Medline ® Abstracts for References 77,78,83

of 'Treatment of community-acquired pneumonia in adults who require hospitalization'

77
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Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial.
AU
CarratalàJ, Garcia-Vidal C, Ortega L, Fernández-SabéN, Clemente M, Albero G, López M, CastellsaguéX, Dorca J, Verdaguer R, Martínez-Montauti J, Manresa F, Gudiol F
SO
Arch Intern Med. 2012;172(12):922.
 
BACKGROUND: The length of hospital stay (LOS) for community-acquired pneumonia (CAP) varies considerably, even though this factor has a major impact on the cost of care. We aimed to determine whether the use of a 3-step critical pathway is safe and effective in reducing duration of intravenous antibiotic therapy and length of stay in hospitalized patients with CAP.
METHODS: We randomly assigned 401 adults who required hospitalization for CAP to follow a 3-step critical pathway including early mobilization and use of objective criteria for switching to oral antibiotic therapy and for deciding on hospital discharge or usual care. The primary end point was LOS. Secondary end points were the duration of intravenous antibiotic therapy, adverse drug reactions, need for readmission, overall case-fatality rate, and patients' satisfaction.
RESULTS: Median LOS was 3.9 days in the 3-step group and 6.0 days in the usual care group (difference, -2.1 days; 95% CI, -2.7 to -1.7; P<.001). Median duration of intravenous antibiotic therapy was 2.0 days in the 3-step group and 4.0 days in the usual care group (difference, -2.0 days; 95% CI, -2.0 to -1.0; P<.001). More patients assigned to usual care experienced adverse drug reactions (4.5% vs 15.9% [difference, -11.4 percentage points; 95% CI, -17.2 to -5.6 percentage points; P<.001]). No significant differences were observed regarding subsequent readmissions, case fatality rate, and patients' satisfaction with care.
CONCLUSIONS: The use of a 3-step critical pathway was safe and effective in reducing the duration of intravenous antibiotic therapy and LOS for CAP and did not adversely affect patient outcomes. Such a strategy will help optimize the process of care of hospitalized patients with CAP, and hospital costs would be reduced.
TRIAL REGISTRATION: isrctn.org Identifier: ISRCTN17875607.
AD
Infectious Disease Service, Bellvitge Institute for Biomedical Research (IDIBELL)-Hospital Universitari de Bellvitge, University of Barcelona, L'Hospitalet, Barcelona, Spain. jcarratala@ub.edu
PMID
78
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Early switch from intravenous to oral antibiotics in hospitalized patients with bacteremic community-acquired Streptococcus pneumoniae pneumonia.
AU
Ramirez JA, Bordon J
SO
Arch Intern Med. 2001;161(6):848.
 
BACKGROUND: The identification of Streptococcus pneumoniae bacteremia in hospitalized patients with community-acquired pneumonia is considered by some investigators to be an exclusion criterion for early switch from intravenous to oral therapy.
OBJECTIVE: To determine whether the switch from intravenous to oral therapy in such patients, once the bx;1patient reaches clinical stability, is associated with poor clinical outcome.
METHODS: The medical records of 400 patients with community-acquired pneumonia hospitalized at the Veterans Affairs Medical Center of Louisville (Louisville, Ky) were reviewed to identify patients with bacteremic S pneumoniae. Four criteria were used to define when a patient reached clinical stability and should be considered a candidate for switch therapy: (1) cough and shortness of breath are improving, (2) patient is afebrile for at least 8 hours, (3) white blood cell count is normalizing, and (4) oral intake and gastrointestinal tract absorption are adequate.
RESULTS: A total of 36 bacteremic patients were identified. No clinical failures occurred in 18 patients who reached clinical stability and were switched to oral therapy or in 7 patients who reached clinical stability and continued intravenous therapy. Clinical failures (5 deaths) occurred in the group of 11 patients who did not reach clinical stability.
CONCLUSION: Once a hospitalized patient with community-acquired pneumonia reaches clinical stability, it is safe to switch from intravenous to oral antibiotics even if bacteremia caused by S pneumoniae was initially documented.
AD
Division of Infectious Diseases, Department of Medicine, University of Louisville, Louisville, KY 40292, USA. j.ramirez@louisville.edu
PMID
83
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Strategies for reduction in duration of antibiotic use in hospitalized patients.
AU
Hayashi Y, Paterson DL
SO
Clin Infect Dis. 2011;52(10):1232.
 
There is a global crisis of antibiotic resistance in part because of the collateral damage of antibiotic use. Reduction in antibiotic consumption is clearly important to minimize this problem. Limiting treatment duration may be the most clinically palatable means of reducing antibiotic consumption. Antimicrobial stewardship programs play an important role in this process. Their effectiveness may be increased by drawing on evidence from randomized controlled trials regarding optimal antibiotic duration. However, in most clinical scenarios, the recommended duration of therapy in published guidelines is based on expert opinion. Biological markers, such as procalcitonin, have been shown to reduce antimicrobial consumption with no adverse outcome in 11 randomized controlled trials. Although procalcitonin may not be the perfect biomarker, the concept of procalcitonin-guided antibiotic discontinuation after clinical stabilization, in conjunction with antimicrobial stewardship programs, appears to be ready for introduction into clinical practice.
AD
The University of Queensland, Centre for Clinical Research, Brisbane, Australia.
PMID