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Duration of Symptoms Prior to Antibiotic Use, and Length of Stay in Infected PatientsSymptom Duration Before Antibiotic Use FREE TO VIEW

Andrey Pavlov, MD; Yaw Amoateng-Adjepong, MD, PhD; Ulysses Wu, MD; Constantine A. Manthous, MD, FCCP
Author and Funding Information

From the Department of Internal Medicine (Drs Pavlov and Wu), The Hospital of Central Connecticut; University of Connecticut School of Medicine (Drs Pavlov and Wu); Bridgeport Hospital (Dr Amoateng-Adjepong); Yale University School of Medicine (Dr Amoateng-Adjepong); and Lawrence & Memorial Hospital (Dr Manthous).

CORRESPONDENCE TO: Constantine A. Manthous, MD, FCCP, Lawrence & Memorial Hospital, 365 Montauk Ave, New London, CT 06320; e-mail: constantinemanthous@gmail.com


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2014;146(5):e184-e185. doi:10.1378/chest.14-1684
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To the Editor:

Timing of antibiotics administration indexed at time of hospital admission (Tr) has been shown to correlate with outcomes1-4 and has been used in national quality-outcome measures.5 Tr does not reflect trajectory of illness, since it does not include duration of infectious symptoms prior to presentation. One previous study4 suggests that duration of symptoms prior to antibiotics (Ts) better predicts outcomes in patients with meningitis, but this has not been replicated in other infections.

We hypothesized that Ts better predicts outcomes than Tr in patients presenting to the hospital with acute infections. This institutional review board-exempted study prospectively followed 255 patients at the Hospital of Central Connecticut who were admitted to wards with acute infections.

Mean (± SD) age was 64 years (± 18 years), 42% were male patients, and patients had an average of one comorbid condition. The mean (± SD) length of stay (LOS) was 4.6 days (± 3.8 days). The median (± SD) Ts to first antibiotic dose was 30 h (± 28 h). Eleven patients required transfer from wards to receive care in an ICU. By linear regression, (R2, 0.30), Ts (P = .00001), Simplified Acute Physiology Score (SAPS) II score (P = .0004), age (P = .04), and ICU transfer (P = .000003) were most associated with LOS. Tr was not associated with LOS (P = .58). The odds of LOS being > 7 days were higher for patients with ICU transfer (15.3; 95% CI, 3.6-65.3; P = .0002), Ts > 48 h (4.2; 95% CI, 1.7-10.4; P = .002), and admission SAPS II score > 30 (2.6; 95% CI, 0.98-6.7; P = .05). Transfer to the ICU was most associated with increasing comorbidity count (P = .009). There was no association between ICU transfer and Tr, Ts, or SAPS II score.

When patients were stratified into three risk groups—low (no comorbidities and Ts < 24 h), medium (one comorbidity or more or Ts > 24 h), and high (one comorbidity or more and Ts > 24 h)—mean LOS increased with risk (Table 1). Mean (± SD) LOS for low-risk patients was 2.5 days (± 1.5 days), for medium-risk patients was 4.1 days (± 3.0 days), and for high-risk patients was 5.4 days (± 4.4 days; analysis of variance, P = .02).

Table Graphic Jump Location
TABLE 1 ]  Demographics and Outcomes of Patients

LOS = length of stay; Tr = timing of antibiotics administration indexed at time of hospital admission; Ts = duration of symptoms prior to antibiotics.

Even though Tr is used as a national standard for indexing risk,5 other variables are more likely to predict morbidity in patients presenting with infections. Houck6 adeptly reviewed the available data (in 2006) and pathophysiologic mechanisms whereby early antibiotic administration may impact outcomes. Previously, Ts was associated with outcomes in only patients with meningitis.4 Accordingly, our pilot study extends to more general infections that Ts is associated with outcome measured by hospital LOS. If confirmed, Ts and number of comorbidities, also associated with outcomes, may be helpful, considered with other validated risk-scoring tools (like SAPS), in identifying a cohort of admitted patients who are at greater risk for longer stay.

References

Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA. 1997;278(23):2080-2084. [CrossRef] [PubMed]
 
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med. 2004;164(6):637-644. [CrossRef] [PubMed]
 
Berjohn CM, Fishman NO, Joffe MM, Edelstein PH, Metlay JP. Treatment and outcomes for patients with bacteremic pneumococcal pneumonia. Medicine (Baltimore). 2008;87(3):160-166. [CrossRef] [PubMed]
 
Lepur D, Barsić B. Community-acquired bacterial meningitis in adults: antibiotic timing in disease course and outcome. Infection. 2007;35(4):225-231. [CrossRef] [PubMed]
 
Fiscal year 2009 quality measure reporting for 2010. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/HospitalRHQDAPU200808.pdf. Accessed November 13, 2013.
 
Houck PM. Antibiotics and pneumonia: is timing everything or just a cause of more problems? Chest. 2006;130(1):1-3. [CrossRef] [PubMed]
 

Figures

Tables

Table Graphic Jump Location
TABLE 1 ]  Demographics and Outcomes of Patients

LOS = length of stay; Tr = timing of antibiotics administration indexed at time of hospital admission; Ts = duration of symptoms prior to antibiotics.

References

Meehan TP, Fine MJ, Krumholz HM, et al. Quality of care, process, and outcomes in elderly patients with pneumonia. JAMA. 1997;278(23):2080-2084. [CrossRef] [PubMed]
 
Houck PM, Bratzler DW, Nsa W, Ma A, Bartlett JG. Timing of antibiotic administration and outcomes for Medicare patients hospitalized with community-acquired pneumonia. Arch Intern Med. 2004;164(6):637-644. [CrossRef] [PubMed]
 
Berjohn CM, Fishman NO, Joffe MM, Edelstein PH, Metlay JP. Treatment and outcomes for patients with bacteremic pneumococcal pneumonia. Medicine (Baltimore). 2008;87(3):160-166. [CrossRef] [PubMed]
 
Lepur D, Barsić B. Community-acquired bacterial meningitis in adults: antibiotic timing in disease course and outcome. Infection. 2007;35(4):225-231. [CrossRef] [PubMed]
 
Fiscal year 2009 quality measure reporting for 2010. Centers for Medicare & Medicaid Services website. http://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HospitalQualityInits/Downloads/HospitalRHQDAPU200808.pdf. Accessed November 13, 2013.
 
Houck PM. Antibiotics and pneumonia: is timing everything or just a cause of more problems? Chest. 2006;130(1):1-3. [CrossRef] [PubMed]
 
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