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Hospital Stay Decreases With Clinic I.V. Therapy

Kate Traynor

With appropriate antimicrobial therapy and the availability of an outpatient infusion clinic, many patients with common infections can safely recuperate at home after a minimal hospital stay, report researchers.

In a small study reported in the Jan. 8 Archives of Internal Medicine, researchers examined hospitalized patients receiving antimicrobial therapy for community-acquired pneumonia (CAP), urinary-tract infection (UTI), or cellulitis. Care of half of the patients was overseen by hospitalists specializing in internal medicine, who sent the patients home after their fever abated and clinical symptoms improved. The remaining patients were placed under the care of an infectious diseases hospitalist—the study’s lead author—who sent the patients home before their fever and symptoms resolved.

On average, patients cared for by the infectious diseases specialist spent 1.3 days in the hospital, while patients under the care of internal medicine specialists left the hospital after 3.0 days.

Patients in both treatment groups received antimicrobial therapy during and after their hospital stay. Only one study participant—a patient whose CAP was treated by an internal medicine specialist—was readmitted to the hospital for a recurrent infection within 30 days.

The study took place at the Kaiser Permanente Medical Center in Honolulu from May 1, 1998, through July 31, 1999. Only patients who were predicted by a triage physician to require six or fewer days of hospitalization were eligible for the study. The average patient age was 62.

Study data came from 111 consecutively discharged patients who had been under the care of the infectious diseases hospitalist, who also directed the patients’ treatment at home. These patients were matched by age, sex, diagnosis, and comorbid conditions to 112 patients who had been under the care of internal medicine hospitalists. A primary care physician or the hospital physician who managed the inpatient portion of the treatment orchestrated the outpatient treatment of the matched patients.

Antimicrobial choice and timing varied widely between the infectious diseases specialist and the other physicians. The infectious diseases specialist, but not the internal medicine physicians, made heavy use of an outpatient infusion clinic for treatment of the patients with cellulitis. Patients with CAP were switched more rapidly from intravenous (i.v.) antimicrobials to oral agents by the infectious diseases specialist than by the other physicians.

Among patients with cellulitis, the infectious diseases specialist prescribed i.v. ceftriaxone to 50 percent of the group when discharged from the hospital but ordered no cephalexin, an oral agent. In contrast, the internal medicine physicians prescribed cephalexin to 64 percent of their cellulitis patients at discharge and no ceftriaxone.

The infectious diseases specialist prescribed oral or i.v. ciprofloxacin to 89 percent of his UTI patients while they were in the hospital; 71 percent of his UTI patients used oral ciprofloxacin after discharge. Only 18 percent of the other physicians' UTI patients received i.v. ciprofloxacin as inpatients but 71 percent received ceftriaxone. After discharge, the internal medicine specialists prescribed ciprofloxacin to only 36 percent of their UTI patients.

In treating patients with CAP, the infectious diseases specialist nearly always used i.v. ceftriaxone in combination with oral doxycycline or azithromycin for the inpatient phase. The internal medicine specialists used that treatment for only 58 percent of comparable patients. After discharge from the hospital, all CAP patients under the care of the infectious diseases specialist but just 40 percent of the other physicians’ CAP patients received oral azithromycin or doxycycline.

When queried about one month after their release from the hospital, 60 percent of the patients treated by the infectious diseases specialist strongly agreed that they felt satisfied with the timing of their discharge from the hospital. This sentiment was shared by only 28 percent of patients who had been under the care of the internal medicine specialists.

The infectious diseases specialist's patients returned to work an average of 1.7 days earlier than the other patients in the study.