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Time to Antibiotics for Community-Acquired Pneumonia: Errors in Diagnosis

Daas, Hanady MD*; Sanchez, Kathryn MD*; Khatib, Riad MD*; Kanwar, Manreet MD; Brar, Navkiranjot MD; Fakih, Mohamad G. MD, MPH*

Infectious Diseases in Clinical Practice: January 2012 - Volume 20 - Issue 1 - p 58–62
doi: 10.1097/IPC.0b013e31823c4bb1
Original Articles

Background Enforcing the 4-hour rule for time to first antibiotic dose (TFAD) in patients with suspected community-acquired pneumonia (CAP) has been associated with increased antibiotic use and misdiagnosis for CAP in the emergency department (ED). We evaluated the impact of extending the TFAD window to 6 hours.

Methods All patients 21 years and older admitted with CAP diagnosis through the ED during the TFAD of 6-hour rule (January-June 2008) were compared to patients from periods of January to June 2003 (8-hour rule) and January to June 2005 (4-hour rule). Data included clinical characteristics, radiographic findings, severity of illness scores, admitting and final diagnosis concordance, process, and outcome measures.

Results A total of 659 patients were included. The TFAD within 6 hours improved in 2008 compared to the 2 previous periods (90.6% vs 80.4% in 2005 and 81.8% in 2003, P = 0.008). However, the concordance between final and admitting diagnosis of CAP did not improve in 2008 (64.3%) compared to that in 2005 (60.1%) and remained significantly lower than in 2003 (75.5%, P = 0.005). More antibiotics per patient were started in the ED in 2008 and 2005 compared to the period in 2003 (1.81 [0.55] and 1.68 [0.50] vs 1.45 [0.57], P < 0.001, respectively).

Conclusions Extending the process measure of TFAD from 4 to 6 hours was associated with increased compliance with this measure but did not lead to an improvement in reaching the correct diagnosis of CAP. Our data support the current guidelines from the Infectious Diseases Society of America and American Thoracic Society, which recommend prompt antibiotic administration in the ED when the diagnosis is made without mandating a specific period.

From the *Division of Infectious Diseases and †Department of Medicine, St John Hospital and Medical Center, Detroit, MI.

Correspondence to: Mohamad G. Fakih, MD, MPH, Infection Prevention and Control, St John Hospital and Medical Center, 19251 Mack Ave, Suite 190, Grosse Pointe Woods, MI 48236. E-mail:

The authors have no funding or conflicts of interest to disclose.

This study was presented at the 50th Annual Meeting of the Interscience Conference for Antimicrobial Agents and Chemotherapy, Boston, Mass; September 2010.

© 2012 Lippincott Williams & Wilkins, Inc.