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Dr. Bryan is Heyward Gibbes Distinguished Professor of Internal Medicine and Chair, Department of Medicine, University of South Carolina School of Medicine.
Correspondence to: Charles S. Bryan, MD, 2 Medical Park, Suite 502, Columbia, SC 29203; e-mail: cbryan@richmed.medpark.sc.edu
In this issue of CHEST (see page 1278), Waterer et al report a provocative retrospective study of the impact of blood cultures on antibiotic prescribing for community-acquired pneumonia. Physicians seldom simplified antimicrobial therapy, even when Streptococcus pneumoniae had been isolated from blood cultures, which was the case in 74 of 1,805 patients with community-acquired pneumonia who were admitted to a large private hospital. Waterer et al conclude that "in an era of escalating costs and rationalization of health care," we should address seriously the issue of whether blood cultures need be obtained in severe community-acquired pneumonia.
Any attempt to reduce the cost of medical care without compromising quality is certainly laudable. However, we lack sufficient data to recommend that blood cultures no longer be obtained for severe community-acquired pneumonia (ie, pneumonia requiring hospitalization). To the contrary, there are compelling reasons to obtain two sets of blood cultures before starting antibiotic therapy.
First, pneumococcal pneumonia is an inappropriate place to begin cost cutting. In the Oregon Plan—a recent, admirable attempt to rank what we do for patients in order of cost-effectiveness and social desirability—antibiotic therapy for pneumococcal pneumonia topped the list, and for good reasons (Ralph Crawshaw, MD; personal communication; July 13, 1999). The cost of two sets of blood cultures from patients with severe pneumonia pales by comparison with other common expenditures in pulmonary and critical care medicine.
Second, and as Waterer et al point out, blood cultures can be invaluable to decision making in individual cases. Two such cases stand out in my own recent memory. One patient seemed to have the ALPS syndrome (alcoholism, leukopenia, and pneumococcal sepsis) until blood cultures disclosed Klebsiella pneumoniae. The other patient was about to undergo lobectomy for cavitary pneumonia with sequestered lung until it was pointed out, since pneumococci had been isolated from blood, that the prognosis for spontaneous resolution was excellent.1 Before abandoning blood cultures, we should determine the number needed to test and its associated cost to identify a single case in which the findings are enormously lifesaving and/or cost saving.
Third, data derived from susceptibility testing on pneumococcal blood isolates are crucially important to medical decision making. As is well-known, S pneumoniae is acquiring resistance not only to penicillin B but also to the newer cephalosporins and fluoroquinolones.2 We need data—not only national, but also regional and local—on pneumococcal susceptibility trends.
Fourth, it is arguable whether simplifying therapy would actually save money in most cases. I have personally championed the continued use of high-dose penicillin G therapy for treatment of pneumococcal pneumonia when the diagnosis is clear-cut, when meningitis is not present, and when the likelihood of a highly resistant strain (minimum inhibitory concentration to penicillin G, > 4 µg/mL) is low.3 4 Yet, as much as I hate to admit it, the actual cost of IV ceftriaxone, 1 g/d, is probably lower than the cost of high-dose IV penicillin G therapy (due to the equipment and personnel costs for administering penicillin G by continuous or frequent intermittent infusion). Physicians’ decisions to "continue what seems to be working" are in some instances understandable.
Fifth, the best chance to reduce costs for severe community-acquired pneumonia hinges less on the choice of antibiotics than reducing the duration of therapy and hospitalization. Unfortunately, for pneumonia, as for most infectious diseases, we lack good data on which to base the length of therapy. We often quip, therefore, that duration of therapy should always resemble a football score: 3, 7, 10, 14, 21, 28, or 42 days. My MEDLINE search for articles on severe pneumococcal pneumonia between 1975 and 1999 using the search phrase "duration of" yielded only one good article: a study from Nigeria in which the average duration of therapy was but 2.54 days. The authors recommended that antibiotics can be stopped when patients have been afebrile for 24 h.5 Supporting this idea, McCormick et al6 concluded recently from a prospective cohort study of 1,188 adult patients that shorter hospital stays did not adversely affect outcomes. These latter authors imply that shortening the duration of hospitalization would not, however, be appropriate for pneumonia of "high-risk" etiology: Staphylococcus aureus or aerobic gram-negative rods. Documenting these high-risk pathogens is yet another indication for blood cultures.
Positive blood cultures remain the "gold standard" (or the "Austrian and Gold standard," to acknowledge a classic study!7 ) for the diagnosis of pneumococcal pneumonia. Recent data confirm the premier role of the pneumococcus in severe community-acquired pneumonia.8 Waterer et al are to be commended for their provocative study, but the time has not yet come to abandon blood cultures in this disease.
References
This article has been cited by other articles:
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  D. Berild, A. Mohseni, L. M. Diep, M. Jensenius, and S. H. Ringertz Adjustment of antibiotic treatment according to the results of blood cultures leads to decreased antibiotic use and costs J. Antimicrob. Chemother., February 1, 2006; 57(2): 326 - 330. [Abstract] [Full Text] [PDF]
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 C. M. Luna Blood Cultures in Community-Acquired Pneumonia: Are We Ready To Quit? Chest, April 1, 2003; 123(4): 977 - 978. [Full Text] [PDF]
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S. G. Campbell, T. J. Marrie, R. Anstey, G. Dickinson, and S. Ackroyd-Stolarz The Contribution of Blood Cultures to the Clinical Management of Adult Patients Admitted to the Hospital With Community-Acquired Pneumonia: A Prospective Observational Study Chest, April 1, 2003; 123(4): 1142 - 1150. [Abstract] [Full Text] [PDF]
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