Efficacy and tolerance of cefotaxime followed by oral cefixime versus cefotaxime alone in patients with lower respiratory tract infections

Evaluation of an algorithm for switching from IV to PO therapy in clinical practice in patients with community-acquired pneumonia

BACKGROUND

In patients with community-acquired pneumonia (CAP), switching from IV to PO antibiotics offers advantages over IV therapy alone, including improved cost-effectiveness through reductions in the length of hospital stay and treatment costs.

OBJECTIVE

The aim of this study was to determine whether a method for switching therapy in clinical practice could be used in patients with CAP and whether differences were found in the duration of IV treatment and length of hospital stay between the 5 risk classes of the Pneumonia Severity Index (PSI) after the therapy switch.

METHODS

This was a prospective, observational study of patients aged >/=18 years presenting with CAP at our teaching hospital between December 1998 and November 2000. Microbiological and serological tests were performed, and signs and symptoms of CAP, C-reactive protein levels, and white blood cell counts were assessed throughout treatment and at the 1-month follow-up. Patients were stratified by PSI risk class. When the patient's temperature had been normalized for 72 hours and respiratory symptoms (dyspnea, coughing, and thoracal pain) had improved, patients were switched from IV to PO therapy (same drug).

RESULTS

The study included 180 patients with CAP Clinical cure was seen in 174 (97%) patients. No significant difference between the 5 risk classes was found in duration of therapy. Patients in risk class V remained hospitalized for a significantly longer period than patients in risk classes I through IV (P < 0.001). Furthermore, after patients were switched to PO antibiotics, the level of C-reactive protein decreased in patients in all risk classes and was normalized by follow-up.

CONCLUSIONS

In the population studied, use of specific criteria (ie, absence of fever for 72 hours and reduction in respiratory symptoms) allowed successful switch from IV to PO antibiotic therapy for the treatment of CAP Duration of therapy was not affected by PSI risk class, but those in risk class V were hospitalized longer than other risk classes.

Achieving a safe and early discharge for patients with community-acquired pneumonia

The rationale for achieving an early discharge for patients with CAP is that reduced length of stay can result in lower costs. When hospital discharge is premature, however, use of resources after discharge from the hospital may increase. This situation could increase overall cost and worsen quality of care. The objective should be to achieve a safe and early discharge. Several studies have evaluated methods for achieving this goal. Key findings from these studies are as follows: When a patient achieves clinical stability (e.g., systolic blood pressure, > or = 90 mm Hg; heart rate, < or = 100 beats/min; respiratory rate, < or = 24 breaths/min; temperature, < or = 38.3 degrees C [101 degrees F]; oxygen saturation, > or = 90%; able to eat; and stable mental status) or fulfills appropriate criteria (see Table 2), the patient may be eligible for switch from parenteral to oral antibiotics and early discharge. For many patients, this switch or discharge may occur on day 3 of hospitalization. When a patient is switched from parenteral to oral antibiotics, in many cases there does not appear to be a demonstrable clinical benefit to in-hospital observation. Elimination of in-hospital observation for patients who do not have an obvious reason for continued hospitalization potentially could reduce length of stay by 1 day. Improving efficiency of care reduces length of stay. This reduction may be accomplished by implementing clinical pathways, identifying and correcting causes of medically unnecessary hospital days, initiating early discharge planning, enlisting the services of a discharge coordinator, and organizing outpatient parenteral antibiotic treatment programs. These strategies are effective in many but not all patients, and their application should be tempered with careful clinical judgment.

Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital

In recent years 'switch therapy' has been advocated: short intravenous antibiotic therapy, for 2-3 days, followed by oral treatment for the remainder of the course. Little is known about the number of patients that could benefit from early switch therapy and the consequences of introducing this strategy in everyday practice. We prospectively registered all antibiotic courses on wards for Internal Medicine, Surgery, and Pulmonology during a 2 month period, before (n = 362, inventorial phase) and after (n = 281, implementation phase) the introduction of guidelines for switching therapy. Approximately 40% of all patients who started on iv antibiotics were candidates for an early iv-oral switch. During the inventorial phase, 54% (52/97) of eligible patients were switched to oral treatment, after a median of 6 days (range 2-28 days). After implementation of the guidelines, this percentage rose to 83% (66/80) (difference 29%, 95% CI 16-42%; P < 0.001). Therapy was also switched earlier, after a median of 4 days (range 2 to 16 days). In the 6 weeks after completion of the oral course, recurrence of infections, or readmissions due to reinfections did not occur. Compared with the inventorial phase, 43% of iv administrations could be avoided, that is >6000 per year. This means a potential annual reduction of dfl.60,000 (c. US$30,000) of administration costs. The potential savings in purchase costs of the antibiotics were dfl.54,000 (US$27,000) annually. In conclusion, a substantial number of patients starting on iv antibiotics were candidates for an early iv-oral switch. The guidelines were well accepted by the physicians and substantial savings in costs and nursing time were achieved.

Sequential antimicrobial therapy: pharmacokinetic and pharmacodynamic considerations in sequential therapy

The pharmacodynamic factors important in sequential therapy are largely unknown. This is because most pharmacodynamic investigations concentrate on how bacterial populations respond to first antimicrobial exposures. However, it is likely that for B lactams T>MIC and for quinolones the antimicrobial AUC/MIC ratio will be important. Factors which reduce antimicrobial absorption will impact on these parameters and require further study.

Sequential switch therapy for lower respiratory tract infections: a European perspective

Traditionally, serious lower respiratory tract infections (LRTIs) are treated in hospital and with parenteral antibiotics. During the past decade, there has been an impetus to reduce the overall cost of antimicrobial therapy. The availability of new oral antibiotics with superior pharmacokinetics profiles and safety has enabled clinicians increasingly to consider their use in managing serious infections effectively. This article reviews the current published literature regarding the practice of switch therapy for LRTIs, examining the evidence for efficacy, safety, appropriate timing of the switch, the economic benefits, and the suitability of various antibiotics. There is an emphasis on comparing current European and US experience and examining key strategies in implementing such programs and means of assessing their impact.

Switch therapy: the theory and practice of early change from parenteral to non-parenteral antibiotic administration

OBJECTIVE: The idea behind switch therapy is that antibiotic treatment should be changed from the parenteral to another suitable route (usually oral) as soon as the patient's condition allows. This option is cost-effective in terms of both acquisition costs (oral antibiotics are less expensive than their parenteral counterparts) and indirect costs, and patients may be discharged home sooner. This not only releases hospital beds but is also popular with patients and has other advantages. There are relatively few formal clinical trials, most often using oral third-generation cephalosporins and fluoroquinolones; these agents at present seem the most appropriate to use after parenteral antibiotics have been stopped (usually after 2 to 3 days). Logistic aspects are important, and close collaboration is required between pharmacists, physicians and microbiologists. Further trials are needed in specific patient groups and with other antibiotic regimens to validate the efficacy of switch therapy.

Assessment of the use of cefixime for switch therapy

Switch therapy, the switch from a parenteral to an oral antimicrobial agent, has been used successfully in the treatment of many serious infections. Several studies have found that significant cost savings can be achieved by switch therapy. Moreover, it has the further advantages of shortening hospital stay and reducing nosocomial bacteremia. With the exception of Staphylococcus aureus and penicillin-resistant Streptococcus pneumoniae, cefixime has similar in vitro activity to cefotaxime and ceftriaxone. It has a prolonged half-life, allowing for once-a-day dosing, and has excellent tissue penetration (132%). These characteristics support the use of cefixime for switch therapy when a susceptible pathogen has been identified.