Duration of IV antibiotic therapy for pneumonia - Tips from Other Journals

Author: Linz Audain
Date: Feb 15, 1997

The treatment of community-acquired pneumonia typically involves a course of intravenous and oral antibiotic therapy administered over several days. Few studies, however, have addressed the optimal duration of the intravenous and oral aspects of this therapy. Siegel and colleagues conducted a study to determine the optimal duration of intravenous therapy for community-acquired pneumonia that would result in an equivalent therapeutic outcome and cost to the health care system.

In this study, community-acquired pneumonia was defined by the presence of a new pulmonary infiltrate on chest radiograph, as well as by clinical history or signs and symptoms of pneumonia. Seventy-three patients with community-acquired pneumonia were randomized to three treatment groups. Patients in groups 1, 2 and 3 were given two, five and 10 days of intravenous therapy and eight, five and zero days of oral antibiotic therapy, respectively. Intravenous antibiotic therapy consisted of cefuroxime, 750 mg every eight hours. Oral antibiotic therapy consisted of cefuroxime axetil, 500 mg every 12 hours.

Although patients were discharged at the discretion of their attending physicians, patients were evaluated by one of the investigators between days 10 and 14 and again between days 26 and 28. Patients were considered to be therapeutic successes if fever, leukocytosis and chest infiltrate were absent by day 28 of the study.

Because of withdrawals, therapeutic failures (e.g., pneumococcal septic shock 24 hours after admission) and recording irregularities, the clinical outcome analysis was based on 48 patients. Clinical outcome did not differ among the three treatment groups with regard to fever, leukocytosis or chest radiograph resolution. On average, patients classified as therapeutic successes were afebrile within three days and without leukocytosis within four days of treatment. Chest infiltrates had resolved in 83 percent of patients by week 4.

Cost analysis was based on cost and length of hospital stay data obtained from the study site as well as from all Department of Veterans Affairs facilities using the DVA-maintained database of all inpatients. Length of stay analysis was performed for 46 study patients with a length of hospital stay of 12 days or less. The average length of stay for groups 1, 2 and 3 was six, eight and 11 days, respectively. The difference between each group was significant. The authors estimate a cost savings of $95.5 million for the Department of Veterans Affairs and $2.9 billion for private hospitals if community-acquired pneumonia is treated with a two-day intravenous regimen followed by oral antibiotic therapy.

The authors conclude that the optimal duration of intravenous antibiotic therapy for uncomplicated community-acquired pneumonia is two days, to be followed by oral antibiotic therapy. Intravenous therapy of longer duration increases the length of hospital stay and increases cost without changing the therapeutic outcome. The authors advocate larger studies with an increased female-to-male ratio of patients, a private sector setting and more intensive risk stratification to confirm their findings before these results are applied nationally.

Siegel RE, et al. A prospective randomized study of inpatient IV antibiotics for community-acquired pneumonia. The optimal duration of therapy. Chest 1996;110:965-71.

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