 |
|
Early Discharge of Infected Patients Through Appropriate Antibiotic Use
Lawrence J. Eron, MD;
Stacey Passos
Arch Intern Med. 2001;161:61-65.
ABSTRACT
| |
Background Patients with infections are usually discharged from the hospital with
antibiotics when afebrile and clinically improved.
Objectives To compare outcomes of early vs conventionally discharged patients and
to examine the role of antibiotic use in the discharge process.
Methods One hundred eleven patients hospitalized with cellulitis, community-acquired
pneumonia, or pyelonephritis (urinary tract infection) discharged from the
hospital early in their clinical course before defervescence by an infectious
diseases hospitalist (L.J.E.) were compared in a case-controlled study with
112 patients discharged from the hospital according to conventional standards
of care by internal medicine (IM) hospitalists. Patients were matched for
age, sex, diagnosis, and comorbidities. Outcomes were determined for average
lengths of stay, readmission to the hospital within 30 days with the same
diagnosis, satisfaction with their discharge program, and time to return to
their normal activities of daily living.
Results Patients cared for by the infectious diseases hospitalist had a shorter
average length of stay (mean difference, 1.7 days), no readmissions, higher
satisfaction scores, and a shorter time to return to their activities of daily
living, compared with those cared for by the IM hospitalists. Analysis of
the antibiotics that patients were discharged with revealed that the infectious
diseases hospitalist used outpatient parenteral antibiotic therapy more frequently
than IM hospitalists in the treatment of cellulitis, and switched from intravenous
to oral antibiotics sooner than IM hospitalists for patients with community-acquired
pneumonia and urinary tract infection.
Conclusions The infectious diseases hospitalist discharged patients from the hospital
earlier than the IM hospitalists by more efficient use of antibiotics. The
earlier discharge did not adversely affect outcomes.
INTRODUCTION
THREE COMMON community-acquired infections resulting in hospitalization
are community-acquired pneumonia (CAP), urinary tract infection (UTI), and
cellulitis. Patients hospitalized with these types of infections usually complete
their course of antibiotic treatment as outpatients. Economic considerations
have forced clinicians to consider strategies for earlier discharge from the
hospital, including outpatient parenteral antibiotic therapy (OPAT) and a
more rapid switch from intravenous to oral antibiotics.1, 2, 3, 4
However, the decision to discharge a patient with OPAT or with oral antibiotics
may be delayed, for example, because of fever, which may continue despite
optimal antibiotic therapy for several days in patients with cellulitis, CAP,
or pyelonephritis.5 While it has been demonstrated
that there is no benefit to watching patients for 24 hours in the hospital
following defervescence and switch to oral antibiotic therapy, clinicians
may continue to keep patients hospitalized for additional but unnecessary
observation.6, 7, 8, 9
We, therefore, undertook an observational study comparing patients discharged
from the hospital by an infectious diseases (ID) hospitalist (L.J.E.) early
in their clinical course before defervescence with those discharged from the
hospital more conventionally by internal medicine (IM) hospitalists to determine
the effect of early discharge on patient outcomes.
PATIENTS AND METHODS
It was the intent of this study to compare patients discharged from
the hospital early in their clinical course before defervescence with those
discharged from the hospital using the conventional strategy, wherein patients
undergo defervescence and improve clinically before discharge. To accomplish
this, we analyzed 111 consecutive patients discharged early by the ID hospitalist
from May 1, 1998, through July 31, 1999, whose anticipated lengths of stay
would not exceed 6 days, as estimated by the triage physician. This criterion
was required in an attempt to exclude potential outliers from the study that
might skew results. They were matched in a case-controlled fashion as closely
as possible for sex, age, comorbidities, and diagnoses, with a similar pool
of patients discharged conventionally by IM hospitalists during the same period.
These patients were not randomized between the 2 groups but rather were admitted
by the IM hospitalists when the ID hospitalist was not on duty.
Patients were admitted directly by the ID hospitalist from 8 AM to 3
PM Mondays through Fridays or were admitted by night coverage from 8 PM to
8 AM Sundays through Thursdays and reassigned to the ID hospitalist at 8 AM
Mondays through Fridays. They were admitted directly by the IM hospitalists
from 3 PM to 8 PM Mondays through Fridays and during the entire weekend from
Fridays at 8 PM until Sundays at 8 PM. This method of assignment of patients
did not lead to a selection bias, as this Kaiser Foundation hospital's departments
function 7 days a week, and it seems unlikely that confounding differences
could have been introduced solely based on the time of admission. However,
we cannot exclude the possibility of subtle effects leading to a selection
bias, as a result of nonrandomization.
Community-acquired pneumonia was defined as
fever (temperature >38°C), tachypnea, production of purulent sputum, decrease
in oxygen saturation on pulse oximetry, and radiological evidence of alveolar
infiltrates. Urinary tract infection was defined
as fever (temperature >38°C) with abdominal or costovertebral angle tenderness,
pyuria, and bacteriuria. Cellulitis was defined as
fever (temperature >38°C) with signs of inflammation of the skin.
Clinical improvement for cellulitis was defined
as no further advancement of cellulitis, normalization of the white blood
cell count, and improvement in feelings of well-being. Clinical improvement for UTI was defined as lessening of the costovertebral
angle or abdominal tenderness and improvement in feelings of well-being. Clinical improvement for CAP was defined as a decrease
in tachypnea, lessening of crackles on auscultation of the lungs, an increase
in oxygen saturation on pulse oximetry, radiological improvement, and improvement
in feelings of well-being. Cure was defined as disappearance
of all of the previously described signs of infection. Patients were discharged
from the hospital by IM hospitalists following defervescence and clinical
improvement, and by the ID hospitalist before defervescence and demonstration
of improvement in all clinical indications of infection. Following discharge
from the hospital, patients were followed up in the infusion clinic if they
received OPAT. If they were discharged from the hospital with oral antibiotics,
they were followed up by either their hospitalist or their primary care provider,
at the discretion of the hospitalist.
Patients from the IM group were matched to those in the ID group, first
of all, based on diagnosis. Once categorized by diagnosis, patients were next
matched on comorbidities. Finally, patients were matched based on sex and
age. The 2 groups were then compared for average length
of stay, defined as the number of nights spent in the hospital following
admission. If they were admitted during the previous night by night coverage
and sent home the same day by the hospitalist, the length of stay was counted
as 1 day. If they were sent home from the emergency department or from the
infusion clinic without being admitted, their length of stay was counted as
0 days. These patients were usually observed for several hours in the hospital
before being discharged to be sure that they were not worsening clinically.
Approximately 1 month following discharge from the hospital, they were sent
an anonymous questionnaire regarding their attitudes toward the discharge
program and the time it took them to return to their normal activities of
daily living following discharge. The components of the survey included 3
questions: "How long did it take you following discharge from the hospital
to return to at least one of your normal activities of daily living (such
as work, school, homemaking, hobbies, etc)? How did you feel about the timing
of your discharge? Did you feel that your home environment aided in your recovery
(strong agreement, agreement, neutral, disagreement, or strong disagreement)?"
The response rates (77% and 86% for ID and IM hospitalists' patients, respectively)
were similar between the 2 groups.
Antibiotics used in the hospital were compared, as were those used following
discharge from the hospital. Patients were followed up for 30 days after discharge
from the hospital for possible readmission with the same diagnosis. Since
our organization is vertically integrated, it is unlikely that any readmissions
were missed.
We used SAS statistical software, version 6.12 (SAS Institute Inc, Cary,
NC), for all statistical calculations. Statistical analyses were based on
2-sample t test (length of stay and age) and  2 test for equality of distribution (sex and comorbidities).
RESULTS
One hundred eleven patients cared for by the ID hospitalist were evenly
matched to 112 patients cared for by IM hospitalists for sex, age, diagnosis,
and comorbidities (Table 1). The
average length of stay was significantly shorter in the group cared for by
the ID hospitalist overall and for each type of infection (Table 2). There was only one readmission within 30 days, a patient
with CAP, and that occurred in the group conventionally treated by the IM
hospitalists. The patient subsequently did well, and was discharged from the
hospital uneventfully. There were no readmissions within the group discharged
from the hospital early by the ID hospitalist.
|
|
|
|
Table 1. Patient Demographic Characteristics*
|
|
|
|
|
|
|
Table 2. Lengths of Stay and Readmissions*
|
|
|
Patients with cellulitis were treated by the ID hospitalist with intravenous
cefazolin sodium, ceftriaxone sodium, or clindamycin while hospitalized, and
they were discharged from the hospital while still febrile and before improvement
in the cellulitis with ceftriaxone, cefazolin, or oral clindamycin 2.4 days
earlier than those treated by IM hospitalists. Those discharged from the hospital
with intravenous ceftriaxone or cefazolin were later switched to treatment
with oral cloxacillin or cephalexin by the ID hospitalist to complete their
course of therapy, but this was not included in the analysis. Patients with
cellulitis cared for by the IM hospitalists received cefazolin or various
other antibiotics in the hospital, but were not discharged from the hospital
until defervescence with improvement in the cellulitis; they were discharged
with oral cephalexin or a similar antibiotic (Table 3).
|
|
|
|
Table 3. Antibiotics Used for Cellulitis*
|
|
|
Patients with a UTI were treated by the ID hospitalist with oral (or
if nauseous, a single dose of intravenous) ciprofloxacin in the hospital,
and were discharged from the hospital febrile and before clinical improvement
with either oral ciprofloxacin or a combination of trimethoprim and sulfamethoxazole
an average of 1.2 days earlier than those treated by IM hospitalists. Those
patients with UTI cared for by IM hospitalists were treated with ceftriaxone
or intravenous ciprofloxacin during their hospitalization, and were discharged
from the hospital with oral trimethoprim-sulfamethoxazole, ciprofloxacin,
cephalexin, or a combination of amoxicillin and clavulanate potassium following
defervescence and clinical improvement (Table 4).
|
|
|
|
Table 4. Antibiotics Used for UTIs*
|
|
|
Patients with CAP were treated with ceftriaxone plus either oral doxycycline
or azithromycin by the ID hospitalist while in the hospital and were discharged
from the hospital before clinical improvement with either oral doxycycline
or azithromycin a mean of 1.2 days earlier than the group cared for by the
IM hospitalists. The patients with CAP cared for by the IM hospitalists were
treated with ceftriaxone and oral doxycycline, azithromycin, clarithromycin,
or erythromycin while hospitalized and were discharged from the hospital following
defervescence and clinical improvement; they were discharged with various
oral antibiotics (Table 5).
|
|
|
|
Table 5. Antibiotics Used for CAP*
|
|
|
Satisfaction surveys of both groups revealed favorable responses for
the discharge program, although there was one dissatisfied patient in each
group. Using the discriminator of "strong agreement" with the discharge program
(vs "agreement"), there were differences between the 2 groups. Patients discharged
from the hospital earlier were more likely to be in strong agreement, than
those conventionally discharged, with the timing of their discharge (60% vs
28%) and that their home environment aided their recovery (56% vs 29%). The
early discharge group returned to work an average of 1.7 days earlier than
those conventionally discharged (mean ± SD, 5.1 ± 0.3 vs 6.8
± 0.3 days; and median, 5 vs 7 days, respectively).
COMMENT
Patients were discharged from the hospital by the ID hospitalist while
still febrile early in their clinical course, before clinical improvement
of all signs of infection. Patients cared for by the IM hospitalists were
discharged from the hospital after defervescence and following definite clinical
improvement. The use of this early discharge strategy by the ID hospitalist
shortened the average length of stay for all disease categories without increasing
readmissions to the hospital and, in addition, increased patient satisfaction.
This may have been due to the patients' increased feelings of well-being at
home. While at home, they likely participated more in their own care and were
more active, which led to their return to their normal activities of daily
living earlier than those conventionally treated. A multicenter study10 that compared outpatient treatment of CAP with a
group treated as inpatients with equally severe manifestations of disease
also demonstrated that those treated as outpatients recovered earlier and
returned to their normal activities of daily living sooner.
There are, however, several potential limitations to our study. The
study was not a prospective, randomized trial, but rather an observational
study, which may have introduced unrecognized differences between the 2 arms
of the study, such as differences in the types of cases assigned to each group
and in the workloads, personalities, and work ethics of the physicians caring
for a particular patient.
Another limitation of this study is that the exact criteria for discharge
of patients in our study were not standardized for quantity of malaise, pain,
tachypnea, crackles on auscultation, hypoxemia, or leukocytosis. They were
subjective and, therefore, inexact, differing among physicians. However, it
was not the intent of this study to validate criteria for hospital discharge,
but rather to challenge the conventional requirement of defervescence and
clinical improvement before discharge and to support this approach with outcomes
data, which is the main strength of this study. We chose to focus on antibiotic
use as a potential tool for early discharge from the hospital rather than
assaying real or spurious differences between the management styles of ID
compared with IM hospitalists for fear of fostering an "us vs them" mentality.
Such an approach would likely invite methodological criticism based on the
simple fact that having only one ID hospitalist could likely skew results
in that group.
Antibiotic use differed between the 2 groups of patients in this study.
The ID hospitalist's more frequent use of OPAT for cellulitis and earlier
switch to oral antibiotics for UTI and CAP likely resulted in the difference
in average length of stay between the 2 groups. While IM hospitalists had
the same access to OPAT, they did not use it as frequently, as noted elsewhere.11 The earlier switch to oral therapy may also reflect
a familiarity by the ID hospitalist with the bioavailability of orally administered
antibiotics. Indeed, it has been shown elsewhere12
that only 40% of patients with CAP were switched to oral antibiotics when
they were believed to be clinically stable, which led to unnecessary delays
in discharge of 24 hours or longer.
The ID physician has 2 advantages in this regard:greater understanding
of effective antibiotic use, particularly for OPAT and oral therapy, and greater
familiarity with the typical course of infected patients treated with antibiotics.13, 14, 15, 16 While
only 75% of patients with pyelonephritis may undergo defervescence within
48 hours and the additional 25% may take 3 or 4 days of optimal antibiotic
therapy before defervescence,5 physicians may
be reluctant to discharge patients while still febrile because of habit, training,
or fear of litigation in the event of an unsuccessful outcome. If an ID hospitalist
could be involved in an early consultative, if not a primary, capacity in
the care of the infected patient, the clinician could assist with decisions
regarding alternatives to admission and facilitate early discharge from the
hospital.17 Such an arrangement would likely
increase the efficiency with which hospitals operate. Alternatively, clinical
practice guidelines might accomplish the same ends.18, 19
However, hospital discharge criteria remain subjective and controversy exists
surrounding the usefulness of such guidelines in general.20
It remains to be seen whether alternative strategies such as the one described
in the present study might not complement guidelines, with improved outcomes
and increased satisfaction to patients and physicians alike.
AUTHOR INFORMATION
Accepted for publication June 30, 2000.
The data collection and analysis performed by Nelson Lee was supported
by a grant from Roche Labs, Nutley, NJ. This funding source played no role
in the data collection and analysis or in the writing of the manuscript.
Presented in part at the 37th Annual Meeting of the Infectious Diseases
Society of America, Philadelphia, Pa, November 20, 1999.
This study would not have been possible without the collegiality and
expert care rendered by the Division of Inpatient Medicine at Kaiser Permanente
Medical Center, Honolulu, Hawaii, which set a standard that was difficult
to exceed.
From the Division of Inpatient Medicine, Department of Medicine, Kaiser
Permanente Medical Center (Dr Eron and Ms Passos), and the John A. Burns School
of Medicine, University of Hawaii (Dr Eron), Honolulu, Hawaii.
Reprints: Lawrence J. Eron, MD, 3288 Moanalua Rd, Honolulu, HI 96819
(e-mail: Lawrence.Eron{at}kp.org).
REFERENCES
| |
1. Israel RS, Lowenstein SR, Koziol-McLain J, et al. Management of acute pyelonephritis in an emergency department observation
unit. Ann Emerg Med. 1991;20:253-257.
FULL TEXT
|
ISI
| PUBMED
2. Safrin S, Siegel D, Black D. Pyelonephritis in adult women: inpatient vs outpatient therapy. Am J Med. 1988;85:793-798.
ISI
| PUBMED
3. Leder K, Turnidge JD, Grayson ML. Home-based treatment of cellulitis with twice-daily cefazolin. Med J Aust. 1998;169:519-522.
ISI
| PUBMED
4. Fine MJ, Chowdhry T, Ketena A, et al. Outpatient management of community-acquired pneumonia. Hosp Pract (Off Ed). 1998;33:123-133.
5. Gover SA, Komaroff AL, Weisberg M, et al. The characteristics and hospital course of patients admitted for presumed
acute pyelonephritis. J Gen Intern Med. 1987;2:5-10.
ISI
| PUBMED
6. Beaumont M, Schuster MG. Is an observation period necessary after intravenous antibiotics are
changed to oral administration? Am J Med. 1999;106:114-116.
FULL TEXT
|
ISI
| PUBMED
7. Dunn AS, Peterson KL, Schechter CB, et al. The utility of an in-hospital observation period after discontinuing
intravenous antibiotics. Am J Med. 1999;106:6-10.
FULL TEXT
|
ISI
| PUBMED
8. Caceres VM, Stange KC, Kikano GE, et al. The clinical utility of a day of hospital observation after switching
from intravenous to oral antibiotic therapy in the treatment of pyelonephritis. J Fam Pract. 1994;39:337-339.
PUBMED
9. Rhew DC, Hackner D, Henderson L, et al. The clinical benefit of in-hospital observation in low-risk pneumonia
patients after conversion from parenteral to oral antimicrobial therapy. Chest. 1998;113:142-146.
FREE FULL TEXT
10. Fine MJ, Singer DE, Marrie TJ, et al. Medical outcomes of ambulatory and hospitalized low risk patients with
community-acquired pneumonia. J Gen Intern Med. 1994;9(suppl 2):29.
11. Nathwani D, Davey P. Intravenous antimicrobial therapy in the community: underused, inadequately
resourced, or irrelevant to health care in Britain. BMJ. 1996;313:1541-1543.
FREE FULL TEXT
12. Halm EA, Fine MJ, Marrie TJ, et al. Time to clinical stability in patients hospitalized with community-acquired
pneumonia: implications for practice guidelines. JAMA. 1998;279:1452-1457.
FREE FULL TEXT
13. Byl B, Clevenbergh P, Jackobs F, et al. Impact of infectious diseases specialists and microbiological data
on the appropriateness of antimicrobial therapy. Clin Infect Dis. 1999;29:60-66.
ISI
| PUBMED
14. Nathwani D, Davey P, France AJ, et al. Impact of an infection consultation service for bacteraemia on clinical
management and use of resources. QJM. 1996;89:789-797.
FREE FULL TEXT
15. Fowler VG, Sanders LL, Sexton DJ, et al. Outcome of Staphylococcus aureus bacteremia
according to compliance with recommendations of infectious diseases specialists:
experience with 244 patients. Clin Infect Dis. 1998;27:478-486.
ISI
| PUBMED
16. Nathwani D, Davey P. Antibiotic prescribing: are there lessons for physicians? QJM. 1999;92:287-292.
FREE FULL TEXT
17. Wilkins EGL, Hickey MM, Khoo S, et al. Northwick Park Infection Consultation Service part II: contribution
of the service to patient management: an analysis of results between September
1987 and July 1990. J Infect. 1991;23:57-63.
PUBMED
18. Warren JW, Abrutyn E, Hebel JR, et al. Guidelines for antimicrobial treatment of uncomplicated acute bacterial
cystitits and acute pyelonephritis in women. Clin Infect Dis. 1999;29:745-758.
ISI
| PUBMED
19. Bartlett JG, Breiman RF, Mandell LA, et al. Community-acquired pneumonia in adults: guidelines for management. Clin Infect Dis. 1998;26:811-838.
ISI
| PUBMED
20. Halm EA, Atlas SJ, Borowsky LH. Understanding physician adherence with a pneumonia practice guideline. Arch Intern Med. 2000;160:98-104.
FREE FULL TEXT
 CiteULike  Connotea  Del.icio.us  Digg  Reddit  Technorati  Twitter
What's this?
RELATED ARTICLE
Archives of Internal Medicine Reader's Choice: Continuing Medical Education
Arch Intern Med. 2001;161(1):131-132.
FULL TEXT
THIS ARTICLE HAS BEEN CITED BY OTHER ARTICLES
|
Factors and outcomes associated with physicians' adherence to recommendations of infectious disease consultations for inpatients
Sellier et al.
J Antimicrob Chemother 2009;0:dkp406v1-dkp406.
ABSTRACT
| FULL TEXT
Early Switch From Vancomycin to Oral Linezolid for Treatment of Gram-Positive Heart Valve Endocarditis
Colli et al.
Ann. Thorac. Surg. 2007;84:87-91.
ABSTRACT
| FULL TEXT
Comparison between pathogen directed antibiotic treatment and empirical broad spectrum antibiotic treatment in patients with community acquired pneumonia: a prospective randomised study
van der Eerden et al.
Thorax 2005;60:672-678.
ABSTRACT
| FULL TEXT
Randomised controlled trial of intravenous antibiotic treatment for cellulitis at home compared with hospital
Corwin et al.
BMJ 2005;330:129.
ABSTRACT
| FULL TEXT
Early Discharge of Infected Patients Through Appropriate Antibiotic Use: A Response
Ravakhah et al.
Arch Intern Med 2001;161:2047-2048.
FULL TEXT
|
