Early administration of antibiotic therapy has been considered a standard of care
in the management of community-acquired pneumonia (CAP) since two retrospective studies
showed that receiving the first antibiotic dose within 8 or 4 hours of admission improved
survival [
1
,
2
]. These studies prompted the use of ‘time to first antibiotic dose’ (TFAD) as a quality-of-care
indicator in the management of patients evaluated for CAP. However, such studies were
criticized because of their retrospective, dataset-based design, their use of discharge
diagnosis instead of the real-life perspective of a patient suspected of having CAP,
and their lack of adjustment for several confounding factors. Indeed, a clear association
between early TFAD (4–8 hours) and improved outcome was not confirmed in further prospective
studies and meta-analyses [
3
]. In addition, adherence to a predefined TFAD was associated with an increased rate
of CAP misdiagnosis, lowering the yield in microbiological workup and leading to antibiotic
overuse [
4
]. A severe outbreak of
Clostridioides difficile infection linked to a strict pneumonia care plan, including predefined TFAD as quality-of-care
indicator, was reported. Review of medical records showed that half of patients treated
for pneumonia may not have had pneumonia [
5
]. Thus, the Infectious Diseases Society of America (IDSA) guidelines released in
2007 abandoned a predefined time window for delivery of the first antibiotic dose,
but just recommended that it should be given in the Emergency Department (ED) [
6
]. Current IDSA guidelines on the management of adults with CAP, published in 2019,
do not address the issue of the ‘time to first antibiotic dose’ [
7
]. However, the debate about TFAD in patients suspected of having CAP is far from
being closed, mainly because the available evidence comes from observational low-quality
studies [
- Metlay J.P.
- Waterer G.W.
- Long A.C.
- Anzueto A.
- Brozek J.
- Crothers K.
- et al.
Diagnosis and treatment of adults with community-acquired pneumonia. An official clinical
practice guideline of the American thoracic society and infectious diseases society
of America.
Am J Respir Crit Care Med.
2019;
200
:
e45-e67
8
]. Another issue is the use of early (3–5 days) versus late (30 days) endpoints for
assessing therapeutic strategies in patients with CAP [
9
], which adds concerns about the interpretation of results from previous studies and
the design of new ones.
- Talbot G.H.
- Powers J.H.
- Fleming T.R.
- Siuciak J.A.
- Bradley J.
- Boucher H.
Progress on developing endpoints for registrational clinical trials of community-acquired
bacterial pneumonia and acute bacterial skin and skin structure infections: update
from the Biomarkers Consortium of the Foundation for the National Institutes of Health.
Clin Infect Dis.
2012;
55
:
1114-1121
Keywords
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Article Info
Publication History
Published online: October 29, 2020
Accepted:
October 20,
2020
Received in revised form:
October 19,
2020
Received:
September 9,
2020
Publication stage
In Press Journal Pre-ProofIdentification
Copyright
© 2020 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved.
