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J Emerg Med. 2009 Oct;37(3):335-40. doi: 10.1016/j.jemermed.2009.06.127. Epub 2009 Aug 31.

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.

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Department of Emergency Medicine, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.



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


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.


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.


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.


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.

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