title: Time for first antibiotic dose is not predictive for the early clinical failure of moderate-severe community-acquired pneumonia.
abstract: The time to first antibiotic dose (TFAD) has been mentioned as an important performance indicator in community-acquired pneumonia (CAP). However, the advice to minimise TFAD to 4 hours (4 h) is only based on database studies. We prospectively studied the effect of minimising the TFAD on the early clinical outcome of moderate-severe CAP. On admission, patients' medical data and TFAD were recorded. Early clinical failure was expressed as the proportion of patients with clinical instability, admission to the intensive care unit (ICU) or mortality on day three. Of 166 patients included in the study, 27 patients (29.7%) with TFAD <4 h had early clinical failure compared to 23 patients (37.7%) with TFAD >4 h (odds ratio [OR] 0.69; 95% confidence interval [CI] 0.35-1.35). In multivariate analysis, the pneumonia severity index (OR 1.03; 95%CI 1.01-1.04), confusion (OR 2.63; 95%CI 1.14-6.06), Staphylococcus aureus infection (OR 7.26; 95%CI 1.33-39.69) and multilobar pneumonia (OR 2.40; 95%CI 1.11-5.22) but not TFAD were independently associated with early clinical failure. Clinical parameters on admission other than the TFAD predict early clinical outcome in moderate-severe CAP. In contrast to severe CAP necessitating treatment in the ICU directly, in the case of suspected moderate-severe CAP, there is time to establish a reliable diagnosis of CAP before antibiotics are administered. Therefore, the implementation of the TFAD as a performance indicator is not desirable.
authors.affiliation: Division of Medicine, Department of Internal Medicine and Infectious Diseases, University Medical Center, P.O. Box 85500, 3508 GA, Utrecht, The Netherlands. A.H.W.Bruns@umcutrecht.nl
authors.forename: A H W
authors.initials: AH
authors.lastname: Bruns
authors.forename: J J
authors.initials: JJ
authors.lastname: Oosterheert
authors.forename: W N M
authors.initials: WN
authors.lastname: Hustinx
authors.forename: C A J M
authors.initials: CA
authors.lastname: Gaillard
authors.forename: E
authors.initials: E
authors.lastname: Hak
authors.forename: A I M
authors.initials: AI
authors.lastname: Hoepelman
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000401:mortality / Q000503:physiopathology; D012720:Severity of Illness Index; D013997:Time Factors; D017211:Treatment Failure
chemical_list: D000900:Anti-Bacterial Agents