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Am Fam Physician. 2004;70(10):1996

The cost of care for patients with community-acquired pneumonia (CAP) is substantial in the United States. Most of the cost comes from treatment of patients in the hospital setting, which accounts for 89 percent of the $8.4 billion spent annually on the treatment of patients with CAP. Inpatient care of patients with CAP usually consists of intravenous antibiotics during the initial phase of the treatment course, followed by a switch to oral antibiotics. Recent studies have shown that there can be favorable outcomes and reductions in length of stay and cost if patients are treated only with oral antibiotics. Oral therapy probably is preferred by patients and could avoid potential complications from intravenous access. Although guidelines recommend oral therapy in selected patients with CAP, few data support this concept. Marras and colleagues evaluated the efficacy of oral antibiotics in hospitalized patients with CAP and assessed risk factors that would preclude oral therapy.

The study design was a meta-analysis of published data comparing inpatient oral and parenteral therapy in patients with CAP. The authors searched multiple databases for published articles and searched evidence-based medicine reviews. The studies were rated using a standardized rating scale, and the outcomes of clinical success and mortality were summarized. The authors also performed a retrospective analysis of the medical records of patients admitted to two urban teaching hospitals with the diagnosis of CAP. Patients were considered to be treated with oral therapy if they received no intravenous antibiotics during the hospitalization. Outcome measures included length of stay and mortality. Cost of the antibiotics also was analyzed.

Seven studies with a total of 1,366 patients were included in the meta-analysis. No significant difference was found in the relative risk for mortality at the end of treatment or at follow-up between patients who received oral versus intravenous antibiotic therapy. The mean hospital stay was shorter in the group receiving oral therapy than in the group receiving intravenous treatment.

The retrospective part of the study included 698 patients, with 18 percent receiving oral antibiotic therapy. Patients who received oral therapy were younger and had a lower mean pneumonia severity index than those who received intravenous therapy. Median length of hospitalization was 1.3 days shorter in the oral antibiotic treatment group, and antibiotic costs were $56 less than costs in the intravenous treatment group. This cost included only the medication and did not include any indirect costs. There was no significant difference in mortality rates between the treatment groups.

The authors conclude that, in certain hospitalized patients with CAP, oral antibiotics are effective. The data were inadequate to determine which risk factors should determine the route of antibiotic administration. They add that the selection of the route of administration must be individualized, but that oral administration provides an option that causes less discomfort for patients and reduces the potential complications associated with intravenous access.

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