IV to PO Conversion Developed by Dr
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January 4, 2017 Issue 13 CHASE Covenant Health Antimicrobial Stewardship E-Newsletter IV to PO Conversion Developed by Dr. Sarah Mansour, Infectious Diseases Physician Converting antibiotics from intravenous (IV) to oral (PO) when possible is better Inside this issue: for the individual and the health care system. IV vs PO 1 Disadvantages of IV therapy: Benefits of PO antibiotics: Switch Therapy 1 Risk of line related complications Increased patient satisfaction (eg. thrombophlebitis, cellulitis, Reduced length of hospital stay Step-down 2 bacteremia, endocarditis) Therapy No mobility restriction for patients Increased cost Antibiotic Reduced resources/medication 2 Prolonged hospital stay Time-Out preparation time Bioavailability of Antibiotics: Corresponds to the blood levels achieved after oral administration (i.e. the percent- age of drug available to be used by the different tissues). Certain oral antibiotics* have high bioavailability where blood levels are nearly equiv- alent to the IV form. Dr. Holly Hoang, MD FRCPC Pager: 780-735-7000 Switch Therapy: Phone: 780-735-7236 Karen Zurek, BScPharm When the oral formulation has high bio- Pager: 780– 445-1744 *The following antibiotics Phone: 780-735-9823 availability, IV and oral formulations are should be given orally considered interchangeable. In this case, whenever possible: Dr. Shahileen Remtulla, PharmD the PO route is PREFERRED. Clindamycin Pager: 780-445-6710 Clinical contraindications to switch therapy Phone: 780-735-2553 Fluconazole include malabsorption, short gut, GI bleed- Fluoroquinolones E-mail us at: ing and persistent vomiting. AntimicrobialStewardship Linezolid @covenanthealth.ca Metronidazole TMP-SMX Step-Down Therapy: Involves de-escalating a patient from IV to oral antibiotics once clinically improved (the oral formulation is not equivalent to IV). Step down should take into account clinical syndrome and culture results. When is my patient ready for step-down? When is step-down NOT appropriate? Hemodynamically stable Bacteremia (generally requires a minimum of 14 days Clinically improving IV therapy from first negative blood culture) Afebrile Endocarditis Decreasing WBC Osteomyelitis/septic arthritis Functional GI tract (tolerating food, feeds or other Central nervous system infection (e.g. meningitis) oral medications) Examples of oral step-down options*: IV Antibiotic Oral Antibiotic Oral Bioavailability Ampicillin 1-2 g IV q6h Amoxicillin 500 mg TID 80% Cefazolin 1-2 g IV q8h Cephalexin 500 mg QID 90% Cefuroxime 0.75-1.5 g q8h Cefuroxime axetil 0.5-1 g BID 52% Piperacillin-tazobactam 4.5 g IV q8h Amoxicillin-clavulanate† 875 mg BID 80% † Does not cover Pseudomonas, whereas piperacillin-tazobactam does *Ensure that pathogen identified is susceptible Antibiotic Time-Out: Perform an Antibiotic Timeout 48 to 72 hours after initiating antibiotics and consider the following: 1. Is my diagnosis correct — does the patient have an infection and do they require antibiotics? 2. Can I use PO over IV antibiotics (switch therapy)? 3. Can I change the antibiotics(s) based on susceptibilities (target therapy)? 4. Can I step-down the antibiotic(s) based on clinical improvement? CHASE References: Blondel-Hill,E., Fryters, S. Bugs and Drugs 2012; 83. The Sanford Guide to Antimicrobial Therapy Covenant Health 2015. MacGregor, R. , Graziani, A. Oral Administration of Antibiotics: A Rational Alternative to the Parenteral Antimicrobial Route CID 1997; 24:457-67. Sevinç, F., Prins, J., Koopmans, R., Langendijk, P., Bossuyt,P., Dankert, J., Speelman, Stewardship P.Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital J. E-Newsletter Antimicrob. Chemother. (1999) 43 (4): 601-606 Page 2 Visit our website at: http://www.compassionnet.ca/Page450.aspx .