Oral stepdown in Gram‐positive bloodstream infections: A step in the right direction

Abstract

Bloodstream infections (BSIs) are associated with significant shortand long-term morbidity and mortality. [1][2][3] It is estimated there are over 536,000 BSIs in the United States annually, contributing to at least 72,000 deaths. 1 Among these, Gram-positive organisms are the causative pathogen in approximately one-half of cases. 4 Staphylococcus aureus and Enterococcus spp. are the most frequently identified Gram-positive organisms contributing to BSI, followed by coagulase-negative Staphylococcus spp. and Streptococcus spp. 4 The main pillars of BSI management, including those caused by Gram-positive pathogens, are source control and antimicrobial therapy. 5 Traditionally, intravenous antimicrobials have been utilized due to bioavailability concerns with oral therapy. 6 Undoubtedly, acutely ill patients benefit from early administration of active intravenous antimicrobials due to their rapid attainment of therapeutic drug concentrations. [7][8][9][10] The use of intravenous therapy in those who are clinically stable, however, may add significant burden to patients and health care systems alike given the prolonged treatment duration often required in BSIs. 7,11 Thus, the necessity of intravenous therapy for the entire treatment course has been increasingly called into question.Oral stepdown therapy is the practice of converting from an intravenous drug to an active oral agent, which may be an interchange to a medication in the same class or a different class altogether. 12 This differs from sequential therapy, in which an intravenous medication is converted to the oral formulation of the same compound. 12 Sequential therapy is ideal as patient tolerability is already known, preventing delays in care or discharge. This type of conversion is not always possible due to the lack of bioavailable oral formulations

Intravenous versus Partial Oral Antibiotic Therapy in the Treatment of Uncomplicated Bloodstream Infection Due to Streptococcus Species

“…In the past, intravenous antibiotics have been considered the preferred treatment for BSIs due to concerns of impaired gastrointestinal absorption and subtherapeutic serum levels with oral antibiotics. Despite differences in bioavailability, partial oral antibiotic therapy may reduce healthcare costs, hospital length of stay (HLOS), and complications associated with intravenous catheters in the outpatient setting [ 5 , 6 , 7 , 8 ]. Several studies have demonstrated the lower healthcare costs, infection risk, and shorter HLOS associated with partial oral antibiotic therapy compared to standard intravenous regimens [ 9 , 10 , 11 , 12 ].…”

“…However, the utilization of partial oral antibiotic therapy for the treatment of streptococcal BSIs is a relatively a new concept, and the susceptibility of Streptococcus species to penicillin lends to different oral options than most Gram-negative BSIs. Although oral antibiotics have been used in the treatment of streptococcal BSIs, their specific role in therapy remains unclear [ 5 , 15 , 16 , 17 ].…”