Are IV Antibiotics Unnecessarily Prolonged Before Transition to Oral?


Investigators studying over 4500 patients with gram-negative bacteremia see opportunities for earlier transition from IV to oral antibiotics.

There could be unnecessary delays in transitioning from intravenous to oral antibiotic treatment of gram-negative bacteremia, according to findings of a retrospective cohort study.1

"Transition to oral antibiotic therapy by day 7 occurred in fewer than half of episodes," reported Drew Engers, MD, Department of Internal Medicine, Infectious Diseases, Trinity Health, Ann Arbor, MI, and colleagues. "There may have been additional opportunities for earlier and more frequent oral antibiotic transitions because most patients demonstrated clinical stability by day 5."

In addition to increased product and personnel costs, Engers and colleagues point out that prolonged IV treatment carries risks such as phlebitis, venous thromboembolism, catheter occlusions and catheter-related blood stream infections.

The investigators reviewed records of 4581 patients treated for gram-negative bacteremia in 24 hospitals in diverse locations across the US during 2019. They compared demographic characteristics, clinical parameters, host factors, sources of infection and antibiotic selection of patients who were transitioned to an oral antibiotic within, or after 7 days of intravenous treatment.

The investigators chose the 7 day duration of intravenous antibiotic to separate groups for comparison based on several cited studies, "given evidence favoring the duration of only 7 days of antibiotic therapy for uncomplicated gram-negative blood stream infections."

The proportion of patients converted to oral treatment within 7 days varied substantially between hospitals, from 25.8% to 65.9%, with most between 30 to 50%. The investigators suggest that contributing factors could include the availability of infectious diseases and antibiotic stewardship. They also acknowledge that prolonged intravenous treatment can reflect patient characteristics such as severity of illness, immunosuppression, source of infection, source control, susceptible oral options and antibiotic allergies.

What You Need to Know

The study highlights that less than half of the episodes of gram-negative bacteremia transitioned to oral antibiotic therapy by day 7, despite many patients demonstrating clinical stability by day 5.

The proportion of patients converted to oral treatment within 7 days varied significantly between hospitals, ranging from 25.8% to 65.9%.

Patients maintained on intravenous treatment were more likely to be immunosuppressed, required intensive care unit admission more often, had fever or hypotension as of day 5, required kidney replacement therapy, and were less likely to have control of infection source within 7 days.

Patients maintained on IV treatment were more likely to be immunosuppressed than those who transitioned within 7 days (31.9% vs 24.6%). They more often required intensive care unit admission (39.5% vs 17.0%); had fever or hypotension as of day 5 (16.2% vs 2.5%); required kidney replacement therapy (10.7% vs 3.2%); and were less likely to have control of infection source within 7 days (70.9% vs 80.1%).

Urinary tract was the most common source of infection in both groups, 64.9% of those transitioned to oral within 7 days and 38.6% of those maintained on IV; with Escherichia coli the most common organism.ß-lactamase-producing bacterial infections were more common in the IV group than in those transitioned to oral therapy within 7 days (10.6% vs 2.6%).

Engers and colleagues find possible missed opportunities for earlier transition to oral treatment in the approximate 90% of patients achieving clinical stability by day 5, the approximate 75% having source control within the first week (median 2 days) and 1 day median bacteremia.They also found that the total antibiotic treatment duration was significantly shorter for those transitioned to oral treatment within 7 days, (11 days vs 13 days).

"With the knowledge that safe and effective clinical outcomes are possible in oral transition therapy, the current study suggests that many of the patients in our cohort may have had options for an earlier transition to oral therapy with a higher frequency than what was observed," Engers and colleagues conclude.


1.Engers DW, Tamma PD, Flawoo S, et al. Transition to oral antibiotic therapy for hospitalized adults with gram-negative bloodstream infections. JAMA Netw Open 2024; 7(1):e2349864. doi:10.100/jamanetworkopen.2023.49864. Accessed Jan 3, 2024.

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