Evaluation of an antibiotic intravenous to oral sequential therapy program

Current Practice and Barriers to an Early Antimicrobial Conversion from Intravenous to Oral among Hospitalized Patients at Jimma University Specialized Hospital: Prospective Observational Study

Objective

The aim of the present study was to explore the current practice and its barriers to an early antimicrobial conversion from intravenous (IV) to oral (PO) therapy among hospitalized patients.

Method

Hospital based prospective observational study was conducted to assess the practice of an early antimicrobial IV to PO conversion and its barriers using medical chart and case-specific physicians' interviews, respectively, from February to September, 2014. Patient charts and medication records were reviewed for appropriateness of IV to PO conversion program every 24hrs using a pretested data collection abstraction format. Independent samples t-test was used to compare the duration of therapy and time to clinical stability between converted and nonconverted patients. Two-tailed P values of < 0.05 were regarded as statistically significant.

Results

One hundred forty-two patients were included in the study, of whom two-thirds (67.6%) of the patients were eligible for IV to PO antimicrobial conversion. However, only 20.9% of patients' timely conversion was made. A shorter duration of IV therapy was recorded for converted (2.80±1.87) versus nonconverted patients (8.50±6.32), (P=0.009). The most important barriers of not converting IV to PO in clinically stable patients were presence of comorbidity; clinicians perceived that the patient should always complete IV course of antimicrobials as a standard practice.

Conclusion

Conversion from IV to PO antimicrobials was found to be unnecessarily delayed in a significant proportion of patients hospitalized with moderate to severe infection due to a range of different barriers. Addressing these issues has the potential to reduce inappropriate antimicrobial use and resistance.

The High Impact of Penicillin Allergy Registration in Hospitalized Patients

BACKGROUND

Suspected penicillin allergy (Pen-A) is often not verified or excluded by diagnostic testing.

OBJECTIVE

To assess the prevalence and impact of Pen-A registration in a Dutch University Medical Center.

METHODS

In a prospective matched cohort study, all admitted patients (July 2013-July 2014) who underwent a pharmacotherapeutic interview were selected. Patients with a registered Pen-A were matched on age, sex, and department of admission with up to 3 patients without a registered Pen-A. Relative risks (RRs) of receiving a reserve antibiotic, death during hospitalization, and rehospitalization were compared in the 2 cohorts. The number and type of antibiotics prescribed during admission and duration of hospitalization were compared.

RESULTS

Of 17,959 patients, 1010 (5.6%) patients (66.7% women; median age, 55 years) had a Pen-A registration. These patients had a higher risk of receiving reserve antibiotics (RR, 1.38; 95% CI, 1.22-1.56) and of being rehospitalized within 12 weeks (RR, 1.28; 95% CI, 1.10-1.49). A significantly larger proportion of Pen-A registered patients received reserve antibiotics such as tetracyclines (1.8% vs 0.8%), macrolides/lincosamides/streptogramins (12.5% vs 4.9%), and quinolones (7.9% vs 4.3%) or received 2 or more types of antibiotics during hospitalization (21.7% vs 16.9%).

CONCLUSIONS

Prevalence of Pen-A registration in hospitalized patients is high, has high impact on antibiotic prescribing, and is associated with a higher risk of readmission. Verification of the Pen-A in hospitalized patients might restrict the use of reserve antibiotics and improve patient outcome.

Association Between Initial Route of Fluoroquinolone Administration and Outcomes in Patients Hospitalized for Community-acquired Pneumonia

BACKGROUND

Fluoroquinolones have equivalent oral and intravenous bioavailability, but hospitalized patients with community-acquired pneumonia (CAP) generally are treated intravenously. Our objectives were to compare outcomes of hospitalized CAP patients initially receiving intravenous vs oral respiratory fluoroquinolones.

METHODS

This was a retrospective cohort study utilizing data from 340 hospitals involving CAP patients admitted to a non-intensive care unit (ICU) setting from 2007 to 2010, who received intravenous or oral levofloxacin or moxifloxacin. The primary outcome was in-hospital mortality. Secondary outcomes included clinical deterioration (transfer to ICU, initiation of vasopressors, or invasive mechanical ventilation [IMV] initiated after the second hospital day), antibiotic escalation, length of stay (LOS), and cost.

RESULTS

Of 36 405 patients who met inclusion criteria, 34 200 (94%) initially received intravenous treatment and 2205 (6%) received oral treatment. Patients who received oral fluoroquinolones had lower unadjusted mortality (1.4% vs 2.5%; P = .002), and shorter mean LOS (5.0 vs 5.3; P < .001). Multivariable models using stabilized inverse propensity treatment weighting revealed lower rates of antibiotic escalation for oral vs intravenous therapy (odds ratio [OR], 0.84; 95% confidence interval [CI], .74-.96) but no differences in hospital mortality (OR, 0.82; 95% CI, .58-1.15), LOS (difference in days 0.03; 95% CI, -.09-.15), cost (difference in $-7.7; 95% CI, -197.4-182.0), late ICU admission (OR, 1.04; 95% CI, .80-1.36), late IMV (OR, 1.17; 95% CI, .87-1.56), or late vasopressor use (OR, 0.94; 95% CI, .68-1.30).

CONCLUSIONS

Among hospitalized patients who received fluoroquinolones for CAP, there was no association between initial route of administration and outcomes. More patients may be treated orally without worsening outcomes.

Practice of switch from intravenous to oral antibiotics

Hospitalized patients initially on intravenous antibiotics can be safely switched to an oral equivalent within the third day of admission once clinical stability is established. This conversion has many advantages as fewer complications, less healthcare costs and earlier hospital discharge. The three types of intravenous to oral conversion include sequential, switch, and step-down therapy. The aim of the study was to evaluate the practice of switching from intravenous to oral antibiotics, its types and its impact on the clinical outcomes. This was a retrospective observational study conducted in three Lebanese hospitals over a period of six months. Adult inpatients on intravenous antibiotics for 2 days and more were eligible for study enrollment. Excluded were patients admitted to care or surgery units, or those with gastrointestinal diseases, infections that require prolonged course of parenteral therapy, or malignancies.

The study showed that among 452 intravenous antibiotic courses from 356 patients who were eligible for conversion, only one third were switched and the others continued on intravenous antibiotics beyond day 3 (P <0.0001). The mean duration of intravenous therapy of converted patients was markedly shorter than the non-converted (P <0.0001) with no significant change in the mean length of stay. Fluoroquinolones and macrolides were the most commonly converted antibiotics. However, the sequential therapy was the major type of conversion practiced in this study. Based on the study findings, a significant proportion of patients can be considered for switch. This emphasizes an important gap in the field of conversion from intravenous to oral antibiotic therapy and the need for integration and reinforcement of the appropriate Antibiotic Stewardship Programs in hospitals.

Antibiotic intravenous-to-oral switch guidelines: barriers to adherence and possible solutions

Objectives

To identify reasons for poor adherence to antibiotic intravenous-to-oral switch guidelines and to explore the possible solutions. To rate the importance of the barriers and solutions identified, as perceived by a multidisciplinary expert panel.

Methods

Three-round Delphi study in an expert panel comprising doctors, nurses and pharmacists, with concurrent semi-structured interviews.

Key findings

The three rounds of the Delphi were completed by 13 out of the 30 healthcare professionals invited to participate. No nurses were included in the final round. Consensus was achieved for 28 out of 35 statements, with the most important barrier being that of inappropriate antibiotic review at the weekend, and the most important solution being to raise guideline awareness. The findings from the seven interviews (three doctors, two pharmacists and two nurses) complemented those from the Delphi study, although they provided more specific suggestions on how to improve the adherence to guidelines.

Conclusion

This study, using a combination of quantitative and qualitative methods, has identified several barriers to explore further and offered many practical solutions to improve practice. The importance of a multidisciplinary approach to address guideline non-adherence was emphasised. Clinical guidelines must be well publicised and well written to prevent a feeling of guideline saturation in the healthcare populous. Novel approaches may have to be investigated in order to further encourage adherence with antibiotic intravenous-to-oral switch guidelines.

Cost effectiveness of three drugs for the treatment of S. aureus infections in Nigeria

BACKGROUND

Resistance of microorganisms to existing antimicrobial agents threatens the effective utilization of available resources in sub-Saharan Africa. Cost-effective utilization of antibacterial agents is essential in effective health care delivery in Nigeria.

OBJECTIVES

To determine the most cost effective antibacterial agent in the treatment of S. aureus infections in Lagos metropolis.

SETTING

The study was carried out in a teaching hospital, a specialist hospital, a referral center and two private hospitals.

METHODS

Cost effectiveness analysis of ciprofloxacin, cefuroxime and gentamicin identified to be most effective agent against 463 clinical isolates of S. aureus obtained from the five hospitals was carried out on the basis of societal, health care and third party perspectives using 'decision table" as an analytical model. Criteria considered in the model included degree of efficacy of the agents, adherence tendencies and tolerability. Both direct (cost of drugs, diagnosis/monitoring, personnel and transportation) and indirect (loss of productivity) costs were evaluated.

MAIN OUTCOME MEASURES

These include economic outcome as total therapy cost, clinical outcomes as extent of antibacterial effectiveness obtained from degree of antibacterial efficacy, a proxy measurement of cure rates, and adherence tendency. Humanistic outcome was also measured as tolerability prorated from literature reported degree of adverse drug reactions events, risk of infection and pains from drug administration.

RESULTS

Ciprofloxacin tablet is a dominant option and much more cost-effective than either cefuroxime or gentamicin in the treatment of S. aureus in Lagos. Regardless of the perspective of analysis, ciprofloxacin has the least cost effectiveness ratio of NGN4214.66 ($28.09), NGN2392.63 ($16.00) and NGN2048.66 ($13.65) from societal, health care and third party payer perspectives, respectively. Sensitivity analysis by increasing the effectiveness index of gentamicin injection-the least cost effective option to the value for the most cost effective option did not change the results.

CONCLUSION

Ciprofloxacin should be used as first-line-treatment of S aureus in Lagos as it will lead to significant cost savings in the treatment of S. aureus infections.

Outcomes of early switching from intravenous to oral antibiotics on medical wards

Objectives

To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards.

Methods

During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before–after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes).

Results

In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%–29%, P = 0.001; 6.0–5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185).

Conclusions

On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.

Early switch to oral versus intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials

BACKGROUND

Acute pyelonephritis is a common infection with significant morbidity and mortality, particularly in pediatric populations. Early-switch strategies (from intravenous to oral treatment) may be an acceptable or even preferred option in the treatment of patients with acute pyelonephritis in terms of effectiveness and safety and can also reduce the economical burden associated with pyelonephritis.

OBJECTIVE

We sought to evaluate the effectiveness and safety of early-switch strategies in hospitalized patients with acute uncomplicated pyelonephritis.

METHODS

We searched in PubMed, Cochrane Central Register of Controlled Trials, and Scopus to identify randomized controlled trials (RCTs) that compared intravenous antibiotic regimens to regimens including an early switch to oral (after initial intravenous) treatment.

RESULTS

Eight RCTs (6 in children) were eligible for inclusion. In 5 RCTs the intravenous antibiotic treatment arms were not switched to oral treatment until the end of the study while in the remaining 3 RCTs the intravenous arms were switched late to oral treatment (after 5-10 days). Data regarding the incidence of renal scars, microbiological eradication, clinical cure, reinfection, persistence of acute pyelonephritis, and adverse events were provided in 4 (all pediatric trials), 6 (4 pediatric), 4 (2 pediatric), 5 (3 pediatric), 3 (1 pediatric), and 5 RCTs (3 pediatric), respectively. There were no differences regarding the above outcomes between the two compared treatment regimens in either pediatric or adult populations.

CONCLUSION

Early switch to oral antibiotic strategies seem to be as effective and safe as intravenous regimens for the treatment of hospitalized patients with acute pyelonephritis. These findings suggest that there is probably a potential to decrease the duration of intravenous treatment by 4-11 days in hospitalized patients with acute pyelonephritis without compromising their outcomes.

[Good clinical practices and inpatient antibiotics: optimization of fluoroquinolone switch therapy]

OBJECTIVE

Intravenous-to-oral switch therapy is strongly recommended in the medical literature. The aim of this study was to assess how we can improve fluoroquinolone switch therapy.

METHODS

In this comparative prospective study, we analyzed 243 intravenous ciprofloxacin treatments and assessed the impact of promoting a switch to oral step-down therapy.

RESULTS

This study found that switches from intravenous to oral therapy increased, mainly in medical wards, and led to significant savings in direct costs.

DISCUSSION

Promoting switch therapy has improved clinical practices in antibiotic use and led to lower direct and probably indirect drug-related costs.

CONCLUSION

Our findings will help define the role of switch therapy in improving clinical practices in inpatient antibiotic use.

Impact of the Hospital Pharmacy Initiative for promoting prudent use of antibiotics in hospitals in England

OBJECTIVES

In July 2003, the UK Department of Health announced an allocation of 12 million pounds sterling to hospital pharmacists to improve the monitoring and control of anti-infective use over the ensuing 3 year period (the Hospital Pharmacy Initiative, or HPI). Chief Pharmacists were asked to use this money for developments to promote prudent antibiotic use and monitoring of antimicrobials within their Trusts. This study aimed to evaluate the impact of the HPI funding, which at the time had been in place for nearly 2 years, on pharmacy activities in this area.

METHODS

A postal questionnaire was sent to the pharmacy department of each acute hospital Trust in England, aiming to provide a descriptive overview of the activities of hospital pharmacy staff in the field of anti-infectives and to explore the extent to which these activities were made possible by the HPI funding.

RESULTS

One hundred and forty-one specialist antimicrobial pharmacy staff were employed in 130 responding Trusts; 89% were pharmacists, 7% pharmacy technicians and the remainder administrative staff. Three-quarters of these staff had been employed due to the funding, resulting in review of antimicrobial prescribing guidelines, antibiotic audit projects and multidisciplinary work with Microbiology/Infectious Diseases staff. Thirteen Trusts gave details of drug acquisition cost savings; over the course of a year, these Trusts saved 1.1 million pounds sterling in total.

CONCLUSIONS

The HPI funding has facilitated greater interaction between Pharmacy and Microbiology/Infectious Diseases departments than was previously possible. Significant reductions in antibiotic acquisition costs have been demonstrated, though further work is warranted to fully establish the impact of pharmacy activities on clinical and microbiological outcomes.

Quinolones in 2005: an update

Quinolones are one of the largest classes of antimicrobial agents used worldwide. This review considers the quinolones that are available currently and used widely in Europe (norfoxacin, ciprofloxacin, ofloxacin, levofloxacin and moxifloxacin) within their historical perspective, while trying to position them in the context of recent and possible future advances based on an understanding of: (1) their chemical structures and how these impact on activity and toxicity; (2) resistance mechanisms (mutations in target genes, efflux pumps); (3) their pharmacodynamic properties (AUC/MIC and Cmax/MIC ratios; mutant prevention concentration and mutant selection window); and (4) epidemiological considerations (risk of emergence of resistance, clonal spread). Their main indications are examined in relation to their advantages and drawbacks. Overall, it is concluded that these important agents should be used in an educated fashion, based on a careful balance between their ease of use and efficacy vs. the risk of emerging resistance and toxicity. However, there is now substantial evidence to support use of the most potent drug at the appropriate dose whenever this is required.