Switch tactics

The length of stay in severe community-acquired pneumonia (CAP) is often determined by the duration of intravenous (IV) antibiotic treatment. An earlier switch to oral antibiotics might facilitate early discharge, but there have been concerns that it might increase the rate of treatment failure, readmission, or death.

Researchers from the Netherlands conducted a multicentre randomized trial to evaluate the effectiveness of an early switch to oral antibiotics with the usual 7-day course of IV antibiotics in severe CAP. The primary outcome measure was clinical cure (defined as patients discharged in good health without signs and symptoms of pneumonia and no treatment failure during follow-up); the secondary measure was length of hospital stay.

More than 300 patients with pneumonia with a severity index class IV or V were enrolled in the trial that was set in 7 academic hospitals. Patients were excluded if they required mechanical ventilation or had other significant complicating factors (eg, cystic fibrosis, severe immunosuppression). If clinically stable, patients randomized to the intervention group were switched from IV to oral antibiotics on the third day of hospitalization to complete a total of 10 days. Patients in the control group received a standard regimen of 7 days of IV treatment. Antibiotics were chosen on the basis of Dutch treatment guidelines.

What did the researchers find out? Thirty-seven patients were excluded from analysis before day 3, leaving 265 patients in the intention-to-treat analysis. Most patients were treated with amoxicillin alone or in combination with clavulinic acid, or a cephalosporin alone. Only 3 patients were restarted on IV drugs after being switched to oral antibiotics. Mortality at 28 days was 4% in the intervention group and 6% in the control group. Clinical cure was similar in both groups (83% to 85%). Duration of IV treatment was 3.4 days shorter in the intervention group. Length of hospital stay was 1.9 days shorter.

Bottom line

Early switch from intravenous to oral antibiotics in patients with severe community-acquired pneumonia who do not need treatment in intensive care is safe and leads to shorter hospital stays.

Footnotes

Source: Oosterheert JJ, Bonten MJ, Schneider MM, Buskens E, Lammers JW, Hustinx WM, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia; multicentre randomised trial. BMJ 2006;333(7580):1193. DOI:10.1136/bmj.38993.560984.BE.