IV Antimicrobial Therapy

• For patients who are strictly Nil-By-Mouth.
• For patients with non-functional GI tract or malabsoprtion.
• For life-threatening infections or severe sepsis.
• For patients with bacteraemia.
• For patients with serious deep-seated infections requiring intravenous antimicrobials to guarantee adequate drug levels at the site of infection as listed below:
  

  Bone and joint infections	Peritonitis
  Spreading cellulitis	Osteomyelitis
  Lymphadenopathy and high fever	Septicaemia
  Endocarditis	Septic arthritis
  Encephalitis	Severe pneumonia
  Febrile neutropenia	Staphylococcal bacteraemia
  Infective gangrene	Meningitis

Please note some agents such as Clindamycin and Linezolid are well absorbed orally and substantially cheaper. There is little benefit to using them IV where oral route can be used.

Intravenous antimicrobial therapy must be reviewed at 48 hours and switched to oral alternatives when clinically appropriate.

Unnecessarily prolonged intravenous therapy is associated with an increased risk of superinfection, extravasation and thrombophlebitis, and has been shown to delay discharge from hospital.  Switch to oral antimicrobial therapy should be considered for patients who meet the criteria outlined in the Change to ORAL Antibiotics Guideline (CHORAL).

Purpose

To provide guidance for the rational conversion of patients from parenteral antibiotic therapy to oral after 48 hours wherever possible.

Rationale

To reduce the risk of complications associated with parenteral antibiotic use:

• Morbidity associated with IV access (superinfection, extravasation, thrombophlebitis)
• Delayed discharge from hospital
• Increased nursing time
• Increased expenditure
• Increased adverse effects

Guideline

For most infections and most patients, intravenous antibiotic therapy can be converted to oral 24-48 hours after the start of treatment, as long as the following criteria are met:

• The infection is no longer life-threatening or able to cause major disability
• Temperature and other signs of infection appear to be returning to normal
• It is recommended that the following inclusion criteria are checked before a decision is taken:
  1. Signs and symptoms of infection are resolving
  2. Oral fluids are well tolerated
  3. There is a functioning GI tract, with no signs of malabsorption
  4. Oral formulation to be used has adequate and reliable absorption profile

Patients presenting with any of the following should NOT be converted to oral antibiotics without discussing with responsible consultant / Microbiologist during working hours:

• Ongoing/ potential GI absorption problems (vomiting, GI surgery or ileus)
• Immunocompromised patients
• Patients suffering from SEVERE infections e.g.
  

  Bone and joint infections	Peritonitis
  Spreading cellulitis	Osteomyelitis
  Lymphadenopathy and high fever	Septicaemia
  Endocarditis	Septic arthritis
  Encephalitis	Severe pneumonia
  Febrile neutropenia	Staphylococcal bacteraemia
  Infective gangrene	Meningitis

N.B. in ALL these cases targeted/planned duration of parenteral antibiotics should be used.

THINK COMMIT: Intravenous antibiotics for medically stable adult patients with any infectious condition requiring IV antibiotics is available from South Shore primary care centre based IV clinic or home administration. Please contact consultant microbiologists or ID physician to discuss and refer suitable patients.

This list is NOT exhaustive, but shows the step down oral therapy for commonly prescribed intravenous antibiotics.  Where a dose range is stated, the dose should be selected based on the severity and site of infection.