The Journal of Informed Pharmacotherapy 2001;5:200-202.
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Reviewer: Alfred Gin,
Reviewer's email address: firstname.lastname@example.org
Reviewer's profession/specialty: Clinical Pharmacist/Infectious Diseases
Rhew DC, Tu GS, Ofman J, Henning JM, Richards MS, Weingarten SR. Early Switch and Early Discharge Strategies in Patients With Community-Acquired Pneumonia: A Meta-analysis. Arch Intern Med 2001 Mar 12;161:722-727. PubMed Cit
To evaluate criteria used in studies of community-acquired pneumonia (CAP) for early switch therapy (i.e. parenteral to oral therapy conversion) and to assess the impact of early switch and early discharge on clinical outcomes and length of stay (LOS). Several past studies have been published have suggested that early switch and early discharge may decrease the length of stay without adverse affecting outcomes.
1. Did the overview address a focused clinical question?
The authors specifically focused on the impact of early switch therapy and
discharge on clinical outcomes and LOS.
Yes. The researchers searched several databases using several search terms for articles addressing early switch therapy antibiotic therapy and early discharge in CAP patients. Early switch and early discharge strategy was defined as a method or intervention designed to shorten LOS through early switch and/or early discharge recommendations. Articles were excluded if following existed less rigorous study design, specific patient population (e.g. unrelated to CAP), non-bacterial cause of CAP, non-clinical evaluation, unrelated study objective and absence of early switch criteria.
No. The authors searched
language articles published between January
1, 1980 and March 31, 2000. The researchers searched MEDLINE, HEALTHSTAR,
EMBASE, Cochrane Collaboration and Best Evidence databases for prospective and
retrospective trials, meta-analyses and systematic reviews. The extent of search terms used would have
captured the majority of relevant articles pertaining to the study question.
articles selected were not evaluated specifically.
authors evaluated articles to address four areas of investigation; criteria for
switch therapy, criteria for discharge, switch on specific day/length of
parenteral therapy and outcomes.
The authors applied
criteria to reviewed articles to compare criteria for early switch and early
discharge in CAP.
Only articles that examined LOS are
included in the outcomes evaluation. Chi-square and random effects meta-analysis
was conducted on LOS for qualifying studies.
of clinical outcomes between intervention and control groups was not well
Kappa values for agreement
were calculated for the article reviewers.
Differences in the criteria and methodology used in early switch and
early discharge studies assessed by the researchers resulted in variation in
results with respect to the LOS and discharge. This also made it difficult
for the researchers to assess the outcome resulting from the early switch and/or
discharge. Although mean age among assessed studies appeared similar, the
researchers suggested the patients included in the pooled analysis may not have
been similar. Two of the assessed studies enrolled "low-risk"
patients with stays shorter than the interventional guidelines. Other
factors accounting for the variation in LOS included geographic variation and
1. What are the overall results of the review?
The authors identified
1794 articles, of which 266 abstracts were reviewed.
Only 10 prospective, interventional CAP studiesinvolved an evaluation of
Criteria for switch were reported in 9 studies. The most common criteria for switch was afebrile (100%), improvement/resolution of signs and symptoms (89%)and able to take oral antibiotics (67%).
Five studies applied criteria for early discharge criteria with care of comorbid condition the most common.
There was disparity in other discharge criteria among the 5 studies.
The median recommended day of switch therapy was 3 days (range 2-10 days) in 3 studies.
Five studies recommended switch therapy after a minimum number of parenteral days (3 days, range 2-10). Chi-square analysisrevealed
significant variability (p<0.001) in the LOS among
st the studies. Of the 10 prospective studies, 6 applied early switch and discharge criteria to an intervention and control group. The remaining 4 studiesinvolved
no control group
s or used historical controls.
Among the 6 evaluable studies, the LOS was
quite variable (range, 3.5 to 11 days). Meta-analysis was performed on 5 studies where standard deviation values for LOS were provided.
The mean change in LOS between the intervention and control was not significantly reduced (p=0.05) based on a random effects meta-analysis (-1.64 days; 95% confidence interval
-3.30 to 0.02).
Two studies had an interventional LOS equal or longer than the control.
Exclusion of these studies increased the mean change of LOS between the intervention and control group to 3 days (-3.04 days; 95% confidence interval-4.90 to -1.19).
2.How precise were the results?
3. How much does allowance for uncertainty change the results? (i.e. Sensitivity analysis? Analysis of heterogeneity?)
Sensitivity analysis or analysis of heterogeneity was not done.Characteristics of the 5 prospective interventional studies that may have confounded LOS analysis were presented.
1. Can the results be applied to my patient care?
Although criteria for switch therapy are generally similar, there are variations in the definitions used among some of the studies. As noted above, there is considerable variability in the criteria for early discharge and LOS due to study design. Overall, the comparison of criteria used for early switch therapy provides guidance to clinicians when evaluating a patient for oral antibiotic therapy. The authors correctly indicate that the baseline LOS affects the impact (change in LOS) as a result of early switch or discharge interventions and must thus be considered if institutions were to implement similar programs.
Due to differences in the methodology of the studies assessed, clinical outcomes (e.g. complicationsor
Intuitively, the application of early switch and discharge criteria should decrease the LOS of stay.
With the increasing armamentarium of antibiotics directed specifically against CAP, there is perhaps increasing confusion with respect to the therapeutic differences among and within antibiotic classes.
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