'Switch Therapy' Deemed Safe In Elderly With Pneumonia

SAN DIEGO — Advanced age by itself should not be a barrier to switching a patient with community-acquired pneumonia from intravenous to oral antimicrobial therapy soon after the patient shows clinical improvement, Dr. Paulo Rossi said in a poster presentation at the International Conference of the American Thoracic Society.

An observational study of 2,648 adult patients at 40 hospitals in 13 countries showed that, regardless of age, about two-thirds were discharged within 24 hours of meeting the criteria for “switch therapy.” Of 372 patients aged 85 years or older, 65% were discharged in this early time frame, as were 68% of 1,161 patients aged 65–84 years and 72% of 1,115 patients aged 18–64 years.

No deaths occurred in the youngest group after switch therapy, and mortality was low among the older groups: 9 deaths (1.6%) of the 554 switch-therapy patients in the 65–84 age group and 2 deaths (1.2%) of the 164 patients in the oldest cohort.

The study shows that frail elderly patients with community-acquired pneumonia (CAP) can handle switch therapy, said Dr. Rossi of S. Maria della Misericordia Hospital in Udine, Italy. “Even if they are over 90 they can, more or less,” he said in an interview.

He and his coinvestigators reviewed records of CAP patients who were entered into the Community-Acquired Pneumonia Organization database from June 2001 to May 2005. The database includes hospitals in the United States, and the study coordinator was based at the University of Louisville (Ky.).

The study relied on American Thoracic Society guidelines for time to switch therapy. Patients had to meet four criteria to be considered candidates for a switch: improvement in cough and shortness of breath; at least 8 hours without a fever; leukocytosis reduced by at least 10% from the previous day; and “tolerating oral intake with adequate gastrointestinal absorption.”

The investigators considered patients to be candidates for hospital discharge once they met the above criteria for oral therapy, a diagnostic work-up was completed, any comorbidity was treated, and social needs were met. Any discharge within 24 hours of the patient's meeting the criteria for switch therapy was considered an early discharge.

Of the oldest patients, 90% were classified as being at high risk. Nonetheless, 51.6% met the criteria for switch therapy on or before the 6th day of hospitalization. In the middle group of patients, aged 65–84 years, 54.2% passed this goal by the 5th day, and in the youngest group, 57.1% passed this goal by the 4th day.

All told, the proportions of patients who met the criteria for switch therapy declined with age, going from 71% of the youngest group to 63% of the middle group to 56% of the oldest patients. The proportion of patients who were switched was similar across groups, however: 80% of the under-65 patients, 76% of the middle group, and 78% of those aged 85 and up.

After therapy was switched, the oldest patients were the least likely to require reestablishment of IV antibiotics. Just 2 (1.2%) of the 164 patients in the oldest group had to be switched back, vs. 20 (3.6%) of the 554 patients in the middle group and 46 (7.4%) of the 621 patients in the youngest group.

Older patients often have comorbidities that present a barrier to switch therapy but also put them at risk of nosocomial infection if they stay in the hospital, Dr. Rossi said. Hence, as stated on the poster, “for these patients an early discharge is potentially more important than in younger patients.”

SAN DIEGO — Advanced age by itself should not be a barrier to switching a patient with community-acquired pneumonia from intravenous to oral antimicrobial therapy soon after the patient shows clinical improvement, Dr. Paulo Rossi said in a poster presentation at the International Conference of the American Thoracic Society.

An observational study of 2,648 adult patients at 40 hospitals in 13 countries showed that, regardless of age, about two-thirds were discharged within 24 hours of meeting the criteria for “switch therapy.” Of 372 patients aged 85 years or older, 65% were discharged in this early time frame, as were 68% of 1,161 patients aged 65–84 years and 72% of 1,115 patients aged 18–64 years.

No deaths occurred in the youngest group after switch therapy, and mortality was low among the older groups: 9 deaths (1.6%) of the 554 switch-therapy patients in the 65–84 age group and 2 deaths (1.2%) of the 164 patients in the oldest cohort.

The study shows that frail elderly patients with community-acquired pneumonia (CAP) can handle switch therapy, said Dr. Rossi of S. Maria della Misericordia Hospital in Udine, Italy. “Even if they are over 90 they can, more or less,” he said in an interview.

He and his coinvestigators reviewed records of CAP patients who were entered into the Community-Acquired Pneumonia Organization database from June 2001 to May 2005. The database includes hospitals in the United States, and the study coordinator was based at the University of Louisville (Ky.).

The study relied on American Thoracic Society guidelines for time to switch therapy. Patients had to meet four criteria to be considered candidates for a switch: improvement in cough and shortness of breath; at least 8 hours without a fever; leukocytosis reduced by at least 10% from the previous day; and “tolerating oral intake with adequate gastrointestinal absorption.”

The investigators considered patients to be candidates for hospital discharge once they met the above criteria for oral therapy, a diagnostic work-up was completed, any comorbidity was treated, and social needs were met. Any discharge within 24 hours of the patient's meeting the criteria for switch therapy was considered an early discharge.

Of the oldest patients, 90% were classified as being at high risk. Nonetheless, 51.6% met the criteria for switch therapy on or before the 6th day of hospitalization. In the middle group of patients, aged 65–84 years, 54.2% passed this goal by the 5th day, and in the youngest group, 57.1% passed this goal by the 4th day.

All told, the proportions of patients who met the criteria for switch therapy declined with age, going from 71% of the youngest group to 63% of the middle group to 56% of the oldest patients. The proportion of patients who were switched was similar across groups, however: 80% of the under-65 patients, 76% of the middle group, and 78% of those aged 85 and up.

After therapy was switched, the oldest patients were the least likely to require reestablishment of IV antibiotics. Just 2 (1.2%) of the 164 patients in the oldest group had to be switched back, vs. 20 (3.6%) of the 554 patients in the middle group and 46 (7.4%) of the 621 patients in the youngest group.

Older patients often have comorbidities that present a barrier to switch therapy but also put them at risk of nosocomial infection if they stay in the hospital, Dr. Rossi said. Hence, as stated on the poster, “for these patients an early discharge is potentially more important than in younger patients.”

SAN DIEGO — Advanced age by itself should not be a barrier to switching a patient with community-acquired pneumonia from intravenous to oral antimicrobial therapy soon after the patient shows clinical improvement, Dr. Paulo Rossi said in a poster presentation at the International Conference of the American Thoracic Society.

An observational study of 2,648 adult patients at 40 hospitals in 13 countries showed that, regardless of age, about two-thirds were discharged within 24 hours of meeting the criteria for “switch therapy.” Of 372 patients aged 85 years or older, 65% were discharged in this early time frame, as were 68% of 1,161 patients aged 65–84 years and 72% of 1,115 patients aged 18–64 years.

No deaths occurred in the youngest group after switch therapy, and mortality was low among the older groups: 9 deaths (1.6%) of the 554 switch-therapy patients in the 65–84 age group and 2 deaths (1.2%) of the 164 patients in the oldest cohort.

The study shows that frail elderly patients with community-acquired pneumonia (CAP) can handle switch therapy, said Dr. Rossi of S. Maria della Misericordia Hospital in Udine, Italy. “Even if they are over 90 they can, more or less,” he said in an interview.

He and his coinvestigators reviewed records of CAP patients who were entered into the Community-Acquired Pneumonia Organization database from June 2001 to May 2005. The database includes hospitals in the United States, and the study coordinator was based at the University of Louisville (Ky.).

The study relied on American Thoracic Society guidelines for time to switch therapy. Patients had to meet four criteria to be considered candidates for a switch: improvement in cough and shortness of breath; at least 8 hours without a fever; leukocytosis reduced by at least 10% from the previous day; and “tolerating oral intake with adequate gastrointestinal absorption.”

The investigators considered patients to be candidates for hospital discharge once they met the above criteria for oral therapy, a diagnostic work-up was completed, any comorbidity was treated, and social needs were met. Any discharge within 24 hours of the patient's meeting the criteria for switch therapy was considered an early discharge.

Of the oldest patients, 90% were classified as being at high risk. Nonetheless, 51.6% met the criteria for switch therapy on or before the 6th day of hospitalization. In the middle group of patients, aged 65–84 years, 54.2% passed this goal by the 5th day, and in the youngest group, 57.1% passed this goal by the 4th day.

All told, the proportions of patients who met the criteria for switch therapy declined with age, going from 71% of the youngest group to 63% of the middle group to 56% of the oldest patients. The proportion of patients who were switched was similar across groups, however: 80% of the under-65 patients, 76% of the middle group, and 78% of those aged 85 and up.

After therapy was switched, the oldest patients were the least likely to require reestablishment of IV antibiotics. Just 2 (1.2%) of the 164 patients in the oldest group had to be switched back, vs. 20 (3.6%) of the 554 patients in the middle group and 46 (7.4%) of the 621 patients in the youngest group.

Older patients often have comorbidities that present a barrier to switch therapy but also put them at risk of nosocomial infection if they stay in the hospital, Dr. Rossi said. Hence, as stated on the poster, “for these patients an early discharge is potentially more important than in younger patients.”