What should be done when switching from intravenous (IV) cefepime and azithromycin to oral medication for community-acquired pneumonia (CAP)?

From the Guidelines

For transitioning from IV cefepime and azithromycin to oral antibiotics for community-acquired pneumonia (CAP), I recommend switching to oral amoxicillin-clavulanate 875/125 mg twice daily plus azithromycin 500 mg once daily for a total of 5 days of therapy (including both IV and oral treatment) as per the guidelines from the American Thoracic Society and Infectious Diseases Society of America 1. This transition should occur when the patient shows clinical improvement, including being afebrile for 24-48 hours, having stable vital signs, improved respiratory symptoms, and ability to take oral medications. Before switching, ensure the patient can tolerate oral intake and has no absorption issues. The amoxicillin-clavulanate provides coverage against common CAP pathogens including Streptococcus pneumoniae and Haemophilus influenzae, while continuing azithromycin maintains coverage for atypical pathogens like Mycoplasma and Legionella. Some key points to consider when making this transition include:

• The patient's ability to tolerate oral medications and the absence of any absorption issues
• The need to complete a total of 5 days of therapy, including both IV and oral treatment, as recommended by the guidelines 1
• The importance of maintaining effective antimicrobial coverage while reducing hospital stay, decreasing risk of catheter-related complications, and lowering healthcare costs
• For patients with penicillin allergies, alternatives include doxycycline 100 mg twice daily or a respiratory fluoroquinolone like levofloxacin 750 mg daily, as suggested by previous guidelines 1. However, it's essential to prioritize the most recent and highest quality study, which in this case is the 2019 guideline from the American Thoracic Society and Infectious Diseases Society of America 1. This approach ensures that the treatment strategy is based on the latest evidence and expert recommendations, ultimately prioritizing the patient's morbidity, mortality, and quality of life outcomes.

From the FDA Drug Label

Community-acquired pneumonia due to Chlamydophila pneumoniae, Haemophilus influenzae, Mycoplasma pneumoniae or Streptococcus pneumoniae in patients appropriate for oral therapy NOTE: 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).

When switching from intravenous (IV) cefepime and azithromycin to oral medication for community-acquired pneumonia (CAP), azithromycin can be used as an oral therapy option if the patient is deemed appropriate for oral therapy. The decision to switch should be based on the patient's clinical condition and the severity of their illness. Patients with moderate to severe illness or certain risk factors should not be switched to oral azithromycin therapy.

• Key considerations for switching to oral therapy include:
  • Severity of illness
  • Presence of risk factors (e.g. cystic fibrosis, nosocomially acquired infections, known or suspected bacteremia)
  • Patient's ability to respond to oral therapy
  • Clinical judgment of the healthcare provider 2 2

From the Research

Switching from IV to Oral Antibiotics for CAP

When switching from intravenous (IV) cefepime and azithromycin to oral medication for community-acquired pneumonia (CAP), the following points should be considered:

• Hospitalized patients may be switched from IV to oral antibiotics after they have shown clinical improvement and are able to tolerate oral medications, typically within the first three days 3.
• Early switching to oral antibiotics, such as fluoroquinolones, can result in shorter lengths of stay, shorter duration of inpatient antibiotic treatment, and lower hospitalization costs without compromising outcomes 4.
• The decision to switch to oral antibiotics should be based on the patient's clinical stability and ability to tolerate oral medications 3, 5.
• Combination antibiotic therapy, including a macrolide, can achieve better outcomes compared to monotherapy in certain subsets of patients with CAP, such as those with comorbidities, severe CAP, or bacteremic pneumococcal CAP 6.

Oral Antibiotic Options

Some oral antibiotic options for CAP include:

• Macrolides, such as azithromycin 7, 3, 6
• Doxycycline 3
• Respiratory fluoroquinolones, such as levofloxacin, gemifloxacin, or moxifloxacin 4, 3, 6
• Oral beta-lactam antibiotics, such as amoxicillin-clavulanate 7, 3

Considerations for Switching

When switching from IV to oral antibiotics, consider the following:

• The patient's clinical stability and ability to tolerate oral medications 3, 5
• The severity of the CAP and the presence of comorbidities 3, 6
• The potential for resistance and the need for combination therapy 3, 6
• The patient's previous antibiotic use and potential allergies 3