Time to first antibiotic dose for community-acquired pneumonia: a challenging balance

This is a commentary on the manuscript of Fally et al. focused on the time to first antibiotic dose (TFAD) in patients with community-acquired pneumonia (CAP). The authors analyzed the impact of 4 and 8-h timeframes on several outcomes in a cohort of 2,264 patients with CAP hospitalized at four hospitals in Denmark. After accounting for potential confounders and stratifying patients by the pneumonia severity or the probability to receive early antibiotic therapy, none of the outcomes was affected by the early antibiotic administration. To place the study in the context, we have revised the history of the debate about TFAD for CAP, mentioning also the evidence for other bacterial infections. Except of septic shock and bacterial meningitis for which literature supports the use of early (<1-3 h) antibiotic initiation, for other less severe conditions the evidence of benefit is missing. On the other hand, to pursue strict TFAD may be associated with adverse events. We deem the study of Fally et al. underlines that the real challenge in the management of patients suspected of having CAP or other non-severe bacterial infections is to differentiate patients who need to be treated in few hours from those who would not be harmed by withholding antibiotics until the diagnosis of infection is confirmed.