Talk to the Veterans Crisis Line now
U.S. flag
An official website of the United States government

VA Health Systems Research

Go to the VA ORD website
Go to the QUERI website

HSR&D Citation Abstract

Search | Search by Center | Search by Source | Keywords in Title

The Antibiotic conversion decision in patients hospitalized with pneumonia: Do generalists and specialists think alike?

Halm EA, Mittman BS, Walsh MB, Switzer GE, Chang CH, Fine MJ. The Antibiotic conversion decision in patients hospitalized with pneumonia: Do generalists and specialists think alike? Paper presented at: Society of General Internal Medicine Annual Meeting; 1999 Apr 1; San Francisco, CA.




Abstract:

We sought to determine the factors influencing the decision to convert from IV to oral (PO) antibiotics in patients (Pt) hospitalized with community-acquired pneumonia (CAP) As part of a guideline trial, we developed a pre-intervention written survey to assess baseline attitudes about CAP management. Physicians (MDs) rated the importance of 14 clinical factors on the antibiotic (ABX) conversion decision on a 3 point scale (not, somewhat, and very important). They also reported vital sign threshold values at which they would consider a typical Pt stable to be switched from IV to PO ABX. We surveyed 641 internal medicine (IM) attendings who treat CAP in 7 hospitals in Pittsburgh, PA hospitals (1 university, 3 community teaching and 3 community non-teaching).We received 352 completed surveys (55% response rate): 86/128 at Univ. of Pittsburgh Medical Center (UPMC) Montefiore, 49/84 at Jefferson, 19/34 at UPMC Braddock, 55/99 at UPMC Passavant, 78/147 at UPMC Shadyside, 45/102 at St. Francis, and 20/47 at UPMC McKeesport. Overall, 79% of MDs were generalists (general IM, family, general practice) and 21% IM subspecialists (pulmonary/infectious diseases). Specialists cared for more CAP inpatients/yr (32 v. 18; p < .000 1) and did more inpatient care (27 v. 12 hrs/wk; p < .0001) then generalists. Among all MDs, absence of metastatic infection was the most influential factor in streamlining ABX with MDs rating as very important 'no suppurative infection' (93%) and 'no positive blood cultures' (63%). Other factors rated as very important were: ability to take POs (79%), respiratory rate (RR) baseline (64%), temperature (Temp) normal (62%), 02 sat baseline (55%) and mental status baseline (50%). Less important factors included: general appearance (46%), heart rate [HR] (42%), etiology (39%), comorbidities (38%), and blood pressure [BP] (27%). Only 17%of MDs felt the WBC should be normal and 8% the CXR resolved. Mean threshold at which MDs would first consider switching ABX from IV to PO were: Temp < orequal to 100F, RR < or equal to 22, HR < or equal to 100, 02 sat > or equal to 90% and systolic BP > or equal to 100. Opinion was split about Pts being 'afebrile for 24 hours before conversion to PO ABX' (48% agreed, 5% no opinion, 37% disagreed). Only 18% of MDs felt 'Pts should receive a standard duration of IV ABX.' Generalists and specialists rated the same factors important to the ABX conversion decision except that more specialists emphasized CXR resolution (14% v. 7%; p = .04) and more generalists stressed BP (29% v. 17%; p = .05) and mental status (53% v. 41%; p = .07). We found no significant differences between the 2 groups in vital sign thresholds for judging clinical stability or attitudes about Pts being afebrile for 24 hours before being switched to POs or needing a standard duration of IV ABX.Guidelines and pathways to decrease delays in streamlining ABX should take into account the importance of stable vital signs and metastatic infection. Generalists and specialists had very similar heuristics for making the ABX conversion decision





Questions about the HSR website? Email the Web Team

Any health information on this website is strictly for informational purposes and is not intended as medical advice. It should not be used to diagnose or treat any condition.