Should Health Care Systems and Health Care Providers Implement a New Pathway for Hospitalized Patients With Community-Acquired Pneumonia?—Reply

In reply

We thank Carugati et al for their interest in our randomized trial.¹ As in other recent controlled trials evaluating strategies aimed to reduce the duration of hospitalization in patients with community-acquired pneumonia (CAP),² we selected length of stay as the primary end point. Accordingly, we used length of stay to determine sample size. Carugati et al were concerned that 30-day case-fatality rate was a secondary end point. They stated that secondary end points should not be used to modify clinical practice. However, although mortality is objective and important, most patients with CAP do not die. Because new interventions for CAP are likely to result in only small changes in mortality, large sample sizes are required to detect clinically important changes. Therefore, it has been suggested that mortality is an insensitive measure of quality of care or treatment failure in CAP.³ In our article,¹ we clearly pointed out that our study was not powered to detect a survival difference. Nevertheless, we found that only 4 of 200 patients (2%) in the 3-step group and 2 of 201 patients (1%) in the usual care group died. Importantly, no patient died during the 30-day follow-up period after discharge. However, it should be noted that patients receiving usual care were more likely to experience adverse drug reactions, mainly phlebitis, probably related to the longer duration of intravenous antibiotic therapy in this group.