Variability in oral antibiotic step-down therapy in the management of Gram-negative bloodstream infections

•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI).•Many ID providers (40%) practice oral step-down for some sources of GN-BSI but not others.•ID providers in the USA are more likely to practice oral step-down that those outside the...

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Published in:	International Journal of Antimicrobial Agents Vol. 58; no. 6; p. 106451
Main Authors:	Thaden, Joshua T., Tamma, Pranita D., Doi, Yohei, Daneman, Nick
Format:	Journal Article
Language:	English
Published:	Netherlands Elsevier Ltd 01.12.2021 Elsevier BV
Subjects:	Administration, Intravenous Administration, Oral Anti-Bacterial Agents Anti-Bacterial Agents - administration & dosage Anti-Bacterial Agents - therapeutic use antibiotics Bacteraemia Bacteremia Bacteremia - drug therapy Bacteremia - microbiology blood flow Bloodstream infection Cross Infection Cross Infection - drug therapy Gram-negative Gram-Negative Bacterial Infections Gram-Negative Bacterial Infections - drug therapy Humans Infectious Disease intravenous injection Oral step-down pneumonia Practice Patterns, Physicians Practice Patterns, Physicians' - statistics & numerical data surveys Surveys and Questionnaires Bacteraemia Bloodstream infection Gram-negative Oral step-down
ISSN:	0924-8579, 1872-7913, 1872-7913
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Abstract	•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI).•Many ID providers (40%) practice oral step-down for some sources of GN-BSI but not others.•ID providers in the USA are more likely to practice oral step-down that those outside the USA (OR = 4.35; P < 0.001).•Most ID providers (76%) were willing to enrol patients in a RCT of early oral step-down versus full IV therapy for GN-BSI. There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ2 tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48–2.61); P < 0.001], pneumonia [2.24 (1.67–2.99); P < 0.001], skin [7.26 (4.71–11.20); P < 0.001] and urinary [9.15 (5.73–14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57–7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23–53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation.
AbstractList	•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI).•Many ID providers (40%) practice oral step-down for some sources of GN-BSI but not others.•ID providers in the USA are more likely to practice oral step-down that those outside the USA (OR = 4.35; P < 0.001).•Most ID providers (76%) were willing to enrol patients in a RCT of early oral step-down versus full IV therapy for GN-BSI. There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ2 tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48–2.61); P < 0.001], pneumonia [2.24 (1.67–2.99); P < 0.001], skin [7.26 (4.71–11.20); P < 0.001] and urinary [9.15 (5.73–14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57–7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23–53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation. There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ2 tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48-2.61); P < 0.001], pneumonia [2.24 (1.67-2.99); P < 0.001], skin [7.26 (4.71-11.20); P < 0.001] and urinary [9.15 (5.73-14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57-7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23-53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation.There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ2 tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48-2.61); P < 0.001], pneumonia [2.24 (1.67-2.99); P < 0.001], skin [7.26 (4.71-11.20); P < 0.001] and urinary [9.15 (5.73-14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57-7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23-53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation. Highlights•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI). •Many ID providers (40%) practice oral step-down for some sources of GN-BSI but not others. •ID providers in the USA are more likely to practice oral step-down that those outside the USA (OR = 4.35; P < 0.001). •Most ID providers (76%) were willing to enrol patients in a RCT of early oral step-down versus full IV therapy for GN-BSI. There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48-2.61); P < 0.001], pneumonia [2.24 (1.67-2.99); P < 0.001], skin [7.26 (4.71-11.20); P < 0.001] and urinary [9.15 (5.73-14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57-7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23-53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation. There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better understand contemporary management practices involving oral step-down in GN-BSI, we conducted an international survey of infectious diseases (ID) specialists. We developed and disseminated an online survey to ID specialists to assess practice patterns involving oral step-down in GN-BSIs, including providers from six continents and 28 countries. χ² tests and generalised estimating equations were used to identify factors associated with oral step-down. In total, 277 ID specialists completed the survey (64% physicians, 31% pharmacists). Relative to a line source, oral step-down was more common in abdominal [OR = 1.96 (95% CI 1.48–2.61); P < 0.001], pneumonia [2.24 (1.67–2.99); P < 0.001], skin [7.26 (4.71–11.20); P < 0.001] and urinary [9.15 (5.73–14.60); P < 0.001] sources of GN-BSI. US providers were more likely to practice oral step-down than non-US providers (OR = 4.35, 95% CI 2.57–7.36; P < 0.001). Moreover, 40% of providers practice oral step-down for some, but not all, sources of GN-BSI. Among all providers, 23–53% (depending on GN-BSI source) recommend extended (≥5 days) intravenous (IV) therapy before oral step-down or ongoing IV therapy. Most respondents (76% of all providers; 80% of ID physicians) expressed interest in enrolling patients in a trial of full IV versus early oral step-down for GN-BSI. There is extensive heterogeneity in oral step-down practices for GN-BSI. The optimal role of oral step-down in managing GN-BSIs warrants further investigation.
ArticleNumber	106451
Author	Tamma, Pranita D. Thaden, Joshua T. Doi, Yohei Daneman, Nick
AuthorAffiliation	b Department of Pediatrics, Johns Hopkins University School of Medicine. 1800 Orleans Street, Sheikh Zayed Tower, Baltimore, MD, USA 21287 c Center for Innovative Antimicrobial Therapy, Division of Infectious Diseases, University of Pittsburgh School of Medicine. Scaife Hall, Suite 829, 3550 Terrace Street, Pittsburgh, PA, USA 15213 d Departments of Microbiology and Infectious Diseases, Fujita Health University School of Medicine, Toyoake, Aichi, Japan 470-1192 e Sunnybrook Health Sciences Centre, University of Toronto. 2075 Bayview Avenue, Room G1 06, Toronto, Ontario, Canada M4N 3M5 a Division of Infectious Diseases, Duke University School of Medicine. DUMC Box 102359, Durham, NC, USA 27701
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Snippet	•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI).•Many ID providers (40%) practice oral... Highlights•Among ID providers, there is wide variety in oral step down practices in Gram-negative bloodstream infection (GN-BSI). •Many ID providers (40%)... There are important gaps in the literature regarding the role and timing of oral therapy for Gram-negative bloodstream infections (GN-BSIs). To better...
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SubjectTerms	Administration, Intravenous Administration, Oral Anti-Bacterial Agents Anti-Bacterial Agents - administration & dosage Anti-Bacterial Agents - therapeutic use antibiotics Bacteraemia Bacteremia Bacteremia - drug therapy Bacteremia - microbiology blood flow Bloodstream infection Cross Infection Cross Infection - drug therapy Gram-negative Gram-Negative Bacterial Infections Gram-Negative Bacterial Infections - drug therapy Humans Infectious Disease intravenous injection Oral step-down pneumonia Practice Patterns, Physicians Practice Patterns, Physicians' - statistics & numerical data surveys Surveys and Questionnaires
Title	Variability in oral antibiotic step-down therapy in the management of Gram-negative bloodstream infections
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