Clinical study
Efficacy of exclusively oral antibiotic therapy in patients hospitalized with nonsevere community-acquired pneumonia: a retrospective study and meta-analysis

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Abstract

Purpose

To assess the efficacy of oral antibiotics in patients hospitalized with community-acquired pneumonia and to identify factors precluding oral therapy.

Methods

In a meta-analysis, we compared inpatient oral and parenteral therapy in community-acquired pneumonia. Studies were reviewed independently and rated by two reviewers, and results were summarized. We also performed a retrospective cohort study of hospitalized patients with community-acquired pneumonia and compared outcomes in patients treated with oral versus parenteral therapy.

Results

For the meta-analysis, we identified seven studies involving 1366 patients. Study exclusions included severe pneumonia or impaired oral absorption. There was no significant difference in the relative risk of mortality at the end of treatment or at follow-up. Mean length of hospital stay was shorter (6.1 days vs. 7.8 days) in patients taking oral antibiotics than in those taking the parental form. In the retrospective cohort, 18% (124/698) of patients received oral-only therapy; these patients were younger (median age, 75 vs. 78 years, P = 0.01) and had lower mean pneumonia severity index scores (101 vs. 119, P <0.0001) than those who received parenteral therapy. In multivariable models, oral-only patients had a median length of stay that was 1.3 days shorter (95% CI: 0.4% to 2.2% days; P = 0.008) and a median antibiotic cost that was $56 lower (95% CI: $53 to $58; P <0.0001) than that of patients in the parenteral group, but mortality was similar.

Conclusion

Although prospective data are limited, oral antibiotics in certain hospitalized patients with community-acquired pneumonia are effective. More data are needed to identify appropriate candidates for exclusively oral antibiotic therapy.

Section snippets

Meta-analysis

We identified studies of oral and parenteral antibiotic therapies for adult inpatients with community-acquired pneumonia. Studies had to have presented data on clinical improvement or success, mortality, or length of stay. We searched MEDLINE (1966 to March 2003; and PreMEDLINE until May 15, 2003) and EMBASE (1980 to March 2003) using the terms pneumo (truncated), bronchopneumonia, or lower respiratory tract infection; combined with hospitalization, hospital (truncated), admit, or admission;

Meta-analysis

The search yielded 63 studies, of which 48 were rejected because patients in both groups received parenteral therapy (38 compared switch and parenteral therapy, 10 compared different parenteral regimens), five were rejected because they compared different oral regimens, and three were rejected because they included patients with hospital-acquired pneumonia. The seven eligible studies (Appendix) included 1366 patients, of whom 616 (45%) received oral therapy and 750 (55%) received parenteral

Discussion

Our meta-analysis of exclusively oral antibiotic treatment in hospitalized patients with community-acquired pneumonia found similar outcomes in orally and parenterally treated patients. The results, however, should be interpreted in light of several factors. First, younger age in the oral group suggests an inadvertent failure of randomization. Since age is a major determinant of mortality in this disease (11), orally treated patients may have had a lower risk. Second, patients with severe

Acknowledgements

We are indebted to Linda Jamieson, RN, for data collection and database maintenance, and Leslie Lee Pack for database design and maintenance.

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