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January 20, 1999

Time to Clinical Stability for Patients With Community-Acquired Pneumonia—Reply

Author Affiliations

Margaret A.Winker, MDIndividualAuthorPhil B.FontanarosaMD, Senior EditorsIndividualAuthor

JAMA. 1999;281(3):231-232. doi:10-1001/pubs.JAMA-ISSN-0098-7484-281-3-jbk0120

In Reply: We agree that the traditional practice of treating patients hospitalized for CAP with 7 to 10 days of IV antibiotics is based on custom, not substantive data. While the impetus for early conversion to oral antibiotics has been primarily financial (shortening length of stay), there are other clinical advantages, including lower risk of phlebitis, line sepsis, and fluid overload, as well as earlier mobilization and return to usual activities.

The median duration of IV antibiotics in our observational study was 6 days. However, the total number of days of parenteral therapy is less important to us than the number of potentially unnecessary days. Once patients are clinically stable, they should not need to continue to receive IV antibiotics in the absence of serious bacteremia or metastatic infection. The purpose of our study was to develop a definition of stability that was objective, clinically sensible, and a valid predictor of good outcomes. We found a median delay of 3 days between stabilization and conversion to oral antibiotics; thus, there is ample opportunity for improvement. To further validate this strategy, we are conducting a prospective, randomized controlled trial of an actively implemented practice guideline emphasizing early conversion to oral antibiotics and timely discharge once stability is attained.