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Fluoroquinolone administration route does not affect CAP outcomes
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Patients hospitalized with community-acquired pneumonia demonstrated similar clinical outcomes regardless of whether initial fluoroquinolone treatment was administered orally or intravenously, according to a recently published study.
These findings could conflict with practice guidelines published by the Infectious Diseases Society of America and the American Thoracic Society, the researchers wrote, which recommend community-acquired pneumonia (CAP) patients only receive oral fluoroquinolones if there is no risk for severe pneumonia.
“For patients able to take oral medications on admission, the rationale for routine IV fluoroquinolones is unclear, since the intravenous and oral formulations are bioequivalent,” the researchers wrote. “Moreover, intravenous medications could result in complications such as injection-site reactions and increased length of stay for medication administration.”
To gauge the implications of each administration route, researchers retrospectively examined patient data collected from 340 hospitals from July 2007 through June 2010. Adult pneumonia patients who received a chest radiograph and either levofloxacin or moxifloxacin in the ED were included, while those who received other antibiotics during their first day of admission, met criteria for health care-associated pneumonia, or had lymphoma or cystic fibrosis were excluded. Researcher examined data on patient characteristics and care, most importantly the initial treatment administration route and the incidence of in-hospital mortality.
The researchers included 36,405 CAP patients in the analysis. These patients were aged a median of 71 years and predominantly white. The average length of a patient’s hospital stay was 4.9 days, and overall in-hospital mortality was 2%.
Ninety-four percent of patients initially received IV fluoroquinolones, while 6% received oral fluoroquinolones. Those receiving oral treatment were younger (P < .001), more often black (P < .001) or obese (P = .05), and less likely to have a principal diagnosis of sepsis (P <.001). These patients also were less likely to have sputum cultures, blood cultures or blood lactate levels drawn within their first 2 days of hospitalization.
The researchers found that, before adjustment, patients who received oral treatment had lower mortality (1.4% vs. 2.5%; P = .002), as well as reduced antibiotic escalation, average length of stay and hospital cost. However, regression modeling which adjusted for demographics, comorbidities and other initial medications demonstrated no difference in mortality (OR = 0.82; 95% CI, 0.58-1.15), hospital length of stay or costs, as well as no difference in the risk for late ICU admission, late invasive mechanical ventilation or late vasopressors. As IV and oral fluoroquinolones are equally available, the researchers wrote that recommendations against oral treatment may be worth reconsidering.
“We found that only a small percentage of patients who could take oral medications received them, despite their bioequivalence,” they wrote. “Future guidelines should take care to emphasize the evidence for oral antibiotics when feasible. As oral regimens become more common, future studies may be able to identify risk factors for treatment failure and those patients for whom IV therapy can be avoided.” – by Dave Muoio
Disclosure: Belforti reports no relevant financial disclosures. Please see the full study for a list of all other authors’ relevant financial disclosures.
Perspective
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Paul G. Auwaerter, MD, MBA
This large, retrospective study suggests that oral fluoroquinolones are probably underused in patients admitted with CAP. This is unsurprising since oral fluoroquinolones are highly bioavailable and, except for patients in septic shock, likely can be used compared with parenteral therapy. This could result in some cost savings for health systems.
That said, many clinicians favor ceftriaxone and azithromycin therapy for CAP to avoid potential rare complications of fluoroquinolone therapy, such as tendon rupture or QT prolongation, or with the belief that they may offer better treatment for severe pneumococcal pneumonia. Both typical regimens used for CAP have risks for Clostridium difficile colitis. One hope is that new molecular diagnostics might improve our ability to precisely diagnose the causes of CAP and allow for appropriately narrow, targeted antibiotic therapy rather than our current approaches.
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