Elderly Pneumonia Patients after Antibiotic Switch
Nathan RV, Rhew DC, Bratzler DW, et al. In-hospital observation after antibiotic switch in pneumonia: a national evaluation. Am J Med. 2006 Jun;119(6):512.e1-7.
Community-acquired pneumonia (CAP) continues to be a common reason for hospital admission—especially among the elderly. As with many infectious diseases, the duration and route of antibiotic therapy is often based on expert recommendations rather than prospective randomized trials. The Patient Outcome Research Team (PORT) trials address the decision to admit a patient, but not other aspects of care. For hospitalists, the decision of when to discharge any patient with reasonable safety is often fraught with uncertainty. This study addresses the necessity of observing a patient for one day following the switch from IV to oral therapy. Two previous smaller retrospective studies have suggested this was unnecessary.
The current study is also retrospective but involves a large database derived from the U.S. Medicare National Pneumonia Project database. Ultimately 5,248 patients over 65 (mean age=80) were selected for analysis; 2,536 were not observed; and 2,712 were observed for one day.) Patients were excluded if their length of stay was greater than seven days or less than two days, suggesting complicated cases in the former instance and mild illness in the latter (i.e., perhaps not even requiring admission). Immunosupressed patients were also excluded. There was no significant difference in the observed 30-day mortality (5.1% in the “not observed” versus 4.4% in the “observed” cohort, respectively).
The obvious limitation of this study is that it was retrospective/observational and thus potentially subject to the bias inherent in this study design. It is possible that the sicker patients were logically watched longer. Propensity analysis was not a component of this study. The authors do present reasons why certain structural weaknesses would have favored the “observed “group.
Certainly there may be other reasons to observe a patient after the switch to oral therapy. A patient with associated gastrointestinal disturbance or a questionable history of GI or other intolerance to a class of antibiotics is an obvious example. Nevertheless, this study should convey a certain confidence to hospitalists when they assess the suitability for discharge for the type of patient covered in this analysis. Interestingly the recently published guidelines for treatment of community acquired pneumonia are concordant with this study.1
- Mandell L, Wundrelink A, Bartlett J. Guideline for the treatment of community acquired pneumonia. Clin Infect Dis. 2007;44: S27-72.
The Revised Geneva Score for PE
Le Gal G, Righini M, Roy PM, et al. Prediction of pulmonary embolism in the emergency department. Ann Intern Med. 2006 Feb 7:144(3):165-171. Comment in: ACP J Club. 2006 Jul-Aug;145(1):25 & Ann Intern Med. 2006 Feb 7;144(3):210-212.
Pulmonary embolism is a diagnosis frequently considered by the hospitalist—both as an explanation for the admitting clinical picture, as well as a complication arising during the course of a hospitalization for another condition.
My institutions’ ability to identify patients with this potentially lethal condition has greatly improved with the advent of multidetector CT angiography and various diagnostic schemata that include d-dimer testing and estimations of pre-test probability. It is a classic consideration whenever there is a onset of pleurisy, dyspnea, or aggravation thereof. Nevertheless multiple other situations arise in the hospital setting, such as unexplained tachycardia, hemoptysis, or vaguely possible but not clear-cut pleuritic chest pain, in which one feels obligated to at least consider the diagnosis. Further, to have to incorporate d-dimer testing into the diagnostic strategy is problematic as up to 80% of hospitalized patients are likely to be positive. Hospitalists need a reasonable strategy to avoid going down that proverbial pathway in certain low risk situations.