Clinical Benefit of In-Hospital Observation in 'Low-Risk' Pneumonia Patients
ABSTRACT & COMMENTARY
Synopsis: In 144 patients, classified as low-risk for pneumonia, observation following switch to oral antibiotic did not improve outcome. Similar numbers of patients, who were and were not observed, returned to the Emergency Department, and no patient from either group died within a 30-day follow-up. Observation of patients after switch-therapy appeared only to add to length of stay.
Source: Rhew DC, et al. Chest 1998;113:142-146.
Because pneumonia is a common and costly illness, clinicians have sought new approaches to manage these patients.2 While traditional antibiotic therapy has been given in the hospital for 7-10 days, numerous recent studies have suggested that efficiency could be improved by shortening intravenous therapy in low-risk patients. Patients are switched, after 2-5 days of intravenous therapy, to oral therapy without evidence of increased morbidity and mortality.2,4 However, even after antibiotic therapy is switched to oral, many clinicians, including myself, have still advised an observation period of 12-24 hours after conversion to oral therapy. A group of investigators from the Cedars Sinai Health System attempted to evaluate this process by conducting a retrospective review of data from a previously published prospective study.5 In a recent study from Rhew and colleagues, among 717 consecutive, adult patients admitted to the hospital for pneumonia, 144 patients were determined to be low-risk. Low-risk patients included patients with absence of significant serious comorbid disease including cancer, HIV or other immuno-suppression, no high-risk pathogen (i.e., Staphylococcus aureus or gram-negative rods), and no evidence of continued sepsis, physiologic deterioration, or worsening of comorbid illness, like exacerbation of COPD or persistent high fever. Patients also had to have no life-threatening complications, like myocardial infarction, brady- or tachyarrhythmias, or congestive heart failure. Low-risk patients were evaluated from time of conversion and for a 30-day follow-up. Patients were classified as "not observed" when the order to switch to oral antibiotics was written on the same day as the hospital discharge, whereas "observed" patients were switched to oral antibiotics at least one day before the hospital discharge. Only two low-risk patients had an explicit reason for continuing hospitalization-in one, an exacerbation of COPD and in another, small bowel obstruction. At 30 days, none of the patients "observed" had died, and only five had returned to the Emergency Department. Of the five patients requiring re-hospitalization, two were readmitted for respiratory problems. Of the patients who were "not observed," none of the patients required medical intervention within 24 hours of discharge, and there were no deaths at 30 days. Only one patient returned to the Emergency Department, and only two were readmitted for non-respiratory complaints. Observation took place for an average of 33 hours. Length-of-stay for patients in the "observed" group was 98 hours compared to 83 hours in those who were "not observed." The potential savings was approximately $57,200 for patients who were unnecessarily observed during the 22 months of the study.
COMMENT BY ALAN M. FEIN, MD
Pneumonia treated in the community and that treated in the hospital are clearly different diseases. Patients managed in the community are generally young, without comorbid illness, and have extremely low mortalities, almost always under 5% and, in most cases, less than 1%. Patients managed in the hospital are usually older, often quite elderly and with multiple comorbid illnesses and immuno-suppression. Mortality in the hospital may be as high as 10% and, for critically ill patients, is often above 25%. Traditionally, patients who have been managed in the hospital are given intravenous antibiotics empirically to cover pneumococcus and H. influenza. In severely ill patients, gram-negative and, sometimes, anti-pseudomonal coverage may be offered. The duration of therapy, until recently, had been assumed to be 7-14 days of intravenous therapy. With increased potency of antibiotic therapy and greater bioavailability, switching patients within 2-4 days to an oral regimen with similar coverage has been possible. Thus, a patient may move from an intravenous to oral cephalosporin, macrolide, or quinolone antibiotic, thereby reducing nursing care needs and risk of nosocomial infection.
Numerous studies have documented that so called "switch" or "stepdown" therapy may be accomplished with safety and equivalent efficacy to that available with traditional therapy.2-4 The current investigators take this concept one step further. Because of the uncertainty in outcomes, clinicians often observe patients for at least 12-24 hours following switch to oral therapy. This practice was based more on clinical insecurity than objective data. These authors retrospectively looked at a previously defined group of low-risk patients. This group, surprisingly, was an elderly one, with an average age between 67 and 71 years; however, no significant high-risk comorbid illnesses, high-risk pathogens, or life-threatening complications were noted at the time of switch. Additional observation time only added to overall length-of-stay and, thus, to cost of care. It was clear that in this defined group, representing only approximately 15% of the total group of patients hospitalized for pneumonia, safe discharge could have been accomplished at the time of stepdown to oral therapy. Pushing this envelope even further, one has to wonder whether all these patients needed to be in the hospital at all. Given the high bio-availability of many current antibiotics and the potential for administration of antibiotics intravenously at home, perhaps such low-risk patients could be prospectively defined and treated as outpatients from the beginning. The current crisis in healthcare has provided us with new opportunities-not all of them negative. Our patients who are low-risk prefer treatment at home. The report suggests that, even in elderly patients, this may be accomplished readily and safely in patients without significant pre-existing illness or pneumonia complications.
References
1. Fein AM, Niederman MS. Guidelines for the initial management of community-acquired pneumonia: Savory recipe or cookbook for disaster? Am J Respir Crit Care Med 1995;152:1149-1153.
2. Ramirez JA, et al. Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia. Arch Intern Med 1995;155:1273-1276.
3. Frighetto L, et al. Intravenous-to-oral stepdown program: 4 years of experience in a large teaching hospital. Ann Pharmacother 1992;26:1447-1451.
4. Siegel RE, et al. A prospective randomized study of inpatient IV antibiotics for community-acquired pneumonia: The optimal duration of therapy. Chest 1995;110:965-971.
5. Weingarten SR, et al. Evaluation of a pneumonia practice guideline in an interventional trial. Am J Respir Crit Care Med 1996;153:1110-1115.
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