Investigators conducted a retrospective cohort study to evaluate factors associated with the transition from IV to PO antibiotics among hospitalized patients with GNBIs. The primary objective of the study was to characterize the timing and frequency of transitioning from IV to PO antibiotics by Day 7 in adult patients hospitalized with a GNBI. The oral transition group was defined as those who received PO antibiotic therapy by Day 7, whereas those who were maintained on IV antibiotics as of Day 7 were deemed the IV therapy group. The secondary objective was to compare patient characteristics (demographics and host factors), clinical parameters, sources of infection, and antibiotic selection between the groups.
The study enrolled patients aged >18 years who were hospitalized in any of 24 participating U.S. hospitals (i.e., academic, community, or Veterans Affairs) and who were diagnosed with a GNBI between January 1, 2019, and December 31, 2019. Patients could be enrolled in the study more than once if the subsequent infection occurred >90 days from the index infection. Patients were excluded from the study if they died or entered the hospital within 72 hours of GNBI onset.
Data were retrieved from the electronic health records from each facility and stored in a REDCap (Research Electronic Data Capture) database. Pitt bacteremia score, which is a measure of critical illness and risk of death, was calculated.
A total of 4,581 episodes of GNBIs occurred across the network (mean age of patients: 67 years in both groups) with 264 episodes excluded due to death or entry into a hospice. The group receiving IV therapy included more men (56% vs. 47%, P <.001) and more black patients (24.6% vs. 20.5%, P = .001) compared with the PO antibiotic group. By Day 7, 43% of the cohort had transitioned to PO antibiotics, with a median time to transition of Day 5. Additional factors associated with IV therapy included a higher rate of myocardial infarction, heart failure, peripheral vascular disease, cerebrovascular disease, chronic obstructive pulmonary disease, dementia, liver disease, kidney disease, immunosuppression, ongoing hypotension, or fever. Source control was achieved within 7 days in three-quarters of patients and was more common in the PO antibiotic group. There was a significant difference between those maintained on IV therapy (vs. the PO group) among those who were admitted to the ICU (39.5% vs.17.0%, respectively, P <.001). Both the median Pitt bacteremia score and the use of kidney replacement therapy were higher in the IV compared with the PO antibiotic group.
Transition from IV to PO varied by hospital. The most common source of infection for those in the PO group was a urinary tract infection (UTI), mostly commonly due to Escherichia coli. UTIs made up almost two-thirds (64.9%) of all infections in the PO group and 38.6% in the IV group. The most common organisms isolated in the PO group after E coli were Klebsiella, Pseudomonas, Enterobacter, Proteus, and Serratia species. The prevalence of extended-spectrum beta-lactamase–producing GNBIs were higher in the IV group versus the PO group (10.6% vs.2.6%, P <.001). Total median duration of antibiotic therapy was significantly less in the PO group than in the IV group (11 days vs.13 days, P <.001). Quinolones (62.2%) followed by beta-lactams (28.3%) and trimethoprim-sulfamethoxazole (11.5%) were the most common pharmacologic options used for oral transition. Among the beta-lactams, cephalosporins were more commonly prescribed that aminopenicillins (20.7% vs. 7.6%, respectively).
The authors concluded that an opportunity exists for earlier and more frequent IV-to-PO antibiotic transition, as this study found that fewer than half of patients were transitioned to PO antibiotic therapy in a timely manner.
Similar findings were observed in another recently published paper that incorporated a target trial emulsion framework design using real-world data from four hospitals in Denmark. This study found that among those with uncomplicated gram-negative bacteremia, 90-day mortality was similar between those who transitioned to PO antibiotics within 4 days of the initial positive blood culture compared with those who remained on IV antibiotic therapy.
These findings have important implications for pharmacists involved in caring for patients with GNBIs who are receiving IV antibiotics, as pharmacists are the antibiotic stewards, and they should advocate for de-escalation to PO antibiotic therapy as soon as is clinically appropriate.
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