Post published:May 26, 2016

Joanna Bonsall, MD, PhD, Daniel D. Dressler, MD, MSc, SFHM, FACP reviewing Lee JS et al. JAMA 2016 Feb 9.

Investigators systematically evaluated published literature to assess associations between mortality in adults hospitalized with communityacquired pneumonia (CAP) and several key aspects of antibiotic therapy.

For time to antibiotic initiation, eight observational studies showed that antibiotic initiation within 4 to 8 hours of hospital arrival was associated with lower mortality.
For initial antibiotic selection in hospitalized CAP patients, results were inconclusive. Systematic review revealed conflicting results of the two randomized controlled trials (RCTs) and inconsistent results from prospective cohorts in which βlactam monotherapy was compared with βlactamplusmacrolide therapy; recent RCT data for this comparison suggested that βlactam therapy was not inferior.
For the transition from intravenous (IV) to oral antibiotics, one small RCT and one prospective cohort showed that transitioning from IV to oral antibiotics when hospitalized patients meet clinical stability criteria shortens hospital length of stay without affecting other outcomes.

Limitations of this systematic review include inclusion of some patients with what now is defined as healthcareassociated pneumonia, exclusion of smaller (<100 patients) and earlier (before 1995) studies, exclusion of studies of non–U.S.approved respiratory fluoroquinolones, and heavy reliance on an older guideline with many author conflicts of interest.

Comment

Despite some caveats, this systematic review supports the current practices of starting antibiotics within 4 to 8 hours of patient presentation with CAP and transitioning from IV to oral antibiotics using objective criteria. Highquality evidence about optimal initial CAP antibiotic therapy is limited, but recent RCT data suggests that most patients hospitalized with CAP could be treated effectively with a βlactam agent alone (NEJM JW Hosp Med May 2015 and N Engl J Med 2015; 372:1312).

Personal comments: It might seem selfevident but CAP should be treated in the community. Because initial therapy may require IV antibiotics, admission is the only option. But when urgent care centers can provide 24/7 care, with IV therapy and short term observation, there is often no need for admission. This could be an excellent way of minimizing exposure to nosocomial infections, especially in patients with comorbid conditions.