IV to PO Antibiotic Therapy

Levofloxacin
(Levaquin®)
750 mg IV once
daily
Linezolid (Zyvox®)
600 mg IV Q12H
Metronidazole (Flagyl®)
500 mg IV Q8-12H
Moxifloxacin (Avelox®)
400 mg IV once
daily
Penicillin G (Pfizerpen®)
1-4 million units IV
Q4H-6H
Sulfamethoxazole/
Trimethoprim (Bactrim®)
800 mg/160 mg
re 2
016
Dose/Frequency
Oral Regimen
Dose/Frequency
Levofloxacin
(Levaquin®)
750 mg PO once daily
Linezolid (Zyvox®)
600 mg PO Q12H
Focus on Converting from IV to PO Antibiotic Therapy
↔
Metronidazole (Flagyl®)
500 mg PO Q8-12H
By Allen Lefkovitz , PharmD, CGP, FASCP
Director, Clinical Pharmacy Education and Drug Data, Geriatric Center of Clinical Excellence, CVS Health
Moxifloxacin (Avelox®)
400 mg PO once daily
↘
Penicillin VK (Veetids®)
500 mg PO Q6H
Sulfamethoxazole/
Trimethoprim
(Bactrim®)
800 mg/160 mg PO
Q12H
↔
↔
↔
↔
↔ = Sequential Therapy with Direct Conversion (same medication with the same IV to Oral Dose)
→ = Sequential Therapy without Direct Conversion (same medication but different IV to Oral Dose)
↘ = Switch or Step Down Therapy (same or different class of medication with same/similar spectrum of activity)
T
he Centers for Disease Control and Prevention (CDC) calls antibiotic stewardship “the single
most important action needed to slow down the development and spread of antibiotic-resistant
infections.” One of the strategies for creating an effective antibiotic stewardship program (ASP) includes
making routine intravenous (IV) to oral (PO) conversion assessments a part of the process. Likewise,
within “The Core Elements of Antibiotic Stewardship for Nursing Homes”, the CDC recommends that
“Nursing homes should have a process in place for a review of antibiotics by the clinical team two to
three days after antibiotics are initiated to answer [some] key questions” including “is the resident on the
most appropriate antibiotic(s), dose, and route of administration?” In regard to the route of administration,
the practice of switching IV to PO antibiotics can be a very important component of a facility’s ASP.
According to a 2005 study, approximately one-third of all inpatients initiated on IV antibiotics are eligible
for oral therapy.
The medical literature has repeatedly demonstrated that switching from IV to PO therapy can be
therapeutically-effective, cost-effective, convenient, and safe. While some may still consider IV antibiotic
therapy as justification for a hospitalization, the appropriate use of an oral medication can have
significant benefits to both the skilled nursing facility and the patient’s overall quality of life. Converting
from IV to PO therapy is associated with many potential benefits including:
mni
ca
Parenteral Regimen
• Lower antibiotic acquisition cost
• Promoting patient comfort
• Eliminating/minimizing risk of IV line infections
• No IV antibiotic preparation costs
• Decreasing length of stay (earlier discharge)
• Decreased risk of phlebitis
• Decreased administration time and costs
• Promotes earlier and easier ambulation
• Improved adherence
©O
According to the American Society of Health-System Pharmacists (ASHP), “The ideal
route of administration for any medication is one that achieves serum concentrations
sufficient to produce the desired effect without producing undesired effects.”
Although converting from IV to PO therapy has been performed with many other classes of medications
(e.g., antifungals, antivirals, H2 antagonists, proton pump inhibitors), this article focuses on IV antibiotics
that may be suitable for a change to oral administration.
When the oral administration of a medication can achieve the desired concentration at the targeted
site of infection, a conversion may be considered. While some oral medications do not have the same
bioavailability (“extent of absorption”) as intravenous medications, other oral medications produce
comparable concentrations when given by either route. Antibiotics with high bioavailability (e.g., greater
than 80%) are often considered suitable candidates for switching therapy.
OMWP-IVPO
16-086 IV to PO Antibiotic Therapy WP_f.indd 1-2
©2016 Omnicare
3/7/16 3:54 PM
re 2
016
Criteria for IV to PO Therapy Changes
Examples of IV to PO Therapy Changes for Consideration
While switching from IV to PO therapy can be associated with significant reduction in administration time and
costs, the savings associated with such changes should not be the sole driving force behind such conversions.
Once a patient is clinically stable, improving, and able to tolerate oral medications, consideration of a conversion
from IV to PO therapy may be warranted. Various guidelines and protocols exist to help prescribers determine
which patients are potentially appropriate for switching from IV to PO therapy. Inclusion and exclusion criteria for
determining appropriateness are outlined below.
At least three types of IV to PO conversions are described in the medical literature:
Inclusion Criteria (continue IV therapy if the following conditions are NOT met)
There is an oral alternative available
Type of Conversion
Definition
1
Sequential
Converting from the IV to the PO
formulation of the same drug
linezolid (Zyvox®) 600 mg IV Q12H to
linezolid (Zyvox®) 600 mg PO Q12H
2
Switch
Converting from an IV drug to a
PO drug with an identical potency
cefazolin (Ancef®) 1 g IV Q8hrs to
cephalexin (Keflex®) 500 mg PO Q6H
3
Step-Down
Converting from an IV drug to a
PO drug with reduced potency
ampicillin/sulbactam (Unasyn®) 3 g
IV Q6H to amoxicillin/clavulanate
(Augmentin®) 875/125 mg PO Q12H
In the absence of a positive culture, the alternative oral agent empirically
covers the commonly suspected organism(s)
Tolerating food or enteral feedings
Able to take other medications by mouth
Patient is conscious
While the final choice of antibiotic therapy is a decision that should be made by the prescriber based on the
individual patient characteristics, culture and sensitivity data, and the clinical situation, some suggested IV to PO
conversions are outlined in the table below. Following any change in therapy, each patient should be evaluated
for clinical progress and tolerability at both 24 and 48 hours after conversion. If the patient’s condition worsens or
fails to improve, alternative therapy or conversion back to IV therapy should be considered.
Parenteral Regimen
Dose/Frequency
Ampicillin/Sulbactam
(Unasyn®)
1.5 g IV Q6H
Ampicillin/Sulbactam
(Unasyn®)
3 g IV Q6H
Azithromycin
(Zithromax®)
250 mg IV once
daily
Azithromycin
(Zithromax®)
500 mg IV once
daily
Allergy to alternative agent
Cefazolin (Ancef®)
1 g IV Q8H
Positive culture shows resistance to the alternative
Cefazolin (Ancef®)
2 g IV Q8H
Active GI bleed
Cefuroxime (Zinacef®)
750 mg IV Q8-12H
Hematological malignancy (e.g., leukemia, lymphoma) or documented neutropenia
Cefuroxime (Zinacef®)
1.5 g IV Q8H
Severely immunocompromised (e.g., solid organ transplant)
Ciprofloxacin (Cipro®)
400 mg IV once
daily
Surgery scheduled within 48 hours
Ciprofloxacin (Cipro®)
400 mg IV Q12H
Severe or persistent nausea or vomiting
Ciprofloxacin (Cipro®)
400 mg IV Q8H
NPO status (nothing by mouth)
Clindamycin (Cleocin®)
300 mg IV Q6-8H
Continuous tube feedings that cannot be interrupted*
Clindamycin (Cleocin®)
600 mg IV Q6-8H
Levofloxacin
(Levaquin®)
250 mg IV once
daily
Levofloxacin
(Levaquin®)
500 mg IV once
daily
mni
ca
EXCLUSION Criteria (continue IV therapy if ANY of the following criteria are met)
Patient is unstable or their clinical condition is worsening as evidenced
by any of the following in the past 24 hours:
• Fever ≥ 38˚C (100˚F) • Systolic blood pressure ≤ 90 mmHg
• Heart rate ≥ 100 beats per minute
• Abnormal WBC count that is not improving
• Respiratory rate ≥ 24 breaths per minute
• Worsening chest x-ray (if applicable)
IV antibiotic is being used for endocarditis, osteomyelitis, sepsis, severe cellultis,
meningitis or other CNS infections, or an infection involving a prosthethic device
©O
IV antibiotic used for less than 48 hours or is scheduled to be discontinued in the next 24 hours
GI obstruction, ileus, or malabsorption syndrome
Difficulty swallowing or refusing other oral medications
Grade III or Grade IV mucositis
Use of vasopressor in the past 24 hours (e.g., dobutamine)
* Only applies to particular oral antibiotics (e.g., fluoroquinolones) that must be separated from enteral products by several hours
16-086 IV to PO Antibiotic Therapy WP_f.indd 3-4
Example
Oral Regimen
Dose/Frequency
↘
Amoxicillin/Clavulanate
(Augmentin®)
500 mg/125 mg PO
Q12H
Amoxicillin/Clavulanate
(Augmentin®)
875 mg/125 mg PO
Q12H
↔
Azithromycin
(Zithromax®)
250 mg PO once daily
Azithromycin
(Zithromax®)
500 mg PO once daily
↘
Cephalexin (Keflex®)
500 mg PO Q6H
Cephalexin (Keflex®)
1000 mg PO Q6H
→
Cefuroxime (Ceftin®)
500 mg PO Q12H
Cefuroxime (Ceftin®)
500 mg PO Q12H
→
Ciprofloxacin (Cipro®)
500 mg PO daily
→
Ciprofloxacin (Cipro®)
500 mg PO Q12H
→
Ciprofloxacin (Cipro®)
750 mg PO Q12H
→
Clindamycin (Cleocin®)
150 mg PO Q6-8H
→
Clindamycin (Cleocin®)
300 mg PO Q6-8H
↔
Levofloxacin
(Levaquin®)
250 mg PO once daily
↔
Levofloxacin
(Levaquin®)
500 mg PO once daily
↘
↔
↘
→
3/7/16 3:54 PM
re 2
016
Criteria for IV to PO Therapy Changes
Examples of IV to PO Therapy Changes for Consideration
While switching from IV to PO therapy can be associated with significant reduction in administration time and
costs, the savings associated with such changes should not be the sole driving force behind such conversions.
Once a patient is clinically stable, improving, and able to tolerate oral medications, consideration of a conversion
from IV to PO therapy may be warranted. Various guidelines and protocols exist to help prescribers determine
which patients are potentially appropriate for switching from IV to PO therapy. Inclusion and exclusion criteria for
determining appropriateness are outlined below.
At least three types of IV to PO conversions are described in the medical literature:
Inclusion Criteria (continue IV therapy if the following conditions are NOT met)
There is an oral alternative available
Type of Conversion
Definition
1
Sequential
Converting from the IV to the PO
formulation of the same drug
linezolid (Zyvox®) 600 mg IV Q12H to
linezolid (Zyvox®) 600 mg PO Q12H
2
Switch
Converting from an IV drug to a
PO drug with an identical potency
cefazolin (Ancef®) 1 g IV Q8hrs to
cephalexin (Keflex®) 500 mg PO Q6H
3
Step-Down
Converting from an IV drug to a
PO drug with reduced potency
ampicillin/sulbactam (Unasyn®) 3 g
IV Q6H to amoxicillin/clavulanate
(Augmentin®) 875/125 mg PO Q12H
In the absence of a positive culture, the alternative oral agent empirically
covers the commonly suspected organism(s)
Able to take other medications by mouth
Patient is conscious
EXCLUSION Criteria (continue IV therapy if ANY of the following criteria are met)
Patient is unstable or their clinical condition is worsening as evidenced
by any of the following in the past 24 hours:
• Fever ≥ 38˚C (100˚F) • Systolic blood pressure ≤ 90 mmHg
• Heart rate ≥ 100 beats per minute
• Abnormal WBC count that is not improving
• Respiratory rate ≥ 24 breaths per minute
• Worsening chest x-ray (if applicable)
IV antibiotic is being used for endocarditis, osteomyelitis, sepsis, severe cellultis,
meningitis or other CNS infections, or an infection involving a prosthethic device
IV antibiotic used for less than 48 hours or is scheduled to be discontinued in the next 24 hours
While the final choice of antibiotic therapy is a decision that should be made by the prescriber based on the
individual patient characteristics, culture and sensitivity data, and the clinical situation, some suggested IV to PO
conversions are outlined in the table below. Following any change in therapy, each patient should be evaluated
for clinical progress and tolerability at both 24 and 48 hours after conversion. If the patient’s condition worsens or
fails to improve, alternative therapy or conversion back to IV therapy should be considered.
Parenteral Regimen
Dose/Frequency
Ampicillin/Sulbactam
(Unasyn®)
1.5 g IV Q6H
Ampicillin/Sulbactam
(Unasyn®)
500 mg IV once
daily
Azithromycin
(Zithromax®)
Allergy to alternative agent
Cefazolin (Ancef®)
Positive culture shows resistance to the alternative
Cefazolin (Ancef®)
Cefuroxime (Zinacef®)
Hematological malignancy (e.g., leukemia, lymphoma) or documented neutropenia
Cefuroxime (Zinacef®)
Severely immunocompromised (e.g., solid organ transplant)
Ciprofloxacin (Cipro®)
2 g IV Q8H
750 mg IV Q8-12H
1.5 g IV Q8H
400 mg IV once
daily
Surgery scheduled within 48 hours
Ciprofloxacin (Cipro®)
400 mg IV Q12H
Severe or persistent nausea or vomiting
Ciprofloxacin (Cipro®)
400 mg IV Q8H
NPO status (nothing by mouth)
Clindamycin (Cleocin®)
300 mg IV Q6-8H
Continuous tube feedings that cannot be interrupted*
Clindamycin (Cleocin®)
600 mg IV Q6-8H
Levofloxacin
(Levaquin®)
250 mg IV once
daily
Difficulty swallowing or refusing other oral medications
Grade III or Grade IV mucositis
Use of vasopressor in the past 24 hours (e.g., dobutamine)
* Only applies to particular oral antibiotics (e.g., fluoroquinolones) that must be separated from enteral products by several hours
16-086 IV to PO Antibiotic Therapy WP_f.indd 3-4
1 g IV Q8H
©O
Active GI bleed
GI obstruction, ileus, or malabsorption syndrome
3 g IV Q6H
250 mg IV once
daily
Azithromycin
(Zithromax®)
Levofloxacin
(Levaquin®)
Oral Regimen
Dose/Frequency
↘
Amoxicillin/Clavulanate
(Augmentin®)
500 mg/125 mg PO
Q12H
Amoxicillin/Clavulanate
(Augmentin®)
875 mg/125 mg PO
Q12H
↔
Azithromycin
(Zithromax®)
250 mg PO once daily
Azithromycin
(Zithromax®)
500 mg PO once daily
↘
Cephalexin (Keflex®)
500 mg PO Q6H
Cephalexin (Keflex®)
1000 mg PO Q6H
→
Cefuroxime (Ceftin®)
500 mg PO Q12H
Cefuroxime (Ceftin®)
500 mg PO Q12H
→
Ciprofloxacin (Cipro®)
500 mg PO daily
→
Ciprofloxacin (Cipro®)
500 mg PO Q12H
→
Ciprofloxacin (Cipro®)
750 mg PO Q12H
→
Clindamycin (Cleocin®)
150 mg PO Q6-8H
→
Clindamycin (Cleocin®)
300 mg PO Q6-8H
↔
Levofloxacin
(Levaquin®)
250 mg PO once daily
↔
Levofloxacin
(Levaquin®)
500 mg PO once daily
mni
ca
Tolerating food or enteral feedings
Example
500 mg IV once
daily
↘
↔
↘
→
3/7/16 3:54 PM
re 2
016
Parenteral Regimen
Dose/Frequency
Levofloxacin
(Levaquin®)
750 mg IV once
daily
Linezolid (Zyvox®)
600 mg IV Q12H
Metronidazole (Flagyl®)
500 mg IV Q8-12H
Moxifloxacin (Avelox®)
400 mg IV once
daily
Penicillin G (Pfizerpen®)
1-4 million units IV
Q4H-6H
Sulfamethoxazole/
Trimethoprim (Bactrim®)
800 mg/160 mg
Oral Regimen
Dose/Frequency
Levofloxacin
(Levaquin®)
750 mg PO once daily
Linezolid (Zyvox®)
600 mg PO Q12H
Focus on Converting from IV to PO Antibiotic Therapy
↔
Metronidazole (Flagyl®)
500 mg PO Q8-12H
By Allen Lefkovitz , PharmD, CGP, FASCP
Director, Clinical Pharmacy Education and Drug Data, Geriatric Center of Clinical Excellence, CVS Health
Moxifloxacin (Avelox®)
400 mg PO once daily
↘
Penicillin VK (Veetids®)
500 mg PO Q6H
Sulfamethoxazole/
Trimethoprim
(Bactrim®)
800 mg/160 mg PO
Q12H
↔
↔
↔
↔
↔ = Sequential Therapy with Direct Conversion (same medication with the same IV to Oral Dose)
→ = Sequential Therapy without Direct Conversion (same medication but different IV to Oral Dose)
mni
ca
↘ = Switch or Step Down Therapy (same or different class of medication with same/similar spectrum of activity)
16-086 IV to PO Antibiotic Therapy WP_f.indd 1-2
The medical literature has repeatedly demonstrated that switching from IV to PO therapy can be
therapeutically-effective, cost-effective, convenient, and safe. While some may still consider IV antibiotic
therapy as justification for a hospitalization, the appropriate use of an oral medication can have
significant benefits to both the skilled nursing facility and the patient’s overall quality of life. Converting
from IV to PO therapy is associated with many potential benefits including:
• Lower antibiotic acquisition cost
• Promoting patient comfort
• Eliminating/minimizing risk of IV line infections
• No IV antibiotic preparation costs
• Decreasing length of stay (earlier discharge)
• Decreased risk of phlebitis
• Decreased administration time and costs
• Promotes earlier and easier ambulation
• Improved adherence
According to the American Society of Health-System Pharmacists (ASHP), “The ideal
route of administration for any medication is one that achieves serum concentrations
sufficient to produce the desired effect without producing undesired effects.”
©O
OMWP-IVPO
T
he Centers for Disease Control and Prevention (CDC) calls antibiotic stewardship “the single
most important action needed to slow down the development and spread of antibiotic-resistant
infections.” One of the strategies for creating an effective antibiotic stewardship program (ASP) includes
making routine intravenous (IV) to oral (PO) conversion assessments a part of the process. Likewise,
within “The Core Elements of Antibiotic Stewardship for Nursing Homes”, the CDC recommends that
“Nursing homes should have a process in place for a review of antibiotics by the clinical team two to
three days after antibiotics are initiated to answer [some] key questions” including “is the resident on the
most appropriate antibiotic(s), dose, and route of administration?” In regard to the route of administration,
the practice of switching IV to PO antibiotics can be a very important component of a facility’s ASP.
According to a 2005 study, approximately one-third of all inpatients initiated on IV antibiotics are eligible
for oral therapy.
Although converting from IV to PO therapy has been performed with many other classes of medications
(e.g., antifungals, antivirals, H2 antagonists, proton pump inhibitors), this article focuses on IV antibiotics
that may be suitable for a change to oral administration.
When the oral administration of a medication can achieve the desired concentration at the targeted
site of infection, a conversion may be considered. While some oral medications do not have the same
bioavailability (“extent of absorption”) as intravenous medications, other oral medications produce
comparable concentrations when given by either route. Antibiotics with high bioavailability (e.g., greater
than 80%) are often considered suitable candidates for switching therapy.
©2016 Omnicare
3/7/16 3:54 PM