Early Switch from IV to Oral Antibiotics for Uncomplicated Gram-Negative Bacteremia
Dr. Shindo
Clinical question: Is there a mortality difference between early transition to oral antibiotics versus prolonged intravenous antibiotics in uncomplicated gram-negative bacteremia?
Background: Although there are national guidelines regarding the duration of antibiotic therapy for gram-negative bacteremia, the optimal route of administration and timing for transitioning from intravenous to oral antibiotic therapy remains unclear.
Study design: Cohort study using a target trial emulation framework
Setting: Four hospitals in Copenhagen, Denmark
Synopsis: This study enrolled 914 hospitalized adults (median age, 74.5 years) with uncomplicated gram-negative bacteremia. Individuals were assigned to early oral step-down therapy, defined as a transition to oral antibiotic therapy within four days of blood culture (n=433), or prolonged intravenous antibiotics, defined as a minimum of five days of intravenous antibiotic treatment (n=481). Antibiotic treatment in both groups was maintained for seven to 14 days.
The primary outcome, 90-day all-cause mortality risk, was comparable among the group with early oral step-down therapy (9.1% versus 11.7%), corresponding to a risk difference of -2.5% (95% CI, -5.7% to 0.7%) and a relative risk of 0.78 (95% CI, 0.60 to 1.10). Limitations included the observational nature of this study, the exclusion of immunocompromised patients, and the paucity of multitherapy-resistant organisms represented in the trial.
Bottom line: Transitioning to oral antibiotics within four days after initial blood culture may be an effective alternative to prolonged parenteral antibiotic treatment for uncomplicated gram-negative bacteremia.
Citation: Tingsgård S, Bastrup Israelsen S, et al. Early switch from intravenous to oral antibiotics for patients with uncomplicated gram-negative bacteremia. JAMA Netw Open. 2024;7(1):e2352314.
Dr. Shindo is an assistant clinical professor in the division of hospital medicine at the University of California in San Diego.