Identification of Low-Risk Hospitalized Patients With Pneumonia: Implications for Early Conversion to Oral Antimicrobial Therapy

doi:10.1378/chest.105.4.1109

Chest

Volume 105, Issue 4, April 1994, Pages 1109-1115

https://doi.org/10.1378/chest.105.4.1109 Get rights and content

Purpose

Few available data exist to define either the medically necessary duration of parenteral antimicrobial therapy or length of stay for hospitalized patients with pneumonia. Therefore, we investigated the potential safety and effectiveness of a practice guideline recommending early conversion of low-risk patients with pneumonia from parenteral to oral antimicrobial therapy and early hospital discharge.

Patients and methods

The practice guideline was studied retrospectively in 503 hospitalized patients with pneumonia at a teaching community hospital.

Results

Thirty-three percent of patients with pneumonia were classified as at low risk for complications and potentially suitable for early conversion to oral antimicrobial therapy according to the guideline. Were the guideline to have been used to guide patient discharge decisions, 619 additional bed-days would have been made available to accommodate incoming patients. A consensus among physician reviewers led to the judgment that quality of care would not have worsened for 98.2 percent of low-risk patients had they been switched to oral antimicrobial therapy on the third hospital day, nor would quality of care have been worsened for 93.4 percent of low-risk patients had they been discharged on the fourth hospital day.

Conclusion

The practice guideline that we studied has the potential to safely reduce the duration of parenteral antimicrobial therapy and length of hospital stay for selected low-risk patients with pneumonia. The guideline should be studied in a prospective clinical trial.

Section snippets

Description of Institution

The study was performed at Cedars-Sinai Medical Center, a large teaching community hospital that primarily serves West Los Angeles. The majority of hospitalized patients are cared for by physicians in private practice.

Description of Patients

The inclusionary criteria for pneumonia were the presence of an infiltrate on the chest radiograph and at least one of the major or two of the minor criteria given heretofore:19, 20 major criteria—cough, sputum production, or history of fever; minor criteria—dyspnea, pleuritic

Demographics

A total of 503 consecutively hospitalized patients between June 1, 1990, and May 30, 1991, with pneumonia were enrolled. Medical records were available for abstraction on 97 percent of patients. The average age of study patients was 72.2 ± 18.1 years old (mean ± SD); 74 percent of patients were 65 years of age or older. Fifty-eight percent of patients were women. The mean length of hospital stay was 9.5 ± 9.8 days and the mean ICU length of stay was 0.9 ± 3.9 days. The infectious etiologies of

CONCLUSION

Patients hospitalized with pneumonia commonly receive parenteral antimicrobial therapy for approximately 7 days and then are converted to oral antimicrobial therapy.31, 32 There are few published data to support or refute this commonly followed medical practice, nor are there available data to guide physicians’ decisions about the optimal length of parenteral antimicrobial therapy and hospital length of stay. Our present guideline differs from our previous one in that we included patients with

ACKNOWLEDGMENTS

We would like to thank Vanessa Walker and the Medical Records Department at Cedars-Sinai Medical Center for their contribution to this research study.

REFERENCES (39)

RE Dixon
Economic costs of respiratory tract infections in the United States?
Am J Med
(1985)
SR Weingarten et al.
Selecting the best triage rule for patients hospitalized with chest pain?
Am J Med
(1989)
S Weingarten et al.
Reducing lengths of stay for patients hospitalized with chest pain using medical practice guidelines and opinion leaders?
Am J Cardiol
(1993)
SR Weingarten et al.
Triage practice guideline for patients hospitalized with congestive heart failure: improving the effectiveness of the coronary care unit?
Am J Med
(1993)
HP Selker
Criteria for adoption in practice of medical practice guidelines?
Am J Cardiol
(1993)
JA Paladino et al.
Clinical and economic evaluation of oral ciprofloxacin after an abbreviated course of intravenous antibiotics?
Am J Med
(1991)
WE Sanders et al.
Oral ofloxacin for the treatment of acute bacterial pneumonia: use of a nontraditional protocol to compare experimental therapy with “usual care” in a multicenter clinical trial?
Am J Med
(1991)
MJ Fine et al.
Hospitalization decision in patients with community-acquired pneumonia: a prospective cohort study?
Am J Med
(1990)
MJ Fine et al.
Validation of a pneumonia prognostic index using the MedisGroups comparative hospital database?
Am J Med
(1993)
Detailed diagnoses and procedures, National hospital discharge survey, 1990
(1992)

RW Dubois et al.

Hospital inpatient mortality: is it a predictor of quality?

N Engl J Med

(1987)

RW Dubois et al.

Preventable deaths: who, how often, and why?

Ann Intern Med

(1988)

LF McMahon et al.

Variation in hospital admissions among small areas: a comparison of Maine and Michigan?

Med Care

(1989)

MJ Fine et al.

Differences in length of hospital stay in patients with community-acquired pneumonia: a prospective four-hospital study?

Med Care

(1993)

S Weitzman et al.

Uncomplicated pneumonia: an evaluation of determinants of length of hospitalization?

Isr J Med Sci

(1983)

DM Eddy

Variations in physician practice: the role of uncertainty?

Health Aff

(1984)

S Weingarten et al.

Early “step-down” transfer of low-risk patients with chest pain: a controlled interventional trial?

Ann Intern Med

(1990)

KA Eagle et al.

Length of stay in the intensive care unit: effects of practice guidelines and feedback?

JAMA

(1990)

LO Gentry et al.

Parenteral followed by oral ofloxacin for nosocomial and community-acquired pneumonia requiring hospitalization?

Am Rev Respir Dis

(1992)

Cited by (83)

Prognostic factors for early clinical failure in patients with severe community-acquired pneumonia
2006, Clinical Microbiology and Infection
Citation Excerpt :
Any non-contaminating microorganism cultured from a blood or sputum sample, or detected by urinary antigen testing, was considered to be a cause for the episode of pneumonia. For M. pneumoniae, a four-fold or greater increase in titre between paired sera, or a single titre of ≥1:40, in immune fluorescence tests (Serodia-MycoII; Fujirebio Inc., Malvern, PA, USA), was considered to be indicative of infection [23]. For L. pneumophila, a four-fold increase in the antibody titre to ≥1:128, or single titres of ≥1:256, were considered to be suggestive of Legionella pneumonia [24].
For patients with community-acquired pneumonia (CAP), clinical response during the first days of treatment is predictive of clinical outcome. As risk assessments can improve the efficiency of pneumonia management, a prospective cohort study to assess clinical, biochemical and microbiological predictors of early clinical failure was conducted in patients with severe CAP (pneumonia severity index score of >90 or according to the American Thoracic Society definition). Failure was assessed at day 3 and was defined as death, a need for mechanical ventilation, respiratory rate >25/min, PaO₂ <55 mm Hg, oxygen saturation <90%, haemodynamic instability, temperature >38°C or confusion. Of 260 patients, 80 (31%) had early clinical failure, associated mainly with a respiratory rate >25/minute (n = 34), oxygen saturation <90% (n = 28) and confusion (n = 20). In multivariate logistic regression analysis, failure was associated independently with altered mental state (OR 3.19, 95% CI 1.75–5.80), arterial PaH <7.35 mm Hg (OR 4.29, 95% CI 1.53–12.05) and PaO₂ <60 mm Hg (OR 1.75, 95% CI 0.97–3.15). A history of heart failure was associated inversely with clinical failure (OR 0.30, 95% CI 0.10–0.96). Patients who failed to respond had a higher 28-day mortality rate and a longer hospital stay. It was concluded that routine clinical and biochemical information can be used to predict early clinical failure in patients with severe CAP.
Once-daily oral gatifloxacin vs. three-times-daily co-amoxiclav in the treatment of patients with community-acquired pneumonia
2004, Clinical Microbiology and Infection
Citation Excerpt :
In the USA alone, over four million cases of CAP are diagnosed each year, of which some 600 000 require hospitalisation [1]. With annual costs of about $23 billion, the economic burden posed by this disease is considerable [2]. Antimicrobial therapy plays a vital role in the treatment of CAP, with studies showing that prompt administration of antibiotic therapy can have a significant effect in reducing morbidity and mortality associated with the disease [3].
A double-blind, double-dummy, multicentre, multinational, parallel-group study was designed to establish proof of equivalence between oral gatifloxacin and oral co-amoxiclav in the treatment of 462 patients with mild-to-moderate community-acquired pneumonia. Eligible patients were randomised equally to either gatifloxacin 400 mg once-daily plus matching placebo for 5–10 days, or amoxycillin 500 mg + clavulanic acid 125 mg three-times-daily for 5–10 days. The primary efficacy endpoint was clinical response (clinical cure plus improvement) at the end of treatment. Overall, a successful clinical response was achieved in 86.8% of gatifloxacin-treated patients, compared with 81.6% of those receiving co-amoxiclav, while corresponding rates of bacteriological efficacy (eradication plus presumed eradication) were 83.1% and 78.7%, respectively. The safety and tolerability profile of gatifloxacin was comparable to that of co-amoxiclav, with adverse gastrointestinal events, e.g., diarrhoea and nausea, being the most common treatment-related adverse events in both groups. The study showed no evidence of gatifloxacin-induced phototoxicity, musculoskeletal disorders, or hepatic and renal problems. Overall, this study showed that gatifloxacin was equivalent clinically to a standard course of co-amoxiclav in patients with community-acquired pneumonia, and that gatifloxacin was safe and well-tolerated.
Respiratory infections in adults hospitalized in internal medicine and pneumology departments. DIRA study
2003, Enfermedades Infecciosas y Microbiologia Clinica
Las infecciones del tracto respiratorio son procesos muy frecuentes que originan ingresos hospitalarios o complican a pacientes ya ingresados en servicios de medicina interna o neumolog? La Fundaci??ara el Estudio de la Infecci??mpuls?? Proyecto DIRA (D?de la Infecci??espiratoria en el Adulto), con objeto de conocer y valorar el impacto de este problema en general, y en particular en los servicios antes mencionados.
Se ha realizado un estudio prospectivo de prevalencia con recogida de datos un día determinado, con una periodicidad trimestral (total 4 cortes), con la participación de 158 médicos pertenecientes a 100 servicios de medicina interna y neumología, recogiéndose información sobre el número de pacientes atendidos, pacientes con infección, con infección respiratoria y características epidemiológicas, clínicas, microbiológicas y de tratamiento de estos últimos.
El número total de pacientes ingresados en los 4 cortes fue de 3.596. El 39,1% presentaban sintomatología compatible con una infección y en el 34,3% la infección era infección respiratoria (IR). En los pacientes con IR, la edad media fue de 65,6 años, el 68,8% eran varones, en el 84,1% existía enfermedad de base (la más frecuente, enfermedad pulmonar obstructiva crónica [EPOC]) y en el 25,1% algún factor predisponente. La neumonía fue el diagnóstico más frecuente (41,3% de las IR). La IR fue documentada microbiológicamente en el 15,8% de los casos. El 99,7% de los pacientes con diagnóstico de bronquitis aguda y el 81,8% de los diagnosticados de infección de vías respiratorias altas recibieron tratamiento con antibióticos. Las penicilinas fueron los antibióticos más utilizados. Se presentan datos desglosados por diagnósticos.
La IR es una enfermedad muy frecuente en los pacientes ingresados en los servicios de medicina interna y neumología de los hospitales, siendo la neumonía la que ocupa el primer lugar. La documentación microbiológica es muy escasa. La mayoría de los pacientes con infecciones del tracto respiratorio superior recibieron tratamiento antibiótico probablemente de forma injustificada. En aproximadamente la mitad de los casos, la medicación antimicrobiana suele ser combinando dos o más fármacos.
Respiratory tract infections (RIs) are frequent processes that can require hospitalization or affect already hospitalized patients. The Foundation for the Study of Infection has promoted the DIRA (Adult Respiratory Infection Day) Project, with the aim of investigating and assessing the impact of this problem, particularly in Internal Medicine and Pneumology Departments.
Prospective prevalence study involving 158 physicians in 100 Internal Medicine and Pneumology Departments. Data were collected on predetermined days, once every three months (total of four data sets) and included information on number of patients attended, number of patients with infection, and epidemiologic, clinical, microbiologic and treatment characteristics of patients with RI.
A total of 3,596 patients were hospitalized at the four time points. Among these, 39.1% presented clinical symptoms consistent with infection and 34.3% of these were RIs. The mean age of RI patients was 65.6 years, 68.8% were males, 84.1% had an underlying disease (most frequently chronic obstructive pulmonary disease) and 25.1% had one or more predisposing factors. Pneumonia was the most frequent diagnosis (41.3% of RIs). RI was documented microbiologically in 15.8% of cases. Antibiotic treatment was applied in 99.7% of patients with acute bronchitis and 81.8% of those with upper respiratory tract infection; penicillins were the most frequent treatment. Data are presented by diagnosis.
A substantial rate of respiratory infections was found in patients admitted to hospital Internal Medicine and Pneumology Departments, with pneumonia being the most frequent. There was a paucity of microbiologic documentation. It is likely that antibiotic treatment was not justified in the majority of patients with upper respiratory tract infections. A combination of two or more antimicrobial agents was used in about half of cases.
Comparison of processes and outcomes of pneumonia care between hospitalists and community-based primary care physicians
2002, Mayo Clinic Proceedings
To compare medical care provided by hospitalists and primary care physicians to patients with community-acquired pneumonia in order to identify specific practices that might explain the improved efficiency of care provided by hospitalists.
We retrospectively reviewed the medical charts of 455 patients hospitalized with pneumonia at a community-based tertiary care center between January 1, 1998, and January 1, 1999. Exclusion criteria included human immunodeficiency virus infection, lung cancer, active tuberculosis, hospitalization within 7 days, length of stay (LOS) more than 14 days, and requirement of mechanical ventilation. All patients were cared for by either a full-time hospitalist or a primary care physician. Data collected included patient insurance status, variables to calculate each patient's Pneumonia Severity Index score, initial antibiotic selection, door-to-needle time, time to patient stability for switch to oral antibiotics, time to actual switch, unstable variables at discharge, and subspecialty consultation rate. Each patient's initial chest x-ray film was reviewed and classified as diagnostic of pneumonia, indeterminate, or clear. Outcomes measured via administrative database were mortality, LOS, costs, and readmission rate.
Primary care physicians cared for 270 patients, and hospitalists cared for 185. Primary care physician patients were older, and this group had a higher proportion of the highest-risk patients. The mean time to stability was 3.2 days for hospitalists and 3.3 days for primary care physicians, and the mean time from stability to actual switch from intravenous to oral antibiotics was 1.6 days and 2.3 days, respectively (P=.003). The mean adjusted LOS was 5.6 days for hospitalists and 6.5 days for primary care physicians. Similarly adjusted costs were $594 less per patient treated by hospitalists. A difference in door-to-needle time of 0.9 hour favoring primary care physicians did not contribute to LOS. No significant differences were noted in adjusted inpatient mortality or the appropriateness of initial antibiotics used. Primary care physicians were more likely to prescribe clindamycin and ceftazidime, and they requested infectious disease consultations more often. At discharge, 14% of hospitalist patients and 7% of primary care physician patients had at least 1 unstable variable. Differences in hospital readmission rates at 15 and 30 days were not statistically significant in combined or risk-stratified analyses.
Inpatients with community-acquired pneumonia cared for by hospitalists had a shorter adjusted LOS than those seen by primary care physicians primarily because of earlier recognition of stability and more rapid conversion from intravenous to oral antibiotics. Adjusted costs were likewise reduced. However, patients seen by hospitalists were discharged with an unstable clinical variable more often. Other than earlier switch to oral antibiotics, less use of clindamycin and ceftazidime, and fewer infectious disease consultations, hospitalists' processes of care were similar to those of primary care physicians.
Efficacy and safety of oral and early-switch therapy for community-acquired pneumonia: A randomized controlled trial
2001, American Journal of Medicine
Citation Excerpt :
Our study supports the growing evidence that an oral course of antibiotics is safe and effective in patients currently admitted to the hospital who do not have severe pneumonia; it also suggests that these patients could be treated safely as outpatients or admitted for a short stay until a favorable course is observed. In patients with severe pneumonia, our results support the findings of previous retrospective (22), nonrandomized (23,24), or noncontrolled (25–28) studies and studies that had less well-defined inclusion and severity criteria (29–32). Those studies reported that treatment can be switched to oral therapy in patients who do well clinically.
We sought to determine the safety, efficacy, and cost of oral therapy for patients with community-acquired pneumonia. In patients with nonsevere pneumonia, conventional (parenteral) treatment was compared with the oral route; in patients with severe pneumonia, conventional treatment was compared with early switch from parenteral to oral therapy.
We randomly assigned 85 hospitalized patients with nonsevere pneumonia to one of two groups: 41 received oral antimicrobials from admission, and 44 received parenteral antimicrobials until they had been afebrile for 72 hours before switching to oral treatment. We randomly assigned 103 patients with severe pneumonia who had initially been treated with parenteral antimicrobials to one of two groups: 48 were switched to oral therapy after 48 hours of treatment (early switch), and 55 received a full 10-day course of parenteral antibiotics.
Among patients with nonsevere pneumonia, there were no deaths in the oral treatment group, and one death (2%) in the parenteral treatment group (95% confidence interval [CI] for between-group [oral minus parenteral] difference: −7% to 2%, P = 0.3). The time to resolution of morbidity was ≤5 days in 34 (83%) patients in the oral treatment group and 39 (88%) patients in the parenteral treatment group (P = 0.5); there were treatment failures in 4 (10%) patients in the oral treatment group and 14 (32%) patients in the parenteral treatment group (P = 0.02). Among patients with severe pneumonia, there was one (2%) death in the early-switch group and no deaths in the full course of parenteral antibiotics groups (95% CI for between-group [early switch vs. full course] difference: −2% to 6%, P = 0.5). The time to resolution of morbidity was ≤5 days in 38 (79%) patients in the early-switch group and 41 (75%) in the full-course group (P = 0.3). There were 12 (25%) treatment failures in the early-switch group and 13 (24%) in the full-course group (P = 0.9). There were fewer adverse events in the oral and early-switch groups, primarily due to lower rates of infusion-related phlebitis. Significant cost savings, mainly due to a shorter hospitalization, occurred among patients with severe pneumonia in the early-switch group.
Inpatients with nonsevere community-acquired pneumonia can be effectively and safely treated with oral antimicrobials from the time of admission, whereas those with severe pneumonia can be treated with early-switch therapy.
Management of patients with infectious diseases in an emergency department observation unit
2001, Emergency Medicine Clinics of North America
Citation Excerpt :
They are instructed to push oral fluids and to return if fever, pain, hematuria, vomiting, weakness, or extremity swelling occurs. Pneumonia, cellulitis, and pyelonephritis are discussed in this review because they are the most common infections requiring hospital care, and they all have significant death or complication rates and broad differential diagnoses.27,29,31,76 They also demonstrate many of the considerations that could be applied to other infections appropriate for OU care.
Decision making for patients with infectious diseases (ID) is difficult because of the huge and expanding variety of causal organisms and their constantly changing antibiotic susceptibilities.⁵⁷ Worse still, the infecting organisms vary by age group, comorbidities, and anatomic location of infection.⁵² Antibiotic susceptibility for a specific organism can vary by age, living conditions and daily contacts, past exposure to antibiotics, anatomic location, geographic regions, and even hospital ward within a single institution.51, 52
Emergency physicians frequently are forced to initiate empiric antibiotics without benefit of Gram's stain, culture, or sensitivity results. Compared with other specialties, the opportunity for learning from patient follow-up is limited. Emergency physicians, more than most therefore must be up to date on both the pertinent ID literature, as well the specific epidemiology and susceptibility patterns in their own individual practice settings. This article focuses on three common causes of hospitalization for IDs: pneumonia, cellulitis, and pyelonephritis.6, 12, 22, 42 In 1994, these three diseases accounted for 5% of all hospital admissions and billions in expenditures.26, 28, 36, 37 This area offers plenty of opportunity for improvement in the use of hospitals and health care dollars. Many studies have explored treating patients with antibiotics at home.2, 4, 23, 62, 66 However, severe illness is really a continuum. Even if more patients are treated at home, a group of patients remains, who are too sick for discharge directly to home, but who do not require full hospital admission either. Those patients are ideal candidates for short-stay observation unit (OU) treatment.25, 32, 41, 74, 76 Accurately selecting this group of patients and designing empiric treatment guidelines specifically for them is the first challenge this article addresses. The material is presented both for those designing new guidelines and for physicians making decisions for individual patients. It becomes apparent that precise data for making these recommendations are not now available,6, 48, 75, 76 the author will try to review the best existing evidence and highlight where research needs to be done to refine future guidelines. There are also some unavoidable inconsistencies between the discussions and tables for each disease because the three entities are so different.

View all citing articles on Scopus

: This study was funded by a grant from Miles, Inc.

View full text

Chest

Identification of Low-Risk Hospitalized Patients With Pneumonia: Implications for Early Conversion to Oral Antimicrobial Therapy

Purpose

Patients and methods

Results

Conclusion

Section snippets

Description of Institution

Description of Patients

Demographics

CONCLUSION

ACKNOWLEDGMENTS

Am J Med

Am J Med

Am J Cardiol

Am J Med

Am J Cardiol

Am J Med

Am J Med

Am J Med

Am J Med

Detailed diagnoses and procedures, National hospital discharge survey, 1990

Hospital inpatient mortality: is it a predictor of quality?

N Engl J Med

Preventable deaths: who, how often, and why?

Ann Intern Med

Variation in hospital admissions among small areas: a comparison of Maine and Michigan?

Med Care

Differences in length of hospital stay in patients with community-acquired pneumonia: a prospective four-hospital study?

Med Care

Uncomplicated pneumonia: an evaluation of determinants of length of hospitalization?

Isr J Med Sci

Variations in physician practice: the role of uncertainty?

Health Aff

Early “step-down” transfer of low-risk patients with chest pain: a controlled interventional trial?

Ann Intern Med

Length of stay in the intensive care unit: effects of practice guidelines and feedback?

JAMA

Parenteral followed by oral ofloxacin for nosocomial and community-acquired pneumonia requiring hospitalization?

Am Rev Respir Dis