Broad- versus Narrow-Spectrum Oral Antibiotic Transition and Outcomes in Health Care-associated Pneumonia.
BACKGROUND
Guidelines recommend a switch from intravenous to oral antibiotics once patients who are hospitalized with pneumonia achieve clinical stability. However, little evidence guides the selection of an oral antibiotic for patients with health care-associated pneumonia, especially where no microbiological diagnosis is made.


OBJECTIVE
To compare outcomes between patients who were transitioned to broad- versus narrow-spectrum oral antibiotics after initially receiving broad-spectrum intravenous antibiotic coverage.


METHODS
We performed a secondary analysis of an existing database of adults with community-onset pneumonia admitted to seven Utah hospitals. We identified 220 inpatients with microbiology-negative health care-associated pneumonia from 2010 to 2012. After excluding inpatient deaths and treatment failures, 173 patients remained in which broad-spectrum intravenous antibiotics were transitioned to an oral regimen. We classified oral regimens as broad-spectrum (fluoroquinolone) versus narrow-spectrum (usually a β-lactam). We compared demographic and clinical characteristics between groups. Using a multivariable regression model, we adjusted outcomes by severity (electronically calculated CURB-65), comorbidity (Charlson Index), time to clinical stability, and length of intravenous therapy.


RESULTS
Age, severity, comorbidity, length of intravenous therapy, and clinical response were similar between the two groups. Observed 30-day readmission (11.9 vs. 21.4%; P = 0.26) and 30-day all-cause mortality (2.3 vs. 5.3%; P = 0.68) were also similar between the narrow and broad oral antibiotic groups. In multivariable analysis, we found no statistically significant differences for adjusted odds of 30-day readmission (adjusted odds ratio, 0.56; 95% confidence interval, 0.06-5.2; P = 0.61) or 30-day all-cause mortality (adjusted odds ratio, 0.55; 95% confidence interval, 0.19-1.6; P = 0.26) between narrow and broad oral antibiotic groups.


CONCLUSIONS
On the basis of analysis of a limited number of patients observed retrospectively, our findings suggest that it may be safe to switch from broad-spectrum intravenous antibiotic coverage to a narrow-spectrum oral antibiotic once clinical stability is achieved for hospitalized patients with health care-associated pneumonia when no microbiological diagnosis is made. A larger retrospective study with propensity matching or regression-adjusted test of equivalence or ideally a prospective comparative effectiveness study will be necessary to confirm our observations.
1 Department of Pharmacy, Intermountain Medical Center, Murray, Utah.
Whitney R
http://orcid.org/0000-0001-9505-2572
WR
Buckel
2 Division of Infectious Diseases, Intermountain Healthcare, Murray, Utah.|3 Division of Infectious Diseases, Stanford University School of Medicine, Stanford, California; and.
Edward
http://orcid.org/0000-0001-6065-9964
E
Stenehjem
4 Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, Utah.
Jeff
J
Sorensen
4 Division of Pulmonary and Critical Care Medicine, Intermountain Medical Center and the University of Utah, Salt Lake City, Utah.
Nathan
http://orcid.org/0000-0002-1996-0533
N
Dean
2 Division of Infectious Diseases, Intermountain Healthcare, Murray, Utah.
Brandon
http://orcid.org/0000-0002-1799-3315
B
Webb
D000284:Administration, Oral; D000368:Aged; D000369:Aged, 80 and over; D000900:Anti-Bacterial Agents / Q000627:therapeutic use*; D017714:Community-Acquired Infections / Q000188:drug therapy*; D016208:Databases, Factual; D024881:Drug Resistance, Bacterial; D005260:Female; D006801:Humans; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009026:Mortality; D015999:Multivariate Analysis; D016017:Odds Ratio; D010359:Patient Readmission / Q000706:statistics & numerical data*; D011014:Pneumonia / Q000188:drug therapy* / Q000401:mortality*; D014589:Utah / Q000453:epidemiology
D000900:Anti-Bacterial Agents
antibiotic stewardship; bacterial antibiotic resistance; pneumonia