Affiliations: Baylor College of Medicine, Houston, TX,
St John Hospital and Medical Center, Grosse Pointe Woods, MI
Correspondence to: Poyyapakkam R. Srivaths, MD, Baylor College of Medicine, Department of Pediatrics, 6621 Fannin St, MC 3-2482, Houston, TX 77030; e-mail: firstname.lastname@example.org
We read with interest the recent article in CHEST (June 2007) by Kanwar et al1 about the misdiagnosis of community-acquired pneumonia (CAP) after the implementation of the “4-h antibiotic administrtion rule.” We agree that the topic is of great relevance; however, we have the following comments. Although a retrospective cohort study evaluating different points in time (ie, before and after the implementation of the rule) was appropriate, the fact that it was at a single center makes their observations dependant on singularities of a particular center such as, for example, changes in staffing, equipment, temporary policies other than the 4-h rule. This makes the external validity of the study questionable. Obtaining data from other centers and at different calendar times for comparison would achieve stronger conclusions. Also, the table of results (Table 2 in the article) illustrated only hard outcomes such as mortality and length of hospital stay, which the study was not powered to examine.
Finally, the authors concluded that “compliance with the 4 h-antibiotic-administration rule led to an increase in the misdiagnosis of CAP, and subsequently to greater utilization of inappropriate antibiotics.” Based on their data, we have tabulated the rate of misdiagnosis of CAP in Table 1
. We see a trend toward significant bias. The final diagnosis of pneumonia was based on subjective criteria, and when the authors used more stringent definitions of pneumonia (definitions A and B) the difference between the two groups was no longer significant (p = 0.06 and 0.17, respectively). Along the same line, the mean time to the administration of antibiotics was not significantly different between the groups. Moreover, though the 2005 cohort received a higher proportion of antibiotics, 34.2% of cases including 35.6% with a final diagnosis of CAP did not receive antibiotics within the prescribed 4-h period, so final conclusions based on this could lead to misinterpretations.
The authors have reported to the ACCP that no significant conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.
Values are given as % or mean ± SD, unless otherwise indicated. Misdiagnosis of CAP = No. of patients with a final diagnosis of pneumonia/No. of patients admitted to the hospital with a diagnosis of pneumonia × 100; final diagnosis of pneumonia = diagnosis of pneumonia during hospital stay (as documented in the progress notes) or on hospital discharge (per the hospital discharge summary) by the attending physician, infectious disease specialist, or a pulmonologist; definition A = chest radiograph showing an infiltrate or consolidation, and one or more among shortness of breath, cough, sputum production, and a temperature of > 37.8°C; definition B = an infiltrate seen on a chest radiograph and two or more of the symptoms and signs for definition A.
By Fisher exact test.
By t test.
The authors have no conflicts of interest to disclose.
We appreciate the interest of Srivaths and Corrales-Medina in our study.1Their conclusions are based on the assumption that our final diagnosis was biased.2 We disagree that using hospital discharge diagnosis would lead to a bias. This diagnosis was based on the assessment of the attending and consultant physicians, and none of them were involved in the study.
We agree that we cannot generalize our study to every single hospital; this was not our intent. However, similar concerns about the 4-h rule have led the Infectious Diseases Society of America/American Thoracic Society 2007 guidelines to recommend the administration of antibiotics in the emergency department rather than adhering to a “specific time window period.”3 The guidelines also caution that “improvements in one area may be offset by worsening in a related area.”
The authors misquoted our findings. When looking at all those with the admitting diagnosis of pneumonia, median time to antibiotic was significantly lower for 2005 (187 min) compared to 2003 (230 min). Moreover, 65.8% of patients in 2005 received antibiotics within 4 h compared to 53.8% in 2003 (p = 0.007). However, looking at patients with the final diagnosis of pneumonia, the 4-h rule did not improve the timing of antibiotics. Our results clearly show that the 4-h rule resulted in lowering the threshold for starting antibiotics without a significant benefit in patients who were confirmed to have pneumonia.
We support antibiotic administration promptly when patients are admitted with pneumonia and when adequate evaluation is done so the correct diagnosis is achieved. We believe that the removal of the 4-h rule will improve the accuracy of the admitting diagnosis and decrease unnecessary antibiotic usage.
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