Sequential antimicrobial therapy: pharmacokinetic and pharmacodynamic considerations in sequential therapy

Compounding Effects of Climate Warming and Antibiotic Resistance

Bacteria have evolved diverse mechanisms to survive environments with antibiotics. Temperature is both a key factor that affects the survival of bacteria in the presence of antibiotics and an environmental trait that is drastically increasing due to climate change. Therefore, it is timely and important to understand links between temperature changes and selection of antibiotic resistance. This review examines these links by synthesizing results from laboratories, hospitals, and environmental studies. First, we describe the transient physiological responses to temperature that alter cellular behavior and lead to antibiotic tolerance and persistence. Second, we focus on the link between thermal stress and the evolution and maintenance of antibiotic resistance mutations. Finally, we explore how local and global changes in temperature are associated with increases in antibiotic resistance and its spread. We suggest that a multidisciplinary, multiscale approach is critical to fully understand how temperature changes are contributing to the antibiotic crisis.

Evaluation of an antibiotic intravenous to oral sequential therapy program

AIM

This study was designed to analyse the drug consumption difference and economic impact of an antibiotic sequential therapy focused on quinolones.

METHOD

We studied the consumption of quinolones (ofloxacin/levofloxacin and ciprofloxacin) 6 months before and after the implementation of a sequential therapy program in hospitalised patients. It was calculated for each antibiotic, in its oral and intravenous forms, in defined daily dose (DDD/100 stays per day) and economical terms (drug acquisition cost). At the beginning of the program ofloxacin was replaced by levofloxacin and, since their clinical uses are similar, the consumption of both drugs was compared during the period.

RESULTS

In economic terms, the consumption of intravenous quinolones decreased 60% whereas the consumption of oral quinolones increased 66%. In DDD/100 stays per day, intravenous forms consumption decreased 53% and oral forms consumption increased 36%.

CONCLUSIONS

Focusing on quinolones, the implementation of a sequential therapy program based on promoting an early switch from intravenous to oral regimen has proved its capacity to alter the utilisation profile of these antibiotics. The program has permitted the hospital a global saving of 41420 dollars for these drugs during the period of time considered.

Sequential antibiotic therapy

Antimicrobials are an important source of hospital expenditure. Traditionally, severe bacterial infections have been treated initially with intravenous antibiotics, followed by physician-directed switch to oral therapy. Unfortunately this approach results in unnecessary prolongation of intravenous treatment, with all its inherent disadvantages. Sequential antibiotic therapy, however, ensures an early switch to the oral route when the patient is clinically stable. This increasingly employed strategy is safe and results in improved quality and cost-effectiveness of health care. To ensure timely and appropriate switch, such programmes need to be underpinned by clear guidelines and supported by a multidisciplinary team. In the future, key questions, such as what is the optimal time of switch for specific infections, and can conditions such as osteomyelitis and endocarditis be efficaciously treated with oral therapy, need to be answered. Only then will clinicians be able to practise evidence-based infection management incorporating sequential antimicrobial therapy.