What factors influence physicians' decisions to switch from intravenous to oral antibiotics for community-acquired pneumonia?
OBJECTIVE
One of the major factors influencing length of stay for patients with community-acquired pneumonia is the timing of conversion from intravenous to oral antibiotics. We measured physician attitudes and beliefs about the antibiotic switch decision and assessed physician characteristics associated with practice beliefs.


METHODS
Written survey assessing attitudes about the antibiotic conversion decision.


METHODS
Seven teaching and non-teaching hospitals in Pittsburgh, Pa.


METHODS
Three hundred forty-five generalist and specialist attending physicians who manage pneumonia in 7 hospitals.


RESULTS
Factors rated as "very important" to the antibiotic conversion decision were: absence of suppurative infection (93%), ability to maintain oral intake (79%), respiratory rate at baseline (64%), no positive blood cultures (63%), normal temperature (62%), oxygenation at baseline (55%), and mental status at baseline (50%). The median thresholds at which physicians believed a typical patient could be converted to oral therapy were: temperature < or =100 degrees F (37.8 degrees C), respiratory rate < or =20 breaths/minute, heart rate < or =100 beats/minute, systolic blood pressure > or =100 mm Hg, and room air oxygen saturation > or =90%. Fifty-eight percent of physicians felt that "patients should be afebrile for 24 hours before conversion to oral antibiotics," and 19% said, "patients should receive a standard duration of intravenous antibiotics." In univariate analyses, pulmonary and infectious diseases physicians were the most predisposed towards early conversion to oral antibiotics, and other medical specialists were the least predisposed, with generalists being intermediate (P <.019). In multivariate analyses, practice beliefs were associated with age, inpatient care activities, attitudes about guidelines, and agreeableness on a personality inventory scale.


CONCLUSIONS
Physicians believed that patients could be switched to oral antibiotics once vital signs and mental status had stabilized and oral intake was possible. However, there was considerable variation in several antibiotic practice beliefs. Guidelines and pathways to streamline antibiotic therapy should include educational strategies to address some of these differences in attitudes.
Halm
E A
EA
Departments of Health Policy and Medicine, Mount Sinai School of Medicine, New York, NY 10029, USA. ethan.halm@mountsinai.org
Switzer
G E
GE
Mittman
B S
BS
Walsh
M B
MB
Chang
C C
CC
Fine
M J
MJ
D000284:Administration, Oral; D000328:Adult; D000704:Analysis of Variance; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D017714:Community-Acquired Infections / Q000188:drug therapy; D003362:Cost-Benefit Analysis; D003657:Decision Making; D005260:Female; D019538:Health Care Surveys; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011014:Pneumonia / Q000188:drug therapy*; D010818:Practice Patterns, Physicians'
D000900:Anti-Bacterial Agents