Early switch from intravenous to oral antibiotics and early hospital discharge: a prospective observational study of 200 consecutive patients with community-acquired pneumonia

Sequential antibiotic therapy for cost containment in the hospital setting: why not?

Antibiotic cost represents a significant part of hospital budgets all over the world. Restriction policies, however and other similar programmes intervening in antimicrobial prescribing have not always been successful in lowering antibiotic expenditure. Timely switch or sequential therapy from initial intravenous to subsequent equivalent oral treatment has been implemented in many institutions for the same purpose. Using strict criteria for optimum patient selection, switch therapy has been proven both effective as antimicrobial treatment and cost saving. As healthcare resources remain lower than needed, cost-saving policies become very desirable. Thus, switch therapy is expected to be more widely used, since it is a cost containing policy which does not compromise treatment outcome.

Intravenous-to-oral transition therapy in community-acquired pneumonia: the INOVA Health System experience

Economic pressures on the delivery of health care have necessitated a focus on reducing costs and resource utilization while maintaining or improving the quality of care. A growing consensus holds that switching from intravenous to oral therapy is a cost-effective and clinically sound approach for a significantly large group of patients with community-acquired pneumonia (CAP). Drug utilization studies within the INOVA Health System revealed that levofloxacin is a cost-effective alternative to ciprofloxacin in infectious disease and that use of risk prediction criteria can reduce inappropriate hospitalizations for CAP, thereby reducing costs. In addition, the INOVA experience demonstrates that the strategy used to implement new antibiotic regimens such as switch-therapy regimens is an important factor in cost reduction: a therapeutic interchange mandate is more successful than standard educational techniques in changing treatment patterns.

A controlled trial of a critical pathway for treating community-acquired pneumonia: the CAPITAL study. Community-Acquired Pneumonia Intervention Trial Assessing Levofloxacin

Recent clinical trials in patients with community-acquired pneumonia (CAP) demonstrated that switching from intravenous to oral antibiotic therapy is safe once clinical improvement is evident, thereby facilitating early hospital discharge. This study evaluated the use of a critical pathway to improve the efficiency of treating CAP in 1743 patients at 19 teaching and community hospitals in Canada. Hospitals were randomized to continue conventional management of CAP (10 hospitals) or implement a critical pathway (9 hospitals). The main clinical outcome measure was patients' scores (assessed 6 wks after hospital presentation) on the Short-Form 36 Physical Component Summary, a quality-of-life questionnaire. Secondary clinical outcome measures included occurrence of complications, readmission rates, and mortality. The primary economic outcome measure was resource utilization, measured by the number of bed days/patient managed (BDPM). Clinical outcomes were good in both groups, with no significant differences between the two management strategies. However, use of the clinical pathway was associated with a 1.7-day reduction in BDPM and fewer admissions of low-risk patients.

Managing antiinfective therapy of community-acquired pneumonia in the hospital setting: focus on switch therapy

Targeting patients for early switch from intravenous to oral antibiotic therapy and early hospital discharge is an important strategy in the management of community-acquired pneumonia (CAP). This strategy can reduce costs due to drug administration and length of hospital stay. We show that switch therapy can be implemented safely when four criteria are met: cough and respiratory distress improve, fever abates for at least 8 hours, white blood cell count is returning to normal, and patient can take drugs orally In prospective clinical studies conducted at our institution, the clinical cure rate with switch therapy was 99%, and mean length of hospital stay was reduced by more than 2 days. Early switch, coupled with hospital discharge, may be possible in nearly half of all CAP patients. Universal use of switch therapy in the United States could result in the total reduction of about 440,000 hospital days annually and an overall savings of $400 million.

Community-acquired pneumonia. Diagnostic and therapeutic approach

Optimal empiric therapy of CAP is with appropriate monotherapy (e.g., doxycycline, levofloxacin). Combination therapy is problematic because of potential side effects and high cost. Empiric coverage should have a high degree of activity against both typical and atypical pathogens. The antibiotic selected should have an excellent side-effect profile and be relatively inexpensive. Clinicians should be selective in their choice of antibiotic for CAP and choose an antimicrobial that has little or no resistance potential, is relatively inexpensive, and permits i.v.-to-PO switch monotherapy.

Sequential antibiotic therapy

Antimicrobials are an important source of hospital expenditure. Traditionally, severe bacterial infections have been treated initially with intravenous antibiotics, followed by physician-directed switch to oral therapy. Unfortunately this approach results in unnecessary prolongation of intravenous treatment, with all its inherent disadvantages. Sequential antibiotic therapy, however, ensures an early switch to the oral route when the patient is clinically stable. This increasingly employed strategy is safe and results in improved quality and cost-effectiveness of health care. To ensure timely and appropriate switch, such programmes need to be underpinned by clear guidelines and supported by a multidisciplinary team. In the future, key questions, such as what is the optimal time of switch for specific infections, and can conditions such as osteomyelitis and endocarditis be efficaciously treated with oral therapy, need to be answered. Only then will clinicians be able to practise evidence-based infection management incorporating sequential antimicrobial therapy.

Clinical use of the fluoroquinolones

The appetite for modification to the basic quinolone nucleus has grown logarithmically since the first quinolone was employed in clinical practice. Important structural refinements have led to expanded microbiologic activity, optimal pharmacokinetics, and increased safety profiles. The practicing clinician and researcher may glean considerable information from the quinolone structure with regard to microbiologic spectra and safety before administering these agents to patients. Although some toxicities can be ominously predictable, such as with the so-called high-risk quinolones (e.g., double-halogenated and trifluorinated quinolones), clinicians must rely on animal models of toxicity and clinical trial data to discern other toxicities (e.g., Q-Tc interval prolongation). A few quinolones enjoy a relatively clean safety profile and are well tolerated (e.g., gatifloxacin, levofloxacin, ciprofloxacin). Other quinolones may be associated with significant collateral system toxicity during therapy; however, under certain conditions, albeit rare, their potential for benefit may outweigh the existing risk. Clinafloxacin, for use in the management of lung infections caused by multiply resistant B. cepacia in cystic fibrosis patients, is an example of a risk that may be outweighed by its therapeutic benefit. Because there are many treatment alternatives within the clinician's armamentarium, the obligation is to select the safest, most therapeutically effective, and most cost-effective agent that is available. In addition to increasing mortality and morbidity, the development of toxicity or an adverse event during therapy may compromise the immediate effectiveness of treatment as well as affect the cost of the patient's care significantly. With the immediate abundance of quinolones available for use, the safest, most effective, and best-tolerated agents will likely emerge as the most appropriate therapeutic choices when a quinolone is indicated.