BMJ  2006;333:1181-1182 (9 December), doi:10.1136/bmj.39050.672639.80

Editorials

Severe community acquired pneumonia

Early switch from intravenous to oral antibiotics is safe and reduces hospital stay

Research into community acquired pneumonia over the past two decades has focused on developing tools to measure the severity of illness and which antibiotics to choose. Several tools can now help clinicians identify patients with severe community acquired pneumonia in clinical settings.¹ In people with severe disease, international guidelines recommend early treatment with broad spectrum antibiotics, which provide cover for atypical pathogens.²

It is less clear how best to manage patients during their stay in hospital. In this week's BMJ, a randomised trial by Oosterheert and colleagues reports the effect of switching from intravenous to oral antibiotics after three days rather than seven days in people with severe community acquired pneumonia.³ Until now, the lack of quality trial data in areas such as route of antibiotic administration, duration of treatment, and assessment of clinical stability has led to a conservative approach to management and prolongation of hospital stay.

The National Health Service spends more than £400m (592m; $780m) a year on community acquired pneumonia.⁴ To reduce healthcare costs, length of hospital stay should be reduced without compromising patient safety. Our group has shown that clinicians' behaviour is the main determinant of variability in the duration of treatment with intravenous antibiotics. It outweighs all other factors, including patient characteristics, and is therefore the major determinant of length of hospital stay for patients with this disease.⁵ Provision of quality data is key to reducing the pronounced variability in clinical practice.

The trial by Oosterheert and colleagues provides more support for an early switch from intravenous to oral antibiotics. It found that such a switch was safe and reduced length of hospital stay (9.6 v 11.5 days; 95% confidence interval 0.6 to 3.2).⁵ One strength of the study was that it used clinical stability as the basis for switching from intravenous to oral treatment in the intervention arm. The time chosen to switch patients from intravenous to oral antibiotics was three days if clinical stability criteria were met (including respiratory rate <25 per minute, haemodynamic stability, and ability to take oral drugs). Data on the minimum safe duration of intravenous antibiotics in this context are still to be determined. During follow-up, only 2% of patients who were switched to early oral antibiotics needed to restart intravenous therapy.

The other aspect of the study relevant to length of stay was the delay of about five days to discharge despite patients meeting predefined discharge criteria. This occurred even though the discharge criteria were more conservative than the stability criteria used for the intravenous to oral switch. The treating physician decided the time of discharge, and this decision will have been influenced by social factors and comorbidities specific to each patient. The authors suggest that incomplete resolution of all clinical signs of pneumonia delayed discharge even when patients were clinically stable. However, several observational studies found no advantage of observing inpatients once stability criteria comparable to those used in the current study were met.^{6 7} This suggests that the current study used overly conservative discharge practices, and it would have been safe to shorten length of stay further for most patients. However, patients must be stable before discharge, as adverse outcomes have been reported in people discharged with clinical instability.⁸

The challenge now is to design a new era of multicentre studies for community acquired pneumonia. Rather than continuing to search for the best antibiotic regimen, it is time to answer more pragmatic questions. Firstly, what degree of clinical stability needs to occur before switching to oral antibiotics given the pharmacokinetics and recognised modes of action of these drugs?⁹ If most (81%) patients safely tolerated the switch from intravenous to oral antibiotics after three days then some may have tolerated the switch earlier; possibly at the first sign of clinical improvement or even after the first dose. Secondly, would further investigation of the criteria for clinical stability, combined with strategies that deal with social determinants, facilitate further reductions in length of stay without compromising patient safety or satisfaction? We have sufficient evidence to ensure that research into these questions is ethical.

The results of the study should give clinicians the confidence to switch clinically stable patients from intravenous to oral antibiotics at 72 hours, with consideration of early discharge thereafter. The traditional one size fits all approach to the management of community acquired pneumonia can no longer be justified.

¹ Waikato Hospital, Hamilton, New Zealand 3204, ² Christchurch Hospital, Christchurch, New Zealand 8001

---

Research, doi: 10.1136/bmj.38993.560984.BE

Competing interests: GDM was reimbursed by Bristol-Myers Squibb for attending conferences and received consulting fees from ICOS Corporation. GDM also received research funds from GlaxoSmithKline, Boehringer Ingelheim, ICOS Corporation, Sanofi-Aventis, Roche, Pharmacia, and MSD. RL received support funding for staff from GlaxoSmithKline and Boehringer Ingelheim.

References

1. Buising KL, Thursky KA, Black JF, Street AC, Kennedy MP, Brown GV. A prospective comparison of severity scores for identifying patients with severe community acquired pneumonia: reconsidering what is meant by severe pneumonia. Thorax 2006;61:419-24.[Abstract/Free Full Text]
2. Battleman DS, Callahan M, Howard TH. Rapid antibiotic delivery and appropriate antibiotic selection reduce length of hospital stay of patients with community-acquired pneumonia. Arch Intern Med 2002;162:682-8.[Abstract/Free Full Text]
3. Oosterheert JJ, Bonten MJM, Schneider MME, Buskens E, Lammers J-WJ, Hustinx WMN, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ 2006 doi: 10.1136/bmj.38993.560984.BE[Abstract/Free Full Text]
4. Guest JF, Morris A. Community-acquired pneumonia: the annual cost to the National Health Service in the UK. Eur Respir J 1997;10:1530-4.[Abstract]
5. Laing R, Coles C, Chambers S, Frampton C, Jennings L, Karalus N, et al. Community-acquired pneumonia: influence of management practices on length of hospital stay. Intern Med J
6. Nathan RV, Rhew DC, Murray C, Bratzler DW, Houck PM, Weingarten SR. In-hospital observation after antibiotic switch in pneumonia: a national evaluation. Am J Med 2006;119:512-8.[Medline]
7. Halm EA, Fine MJ, Marrie TJ, Coley CM, Kapoor WN, Obrosky S, et al. Time to clinical stability in patients hospitalized with community-acquired pneumonia. JAMA 1998;279:1452-7.[Abstract/Free Full Text]
8. Halm EA, Fine MJ, Kapoor WN, Singer DE, Marrie TJ, Siu AL. Instability on hospital discharge and the risk of adverse outcomes in patients with pneumonia. Arch Intern Med 2002;162:1278-84.[Abstract/Free Full Text]
9. Craig WA, Andes B. Parenteral versus oral antibiotic therapy. Med Clin North Am 1995;79:497-508.[ISI][Medline]

CiteULike    Complore    Connotea    Del.icio.us    Digg    Reddit    Technorati    What's this?

Relevant Articles

US Highlights

Douglas Kamerow
BMJ 2006 333: 0. [Extract] [Full Text]

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

Jan Jelrik Oosterheert, Marc J M Bonten, Margriet M E Schneider, Erik Buskens, Jan-Willem J Lammers, Willem M N Hustinx, Mark H H Kramer, Jan M Prins, Peter H Th J Slee, Karin Kaasjager, and Andy I M Hoepelman
BMJ 2006 333: 1193. [Abstract] [Full Text] [PDF]

This article has been cited by other articles:

• (2007). Early Switch to Oral Antibiotics in CAP. JWatch Infect. Diseases 2007: 3-3 [Full text]