Antibiotic Therapy in Community-Acquired Pneumonia: Switch and Step Down Therapy

Hugh A. Cassiere, MD, Winthrop University Hospital


Medscape General Medicine. 1998;1(3) 

In This Article

Editorial Comment

Reducing Hospital Length of Stay in the Treatment of Community-Acquired Pneumonia

Patient preference and healthcare provider demands have altered the treatment of community-acquired pneumonia (CAP). Clinical studies have demonstrated that fewer hospital admissions and shorter hospital stays for pneumonia treatment can be instituted without compromising patient outcome.

Intravenous antibiotic therapy can clear bacteremia and the high serum levels permit penetration of antibiotics into infected lung tissue. Oral antibiotic administration results in lower serum antibiotic levels, but due to the highly vascular nature of the lung, the pharmacologic levels are adequate to treat the infection provided there is no collection (abscess, necrotizing pneumonia with areas of tissue breakdown or empyema) or spread of the infection outside of the lung. Patients are typically discharged one day after the initiation of oral therapy.[1,2]

Fewer Admissions -- Deciding who to admit. The first step in the process of decreasing hospital days of care for the treatment of pneumonia is to prevent unnecessary hospital admissions. Pneumonia patients can be classified as low risk or high risk for complications on the basis of multiple predictive factors; low risk patients can be treated at home with good follow-up care. Prospective studies have validated independent risks for complications based on age, medical comorbidities, physical findings, laboratory abnormalities, and socioeconomic factors.[3,4,5]

Fine and colleagues[5] developed a prediction rule which delineates weighted risk characteristics related to morbidity and mortality in community-acquired pneumonia. This rule was validated in both inpatient and outpatient populations and uses two steps to assign patients to one of five risk classes based on the number of risk factors. To determine what the risk factors are and how they come together to formulate a risk score, click on the "Clinical Calculator" in the "Related Medscape Resources" listed in the sidebar of this Web page. The calculator was developed by the editors at Medscape based upon Dr. Fine's paper.

To treat CAP in the home setting, appropriate support for patient care is required, as well as assurance that the patient will be compliant with medication instructions and that withdrawal from alcohol or drugs will not be an issue. In a survey of 159 patients treated for CAP, 80% expressed a preference for home treatment and 74% stated that they would be willing to pay an average of 24% of 1 month's household income to be assured of this option.[1]

Timing the switch. In this issue of Medscape Respiratory Care, Dr. Cassiere reviews switch and step-down therapy for hospitalized patients with CAP. He states that oral therapy can be started once the patient has a clinical response to IV therapy and he makes the important point that assessment of clinical stability (CS) should be "ongoing rather than static."

In a recent retrospective review of elderly Medicare patients in New York State, Silver and coworkers[6] found that 63% of patients reached CS on day 3 -- with CS being independent of age or sex. In this study, patients aged <=74 were more likely to be switched to oral therapy by their physicians than patients aged >=75. Those who were switched to oral therapy earlier had a reduction in the hospital length of stay (LOS) and those who had reached CS had the same 30 day mortality, despite whether they were switched to oral therapy early and discharged.

In the prospective, randomized study of hospitalized veterans with CAP that we performed (Siegel RE and colleagues),[2] 2 days of IV followed by 8 days of oral therapy resulted in similar outcome and a shorter LOS than that found for patients treated with a more traditional 5-day course of IV followed by 5 days of oral therapy or a prolonged 10-day all IV regimen. In this study, some patients had a low grade fever or a slightly elevated white blood cell count at the time of switch therapy, but these patients clearly were responsive.[2] Further large, prospective studies will be required to better define the determinants of CS.

Education of the treatment staff on the efficacy of early oral conversion combined with vigilance for the appropriate time to implement switch therapy can lead to reduction in hospital LOS and healthcare dollars spent. Caregivers need to work together to determine when patients can be switched to oral therapy. Treatment algorithms may be of great assistance in developing and instituting standardized criteria for admission and for integration of early switch therapy for patients with pneumonia.

Robert E. Siegel, MD
Associate Chief, Pulmonary Section and Director
Medical Intensive Care Unit
Bronx VA Medical Center


  1. Coley MC, Li YH, Medsger AR, et al: Preferences for home vs hospital care among low-risk patients with community-acquired pneumonia. Arch Intern Med 156:1565-1571, 1996.

  2. Siegel RE, Halpern NA, Almenoff PL, et al: A Prospective Randomized Study of Inpatient Intravenous Antibiotics for Community-Acquired Pneumonia: The Optimal Duration of Therapy. Chest 105:1109-15, 1996.

  3. Fine MJ, Smith DN, Daniel ES: Hospital decision in patients with community-acquired pneumonia: A prospective cohort study. Am J Med 89:713-21, 1990.

  4. American Thoracic Society. Guidelines for the initial management of adults with community-acquired pneumonia: Diagnosis, assessment of severity and initial antimicrobial therapy. Am Rev Resp Dis 148:1418-1426, 1993.

  5. Fine MJ, Auble TE, Yealy DM, et al: A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336:243-50, 1997.

  6. Silver A, Eichorn A, Niederman M, et al: Assessment of clinical stability and use of switch therapy in New York State medicare inpatients with community-acquired pneumonia. Chest 112(3)Supp:6S, 1997.