Take-Home Message

Taken together, these data support the argument that if we used oral antibiotics for most common infections in the ED, we could safely improve throughput and efficiency and decrease our patients’ suffering. So, next time you are faced with a stable non-critically ill patient with a UTI, cellulitis, pneumonia, osteomyelitis, or febrile neutropenia (who is not vomiting and has low aspiration risk), ask yourself whether IV antibiotics are necessary.

If we all chose oral antibiotics most of the time in these situations, we could improve ED efficiency and overcrowding, prevent complications associated with IV insertion, and save our health care system money while safely and effectively providing excellent care for our patients. Meet with your ED group to integrate oral antibiotics choices into your electronic medical records. That alone is likely to help nudge us and our colleagues in the right direction.

Thanks to Dr. Andrew Morris for his contributions to the EM Cases podcasts that inspired this article.

References

1. Pohl A. Modes of administration of antibiotics for symptomatic severe urinary tract infections. Cochrane Database Syst Rev. 2007;(4):CD003237. 
2. Mombelli G, Pezzoli R, Pinoja-Lutz G, et al. Oral vs intravenous ciprofloxacin in the initial empirical management of severe pyelonephritis or complicated urinary tract infections: a prospective randomized clinical trial. Arch Intern Med. 1999;159(1):53-58.
3. Lojanapiwat B, Nimitvilai S, Bamroongya M, et al. Oral sitafloxacin vs intravenous ceftriaxone followed by oral cefdinir for acute pyelonephritis and complicated urinary tract infection: a randomized controlled trial. Infect Drug Resist. 2019;12:173-181.
4. Strohmeier Y, Hodson EM, Willis NS, et al. Antibiotics for acute pyelonephritis in children. Cochrane Database Syst Rev. 2014;(7):CD003772.
5. Cruz C, Spina L. Are oral antibiotics as effective as a combination of intravenous and oral antibiotics for kidney infections in children? Ann Emerg Med. 2016;67(1):30-31.
6. Bernard P, Chosidow O, Vaillant L. Oral pristinamycin versus standard penicillin regimen to treat erysipelas in adults: randomised, non-inferiority, open trial. BMJ. (Clinical research ed.). 2002;325(7369):864.
7. Jorup-Rönström C, Britton S, Gavlevik A, et al. The course, costs and complications of oral versus intravenous penicillin therapy of erysipelas. Infection. 1984;12(6):390-394.
8. Aboltins CA, Hutchinson AF, Sinnappu RN, et al. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. J Antimicrob Chemother. 2015;70(2):581-586. 
9. Kilburn SA, Featherstone P, Higgins B, et al. Interventions for cellulitis and erysipelas. Cochrane Database Syst Rev. 2010;(6):CD004299.
10. Stevens DL, Bisno AL, Chambers HF, et al. Practice guidelines for the diagnosis and management of skin and soft tissue infections: 2014 update by the Infectious Diseases Society of America. Clin Infect Dis. 2014;59(2):e10-52.
11. Haran JP, Wilsterman E, Zeoli T, et al. Deviating from IDSA treatment guidelines for non-purulent skin infections increases the risk of treatment failure in emergency department patients. Epidemiol Infect. 2018;147:e68.
12. Yadav K, Suh KN, Eagles D, et al. Predictors of oral antibiotic treatment failure for nonpurulent skin and soft tissue infections in the emergency department. Acad Emerg Med. 2019;26(1):51-59.
13. Oosterheert JJ, Bonten MJ, Schneider MM, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre randomised trial. BMJ. 2006;333(7580):1193.
14. Siegel RE, Halpern NA, Almenoff PL, et al. A prospective randomized study of inpatient iv. antibiotics for community-acquired pneumonia. The optimal duration of therapy. Chest. 1996;110(4):965-971.
15. Atkinson M, Lakhanpaul M, Smyth A, et al. Comparison of oral amoxicillin and intravenous benzyl penicillin for community acquired pneumonia in children (PIVOT trial): a multicentre pragmatic randomised controlled equivalence trial. Thorax. 2007;62(12):1102-1106.
16. Addo-Yobo E, Chisaka N, Hassan M, et al. Oral amoxicillin versus injectable penicillin for severe pneumonia in children aged 3 to 59 months: a randomised multicentre equivalency study. Lancet. 2004;364(9440):1141-1148.
17. Agweyu A, Gathara D, Oliwa J, et al. Oral amoxicillin versus benzyl penicillin for severe pneumonia among Kenyan children: a pragmatic randomized controlled noninferiority trial. Clin Infect Dis. 2015;60(8):1216-1224.
18. Castro-Guardiola A, Viejo-Rodríguez AL, Soler-Simon S, et al. Efficacy and safety of oral and early-switch therapy for community-acquired pneumonia: a randomized controlled trial. Am J Med. 2001;111(5):367-374.
19. Pakhale S, Mulpuru S, Verheij TJ, et al. Antibiotics for community‐acquired pneumonia in adult outpatients. Cochrane Database Syst Rev. 2014;(10):CD002109.
20. Vidal L, Ben Dor I, Paul M, et al. Oral versus intravenous antibiotic treatment for febrile neutropenia in cancer patients. Cochrane Database Syst Rev. 2013;(10):CD003992.
21. Conterno LO, Turchi MD. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev. 2013;(9):CD004439.
22. Li HK, Rombach I, Zambellas R, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380(5):425-436.
23. Heldman AW, Hartert TV, Ray SC, et al. Oral antibiotic treatment of right-sided staphylococcal endocarditis in injection drug users: prospective randomized comparison with parenteral therapy. Am J Med. 1996;101(1):68-76.
24. Iversen K, Ihlemann N, Gill SU, et al. Partial oral versus intravenous antibiotic treatment of endocarditis. N Engl J Med. 2019;380(5):415-424.
25. Tamma PD, Conley AT, Cosgrove SE, et al. Association of 30-day mortality with oral step-down vs continued intravenous therapy in patients hospitalized with Enterobacteriaceae bacteremia. JAMA Intern Med. 2019;179(3):316-323.
26. Maki DG, Kluger DM, Crnich CJ. The risk of bloodstream infection in adults with different intravascular devices: a systematic review of 200 published prospective studies. Mayo Clin Proc. 2006;81(9):1159-1171.
27. Marras TK, Gutierrez C, Chan CK. Applying a prediction rule to identify low-risk patients with community-acquired pneumonia. Chest. 2000;118(5):1339-1343.
28. Klastersky J, Paesmans M, Georgala A, et al. Outpatient oral antibiotics for febrile neutropenic cancer patients using a score predictive for complications. J Clin Oncol. 2006;24(25):4129-4134.
29. van Zanten AR, Engelfriet PM, van Dillen K, et al. Importance of nondrug costs of intravenous antibiotic therapy. Crit Care. 2003;7(6):R184-190.
30. Li HK, Agweyu A, English M, et al. An unsupported preference for intravenous antibiotics. PLoS Medicine. 2015;12(5):e1001825.
31. Haran JP, Hayward G, Skinner S, et al. Factors influencing the development of antibiotic associated diarrhea in ED patients discharged home: risk of administering IV antibiotics. Am J Emerg Med. 2014; 32(10):1195-1199.