When to Switch Therapy in Patients with Severe Community-Acquired Pneumonia

IN RESPONSE:

We thank Dr. Mortensen and colleagues for their recent letter in regards to our Update in Hospital Medicine, which referred to the article by Oosterheert and colleagues (1). We acknowledge that the original trial by Oosterheert and colleagues has potential limitations (some of which were listed by Dr. Mortensen and colleagues), but the concept of switching from intravenous to oral therapy has been documented in the literature as a strategy for care in community-acquired pneumonia. The 2007 combined American Thoracic Society/Infectious Diseases Society of America guidelines (2) for community-acquired pneumonia give a strong recommendation with level II evidence, stating that therapy should be switched from intravenous to oral when patients are hemodynamically stable, are improving clinically, are able to ingest medications, and have a normally functioning gastrointestinal tract. An early switch to oral antibiotics in patients with community-acquired pneumonia allows for early discharge and reduces drug and treatment costs. Previous studies have evaluated only mild-to-moderate disease, whereas the study by Oosterheert and colleagues was the first to look at the potential role for early-switch therapy in patients with severe community-acquired pneumonia. Such studies are needed to determine whether the early-switch strategy works in patients with more severe disease.

We appreciate that the antibiotic regimen is different from that used in the United States, but this Dutch study based its regimen choice on local Dutch guidelines. We recommend that a similar study be repeated using local U.S. guidelines in patients with severe community-acquired pneumonia. The 2007 American Thoracic Society/Infectious Diseases Society of America recommends not switching antibiotics, but continuing with the regimen started and shown to be effective in the hospital, or at least staying with the same class of antibiotics. So the concept of switch therapy may be more related to maintaining the same class of antibiotics, and the question of which antibiotic to start with should be based on local guidelines.

One should not read too much into the study by Oosterheert and colleagues. It is a good randomized, controlled trial and is the first to suggest that early transition to oral antibiotics (using local guidelines for antibiotic choice) may be safely implemented in patients with severe, community-acquired pneumonia who do not need treatment in the intensive care unit. This strategy may reduce intravenous treatment and duration of hospital stay. Further studies are recommended.