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Intravenous-to-Oral Antibiotic Switch Therapy. Presented By: Ohoud Awad Al-Juhani. Outlines. Introduction Misconception of (IV vs. PO) switch Antibiotic cost factors Four Scenarios of IV:PO Conversions of antibiotic Cost of selected intravenous and oral antibiotic. I . Introduction.
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Intravenous-to-Oral Antibiotic Switch Therapy Presented By: Ohoud Awad Al-Juhani
Outlines • Introduction • Misconception of (IV vs. PO) switch • Antibiotic cost factors • Four Scenarios of IV:PO Conversions of antibiotic • Cost of selected intravenous and oral antibiotic
I. Introduction The term "anti-infective conversion“ describes the practice of converting IV anti-infection therapy to an alternative oral formulation As conversion therapy was based on empirical observations rather than on clinical studies or outcomes, there was concern that oral therapy was less effective In addition, no clinical trials were available to support the conversion from the IV route to oral administration
Factors of the Scientific Basis of IV:PO Conversion These include: • Newer concepts of antimicrobial PD action • The advent of newer, more potent, broad-spectrum oral agents that achieve higher and more consistent serum & tissue concentrations • The availability of randomized clinical trials comparing various IV and oral therapeutic strategies
Advantages • Oral therapy can be as effective as parenteraly administered anti-infectives in the treatment of infections ranging from mild to moderate to severe • Decreasing adverse effects associated with IV therapy • Oral anti-infectives are easier to administer than IV preparations, require less time to prepare, and often improve patient comfort, mobility, and independence • Oral anti-infectives are often less expensive than parenteral agents
II. Misconceptions • The main obstacle limiting IV:PO conversion is the notion that IV anti-infectives are better than oral • One erroneous concept is that all patients with an infectious disease needs IV treatment • Anti-infective therapy should be evaluated regardless of route of administration • Another misconception is the same agent must be used both IV and orally • It has been thought that conversion therapy should be used only at discharge
Common Misconception in that the Antibiotics Chosen for a Switch Regimen Must be of the Same Type or Class • This is not the case at all. The only requirement is that the agents cover essentially the same spectrum and have the same characteristics of tissue penetration • For example, if IV Ampicillinis being used, oral Ampicillin would not be appropriate in a switch program because it does not give anything close to the blood and tissue levels achieved by IV administration.
Cont… • Another example, IV Ceftriaxone has no oral equivalent, but oral TMP-SMX provides exactly the same spectrum of activity and tissue penetration; even though the two drugs are from dissimilar classes and work by different mechanisms, they are therapeutically equivalent • It is not necessary that both oral and IV forms of a given agent be available to use in switch therapy. As noted, the task is to be sure that the spectrum of activity and the PK of IV and oral drugs are similar
Inclusion Criteria for Conversion Therapy • Completion of 48-72 hours of IV therapy • Functioning gastrointestinal tract • A febrile < 99.6°F for 8-24 hours • WBC count < 15,000/mm3 &/or decreasing • Improvement of signs and symptoms of infection
Exclusion Criteria for Conversion Therapy • Patients who cannot use oral route (risk of aspiration, need for complete bowel rest) • Patients with an unreliable response to oral medication (severe N/V, continuous nasogastric suction, malabsorption syndrome) • Patients whose disease state or infection does not permit conversion (e.g. high-risk neutropenia, meningitis, endocarditis)
III. Antibiotic Cost Factors The costs of administering IV antibiotics to hospitalized patients are tremendous, and great efforts are being made to reduce these costs To accomplish a reduction, factors that are important in determining the institutional cost of antimicrobial therapy must be understood
Antibiotic Cost Factors in Hospitalized Patients, with Strategies for Cost Containment
IV. Four Scenarios of IV:PO Conversions of Anti-Infective Drugs
Antibiotics with Excellent Bioavailability Both Orally & IV • Amoxicillin • Doxycycline • Trimethoprim-sulfamethoxazole (TMP-SMX) • Azithromycin • Metronidazole • Chloramphenicol • Levofloxacin • Ciprofloxacin • Clindamycin
Take Home Messages • Every attempt should be made to switch hospitalized patients from IV to oral antibiotic therapy as soon as clinical improvement makes it possible • In addition to tremendous cost savings, the advantages of oral therapy are impressive and include a decrease in the number of nosocomial infections, shorter length of hospital stay, and lower incidence of IV-line infections
The Main Barrier to the Acceptance of Switch Therapy is a Lack of Understanding of its: Efficacy Safety Cost Advantages
Special Thanks to.. My Colleague:Sherihan Abbas
References: • Rodvold KA. Pharmacokinetic and pharmacodynamic considerations for antimicrobial use. Infect Med 2000;12:16-25A • Ballow CH. Cost considerations in oral antibiotic therapy. Adv Ther 2003;12(4):199-206 • J Hosp Infect. 2005 Aug;60(4):340-7 • http://www.medscape.com/pharmacists/journals • http://www.emedicine.com/med/topic3549.htm
