Jessica Otte is a tireless improver and her work with Choosing Wisely led her to a very pragmatic question. When can admitted bacteremic patients be safely switched to oral therapy? Here are some pearls.
Urinary tract infections
Pyelonephritis is the most common source for bacteremia. Many of these patients can be changed to oral therapy quite quickly. By the time ID and susceptibility information is available, the change can be safely made if there has been clinical improvement and there is no worries about oral absorbtion.
Bacteraemic Pneumococcal pneumonia
Many of these patients can be safely and effectively changed to oral therapy if they are obviously improving. There has been a push toward shorter courses of therapy in general for CAP with 5 days now being “standard”. While bacteremia is a predictor of bad outcomes in these patients the ones that do poorly generally do so from the outset. The ones who improve promptly usually do well and oral therapy is appropriate.
Biliary source (usually coliform)
Most often this is associated with obstruction and surgical intervention is commonly needed. After obstruction has been sorted out (stenting etc.) change to oral or even discontinuation can be considered for those with good clinical change.
Beta-hemolytic streptococcus bacteremia from obvious cellulitis or erysipelas.
Once clear that it is not a necrotizing infection requiring urgent debridement, this can be treated in the same fashion as non-bacteraemic cases with the advantage of being able to use very targeted therapy (usually PenV). When systemic signs of infection have abated it is safe and effective to change to oral therapy. And remember that the leg almost always looks worse for several days before it looks better. If the patient FEELS better and is systemically improving, the leg will follow…
Be very careful with S. aureus. It is almost always associated with an occult source that may be hard to identify and that commonly needs surgical attention. A parenteral course of at least 14 days is almost always needed and no generalizations about change to oral therapy can be made. Infectious Diseases consultation is highly recommended.
And as always, my colleagues and I are available 24/7 to help out with these difficult decisions. And if you aren’t familiar yet with Spectrum. Have a look here Spectrum Web Version also available through a link on the top menu bar in PowerChart and FirstNet) and you can download the app for smartphone here Spectrum App.