Buckel Whitney R, Stenehjem Edward, Sorensen Jeff, Dean Nathan, Webb Brandon
1 Department of Pharmacy, Intermountain Medical Center, Murray, Utah.
2 Division of Infectious Diseases, Intermountain Healthcare, Murray, Utah.
Ann Am Thorac Soc. 2017 Feb;14(2):200-205. doi: 10.1513/AnnalsATS.201606-486BC.
Guidelines recommend a switch from intravenous to oral antibiotics once patients who are hospitalized with pneumonia achieve clinical stability. However, little evidence guides the selection of an oral antibiotic for patients with health care-associated pneumonia, especially where no microbiological diagnosis is made.
To compare outcomes between patients who were transitioned to broad- versus narrow-spectrum oral antibiotics after initially receiving broad-spectrum intravenous antibiotic coverage.
We performed a secondary analysis of an existing database of adults with community-onset pneumonia admitted to seven Utah hospitals. We identified 220 inpatients with microbiology-negative health care-associated pneumonia from 2010 to 2012. After excluding inpatient deaths and treatment failures, 173 patients remained in which broad-spectrum intravenous antibiotics were transitioned to an oral regimen. We classified oral regimens as broad-spectrum (fluoroquinolone) versus narrow-spectrum (usually a β-lactam). We compared demographic and clinical characteristics between groups. Using a multivariable regression model, we adjusted outcomes by severity (electronically calculated CURB-65), comorbidity (Charlson Index), time to clinical stability, and length of intravenous therapy.
Age, severity, comorbidity, length of intravenous therapy, and clinical response were similar between the two groups. Observed 30-day readmission (11.9 vs. 21.4%; P = 0.26) and 30-day all-cause mortality (2.3 vs. 5.3%; P = 0.68) were also similar between the narrow and broad oral antibiotic groups. In multivariable analysis, we found no statistically significant differences for adjusted odds of 30-day readmission (adjusted odds ratio, 0.56; 95% confidence interval, 0.06-5.2; P = 0.61) or 30-day all-cause mortality (adjusted odds ratio, 0.55; 95% confidence interval, 0.19-1.6; P = 0.26) between narrow and broad oral antibiotic groups.
On the basis of analysis of a limited number of patients observed retrospectively, our findings suggest that it may be safe to switch from broad-spectrum intravenous antibiotic coverage to a narrow-spectrum oral antibiotic once clinical stability is achieved for hospitalized patients with health care-associated pneumonia when no microbiological diagnosis is made. A larger retrospective study with propensity matching or regression-adjusted test of equivalence or ideally a prospective comparative effectiveness study will be necessary to confirm our observations.
指南建议，肺炎住院患者一旦达到临床稳定，应从静脉用抗生素转换为口服抗生素。然而，几乎没有证据指导为医疗保健相关肺炎患者选择口服抗生素，尤其是在未进行微生物学诊断的情况下。
比较初始接受广谱静脉抗生素治疗后转换为广谱与窄谱口服抗生素的患者的结局。
我们对犹他州七家医院收治的社区获得性肺炎成年患者的现有数据库进行了二次分析。我们确定了2010年至2012年220例微生物学检查阴性的医疗保健相关肺炎住院患者。排除住院死亡和治疗失败病例后，173例患者留存，这些患者从广谱静脉抗生素转换为口服治疗方案。我们将口服治疗方案分为广谱（氟喹诺酮类）和窄谱（通常为β-内酰胺类）。我们比较了两组之间的人口统计学和临床特征。使用多变量回归模型，我们根据严重程度（电子计算的CURB-65）、合并症（查尔森指数）、达到临床稳定的时间和静脉治疗时间对结局进行了调整。
两组之间的年龄、严重程度、合并症、静脉治疗时间和临床反应相似。窄谱和广谱口服抗生素组的30天再入院率（11.9%对21.4%；P = 0.26）和30天全因死亡率（2.3%对5.3%；P = 0.68）也相似。在多变量分析中，我们发现窄谱和广谱口服抗生素组在30天再入院调整比值（调整比值比，0.56；95%置信区间，0.06 - 5.2；P = 0.61）或30天全因死亡率调整比值（调整比值比，0.55；95%置信区间，0.19 - 1.6；P = 0.26）方面无统计学显著差异。
基于对有限数量患者的回顾性观察分析，我们的研究结果表明，对于未进行微生物学诊断的医疗保健相关肺炎住院患者，一旦达到临床稳定，从广谱静脉抗生素转换为窄谱口服抗生素可能是安全的。需要进行更大规模的回顾性研究，采用倾向匹配或回归调整的等效性检验，或者理想情况下进行前瞻性比较有效性研究来证实我们的观察结果。
