Evaluation of an algorithm for switching from IV to PO therapy in clinical practice in patients with community-acquired pneumonia

Effects of Hospital Practice Patterns for Antibiotic Administration for Pneumonia on Hospital Lengths of Stay and Costs

BACKGROUND

Hospital practice patterns vary for switching from intravenous to oral antibiotics for community-acquired pneumonia in pediatric patients, but it is unknown how these practice patterns affect hospital lengths of stay and costs.

METHODS

We conducted a retrospective study of 78673 pediatric patients (aged 3 months to 17 years) hospitalized for community-acquired pneumonia. Analyses were performed with data from the Pediatric Health Information System between 2007 and 2016, including discharge data from 48 freestanding children's hospitals. Patients who received antibiotics used to treat aspiration pneumonia and patients with a complex chronic condition were excluded to focus the study on uncomplicated cases. We modeled hospital practice patterns using hospital-level averages for the last day of service on which patients received antibiotics intravenously or first day of service on which patients received antibiotics orally.

RESULTS

We found that a 1-day decrease in the hospital-level average last day of service on which a patient received antibiotics intravenously reduced the average length of stay by 0.58 day (95% confidence interval [CI], -0.69 to -0.47 day) and average cost by $1332 (95% CI, -$2363 to -$300). Results were similar when hospital practice patterns were modeled using the average first day of service on which a patient received antibiotics orally. These reductions in lengths of stay and costs were not associated with a difference in 30-day readmission rates.

CONCLUSIONS

Given the reductions in lengths of stay and costs without sacrificing patient outcomes (readmissions), antimicrobial stewardship programs could target provider education on the duration of intravenous antibiotic therapy as a way to reduce resource utilization.

Short- vs long-course antibiotic therapy for pneumonia: a comparison of systematic reviews and guidelines for the SIMI Choosing Wisely Campaign

Reduction of the inappropriate use of antibiotics in clinical practice is one of the main goals of the Società Italiana di Medicina Interna (SIMI) choosing wisely campaign. We conducted a systematic review of secondary studies (systematic reviews and guidelines) to verify what evidence is available on the duration of antibiotic treatment in Pneumonia. A literature systematic search was performed to identify all systematic reviews and the three most cited and recent guidelines that address the duration of antibiotic therapy in pneumonia. Moreover, a meta-analysis of non-duplicate data from randomized controlled trials (RCTs) considered in the enrolled systematic reviews was performed together with a trial sequential analysis to identify the need for further studies. Two systematic reviews on antibiotic duration in community-acquired pneumonia (CAP) for a total of 17 RCTs (2764 patients) were enrolled in our study. Meta-analysis of non-duplicate RCTs show a non-significant difference in rate of treatment failure between short (≤ 7 days) and long (> 7 days) antibiotic treatment course: RR 1.05 (95% CI, 0.82-1.36). The trial sequential analysis suggests that further data would not affect current evidence or become clinically relevant. Selected guidelines suggest consideration of a short course, with a low grade of evidence and without citing the already published systematic reviews. Antibiotic treatment of CAP for ≤ 7 days is not associated with a higher rate of treatment failure than longer courses and should thus be taken in consideration. Guidelines should upgrade the evidence on this topic.

Can enteral antibiotics be used to treat pneumonia in the surgical intensive care unit? A clinical outcomes and cost comparison

Background:

Controlling healthcare costs without compromising patient care is a focus given recent healthcare changes in the United States. The purpose of this study was to assess clinical improvement in surgical intensive care unit (SICU) patients initiated on or transitioned to enteral antibiotics compared to those who solely receive intravenous (IV) antibiotic therapy for treatment of bacterial pneumonia.

Materials and Methods:

This retrospective cohort study included patients with a positive quantitative respiratory culture being treated for bacterial pneumonia in a SICU from 1/1/09 to 3/31/11. Two distinct patient groups were identified: Those treated with IV antibiotics exclusively (IV) and those either initiated on or transitioned to enteral antibiotics within 4 days of antibiotic initiation (PO). The primary endpoint of clinical improvement was assessed on day of antibiotic discontinuation.

Results:

A total of 647 patients were evaluated; 124 met inclusion criteria (30 patients PO group and 94 IV group). There was no difference in clinical improvement (86.7 PO vs 72.3% IV, P = 0.14) or recurrence (10 PO vs. 12.8% IV, P > 0.99) between groups. Secondary outcomes of duration of mechanical ventilation, ICU and hospital length of stay, and all-cause mortality were also similar. Antibiotic and infection-related costs were significantly decreased in the PO group ($1,042 vs $697, P = 0.04; $20,776 vs $17,381, P = 0.012, respectively).

Conclusions:

SICU patients initiated on or transitioned to PO antibiotics for pneumonia had similar clinical outcomes, but significantly less infection-related and antibiotic costs compared to those receiving IV therapy. Further, prospective studies are warranted.

Guidelines for the management of adult lower respiratory tract infections--summary

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Guidelines for the management of adult lower respiratory tract infections--full version

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. Background sections and graded evidence tables are also included. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

Procalcitonin vs C-reactive protein as predictive markers of response to antibiotic therapy in acute exacerbations of COPD

BACKGROUND

Rational prescription of antibiotics in acute exacerbations of COPD (AECOPD) requires predictive markers. We aimed to analyze whether markers of systemic inflammation can predict response to antibiotics in AECOPD.

METHODS

We used data from 243 exacerbations out of 205 patients from a placebo-controlled trial on doxycycline in addition to systemic corticosteroids for AECOPD. Clinical and microbiologic response, serum C-reactive protein (CRP) level (cutoffs 5 and 50 mg/L), and serum procalcitonin level (PCT) (cutoffs 0.1 and 0.25 μg) were assessed.

RESULTS

Potential bacterial pathogens were identified in the majority of exacerbations (58%). We found a modest positive correlation between PCT and CRP (r = 0.46, P < .001). The majority of patients (75%) had low PCT levels, with mostly elevated CRP levels. Although CRP levels were higher in the presence of bacteria (median, 33.0 mg/L [interquartile range, 9.75-88.25] vs 17 mg/L [interquartile range, 5.0-61.0] [P = .004]), PCT levels were similar. PCT and CRP performed similarly as markers of clinical success, and we found a clinical success rate of 90% in patients with CRP ≤ 5 mg/L. A significant effect of doxycycline was observed in patients with a PCT level < .1 μg/L (treatment effect, 18.4%; P = .003). A gradually increasing treatment effect of antibiotics (6%, 10%, and 18%), although not significant, was found for patients with CRP values of ≤ 5, 6-50, and > 50 mg/L, respectively.

CONCLUSIONS

Contrary to the current literature, this study suggests that patients with low PCT values do benefit from antibiotics. CRP might be a more valuable marker in these patients.

Potential for cost-savings in the care of hospitalized low-risk community-acquired pneumonia patients in China

BACKGROUND

The cost of treating community-acquired pneumonia (CAP) in China is a heavy economic burden for the society.

OBJECTIVE

To investigate the costs of hospitalization of low-risk CAP patients and how hospitalization costs can be reduced through proper usage of hospital resources.

METHODS

Two hundred thirty-six patients with low-risk CAP who were hospitalized between January 2000 and December 2005 in a 1161-bed tertiary care teaching hospital were included in a retrospective cohort study. Their hospitalization costs and antibiotic therapy were analyzed. General linear model was utilized to determine correlative variables associated with total hospital costs.

RESULTS

The median length of hospital stay was 12 days and the median duration of intravenous (IV) antibiotic therapy was 10 days, they were correlated significantly (P = 0.000, r = 0.81). The median total hospital cost was $556.50 (mean $705.60), of which 48.9% was for drugs, 21.9% for laboratory tests, 8.6% for radiology, 6.5% for medical staff, 6.3% for hospital beds, and 5.3% for examination. General linear model analysis determined that duration of IV antibiotic therapy, Pneumonia Severity Index class, age, and initial empirical antibiotic therapy failure were correlative factors of total hospital costs. Pathogens were identified in 106 patients (44.9%), Mycoplasma pneumoniae was the most common pathogen (19.9%), followed by Streptococcus pneumoniae (8.5%), and Haemophilus influenza (5.5%). The majority of patients accepted initial empirical beta-lactam (37.3%) or fluoroquinolone (30.9%) monotherapy, the empirical treatment failure rates were 20.5% and 5.5%, respectively.

CONCLUSIONS

Efforts to reduce duration of IV antibiotic therapy will have the most profound effect on reducing total hospital costs of low-risk CAP. The atypical pathogens should be considered for initial empirical antibiotics in low-risk CAP therapy in China.

Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial

OBJECTIVES

To compare the effectiveness of an early switch to oral antibiotics with the standard 7 day course of intravenous antibiotics in severe community acquired pneumonia.

DESIGN

Multicentre randomised controlled trial.

SETTING

Five teaching hospitals and 2 university medical centres in the Netherlands.

PARTICIPANTS

302 patients in non-intensive care wards with severe community acquired pneumonia. 265 patients fulfilled the study requirements.

INTERVENTION

Three days of treatment with intravenous antibiotics followed, when clinically stable, by oral antibiotics or by 7 days of intravenous antibiotics.

MAIN OUTCOME MEASURES

Clinical cure and length of hospital stay.

RESULTS

302 patients were randomised (mean age 69.5 (standard deviation 14.0), mean pneumonia severity score 112.7 (26.0)). 37 patients were excluded from analysis because of early dropout before day 3, leaving 265 patients for intention to treat analysis. Mortality at day 28 was 4% in the intervention group and 6% in the control group (mean difference 2%, 95% confidence interval -3% to 8%). Clinical cure was 83% in the intervention group and 85% in the control group (2%, -7% to 10%). Duration of intravenous treatment and length of hospital stay were reduced in the intervention group, with mean differences of 3.4 days (3.6 (1.5) v 7.0 (2.0) days; 2.8 to 3.9) and 1.9 days (9.6 (5.0) v 11.5 (4.9) days; 0.6 to 3.2), respectively.

CONCLUSIONS

Early switch from intravenous to oral antibiotics in patients with severe community acquired pneumonia is safe and decreases length of hospital stay by 2 days.

TRIAL REGISTRATION

Clinical Trials NCT00273676 [ClinicalTrials.gov].

[Follow-up criteria for community acquired pneumonias and acute exacerbations of chronic obstructive pulmonary disease]

The follow-up of Community Acquired Pneumonias (CAP) and Acute Exacerbations of Chronic Obstructive Pulmonary Diseases (AECOPD) differs with the setting of care, but overall calls upon the same investigations as the initial evaluations. In the event of initial ambulatory care, the evaluation is carried out primarily on clinical data, at the 2 or 3rd day for the CAP, at the 2nd to 5th day for the AECOPD. In the event of unfavourable evolution, or from the start in the most severe cases, the follow-up is carried out in hospital; clinical evaluation is readily daily, and all the more frequent that the clinical condition is worrying because of the severity or risk factors. The investigations will be limited to those initially abnormal in the event of favourable evolution; on the contrary, unfavourable evolution can justify new investigations which depend on clinical characteristics. Remotely, i.e. 4 to 8 weeks later, must be checked the return at the baseline clinical state, a chest X-ray (CAP), spirometry and arterial blood gas (AECOPD), even bronchoscopy and thoracic CT-scan.