Emergency physicians question antibiotic guidelines for pneumonia

Feb 8 2009

A new study from Wake Forest University Baptist Medical Center that assessed emergency physicians understanding of time-based, antibiotic treatment guidelines for community-acquired pneumonia (CAP) found that more than half believed they prescribed antibiotics needlessly in order to comply with guidelines.

The report, 'The Centers for Medicare and Medicaid Services (CMS) Community-Acquired Pneumonia Core Measures Lead to Unnecessary Antibiotic Administration by Emergency Physicians,' appears in the February issue of Academic Emergency Medicine.

"This is important because there are often a lot of gray areas in these guidelines and the assertion that sufficient evidence exists to merit adoption of some of these measures has been called into question," said Bret A. Nicks, M.D., lead author of the paper.

Nicks, as assistant professor in the Department of Emergency Medicine, said that CAP is one of the most highly contested of the more than 20 core measures issued in 2002 by the Joint Commission, which became reportable in late 2004. This core measure previously included requirements such as the administration of antibiotics to patients deemed to have CAP within four hours of arrival to an emergency department (ED), with blood cultures drawn before administration of such antibiotics. Nicks states pneumonia is an important and relevant focus for core measures reporting, as it accounts for the acute-care hospitalization of more than 600,000 Medicare recipients annually and is associated with a 12 percent mortality rate at 30 days.

The Joint Commission is an independent, not-for-profit organization that is the nation's predominant standards-setting and accrediting body in health care. Its mission is to continuously improve the safety and quality of care provided to the public through the provision of health care accreditation and related services.

In the study, a total of 121 emergency physicians (81 percent) out of 150 from five N.C. academic medical centers completed the anonymous, Web-based survey. All respondents were aware of the CMS CAP guidelines. Of these, 95 percent correctly understood the time-based guidelines for antibiotic administration, although 24 percent incorrectly identified the onset of this time period, according to the study results.

Nearly all physicians (96 percent) reported institutional commitment to meet these core measures, and 84 percent stated that they had a department-based CAP protocol. More than half of the respondents (55 percent) reported prescribing antibiotics to patients they did not believe had pneumonia in an effort to comply with the CMS guidelines, and 42 percent of these stated that they did so more than three times per month.

"We all know prudent use of antibiotics is important, but because of the mandated guidelines there are negative repercussions if they're not followed,' Nicks said. "The research supports what most of us already know - antibiotics may be given when they're not clinically indicated because the guidelines support gross generalizations across a broad patient spectrum. However, it is encouraging to see the most recent revisions from CMS have accounted for many of the concerns delineated in this study."

Co-authors of the study were David E. Manthey, M.D., and Michael T. Fitch, M.D., Ph.D., both of Wake Forest University Baptist Medical Center.