In-hospital observation after antibiotic switch in pneumonia: a national evaluation.
OBJECTIVE
To evaluate the clinical benefit of in-hospital observation after the switch from intravenous (IV) to oral antibiotics in a large Medicare population. Retrospective studies of relatively small size indicate that the practice of in-hospital observation after the switch from IV to oral antibiotics for patients hospitalized with community-acquired pneumonia (CAP) is unnecessary.


METHODS
We performed a retrospective examination of the US Medicare National Pneumonia Project database. Eligible patients were discharged with an ICD-9-CM diagnosis consistent with community-acquired pneumonia and divided into 2 groups: 1) a "not observed" cohort, in which patients were discharged on the same day as the switch from IV to oral antibiotics and 2) an "observed for 1 day" cohort, in which patients remained hospitalized for 1 day after the switch from IV to oral antibiotics. We compared clinical outcomes between these 2 cohorts.


RESULTS
A total of 39,242 cases were sampled, representing 4341 hospitals in all 50 states and the District of Columbia. There were 5248 elderly patients who fulfilled eligibility criteria involving a length of stay of no more than 7 hospital days (2536 "not observed" and 2712 "observed for 1 day" patients). Mean length of stay was 3.8 days for the "not observed" cohort and 4.5 days for the "observed for 1 day" cohort (P <.0001). There was no significant difference in 14-day hospital readmission rate (7.8% in the "not observed" cohort vs 7.2% "observed for 1 day" cohort, odds ratio 0.91; 95% confidence interval [CI] 0.74-1.12; P =.367) and 30-day mortality rate (5.1% "not observed" cohort vs 4.4% in the "observed for 1 day" cohort, odds ratio 0.86; 95% CI, 0.67-1.11; P =.258) between the "not observed" and "observed for 1 day" cohorts.


CONCLUSIONS
Our analysis of the US Medicare Pneumonia Project database provides further evidence that the routine practice of in-hospital observation after the switch from IV to oral antibiotics for patients with CAP may be avoided in patients who are clinically stable although these findings should be verified in a large randomized controlled trial.
Nathan
Ramesh V
RV
Division of Infectious Diseases, Department of Medicine, Veterans Affairs Greater Los Angeles Healthcare System, Los Angeles, Calif, USA.
Rhew
David C
DC
Murray
Cynthia
C
Bratzler
Dale W
DW
Houck
Peter M
PM
Weingarten
Scott R
SR
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000008:administration & dosage*; D017714:Community-Acquired Infections / Q000188:drug therapy; D015986:Confounding Factors, Epidemiologic; D005260:Female; D006302:Health Services Research; D006801:Humans; D007262:Infusions, Intravenous; D007297:Inpatients / Q000706:statistics & numerical data*; D007902:Length of Stay / Q000191:economics; D008297:Male; D006278:Medicare; D019370:Observation; D016017:Odds Ratio; D010359:Patient Readmission / Q000706:statistics & numerical data; D018410:Pneumonia, Bacterial / Q000188:drug therapy* / Q000191:economics / Q000635:transmission; D012107:Research Design; D012189:Retrospective Studies; D016896:Treatment Outcome; D014481:United States
D000900:Anti-Bacterial Agents