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Treating Community Acquired Pneumonia: Switching from IV to PO antibiotics. November 13, 2006

Posted by rajkmd in Pulmonary/Critical Care.
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 These are the official recommendations from New York Presbytarian

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1. Greg Mints - November 14, 2006

1. Institutional guidelines from other hospitals must be interpreted with caution for a multitude of reasons, including local antibiotic resistance patterns and statistical prevalence of various pathogens. Every hospital tracks antibiotic susceptibilities of all microbiological isolates. Summary of the data for the previous year is known as antibiogram and is always available from our ID department for both Bellevue and Tisch hospitals. I keep the latest Bellevue antibiogram on my site: http://www.strong-mints.com/gregdocs/ID/Antibiograms/Bellevue/BH%20in-pt%20antibiogram%202005.pdf . It is important to use in- and out-pt antibiograms in their appropriate settings, since sensitivities may vary widely.

2. I believe that posting other hospital’s guidelines may be useful for some residents, but will result in data overload and confusion among others. Whoever posts similar documents in the future may want to consider including a commentary by one of our local specialists in the matter along with the original posting. I think such a commentary should be specifically solicited post factum in this instance as well.

3. I do not agree with several recommendations put forth in the paper. In general, for cases of suspected aspiration there seems to be very little need for anything beyond the usual Ceftriaxone in the usual dose, since most anaerobes in the mouth are expected to be sensitive. That said, ampicillin/sulbactam (Unasyn) would be a reasonable, but a bit too broad. There is certainly no reason to use Zosyn, as suggested in these guidelines, unless the patient is believed to be at high risk for pseudomonal infection (ex.: recent h/o hospitalization).

4. As a rule, there is no need to observe patients in the hospital once they have been switched to PO Abx, i.e. “If you are well enough to be on PO antibiotics, you are well enough to be home”. The paper seems to suggest otherwise.

5. Bellevue’s recommended oral equivalent of Ceftriaxone is Cefpodoxime, a 3rd generation cephalosporin with in-vitro antibacterial spectrum similar to that of Ceftriaxone.

6. I strongly oppose switching patients from i.v. Ceftriaxone to PO Levaquin. We MUST limit patient exposure to multiple classes of Abx, especially since quinolone resistance is on the rise and resistance to one member in this class of Abx usually means resistance to all (or most) of them.

7. Finally, I urge the practitioners not to over-use the PORT score. As with any clinical prediction rule, one must know whether a particular score is applicable to a particular patient.

a. If memory serves, the score has been validated principally in identifying low-risk patients, who may not need to be admitted. Its performance in identifying all other groups is less well known.
b. Chronic pulmonary diseases are not included in the scoring system. This is important, since patients with COPD, asthma and cystic fibrosis may all have worse prognosis simply because of poorer reserve, and may need to be admitted despite a low PORT score. In addition some of these are characterized by microbiological epidemiology different from the usual community-acquired pneumonia (ex.: pseudomonas is cystic fibrosis, etc.)
c. Immunocompromized patients are a separate population altogether. Among such patients PORT score has not been tested (as far as I know). In my personal experience, patients on chronic steroids and those with AIDS can do quite poorly despite low scores. I therefore strongly advise against the use of PORT score in such patients.

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2. Dr. Greg Mints on Community Acquired Pneumonia « Medical Discussions - November 14, 2006

[...] This is in relation to the following post [...]

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4. groold - June 24, 2007
5. Medical Symptoms Search - June 20, 2008

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6. cerbcifilla - February 21, 2009