Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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No" One size fits all" when it comes to pnemonia treatmnet
- Mohamed S. Noshi,MD,FACP (9 November 2006)
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Same effectiveness in children?
- Patrícia GM Bezerra (10 November 2006)
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Risk stratification of Community acquired pneumonia
- Kaushik sanyal (11 November 2006)
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Antibiotics In pneumonia
- Sameer Chadha, Shikha Mehta, Medical Student , Maulana Azad Medical College, New Delhi ,India (10 December 2006)
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A straw man?
- Rowan H Harwood (11 December 2006)
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Antibiotics and Severe Pneumonia
- Michael E Reschen (11 December 2006)
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Benefits Wider than Early Discharge
- Alexandra L Thomson-Moore (12 December 2006)
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Shuffled data.
- Christopher S. Musgrove (25 May 2007)
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Mohamed S. Noshi,MD,FACP, Senior consultant Internal Medicine Sheikh Khalifa Medical City, UAE
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While the study advocates an evidence based cost effective treatment to pneumonia, I was hopeful that the many variables that affects decision making in pneumonia treatment, when it comes to host,comorbidities, causative organism..etc to be adressed. For example , a very old patient with a very poor oral intake and difficulty swallowing may not do well with the early switch to oral antibiotics. A patient with multiple comorbidities e.g heart failure , chronic lung disease is also likely to require more days of parentral antibiotics. And in the era of microbial resistance,A commonly encountered scenario now is a sputum culture showing an organism that is not sensitive to any oral antibiotics will require parentral route for the whole duration of treament. Yet the point of the study is well taken in otherwise straight forward uncomplicated pnemonia. Competing interests: None declared |
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Patrícia GM Bezerra, Pediatric pneumologist IMIP Instituto Materno Infantil Prof. Fernando Figueira Recife PE Brazil 52011020
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This is a very important study that make us wonder if the results could be extrapolated for the pediatric population. Of course similar clinical trials must be done before any attempts to do an early switch from intravenous to oral antibiotics in more severe patients. Competing interests: None declared |
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Kaushik sanyal, clinical fellow Norfolk and Norwich University Hospital, Norwich, UK
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CAP leads to 83,000 hospital admissions an year in UK more in autumn and winter. Extremes of age, lifestyle (smoking, alchohol) play an important role in disease presentation. In UK, the BTS designed CURB-65 score for severity assessment is followed .Altered immunofunction due to resistant strain, multiple underlying diseases, end organ damage and immunosuppressant medication can be blamed. Larger studied with randomized design and intensive risk stratification should be thought of. Evidence based guidelines show an insignificant statistical effect on the duration of intravenous antibiotics and length of stay. Duration of outcome should be made on the therapeutic outcome. Recommendation must be on concrete assessment from randomized clinical trials adapted to local population and target setting. Competing interests: None declared |
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Sameer Chadha, Medical Student Maulana Azad Medical College, New Delhi, India, Shikha Mehta, Medical Student , Maulana Azad Medical College, New Delhi ,India
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As the etiology of Community Acquired Pneumonia (CAP) is commonly unknown so the treatment is frequently empirical. Some noteworthy points about the use of antibiotics in CAP are 1. Treatment with combination of 2nd generation cepalosporin and macrolide
or flouroquinolones alone
The switch from intravenous to oral antibiotics can be done safely when 1.The white blood cell count is returning towards normal.
The standard duration for most patients with CAP will be around 10 to 14 days. Competing interests: None declared |
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Rowan H Harwood, consultant physician Nottingham NG5 1PB
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'Conventionally, intravenous treatment is continued until a definite clinical cure'. Really? In 20 years of practice in UK teaching hosptials we have always done exactly what was done in the 'new' intervention arm - namely switching to oral antibiotics as soon as is clinically feasible. The hospital where I work has a written policy mandating this approach. Maybe things are different elsewhere in the world. And randomised trials are always to be applauded (prolonged intravenous treatment could have turned out to be superior). But recently in the UK ill-informed policy makers have made a trade of telling doctors how to do their jobs based on reports like this, so we must tread carefully. The NHS Institute of Innovation and Improvement recently told us how we would need far fewer hospital beds ... by doing things many of us have been doing for the best part of 10 years (like out- patient DVT management). Another 3 days to cut from pneumonia length of stay is just around the corner. Except that it's already in the baseline. Perhaps a better title would have been 'Prolonged IV antibiotics confer no benefit in severe community acquired pneumonia'. Competing interests: None declared |
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Michael E Reschen, SHO CARDIOLOGY John Radcliffe Hospital, Oxford, OX3 9DU
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In their article on early discontinuation of intravenous antibiotics for severe community acquired pneumonia, Osterheert et al., demonstrate the non-inferiority of an abbreviated course of i.v. antibiotics. However the baseline characteristics of the patients differed with more of the control group having renal failure and positive blood cultures, a marker of more severe disease. There is no statistical comparison of these factors. Also there is no mention of the door-to-antibiotic time which is known to affect outcome. The initial antibiotics regimens differed with more of the control group being treated with 'other' antibiotics. The authors report there analysis on an 'intention to treat' basis but in fact over 10% of patients dropped out early and were excluded from the analysis. Importantly the authors have kept the excluded patients in the baseline analysis of patients variables - we therefore do not know how the removal of these patients should have affected the baseline characteristics. Also, in the UK the BTS guideline suggest changing to oral antibiotics at an even earlier stage i.e after 24hrs of well being, rather than 3 days which might already be excessive. This study therefore provides some reassurance to UK physicians who are already curtailing i.v antibiotics earlier but does not answer the question of exactly how soon i.v antibiotics can be discontinued, and is troubled by some methodological flaws. 1. Thorax 2001; 56: (suppl IV) Competing interests: None declared |
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Alexandra L Thomson-Moore, PRHO Eastern Deanery
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Editor – Evidence-based, individually sensitive assessment tools to guide physicians when to safely switch from intravenous to oral antibiotics in the treatment of severe community acquired pneumonia are to be welcomed. The article highlights costs saved from reducing the average length of hospital stay. It could go onto highlight improved patient safety by the reduction in the risk of line infections; improved patient satisfaction through earlier discharge (ref 1); improved patient morale as they (correctly) perceive the switch from intravenous to oral antibiotics as a sign treatment is being successful; and improved patient satisfaction through earlier discharge and because most people find taking oral medication more acceptable with less intrusion and medicalisation of their lives. It is perhaps unsurprising that the editorial focussed on cost saving as the principle benefit from the research. Ironically my clinical experience in the NHS suggests this is the potential benefit least likely to be realised. I find it is commonplace for publicly funded care packages to take more than fourteen days to reinstate or increase. The reasons for this are multifactorial and include a shortage of hands and feet in the community and a lengthy, beauracratic discharge system involving too many specialists, often compounded by a severe lack of common sense. Having recently come through medical finals where a heavy emphasis was placed on exploring an individual’s illness through their own eyes, I now find information I gather on patients’ ideas, concerns, expectations and social environment largely disregarded by other members of the multidisciplinary discharge planning team, even disliked. As a consequence many individuals are subjected to needless assessments, delaying their discharge. The solution for expediting patient discharge is complex. However the key benefits of this research may well not be earlier discharging. Ref 1 Ann Intern Med. 2005;142:165-172 Competing interests: None declared |
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Christopher S. Musgrove, PharmD. Candidate Student at Ferris State University, Big Rapids, MI 49307
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The data in Table 3 does not match up with the data presented in the text. I am referring to the first paragraph under "Clinical Outcome" in the "Results" section. If you look at it you will understand what I am talking about. Competing interests: None declared |
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