的激励性补偿挂钩。我们评估了这一建议对CAP的诊断和抗生素的利用率的影响。方法：所有患者入院诊断CAP前出版的指南（2003年1月至6月）和出版后的指南2005年1月至6月）。我们收集了临床体征和症状的介绍，胸片结果，血培养前抗生素治疗，抗生素管理时间，肺炎严重程度指数（PSI）评分，混乱，尿素，呼吸频率，血压，年龄2：65岁（CURB-65），和mortality.Results：共518例患者被纳入研究。与2003年相比，2005年有更多的患者入院诊断为CAP，而无放射学异常（2005年，91例患者[28.5%]; 2003年，41例患者[20.6%]; p = 0.04），更多患者在分诊后4小时内接受抗生素治疗（2005年，210例患者[65.8%]; 2003年，107例患者[53.8%]; p = 0.007）。抗生素给药前血培养增加（2005年，220例患者[69.6%]; 2003年，93例患者[46.7%]; p < 0.001）。CAP的最终诊断率从2003年的75.9%下降到2005年的58.9%（p < 0.001）。2005年每位患者的平均（+/- SD）抗生素使用率从2003年的1.39 +/- 0.58增加到1.66 +/- 0.54（p < 0.001）。PSI或CURB-65评分，或mortality.Conclusions：链接抗生素管理4小时内入院（作为一个质量指标），以经济补偿可能会导致CAP的诊断不准确，抗生素的不适当利用，从而低于最佳护理。
Background: The 2003 Infectious Diseases Society of America guidelines for community-acquired pneumonia (CAP) recommend the initiation of antibiotic therapy within 4 h of hospitalization. This quality indicator has been linked to the incentive compensation of third-party payers to hospitals. We evaluated the impact of this recommendation on the diagnosis of CAP and the utilization of antibiotics.Methods: All patients with a hospital admission diagnosis of CAP before publication of the guidelines (January to June 2003) and after publication of the guidelines January-June 2005) were included. We collected data on clinical signs and symptoms on presentation, chest radiograph findings, blood cultures prior to therapy with antibiotics, time to antibiotic administration, pneumonia severity index (PSI) score, confusion, urea, respiratory rate, BP, and age 2: 65 years (CURB-65), and mortality.Results: A total of 518 patients were included in the study. More patients in 2005 had a hospital admission diagnosis of CAP without radiographic abnormalities compared to 2003 (2005, 91 patients [28.5%]; 2003, 41 patients [20.6%]; p = 0.04), and more patients received antibiotics within 4 h of triage (2005, 210 patients [65.8%]; 2003, 107 patients [53.8%]; p = 0.007). Blood cultures prior to antibiotic administration increased (2005, 220 patients [69.6%]; 2003, 93 patients [46.7%]; p < 0.001). However, the final diagnosis of CAP dropped to 58.9% in 2005 from 75.9% in 2003 (p < 0.001). The mean (+/- SD) antibiotic utilization per patient increased to 1.66 +/- 0.54 in 2005 compared to 1.39 +/- 0.58 in 2003 (p < 0.001). There were no significant differences in PSI or CURB-65 scores, or mortality.Conclusions: Linking antibiotic administration within 4 h of hospital admission (as a quality indicator) to financial compensation may result in an inaccurate diagnosis of CAP, inappropriate utilization of antibiotics, and thus less than optimal care.