In Reply: We agree that the
traditional practice of treating patients hospitalized for CAP with 7
to 10 days of IV antibiotics is
based on custom, not substantive data. While the
impetus for early conversion to oral antibiotics has been primarily
financial (shortening length of stay), there are other clinical
advantages, including lower risk of phlebitis, line sepsis, and fluid
overload, as well as earlier mobilization and return to usual
activities.
The median duration of IV antibiotics in our observational study was 6
days. However, the total number of days of parenteral therapy is less
important to us than the number of potentially unnecessary days. Once
patients are clinically stable, they should not need to continue to
receive IV antibiotics in the absence of serious bacteremia or
metastatic infection. The purpose of our study was to develop a
definition of stability that was objective, clinically sensible, and a
valid predictor of good outcomes. We found a median delay of 3 days
between stabilization and conversion to oral antibiotics; thus, there
is ample opportunity for improvement. To further validate this
strategy, we are conducting a prospective, randomized controlled trial
of an actively implemented practice guideline emphasizing early
conversion to oral antibiotics and timely discharge once stability is
attained.