One of the most common reasons for hospital admission is pneumonia. Several RCTs studying treatment approaches in both adults and children with community-acquired pneumonia have been performed. In comparing oral to IV antibiotics, and in assessing the efficacy of early switches from IV to oral antibiotics, there are no data to support the notion of an advantage to IV therapies in most cases.13-18 A Cochrane review confirms this.19
Explore This IssueACEP Now: Vol 39 – No 01 – January 2020
Febrile Neutropenia, Osteomyelitis, and Endocarditis
Let’s step it up a bit and consider antibiotic route for cancer patients with febrile neutropenia. Many of us reflexively obtain blood cultures and initiate broad-spectrum antibiotic coverage for these patients without batting an eyelash. And yet again, a Cochrane review of 22 RCTs found that, in patients who were hemodynamically stable without evidence of organ failure or obvious source of infection, oral antibiotics (or an early switch to oral antibiotics) were an acceptable alternative to IV antibiotics.20 Both the mortality rate and treatment failure rate were similar between groups.
How about osteomyelitis? You guessed it—a Cochrane review of five RCTs found no statistically significant difference in remission rates between oral and IV antibiotics for patients with chronic osteomyelitis, and a recent RCT of more than 1,000 patients with bone or joint infection in The New England Journal of Medicine found that the one-year failure rate was similar between patients treated with six weeks of oral antibiotics compared to IV antibiotics of the same duration.21,22
Finally, both an RCT from 1996 and a recent one from 2019 found no advantage of oral over IV antibiotics in patients with endocarditis—the former compared oral directly to IV in IV drug users with endocarditis, while the latter compared patients with left-sided endocarditis in stable condition who had been on IV antibiotics for 10 days either continuing IV antibiotics or switching to oral antibiotics.23,24 All-cause mortality, unplanned cardiac surgery, clinically evident embolism, and relapse of bacteremia were no different between groups.
Surely, all patients confirmed to have bacteremia require at least five days of IV antibiotics! Is nothing sacred? But again, in a recent study of almost 5,000 hospitalized patients with Enterobacteriaceae bacteremia, 30-day mortality was no different between patients who received oral step-down after an appropriate clinical response compared with continued IV antibiotics.25 The authors also found that early transition to oral antibiotics decreased hospital length of stay.
Complications, Efficiency, and Cost
Sometimes patients are admitted to hospital “for IV antibiotics” when they can be safely discharged home on oral antibiotics. The cost savings to the health care system as well as decreased risk of nosocomial infections by avoiding admissions are considerable.26 There are validated decision tools to help us safely discharge such patients on oral antibiotics for a variety of conditions.27,28
Naturally, IV antibiotics are generally more expensive than their oral antibiotic equivalents. However, it isn’t only the direct cost of the drugs that needs to be taken into account, but also the indirect costs of using IV antibiotics compared to oral antibiotics. A United Kingdom study looking at nondrug costs of IV antibiotic therapy for patients admitted to hospital with pneumonia or intra-abdominal infections showed that preparation and administration of antibiotics was more time-consuming in those receiving IV antibiotics compared to those receiving oral antibiotics. Use of IV antibiotics was associated with significantly higher workload and additional costs that sometimes were more than the cost of the medications themselves.29 In the ED, it takes longer to administer IV antibiotics than oral ones. Additionally, there are complications of IV antibiotics to consider, including extravasation injury, phlebitis, as well as local or systemic infection.30 The risk of bacteraemia caused by a peripheral IV can be as high as 0.1%.26 Even antibiotic-associated diarrhea and secondary infections with Clostridium difficile have been shown to be more prevalent in ED patients given a single dose of IV antibiotics before being discharged on oral antibiotics compared to oral antibiotics alone.31