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A new study published in the Annals of Family Medicine shows that even when patients have a negative chest radiography (CR) for community-acquired pneumonia (CAP), a majority of these patients were given antibiotics by their clinicians. Antibiotics were prescribed in 79 of 115 patients with a negative CR. 1
“Despite the absence of radiologic confirmation, most practitioners initiated antibiotics in the case of clinical suspicion of CAP,” the authors wrote.1
This was a prospective cross-sectional study that was performed with general practitioners in France from November 2017 to December 2019. The study included 259 adult patients with suspected CAP after CR were included. CR results were categorized as CAP positive or CAP negative.1
In terms of other findings, 55.6% of patients (144 out of 259) had a positive CR, and of these patients, they were found to be more clinically severe than those with negative CR, and with longer-lasting symptoms. Patients with positive chest X-ray results had higher body temperature, faster heart rate, faster breathing rate, more difficulty breathing, and more frequent unilateral chest pain than patients with negative X-ray results, and their symptoms lasted for a longer time. And in the positive CR group, antibiotics were initiated for 142/143 (99.3% [95% CI, 97.9%-100.0%]).1
[Check out our respiratory infections section.]
Typically, guidelines for diagnosing include blood work and a positive CR to confirm inflammation and the presence of the respiratory infection.2 This study demonstrates the differences in treatment guidelines and actual practice.
The investigators surmise there are some situations in clinical practice where treatment may be best even in the absence of clinical evidence of a positive CR. They write that 1 consideration may be the absence of opacity on the x-ray to be from radiologic delay. Still this did not prove to be the case in the overall results.
“The time to symptom onset before inclusion and CR was not statistically different between CR+ and CR− patients (4.0 days [IQR 2.0-8.0 days] vs 4.0 days [IQR 2.0-7.0 days]; P = .280),” the authors write.1
In addition, the authors developed other potential theories for treatment with antibiotics when patients exhibit a negative CR. Other treatment considerations included a low sensitivity of CR to diagnose pneumonia, premature closure bias, differing opinions between the treating clinician and the radiologist on the x-ray results, lack of ready access to CR, and some clinicians may have obtained a secondary diagnosis that required antibiotics.1
“The effect of a negative CR on the antibiotic initiation decision appears to be low. This raises questions regarding the role of CR in the management strategy for CAP and justifies clarification of the guidelines as to what should be done in case of clinical suspicion of CAP without radiologic confirmation,” the authors wrote.1
