Can patients hospitalized with community-acquired pneumonia be treated safely and effectively with oral antibiotics?

ABSTRACT

BACKGROUND: There is great variation in treatment strategies for community-acquired pneumonia. The authors of this study compared the safety, efficacy, and cost of oral therapy (in nonsevere pneumonia) and early switch to oral therapy (in severe pneumonia) with conventional parenteral treatment of community-acquired pneumonia in hospitalized patients.

POPULATION STUDIED: The investigators enrolled 235 adults, 188 of whom were included in the final analysis. The patients had a diagnosis of pneumonia on the basis of clinical, laboratory, and radiologic criteria. Hospitalization was considered according to published standards: age >60 years, comorbid conditions, or severity criteria (PaO₂ <60mmHg, respiratory rate ≥30/min, heart rate at least 125/min, systolic blood pressure <90mmHg, temperature of ≥40°C or <35°C, altered mental status, multilobar involvement, or patients treated appropriately for 72 hours who showed deterioration or no improvement. Patients were excluded if they had been discharged from an acute-care facility in the previous 8 days or had nosocomial pneumonia, AIDS, aspiration pneumonia, extrapulmonary septic metastases, malabsorption, or problems swallowing. Patients were also excluded if they were pregnant or lactating or had criteria for admission to the intensive care unit. Patients were split into 2 study groups: those with nonsevere pneumonia who required hospitalization but did not meet any of these severity criteria, and those who had at least one severity criterion.

STUDY DESIGN AND VALIDITY: This is a nonblinded, randomized controlled trial. The patients in both the nonsevere and the severe pneumonia groups were assigned to either a new therapeutic strategy or conventional treatment. Allocation was not concealed.

OUTCOMES MEASURED: The main outcomes were treatment failure, including death, time to resolution of morbidity, and cost. Other outcomes were length of hospital stay, length of IV and total antibiotic therapy, time until resumption of normal activities, radio-logic worsening at 48 hours, and adverse events.

RESULTS: In patients with nonsevere pneumonia, no significant differences were found in mortality or time to resolution of morbidity between those assigned to oral therapy and those assigned to IV therapy. Patients receiving parental therapy had significantly more treatment failures in those receiving oral therapy (number needed to treat [NNT] = 5). In patients with severe pneumonia, no significant differences were found in mortality, time to resolution of morbidity, or treatment failures. Fewer adverse events occurred in the oral and early-switch groups, largely because of infusion-related phlebitis (NNT = 4). Significant cost savings occurred among patients with severe pneumonia in the early-switch group, primarily because of their shorter hospitalization.