The measurement of time to first antibiotic dose for pneumonia in the emergency department: a white paper and position statement prepared for the American Academy of Emergency Medicine.

BACKGROUND: Measurement of time to first antibiotic dose (TFAD) in the emergency department (ED) in community-acquired pneumonia (CAP) has been controversial.

OBJECTIVE: To evaluate original articles reporting outcomes in CAP patients before and after TFAD measurement and assess whether it increases antibiotic overuse in non-CAP conditions.

METHODS: We performed searches using PubMed, addressing two questions: 1) Is the measurement of TFAD associated with improved outcomes in CAP? and 2) Is the measurement of TFAD associated with antibiotic overuse or interventions that could result in overuse in non-CAP conditions? Two independent reviewers assessed studies addressing these questions.

RESULTS: Eight studies were identified. All were Grade C or D and of "Adequate" quality: two studies supported TFAD by showing improved outcomes (improved survival in one study and no survival difference but shorter hospital length-of-stay in the second) in CAP patients after the implementation of TFAD; one neutral article reported no difference in survival with improved TFAD timing; five studies opposed TFAD either by showing increases in antibiotic overuse in non-CAP patients, or suggesting that TFAD measurement would promote antibiotic misuse.

CONCLUSION: Given inconsistent evidence to demonstrate that improving TFAD in CAP improves outcomes or that TFAD is associated with antibiotic overuse, a Class C indication has been assigned (not acceptable/not appropriate) for ED TFAD measurement. The American Academy of Emergency Medicine recommends that measurement of TFAD in CAP be discontinued.