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. 2023 Jul 26;77(2):174-185.
doi: 10.1093/cid/ciad196.

Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia

Abhishek Deshpande  1   2 , Michael Klompas  3   4 , Ning Guo  1   5 , Peter B Imrey  5   6 , Andrea M Pallotta  7 , Thomas Higgins  8 , Sarah Haessler  9 , Marya D Zilberberg  10 , Peter K Lindenauer  11 , Michael B Rothberg  1
Affiliations

Intravenous to Oral Antibiotic Switch Therapy Among Patients Hospitalized With Community-Acquired Pneumonia

Abhishek Deshpande et al. Clin Infect Dis. .

Abstract

Background: Community-acquired pneumonia (CAP) is a leading cause of hospital admissions and antimicrobial use. Clinical practice guidelines recommend switching from intravenous (IV) to oral antibiotics once patients are clinically stable.

Methods: We conducted a retrospective cohort study of adults admitted with CAP and initially treated with IV antibiotics at 642 US hospitals from 2010 through 2015. Switching was defined as discontinuation of IV and initiation of oral antibiotics without interrupting therapy. Patients switched by hospital day 3 were considered early switchers. We compared length of stay (LOS), in-hospital 14-day mortality, late deterioration (intensive care unit [ICU] transfer), and hospital costs between early switchers and others, controlling for hospital characteristics, patient demographics, comorbidities, initial treatments, and predicted mortality.

Results: Of 378 041 CAP patients, 21 784 (6%) were switched early, most frequently to fluoroquinolones. Patients switched early had fewer days on IV antibiotics, shorter duration of inpatient antibiotic treatment, shorter LOS, and lower hospitalization costs, but no significant excesses in 14-day in-hospital mortality or late ICU admission. Patients at a higher mortality risk were less likely to be switched. However, even in hospitals with relatively high switch rates, <15% of very low-risk patients were switched early.

Conclusions: Although early switching was not associated with worse outcomes and was associated with shorter LOS and fewer days on antibiotics, it occurred infrequently. Even in hospitals with high switch rates, <15% of very low-risk patients were switched early. Our findings suggest that many more patients could be switched early without compromising outcomes.

Keywords: IV to oral; antimicrobial stewardship; community-acquired pneumonia; switch therapy.

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Conflict of interest statement

Conflict of interest. A. D. reports research funding (to institution) from the Clorox Company, consultant fees from Merck, and grants or contracts to institution, unrelated to the current study, from Seres Therapeutics. M. K. reports royalties from UpToDate and grants or contracts to institution from the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality. M. D. Z. reports research support from Tetraphase Pharmaceuticals, Astellas, Lungpacer, Merck, Spero, Medicines Co, Melinta, scPharma, Shionogi, and Pfizer; consulting fees from Paratek, Arasanis, Shionogi, Pfizer, Nabriva, scPharma, and Melinta; and stock or stock options from Johnson & Johnson. T. H. reports consulting fees from the Cerner Corporation. P. B. I. reports consulting fees from Colgate-Palmolive. S. H. reports a role with the Society for Health Epidemiology of America (councilor, board of trustees, volunteer; no compensation). All remaining authors: No reported conflicts of interest. All authors have submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.

Figures

Figure 1.
Figure 1.
Cohort inclusion-exclusion criteria for selection of hospitalizations. Abbreviations: CT, computed tomography; IMV, invasive mechanical ventilation; IV, intravenous; S. aureus, Staphylococcus aureus.
Figure 2.
Figure 2.
Comparative distributions of oral antibiotic class after switching (colored bars, percentages of patients) by class of initial IV antibiotic (horizontal axis label). Abbreviation: IV, intravenous.
Figure 3.
Figure 3.
Superimposed dot plot and box plot of hospital fractions of community-acquired pneumonia (CAP) patients who were receiving initial intravenous (IV) antibiotics and then switched to oral antibiotics within 3 days for N = 537 hospitals with at least 100 CAP patients initially receiving IV antibiotics. Black star represents mean.
Figure 4.
Figure 4.
Fractions of community-acquired pneumonia (CAP) patients who were receiving initial intravenous antibiotics (at N = 537 hospitals with at least 100 patients) and then switched to oral antibiotics within 3 days, stratified by patient predicted mortality (colored bars), grouped by hospital early switching rate quartile (horizontal axis). Early switching appears to be more strongly guided by hospital practices than by patient prognosis.
See this image and copyright information in PMC

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