Oral step-down antibiotic therapy for gram-negative bacteremia after source control not linked to increased deaths

Reference

Tamma PD, Conley AT, Cosgrove SE, et al, for the Antibacterial Resistance Leadership Group. Association of 30-day mortality with oral step-down vs. continued intravenous therapy in patients hospitalized with Enterobacteriaceae bacteremia. JAMA Intern Med 2019;179(3):316-323.

Synopsis

Using electronic medical records, researchers identified hospitalized adult patients from 3 academic medical centers over 6 years who had monomicrobial Enterobacteriaceae gram-negative bacteremia. Eligible patients were those who had achieved source control, had an appropriate clinical response by day 5 of treatment, had the ability to tolerate oral medications, and had an active oral antibiotic agent that could be used for treatment. The study compared those who transitioned to oral step-down antibiotic therapy within 5 days of treatment (n = 876) with those who received a full course of intravenous antibiotic therapy (n = 1285). At baseline, the patients in the oral step-down therapy group were less likely to be severely ill at the onset of the infection (based on intensive care unit admission on day 1 and Pitt bacteremia score) and were more likely to have an infection due to a urinary tract source. Treatment duration ranged from 7 days to 15 days in both groups. After propensity-score matching using factors such as source of infection, pre-exisiting illnesses, and immunocompromised status, 739 patients in each study arm were matched. There were no significant differences detected in 30-day mortality or 30-day recurrence of bacteremia when comparing the 2 matched groups. The oral step-down group had a significantly shorter duration of hospital stay from day 1 of bacteremia to discharge (5 days vs 7 days; P <.001).