Background: Community-Acquired Pneumonia (CAP) guidelines recommend transition to an oral (PO) beta-lactam (BL) regimen or fluoroquinolone (FQ) when patients are clinically stable. Due to collateral damage associated with FQs, stewardship efforts often focus on reducing initial FQ use for CAP therapy. We hypothesized that FQ use remains prevalent in CAP treatment despite initial intravenous (IV) BL therapy, and examined factors associated with switching to a PO BL versus a FQ and the impact on outcomes.
Methods: In this retrospective cohort study, data were collected 1/2016 through 2/2018 on non-ICU medical patients admitted with CAP at 46 Michigan hospitals. Patients were included if they received IV BL (ceftriaxone or ampicillin-sulbactam) plus macrolide/doxycycline by hospital day 2 and switched to a PO respiratory FQ or BL by therapy day 4. Exclusions included positive culture, concomitant infection, HCAP, unstable on day 4, or severe immune deficiency. Data were analyzed using logistic generalized estimating equation models, accounting for hospital level clustering; outcomes were adjusted using inverse probability of treatment weighting by propensity scores.
Results: Of 555 included patients, 54.4% were switched to a PO BL versus 45.6% to a FQ by day 4 of therapy. The groups had similar durations of therapy (8 days), time to clinical stability, prior antibiotics, and COPD, but the BL group was older, with a higher Pneumonia Severity Index, CURB-65, and more cardiovascular (CV) disease [Figure 1]. In multivariable analysis, CV disease and higher CURB-65 were more common and diabetes (DM) less common in the PO BL group [Figure 2]. Sharing antibiotic use data with providers was associated with less FQ use (83.1% vs 70.8%, OR 0.51, 95%CI 0.27, 0.97, P=0.04). On adjusted analysis there were no differences in patient outcomes [Figure 3].
Conclusion: Among CAP patients started on an IV BL regimen, nearly half were switched to a PO FQ by therapy day 4, including more patients with DM. Although there were sicker patients in the BL group, there were no differences in outcomes between cohorts. To reduce FQ use, stewardship programs should share antibiotic use data and provide guidance for step-down therapy in clinically stable CAP patients.
A. Conlon, None
D. Nielsen, None
V. Vaughn, None
K. Kaye, None
A. Malani, None
D. Osterholzer, None
R. Thyagarajan, None
S. Flanders, None
T. Gandhi, None
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