Barriers to an early switch from intravenous to oral antibiotic therapy in hospitalised patients with CAP

Abstract

Do physicians apply an early-switch strategy (from intravenous to oral antibiotics) in clinically stable patients hospitalised with community-acquired pneumonia (CAP)? If not, why not?In a multicentre prospective cohort study, adult patients admitted for i.v. CAP treatment were included. On day 3 of antibiotic treatment, clinical stability was assessed and treating resident physicians were interviewed on their switch strategies. Additionally, treating physicians were interviewed to evaluate their knowledge of and adherence to guideline advice.149 (92%) out of 162 patients were included and 97 (91%) out of 107 physicians were interviewed. A switch to oral antibiotics was possible in 68 (46%) out of 149 patients on day 3 of treatment but not performed in 27 (40%) out of 68. Patient factors delaying the switch were high CURB-65 (confusion of new onset, urea .7 mmol?L -1 , respiratory rate of o30 breaths?min -1 , blood pressure ,90 mmHg or diastolic blood pressure f60 mmHg, and age o65 yrs) score (on admission) (p50.04) and oxygen treatment (p50.04), high temperature (p50.00) and high respiration rate (p50.04) (day 3). Physicians' barriers to an early switch in clinically stable patients included misconceptions (26 (55%) out of 47), practical considerations (13 (28%) out of 47) and organisational factors (eight (17%) out of 47). Strikingly, 91 (94%) out of 97 interviewed physicians were not aware of guideline advice. The switch from i.v. to oral antibiotics is often unnecessarily delayed in patients hospitalised with CAP due to different types of barriers.

Implementing criteria-based early switch/early discharge programmes: a European perspective

“…Potentially, ES and ED programmes may benefit by administration of IV antibiotics with highly bioavailable oral formulations, by offering precise guidelines regarding which oral antibiotics can be substituted for IV antibiotics or be used to treat specific conditions, or by providing an infectious disease consult [46]. Other prescriber-specific barriers identified include time constraints, rapid rotation of physicians in charge of patients, and the belief that IV therapy is superior to oral therapy [22,44]. …”

“…Unit/hospital level Barriers to ES and ED at a unit/hospital level include staffing time constraints, staffing changes and prescribing etiquette [43,44]. Reassessment of antimicrobial therapy after 48-72 h of treatment is often neglected because of time constraints and changes in staffing [19].…”

A three-step critical pathway for community-acquired pneumonia reduces duration of hospital stay and intravenous antibiotic use by 2 days

“…However, the literature shows that this is not common practice 4. In this study, the authors identified that 94% of physicians who treated these patients were unaware of available guidelines for the timing of the switch from  intravenous to oral antibiotics.…”

Diagnostic, therapeutic and economic consequences of a positive urinary antigen test forLegionellaspp. in patients admitted with community-acquired pneumonia: a 7-year retrospective evaluation

“…Patient factors (eg, comorbidities) or physician factors (eg, reluctance to stop β-lactam treatment or not being aware of guideline advice) may impede a switch to TT in case of a positive LUAT result 9. To date, it is unknown to what extent current use of the LUAT leads to timely detection of Legionella spp.…”