Does community-acquired pneumonia (CAP) treated in hospital require step-down oral (PO) antibiotics for discharge?

From the Guidelines

For most patients with community-acquired pneumonia (CAP) treated in the hospital, step-down to oral antibiotics before discharge is recommended, with a total duration of antibiotic therapy typically being 5-7 days. This approach is supported by recent studies, including a 2023 systematic review and meta-analysis 1, which found that short-duration antibiotic therapy (≤ 6 days) was as effective as long-duration therapy, with fewer serious adverse events and low mortality. Patients can typically be switched from intravenous to oral antibiotics when they are clinically improving, hemodynamically stable, able to take oral medications, and have a functioning gastrointestinal tract. Common oral antibiotic regimens include amoxicillin-clavulanate (875/125 mg twice daily), doxycycline (100 mg twice daily), a respiratory fluoroquinolone like levofloxacin (750 mg daily) or moxifloxacin (400 mg daily), or a combination of amoxicillin with a macrolide like azithromycin.

Some key points to consider when implementing this approach include:

• Clinical stability, as evidenced by resolution of vital sign abnormalities, ability to eat, and normal mentation, is a key factor in determining when to switch to oral antibiotics 1.
• The step-down approach is effective because once the initial infection burden is reduced with IV therapy and the patient shows clinical improvement, oral antibiotics with good bioavailability can maintain adequate tissue concentrations to complete the eradication of the infection.
• Short-duration therapy has been shown to be at least as effective as long-duration therapy in multiple studies, including 14 RCTs with over 8400 patients 1.
• This approach allows for earlier hospital discharge, reducing healthcare costs and hospital-associated complications, while also minimizing the risk of antimicrobial resistance.

It's worth noting that while the evidence supports the use of short-duration antibiotic therapy for CAP, further studies are needed to determine the optimal duration of therapy for specific patient populations, such as those with ventilator-associated pneumonia (VAP) 1. However, based on the current evidence, step-down to oral antibiotics before discharge is a recommended approach for most patients with CAP.

From the FDA Drug Label

Azithromycin should not be used in patients with pneumonia who are judged to be inappropriate for oral therapy because of moderate to severe illness or risk factors such as any of the following: patients with cystic fibrosis, patients with nosocomially acquired infections, patients with known or suspected bacteremia, patients requiring hospitalization, elderly or debilitated patients, or patients with significant underlying health problems that may compromise their ability to respond to their illness (including immunodeficiency or functional asplenia). Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy.

The FDA drug label does not directly answer whether community-acquired pneumonia treated in hospital requires step-down PO antibiotics for discharge. However, it does indicate that azithromycin should not be used in patients with pneumonia who require hospitalization, suggesting that these patients may require alternative treatment.

• Key points:
  • Azithromycin is only indicated for oral therapy in patients with community-acquired pneumonia who are appropriate for oral therapy.
  • Patients with moderate to severe illness or certain risk factors, including those requiring hospitalization, should not be treated with azithromycin.
  • The label does not provide guidance on step-down PO antibiotics for discharge in patients treated in hospital 2, 2.

From the Research

Community-Acquired Pneumonia Treatment

• Community-acquired pneumonia (CAP) is a common condition that requires hospitalization, and its management involves various aspects, including diagnosis, antibiotic therapy, and discharge planning 3.
• The Pneumonia Severity Index (PSI) is used to optimize the location of treatment and provide prognostic information, and patients in PSI risk classes I, II, and III can safely be treated as outpatients 3.
• Hospitalized patients with CAP should be treated promptly with empiric antibiotics, and nonsevere pneumonia should be treated with a parenteral beta-lactam plus either doxycycline or a macrolide 3.

Antibiotic Therapy

• The choice of antibiotic therapy for CAP depends on various factors, including the severity of the disease, patient's risk factors, and local microbiological epidemiology 3, 4, 5.
• Levofloxacin has been shown to be effective in the treatment of CAP, and it can be used as an oral therapy for patients who are clinically stable 4, 5.
• Amoxicillin/clavulanate is another antibiotic that has been used in the treatment of CAP, and it has a broad-spectrum of activity against various pathogens, including Streptococcus pneumoniae and Haemophilus influenzae 6.

Discharge Planning

• Patients with CAP should be considered for a switch to oral therapy and discharge shortly after they reach clinical stability, which is usually within 2-3 days of hospitalization 3.
• Discharge planning should include pneumococcal vaccination, influenza vaccination, and tobacco cessation counseling for eligible patients 3.
• The decision to discharge a patient with CAP should be based on individualized assessment of the patient's condition, including their clinical response to antibiotic therapy and their ability to manage their condition at home 7.