GUIDELINES FOR IV TO ORAL SWITCH FOR ANTIBITOICS

Index No: MMG51t GUIDELINES FOR IV TO ORAL SWITCH FOR ANTIBITOICS Version: 1.0 Date ratified: June 2017 Ratified by: (Name of Committee) Director Lead (Trust-wide policies) Associate Medical Director (local Policies) Clinical Management Team / Directorate Applicable to Name of responsible committee for the policy: Medicines Management Committee Naomi Fleming, Pharmacist Advanced Microbiology and Infectious Disease Essam Rizkalla, Consultant Microbiologist and Antibiotic Lead Dr Andrew Chilton, Medical Director Clinical Services Medicines Management Committee Date issued for publication: June 2017 Review date: March 2020 Expiry date: (Date 3 months following review date) Equality impact assessed by: (name, job title and department) Date impact assessed: CQC Fundamental Standards June 2020 This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with Procedure D10a N/A Regulation 12: Safe Care and Treatment Page 1 of 8

CONTRIBUTION LIST Individuals involved in developing the document Name Naomi Fleming Essam Rizkalla Dr Manjula Natarajan Designation Pharmacist Advanced Microbiology and Infectious Disease Consultant Microbiologist and Antibiotic Lead Consultant Microbiologist and DIPC Circulated to the following individuals for consultation Name Beverley Bone Duane Maclean Domonic Chilon Nasir Siddique Ravinder Joshi Michael Pierides Sandeep Sharma PoornimaPandey Helen Fawdon Salam Musa Designation Antibiotic Steering Group Member and Chief Pharmacist FY2 Page 2 of 8

Index No. MMG51t Approval and Authorisation Completion of the following signature blocks signifies the review and approval of this process. Name Job Title Signature Date Naomi Fleming Antimicrobial Pharmacist June 2017 Local Committee approval (where applicable) Name of Committee Name of Chairperson Date of Approval Medicines Management Committee Mr R Lee June 2017 Change History Version Date Author Reason 1 June 2017 Naomi Fleming, and Essam Rizkalla. New Guideline. Impact Assessment This clinical guideline does not involve direct engagement with staff, patients, carers, visitors, the public or others and therefore does not require an Impact Assessment in line with Procedure D10a A translation service is available for this policy. (I55) is located on the library intranet under Trust wide policies. The Interpretation/Translation Policy, Guidance for Staff Page 3 of 8

CONTENTS PAGE 1.0 INTRODUCTION 5 1.1 PATIENT CRITERIA FOR IV TO ORAL SWITCH 5 2.0 EXCLUSIONS FROM IV TO ORAL SWITCH 6 3.0 ANTIBIOTIC CHOICES FOR ORAL FOLLOW ON THERAPY 7 4.0 ORAL ANTIBIOTICS WITH HIGH BIOAVAILABILITY 8 5.0 MONITORING ARRANGEMENTS FOR COMPLIANCE AND 8 EFFECTIVENESS 6.0 PLAN FOR DISSEMINATION AND IMPLEMENTATION 8 7.0 REFERENCES 8 Page 4 of 8

1.0 INTRODUCTION: The aim of antibiotic therapy is to achieve effective concentrations of the antibiotic at the site of infection. IV antibiotics should only be initiated: In patients with severe infections, threatening life or major disability, for patients who cannot tolerate or absorb oral medication, or when no suitable oral antibiotic is available. In most other conditions requiring initial treatment with parenteral antibiotic therapy, the treatment can be switched to oral therapy after 48 hours, with no adverse effect on clinical outcome. Disadvantages of IV antibiotics: Risks of line infections and/or phlebitis, Adverse drug reactions, Errors in drug administration Patient discomfort and limited mobility Length of stay Nursing time Cost Clinicians are advised to switch patient s therapy from parenteral antibiotics to oral as soon as the clinical condition allows. This is generally judged (with some exceptions) to be at, or after, a full 48 hours of IV therapy. The decision to switch to oral therapy is a clinical decision and clinical considerations override all others. 1.1 PATIENT CRITERIA FOR IV TO ORAL SWITCH: In considering if switch from IV to oral therapy is appropriate, check the following: Normothermia >36 C and <37.5 C for 24 hours Stabilising WCC >4 and <10 x10 4 /L, neutrophil count returning to normal Normal GI absorption; no persistent diarrhoea or vomiting, tolerance of oral intake ie oral route available Haemodynamically stable including BP, RR, HR (<100bpm for last 12 hours) No surgery scheduled within 36 hours Not deep seated infection e.g. meningitis, osteomyelitis, endocarditis An appropriate oral antibiotic is available, (this does not need to be the same antibiotic as the IV, (for example: for a chest infection, IV piperacillin/tazobactam (tazocin) or co-amoxiclav can be switched to doxycycline, for a urinary tract infection, sensitivities should be used to prescribe appropriate oral antibiotics. Patient s drug charts should be frequently and critically reviewed for the need for ongoing antibiotics and the appropriateness of the antibiotics prescribed. Clinicians should: Clearly indicate on all IV antibiotic prescriptions, the review date. The antibiotic decision should be clearly documented in the patient notes A sticker is available to prompt this review). Where antibiotics are to continue (IV or oral), these should be prescribed on the chart with a further review date or duration set. Failure to do this may result in unnecessarily prolonged treatment. Page 5 of 8

2.0 EXCLUSIONS FROM IV-ORAL SWITCH: Patients with compromised oral absorption (e.g: Severe diarrhoea and/or vomiting, Ileus or malabsorption syndromes, severe mucositis) Continuing decompensated sepsis Special indications o Infected implants/prostheses/graft tissue o Deep abscess o Bronchiectasis, cystic fibrosis, empyema o Bloodstream infections due to organisms requiring long-term IV therapy, e.g. Staphylococcus aureus (MSSA or MRSA), Candida spp o Bone and joint sepsis/septic arthritis/osteomyelitis o Endocarditis o Febrile Neutropenia o Infected gangrene o Peritonitis o Cellulitis with lymphadenopathy and fever o Encephalitis /Meningitis/Brain abscess o Immunocompromised patient (eg HIV, neutropenia, immunosuppressants or cytotoxics) Patients receiving IV therapy on specific ID/Micro advice If patient must continue to receive IV therapy, consider Outpatient Parenteral Antimicrobial Therapy as in the Start Smart then Focus guideline. Page 6 of 8

3.0 ANTIBIOTIC CHOICES FOR ORAL FOLLOW ON THERAPY: The table below is a guide to suitable oral follow on therapy: Conditions Current IV treatment Preferred oral choice CAP When CURB- 65 falls to 2 HAP+/- Aspiration Sepsisrespiratory source Legionella Pneumonia Urosepsis/ Sepsis-urinary source Pyelonephritis Cellulitis Cholecystitis/ Biliary Sepsis Co-amoxiclav +Clarithromyicn Or Piperacillin/Tazobactam +Clarithromycin Or Teicoplanin + Clarithromycin Co-amoxiclav Or Piperacillin/tazobactam Or Temocillin combination Piperacillin/Tazobactam Or Meropenem Or Ertapenem Levofloxacin Co-amoxiclav Or Aztreonam Or Cefuroxime Or Temocillin Or Gentamicin Or piperacillin/tazobactam Or Meropenem Or Ertapenem Co-amoxiclav Or Aztreonam Or Cefuroxime Or Cefuroxime Or Temocillin Or Gentamicin Or piperacillin/tazobactam Or Meropenem Or Ertapenem Flucloxacillin Or Vancomycin/Teicoplanin Co-amoxiclav Or Tigycycline+/-Gentamicin Doxycycline PO 200mg STAT then 100mg OD Doxycycline PO 200mg OD+/- Metronidazole PO 400mg TDS Doxycycline PO 200mg STAT then 100mg OD Oral alternative Amoxicillin PO 500mg TDS +Clarithromycin PO 500mg BD Co-amoxiclav PO 625mg TDS (not in patients with current or previous C diffcile) Co-amoxiclav PO 625mg TDS (not in patients with current or previous C diffcile) Levofloxacin PO Levofloxacin PO 500mg BD 500mg BD Prescribe narrowest spectrum oral antibiotic according to sensitivities Co-amoxiclav PO 625mg TDS (not in patients with current or previous C diffcile) Flucloxacillin PO 1g QDS Co-amoxiclav PO 625mg TDS TDS (not in patients with current or previous C diffcile) Ciprofloxacin PO 500mg BD (not in patients at high risk of developing or previous C diffcile) Doxycycline PO100mg BD Co-trimoxazole PO 960mg BD + Metronidazole PO 400mg TDS on discussion with microbiologist/antibiotic pharmacist All other indications/antibiotics, please consult results reporting for sensitivities or contact on-call microbiologist to discuss. Page 7 of 8

4.0 ORAL ANTIBIOTICS WITH HIGH BIOAVAILABILITY: The following antimicrobials have excellent bioavailability, they do not need to be prescribed IV unless the patient is nil by mouth (NBM) or has impaired gut function. Antimicrobial Oral bioavailability Clindamycin 90% Ciprofloxacin 70-80% Fluconazole 90% Levofloxacin 90-100% Linezolid 100% Metronidazole 90-95% Rifampicin (if 30 mins before food) 90-95% Voriconazole 90-95% 5.0 Monitoring Arrangements for Compliance and Effectiveness This policy will be monitored via antibiotic ward rounds. Deviation in practice will be constructively discussed with the clinicians on the wards. An audit will be carried out annually to measure compliance and results shared with the microbiology team and clinical teams. 6.0 Plan for Dissemination and Implementation This guideline will be disseminated via the Antibiotic Steering Group, the Medicines Management Committee and to the endocrinology and admission wards. It will be available as part of the diabetic foot and antibiotic guidelines on KGH intranet. 7.0 References Start smart then focus guidelines Public Health England and Department of Health March 2015 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/417032/start_smart_ Then_Focus_FINAL.PDF UK Five Year Antimicrobial Resistance Strategy 2013 to 2018 Department of Health 2013 ttps://www.gov.uk/government/uploads/system/uploads/attachment_data/file/244058/20130902_uk _5_year_AMR_strategy.pdf Clostridium difficile infection: How to deal with the problem Health Protection Agency and Department of Health 2008 https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/340851/clostridium_d ifficile_infection_how_to_deal_with_the_problem.pdf A new approach to treatment of resistant gram-positive infections: potential impact of targeted IV to oral switch on length of stay Desai M et al BMC Infect Dis 2006; 6:94 Oral administration of antibiotics: a rational alternative to the parenteral route MacGregor and Graiani CID 1997 Electronic Medicines Compendium drug specific summary of product characteristics http://www.medicines.org.uk/emc/ Page 8 of 8