Chest
Volume 110, Issue 4, October 1996, Pages 965-971
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Clinical Investigations: Infection: Articles
A Prospective Randomized Study of Inpatient IV Antibiotics for Community-Acquired Pneumonia: The Optimal Duration of Therapy

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Study objective

To compare therapeutic outcome and perform a cost-benefit analysis of inpatients with community-acquired pneumonia (CAP) treated with a shortened course of IV antibiotic therapy.

Design

A prospective, randomized, parallel group study with a follow-up period of 28 days.

Setting

Bronx Veterans Affairs Medical Center (VAMC) and the Castle Point VAMC; university-affiliated VAMC general medical wards from September 1993 to March 1995.

Patients

Seventy-two male veterans and 1 female veteran with 75 episodes of CAP defined by a new infiltrate on chest radiograph and either history or physical findings consistent with pneumonia. Study population was 42%(31) black, 33%(24) white, and 25%(18) Hispanic.

Interventions

Patients were randomized (1:1:1) to 1 of 3 treatment groups: group 1 received 2 days of IV and 8 days of oral therapy; group 2 received 5 days of IV and 5 days of oral therapy; and group 3 received 10 days of IV therapy. Antibiotics consisted of cefuroxime, 750 mg every 8 h for the IV course, and cefuroxime axetil, 500 mg every 12 h for the oral therapy.

Measurements and Results

No differences were found in the clinical course, cure rates, or resolution of chest radiograph abnormalities among the three groups. A significant difference was found in the length of stay (LOS) among the three groups. The mean±SD LOS was 6±3 days in group 1, 8±2 days in group 2, and 11±1 days in group 3. The shortened LOS could potentially save $95.5 million for the Department of Veterans Affairs and $2.9 billion for the US private sector.

Conclusions

Adult patients hospitalized for CAP who are not severely ill can be successfully treated with an abbreviated (2-day) course of IV antibiotics and then switched to oral therapy. A longer course of IV therapy prolongs hospital stay and cost, without improving the therapeutic cure rate.

Section snippets

Methods

This study was performed at the Bronx Veterans Affairs Medical Center (VAMC) and the Castle Point VAMC. The investigational review boards at both hospitals approved the study and all patients provided signed informed consent prior to enrollment.

Study Protocol

Study participants were recruited from patients admitted to an inpatient acute medical ward, after the treating emergency department or clinic physician determined that the CAP should not be treated in an outpatient setting. Patients with the hospital

Results

Seventy-three patients with 75 episodes of CAP were randomized (1:1:1) into 3 treatment groups from September 1993 to March 1995. The ethnic and racial make-up included 31 (42%) black, 24 (33%) white, and 18 (25%) Hispanic patients. Seventy-two were male and 1 was female. Two patients were enrolled twice, for two distinctly different episodes of CAP. Seventy-one were enrolled at the Bronx VAMC and 4 at the Castle Point VAMC.

The study was completed in 57 (76%) of the 75 episodes of CAP that were

Discussion

This study demonstrates that the course of IV antibiotic therapy for the treatment of CAP can be shortened without compromising a satisfactory clinical outcome. In addition, we have shown that, as a result of a shortened IV course of therapy, the hospital LOS can be reduced with substantial cost savings.

Response to antibiotic therapy was rapid and apparent within 2 days of initiating treatment. In therapeutic successes, clinical features such as fever and leukocytosis responded quickly and

Acknowledgment

We are indebted to Theodore L. Nappi, Pharm D, and Raymond Pecini, Pharm D, for pharmacy support, Darryl Williams for antimicrobial susceptibility testing, Michael P. Fitzmaurice for information management of the VA database, and Norma Kanarek, PhD, for information management of the HSCRC database.

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  • Cited by (0)

    Supported m part by a grant from Glaxo Wellcome Inc.

    This study was presented in part at the American Thoracic Society Meeting, Seattle, May 24, 1995, and the American College of Chest Physicians Meeting, New York, October 31, 1995.

    revision accepted May 16.

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