Intravenous-to-Oral Antibiotics Transition in Healthcare-Associated Pneumonia Safe

Switching from intravenous to oral antibiotics in hospitalized patients with healthcare-associated pneumonia (HCAP) who achieve clinical stability appears to be safe, according to a study published in the Annals of the American Thoracic Society.

The American Thoracic Society/Infectious Disease Society of America guidelines recommend transitioning from an intravenous antibiotic regimen to an oral regimen in patients with community-acquired pneumonia (CAP) who are clinically stable.¹ De-escalating treatment in this setting has been shown to be safe while decreasing length of stay. However, little data are available to guide the use of this strategy in patients with HCAP, especially when the causative pathogen has not been identified.²

Whitney R. Buckel, PharmD, of Intermountain Medical Center in Utah, and colleagues evaluated clinical outcomes in patients with microbiology-negative HCAP who were switched from intravenous antibiotics to oral antibiotics after achieving clinical stability.

A total of 173 patients receiving intravenous antibiotics underwent the transition to oral antibiotics, and 47 patients received intravenous antibiotics for the full course of treatment. Of the patients who were switched to an oral regimen, 24.3% were treated with narrow-spectrum oral antibiotics and 75.7% were treated with broad-spectrum oral antibiotics.

The intravenous-only group had more severe CAP on admission (P = .04), longer times to clinical stability (72 hours vs 24 hours in the intravenous-to-oral group; P <.01), and higher 30-day mortality (14.9% vs 4.6% in the intravenous-to-oral group; P = .02).

Among patients who were transitioned to oral antibiotics, rates of 30-day readmission and 30-day all-cause mortality were similar for the broad-spectrum and narrow-spectrum groups in the unadjusted and multivariable analyses.

“Our findings, derived from a limited number of patients observed retrospectively, suggest that it may be safe to transition to a narrow-spectrum beta-lactam to complete the antibiotic treatment course for patients who achieve early clinical stability if no microbiological etiology has been identified,” the authors concluded.

However, due to small sample size, the authors could not confirm that the outcomes between the groups evaluated in this study were statistically equivalent. “A larger retrospective study with propensity matching or regression-adjusted test of equivalence or ideally a prospective comparative effectiveness study will be necessary in order to confirm our observations,” they wrote.

References

1. Mandell LA, Wunderink RG, Anzueto A, et al; Infectious Diseases Society of America; American Thoracic Society. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72.
2. Buckel WR, Stenehjem E, Sorensen J, Dean N, Webb B. Broad- versus Narrow-Spectrum Oral Antibiotic Transition and Outcomes in Healthcare-Associated Pneumonia. Ann Am Thorac Soc. 2016 Oct 3. doi: 10.1513/AnnalsATS.201606-486BC. [Epub ahead of print]