Antibiotics fail to treat pneumonia 22% of the time – but that may be due to a faulty diagnosis, not an ineffective drug

Pneumonia 3

 

Nearly 1 in 4 patients treated with antibiotics for community-acquired (vs. hospital-acquired) pneumonia required additional antibiotic therapy. Of the 251,947 cases identified, 55,741 patients (22.1%) needed further antibiotic treatment or ended up in the hospital. Failure rates were similar, regardless of the class of antibiotic used.

These were the conclusions of researchers from the LA Biomedical Research Institute at Harbor-UCLA Medical Center in Torrance, California, and presented last weekend at the American Thoracic Society 2017 International Conference, as reported by Medscape Medical News.

The researchers also found that:

(1) Patients older than 65 years were nearly three times more likely to be hospitalized than younger patients.

(2) Treatment for community-acquired pneumonia was more likely to fail if patients had at least one other medical condition.

(3) There were significant regional variations in patient resistance to certain antibiotics; people on the East Coast did better than those on the West Coast. “There might be less antibiotic resistance [on the East Coast as] [d]ifferent antibiotics have resistance in different parts of country,” said James McKinnell, MD, one of the researchers.

“We found it very surprising how frequently treatment fails,” said McKinnell. And, since older patients are more vulnerable they should be treated more carefully, “potentially with more aggressive antibiotic therapy.”

But there’s a problem: What if the failure of the antibiotic had nothing to do with the drug itself but was because the patient didn’t have a bacterial-driven pneumonia – or a pneumonia at all – to begin with?

Shimshon Wiesel, DO, who was not involved in the study and practices internal medicine at Staten Island University Hospital, told Medscape that the data the researchers used was problematic as it only gave the diagnosis entered when the patient was seen:

“It doesn’t tell you how the patient presented, or what workup was done.” The patient might have had bronchitis or a subtle presentation of lung disease; “these are known to fail on antibiotics,” he said. “The biggest reason for treatment failure” is related to diagnostic criteria. [My emphasis.]

The patient may also have had a viral-driven pneumonia, a complication of the viruses that cause colds and the flu, which accounts for about one-third of pneumonia cases.

As it happens, support for Wiesel’s observation can be found in the most read article on Medscape right now, “Making the Correct Diagnosis: The Cornerstone of Antibiotic Stewardship.”

It’s co-authored by the always-enlightening (e.g. here and here) Brad Spellberg, MD, infectious disease specialist and Chief Medical Officer of the Los Angeles County-University of Southern California Medical Center.

He agrees that a basic rule of prescribing is that you have to give the right antibiotic, at the right dose, for the right duration of therapy. But he reminds us that up to 50% of antibiotic prescriptions in the United States continue to be unnecessary or inappropriate. And what’s overlooked, he says, is a more fundamental principle that must underpin effective antibiotic stewardship: making the correct diagnosis.

Spellberg’s article presents 6 cases that illustrate this critical principle and the impact it has on appropriate antibiotic usage. These cases are based on real patients he has encountered recently. He presents them not because they are unusual but rather because they are typical of clinical situations that happen tens of thousands of times per year in the United States – and typical of how doctors get it wrong. It’s a must-read and an involving-read: with each case presentation, the reader is asked to make the right treatment call. See how you do.

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