How long a stay in the hospital is needed for patients with community-acquired pneumonia?

Community-acquired pneumonia is a common infectious disease that is treated by primary care physicians and by medical subspecialists. The mortality ranges from less than 1% for those treated outside of the hospital to 14% for those who require hospitalization (1). Thirty-day mortality can be decreased for hospitalized patients if antibiotic treatment is begun as soon as possible (2), and if common bacterial pathogens and the atypical agents (Mycoplasma pneumoniae, Chlamydia pneumoniae, and Legionella spp.) are targeted in patients with either a macrolide/beta-lactam combination or a fluoroquinolone alone (3). Deaths may be the result of the severity of infection or a result of underlying medical conditions. As studies are identifying ways to improve outcomes in the treatment of pneumonia, the question being addressed is how to decrease the costs of care for these patients. The article by Fine et al (4) in this issue of The American Journal of Medicine shows just how important the issue of length of stay is for these patients. Bed charges during the hospital stay remained relatively constant and were responsible for the major cost of care. In this study, the variation in charges among hospitals was a remarkable 42% for daily bed charges, and there was a 36% variability in total charges among hospitals. The majority of added charges occurred early in the stay, as a result of patient work-up and treatment, and were not bed related. These charges included radiology, pharmacy, and laboratory charges, which decreased during the hospital stay. Savings were estimated to be $680 for a 1-day reduction in length of stay and $1,408 for a 2-day reduction in length of stay. We previously reported that the duration of intravenous therapy can be safely reduced to 2 days for patients with moderately severe community-acquired pneumonia. In that study, average length of stay decreased to 6 days, and a cost analysis suggested that this treatment paradigm would result in $3 billion in cost savings nationwide (5). When patients with community-acquired pneumonia are surveyed, they prefer to be treated outside of the hospital (6). Studies confirm that once patients make the transition to oral therapy, there is no reason to observe them taking their pills in the hospital (7). In a separate study, McCormick studied hospital length of stay for 1,188 patients with community-acquired pneumonia at one community and three university teaching hospitals. They reported that interhospital differences in length of stay, adjusted for patient differences, ranged from 0.9 to 2.3 days, yet there was no difference in clinical outcome, readmission rate, or return to normal activities among the three hospitals (8). Clearly there is wide variation in clinical practice in the treatment of communityacquired pneumonia, and good evidence that length of stay can be reduced safely. There are three patient-care issues that tend to keep patients with pneumonia in the hospital. These issues need to be addressed before physicians will feel comfortable with the new paradigm of care for community-acquired pneumonia, which includes a rapid switch to oral therapy and rapid discharge on oral antibiotics.