Analysis of the practice of switch of antibiotics from intravenous to oral therapy at a tertiary care hospital in Nepal: a prospective observational study

Objective

This study analyzed the practice of switching intravenous antibiotics to oral dosage form in a tertiary care hospital of Nepal.

Design

A prospective observational study was performed among patients admitted to medical/surgical wards in a private tertiary care hospital of Nepal.

Methods

Hospitalized adult patients who received IV antibiotics for at least 48 hours and met the eligibility criteria were enrolled in the study. The detailed information on use of antibiotics such as indication, duration, type time of switch etc. were collected and analyzed.

Results

Among 335 patients, 282(83.9%) met the eligibility criteria for intravenous (IV) to oral conversion however, only 18.7% of patients were switched to oral regimen. Step-down conversion was the common type of IV to oral switch. Almost all patients were empirically treated with β-lactams antibiotics (n = 327). There was significant association between the antibiotic class and duration of IV therapy (P < 0.001). The length of hospital stays and duration of IV antibiotics therapy was lower in the timely converted group than in the non-converted groups (P < 0.001). The duration of IV antibiotics therapy was strongly correlated with duration of hospital stay (r = 0.743, P < 0.001).

Conclusion

The findings revealed a low prevalence of conversion from IV antibiotics to oral, despite a higher percentage of patients meeting the eligibility criteria for conversion. There is a need for the implementation of structured program to review patients on IV antibiotics and promote timely conversion to oral once they meet the conversion criteria.

Guidelines for Antibiotics Prescription in Critically Ill Patients

How to cite this article: Khilnani GC, Tiwari P, Mittal S, Kulkarni AP, Chaudhry D, Zirpe KG, et al. Guidelines for Antibiotics Prescription in Critically Ill Patients. Indian J Crit Care Med 2024;28(S2):S104-S216.

Physicians' understanding of antibiotic intravenous-to-oral switching-a qualitative study in Suzhou, China

BACKGROUND

The implementation of antibiotic intravenous-to-oral switch (IVOS) therapy in hospitals can slow down the development of drug resistance, reduce the occurrence of adverse reactions, and bring significant economic benefits. The aim of this study is to investigate the understanding of physicians at the Second Affiliated Hospital of Soochow University in Suzhou, China towards the antibiotic IVOS therapy.

METHODS

15 physicians working in 9 different departments of the Second Affiliated Hospital of Soochow University participated in this study. A semi-structured face-to-face interview was conducted to collect interview information about the antibiotic IVOS therapy. NVivo12 software was used to organize the entire interview content, and the interview data was analyzed and summarized using the Colaizzi seven step method.

RESULTS

60% of participants were not familiar with antibiotic IVOS therapy. Barriers of antibiotic IVOS therapy were included by three key issues: (i) Physicians' potential cognition: 'Iv is always better than oral'; (ii) Subjective infusion intention of patients; and (iii) Limitations of drug selection. 60% of participants expressed welcome for pharmacists to help them perform antibiotic IVOS treatment. And electronic recognition technology may be a feasible method for prompting IVOS conversion that recognized by all participants in the interview. Participants also provided some suggestions for pharmacists and IVOS computer reminders.

CONCLUSION

Physicians' in China still have insufficient understanding of antibiotic IVOS therapy. The promotion of antibiotic IVOS therapy in China faces many challenges and obstacles. Strategies such as IVOS therapy computer reminders and clinical pharmacists' medication guidance were worth studying to help physicians develop antibiotic IVOS treatment.

A randomized, controlled trial of prulifloxacin as conversion therapy after intravenous carbapenem in the treatment of acute pyelonephritis caused by third generation cephalosporin resistant pathogens: A pilot study

The efficacy of converting to oral fluoroquinolones after initial intravenous antibiotics for the treatment of acute pyelonephritis (APN) caused by the third-generation cephalosporin resistant Enterobacteriaceae (3-GCrEC) needs to be investigated. The objective was to compare the clinical and bacteriological outcome of oral prulifloxacin with intravenous ertapenem for the treatment of APN caused by 3-GCrEC. A pilot, randomized controlled trial of patients with APN caused by 3-GCrEC was conducted at two hospitals from August 2015 to December 2020. Any intravenous antimicrobial drug was initially permitted for empirical therapy. On day 4, adult patients (aged >18 years) with either non-bacteremic or bacteremic APN were eligible for the study if their infection was caused by 3-GCrEC susceptible to the study drugs. The patients were randomly assigned to receive either oral prulifloxacin or intravenous ertapenem. The total duration of antimicrobial therapy was 14 days. Of the 21 enrolled patients, 11 were treated with prulifloxacin, and 10 were treated with ertapenem. At the test of cure visit, there was no statistically significant difference between the patients with overall clinical success who were treated with prulifloxacin (90.9%) and those treated with ertapenem (100%, p = 0.999). In addition, there was no statistically significant difference in microbiological eradication between the prulifloxacin and ertapenem groups (100% vs. 100%, p = 0.999). The converting to oral prulifloxacin after intravenous antibiotics therapy appears to be an alternative option for treatment of APN caused by 3-GCrEC. A further large randomized controlled trial should be investigated.

Opportunities, associations, and impact of early intravenous to oral antimicrobial switch for hospitalized patients in Ethiopia

Objective:

Short intravenous antimicrobial therapy for 2–3 days followed by its per oral comparable antimicrobial course is a crucial part of the antimicrobial stewardship program. However, nothing is known about this practice in Ethiopian hospitals. Therefore, this study assessed the proportion, associations, and outcomes of early intravenous to per oral antimicrobial switch for patients who were admitted to the three wards of Ambo University Referral Hospital.

Method:

A hospital-based prospective cohort pilot study was conducted. During the 3-month period, 117 patients met initial inclusion criteria and were followed until Day 3 of intravenous antimicrobial. Of these, 92 (78.6%) subsequently met criteria for early intravenous to per oral switch and are the cohort investigated in this study. Written informed consent was sought from participants and/or parents or guardian for ages 15–17 years. Logistic regression models and independent t-tests were done with a significance of p ⩽ 0.05.

Results:

Out of 92 study participants, early intravenous to per oral antimicrobial switch was done only for 36 (39.1%). The only independent predictors for lack of early intravenous to per oral antimicrobials switch were poly-pharmacy (adjusted odds ratio = 3.4 at 95% confidence interval, 1.036–11.16; p = 0.044). There was a significant difference in terms of mean length of hospital stay (8.80 ± 3.57 versus 3.17 ± 0.74; p < 0.0001), in-hospital complication rate (95% versus 5%; p < 0.0001), and the mean cost of healthcare in Ethiopian Birrs (652.29 ± 403.29 versus 126.67 ± 29.47; p < 0.0001) between the comparator/early intravenous to per oral not switched and early switched group, respectively.

Conclusion:

The proportion of early intravenous to per oral antimicrobial switch was unsatisfactory. There was a significant difference between the intervention and comparator groups in terms of length of hospital stay, in-hospital complications, and extra cost. Therefore, implementation of interventions that improve the practice of early intravenous to per oral switch is needed urgently.

Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: A systematic review

BACKGROUND

This review aimed to summarize the available evidence on the effectiveness and safety of antimicrobial stewardship interventions to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults.

METHODS

Following the PRISMA guidelines, we searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, and Scopus from inception to September 1, 2020, for original articles investigating any interventions aimed to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults with infectious diseases. We included randomized controlled trials (RCTs) and quasi-experimental studies. Studies were excluded if they evaluated drugs other than antimicrobials, head-to-head comparison of interventions, included pediatrics or oncology patients.

RESULTS

Of 506 unique citations identified, 36 studies met the inclusion criteria. The 36 included studies reported 92 interventions as a single (n = 10) or a bundle of interventions (n = 26). The most common interventions used were guideline/protocol/pathway (n = 25), audit and feedback (n = 20), and education (n = 17).

CONCLUSIONS

This review provides health care providers with a comprehensive summary on the interventions to promote IV-to-PO antimicrobial switch. While no one intervention could be identified as the safest and most effective as most of the included studies used a bundle of interventions, all interventions resulted in optimizing antibiotic use and reducing health care expenditures without compromising the clinical outcomes. As such, each hospital should design and utilize interventions that are applicable based on available resources and expertise.

Impact of Antimicrobial Stewardship Interventions to Improve Antibiotic Prescribing for Hospital Inpatients in Africa: A Systematic Review and Meta-analysis

BACKGROUND

Antimicrobial stewardship (AMS) interventions to improve antibiotic use are being implemented in Africa, but their impact is not fully known.

AIM

To estimate the effectiveness of interventions to improve antibiotic prescribing for hospital inpatients.

METHODS

Systematically searched for studies from PubMed, Embase, African Journals online and Google scholar from January 2010 to July 2022. Studies were included if they reported the impact of AMS interventions on outcomes of interest for hospital inpatients in Africa. Risk of bias was evaluated using the Cochrane Effective Practice and Organization of Care guidelines and the National Heart, Lung and Blood Institute tool. Findings were summarized in tables and meta-analyses were performed using random-effects models.

FINDINGS

Twenty-eight studies were included, 89% being uncontrolled before and after studies. Most interventions employed were multifaceted and found to be effective, evidenced by increased compliance, reduction in antibiotic utilization and cost, and slight reduction or no difference in mortality and length of hospital stay (LOS). Meta-analysis generated a relative risk of 0.82 (95% CI: 0.70∼0.97) for mortality, and a standard mean difference of -0.30 (95% CI: -0.41∼-0.19) for LOS. Generally, a decrease in resistance to most microorganisms was observed. Despite an increase in the number of AMS studies conducted in Africa, the studies lack in most quality design features for AMS studies.

CONCLUSION

Antimicrobial stewardship interventions are likely to be effective, however efforts are still required to align the study design with the quality design features required for validity and to inform practice.

Impact of Multidisciplinary Team Escalating Approach on Antibiotic Stewardship in the United Arab Emirates

Antimicrobial stewardship programs (ASP) are an essential strategy to combat antimicrobial resistance. This study aimed to measure the impact of an ASP multidisciplinary team (MDT) escalating intervention on improvement of clinical, microbiological, and other measured outcomes in hospitalised adult patients from medical, intensive care, and burns units. The escalating intervention reviewed the patients’ cases in the intervention group through the clinical pharmacists in the wards and escalated complex cases to ID clinical pharmacist and ID physicians when needed, while only special cases required direct infectious disease (ID) physicians review. Both non-intervention and intervention groups were each followed up for six months. The study involved a total of 3000 patients, with 1340 (45%) representing the intervention group who received a total of 5669 interventions. In the intervention group, a significant reduction in length of hospital stay (p < 0.01), readmission (p < 0.01), and mortality rates (p < 0.01) was observed. Antibiotic use of the WHO AWaRe Reserve group decreased in the intervention group (relative rate change = 0.88). Intravenous to oral antibiotic ratio in the medical ward decreased from 4.8 to 4.1. The presented ASP MDT intervention, utilizing an escalating approach, successfully improved several clinical and other measured outcomes, demonstrating the significant contribution of clinical pharmacists atimproving antibiotic use and informing antimicrobial stewardship.

Implementation of pharmacist-managed early switch from intravenous to oral therapy using electronic identification at a tertiary academic hospital

Overutilization of intravenous (IV) medications can result in drug shortages, which is one of the major health care crisis, in addition to increasing costs, length of hospital stays (LOS) and the associated complications. We hypothesized that IV therapy was overused at our hospital where oral (PO) was applicable, and that the implementation of IV-PO protocol could result in a cost-effective practice. Hence, we aimed at assessing impact and outcomes of implementing such a protocol. A single center, prospective quasi-interventional study conducted at tertiary academic hospital. A protocol was implemented targeting 17 medications, with educational sessions to medical staff during a 5-month phase. IV orders of 48 h or more, among adult patients at medical or surgical wards with no contraindication to PO route were eligible. Once eligible, pharmacists send interventions using hospital's computerized order entry system, and physicians' responses were monitored on daily basis. Efficacy was estimated by percentage of switch recommendations that resulted in effective switch to PO medication. Cost-minimization analysis was used for course cost between the control phase and intervention phase. Length of hospital stay (LOS), readmissions within 90 days and in-hospital mortality were analyzed as secondary outcomes. During intervention phase, 781 patients had at least one IV order switched to PO. Gastric acid-reducing agents (GARAs) accounted for the most IV prescriptions (50.4%), followed by antibiotics (39.6%). Pharmacists carried out 2677 interventions to which switch recommendations were issued in 1185 (44.3%). Primary switch recommendations (N = 677) led to effective switch in 60.7% cases. These included per protocol switch (8.9%), switch to another PO (2.5%), spontaneous switch by physician (17.6%) and IV discontinuation (31.8%). The overall efficacy was estimated as 62.8%. The intervention was associated with reduced IV consumption from 4,574-18,597 vials in control phase to 3,654-15,546 vials in intervention phase, which resulted in overall cost saving of 50,960.8 SAR ($13,589.5), with an average monthly cost saving of 10,192.2 SAR ($2,717.9). Pharmacist-managed early switch from IV-PO therapy, with physicians' education, showed significant reduction in IV medication use in our hospital. By reducing unnecessary IV use, this strategy enabled considerable cost savings, besides the potential advantages of convenience and safety.

Evaluation of intravenous to oral antimicrobial switch at a hospital with a tightly regulated antimicrobial stewardship program

Timely intravenous (IV) to oral antimicrobial switch (IV-oral-switch) is a key antimicrobial stewardship (AMS) strategy. We aimed to explore concordance with IV-oral-switch guidelines in the context of a long-standing, tightly regulated AMS program. Data was retrospectively collected for 107 adult general medical and surgical patients in an Australian hospital. Median duration of IV antimicrobial courses before switching to oral therapy was 3 days (interquartile range [IQR] 2.25-5.00). Timely IV-oral-switch occurred in 57% (n = 61) of patients. The median delay to switching was 0 days (IQR 0 to 1.25). In most courses (92/106, 86.8%), the choice of oral alternative after switching was appropriate. In 45% (47/105) of courses, total duration of therapy (IV plus oral) exceeded the recommended duration by >1.0 day. Excessive IV antimicrobial duration was uncommon at a hospital with a tightly regulated AMS program. Total duration of therapy was identified as an AMS target for improvement.

Implementation of a Clinical Decision Support Tool to Improve Antibiotic IV-to-Oral Conversion Rates at a Community Academic Hospital

BACKGROUND

Antibiotic IV-to-oral (IV-PO) conversion is a key initiative of antimicrobial stewardship programs. Guidelines and education are commonly described interventions to promote IV-PO conversion; however, technological interventions may be more effective in changing practice.

OBJECTIVE

To determine the impact of a clinical decision support (CDS) tool on the adoption and sustainability of an antibiotic IV-PO conversion program at a community academic hospital.

METHODS

A quasi-experimental study consisting of 3 phases was conducted. During phase 1, the pre-intervention antibiotic IV-PO conversion rate was determined. During phase 2, the IV-PO conversion policy was updated, education was provided to pharmacists and physicians, and a post-intervention evaluation was conducted. During phase 3, a CDS tool was developed to generate real-time electronic alerts prompting pharmacists to assess antibiotic therapy, and post-intervention audits were performed 1 month, 3 months, and 15 months after implementation of the tool. Pantoprazole IV-PO conversion was assessed during each phase as a non-equivalent dependent variable. The primary outcome was the proportion of patients eligible for IV-PO conversion who were switched to oral therapy.

RESULTS

Of 332 patients receiving targeted IV antibiotic therapy during the overall study period, 122 (37%) met the criteria for IV-PO conversion. The phase 2 IV-PO conversion rate of 35% (9/26) was comparable to the pre-intervention rate of 29% (10/35) (p = 0.61). Implementation of the CDS tool significantly increased the conversion rate to 78% (14/18), an increase that was sustained at 3 months (71% [17/24]) and 15 months (74% [14/19]) after implementation (p < 0.05 for all comparisons with phases 1 and 2). Pantoprazole conversion rates were similar across all phases.

CONCLUSIONS

Implementation of the CDS tool was effective in improving and sustaining antibiotic IV-PO conversion rates and enhancing policy compliance beyond the effects of policy revision and education. Refinement of both the policy and the tool is warranted to maximize adoption of the IV-PO conversion program.

Early switching of antibiotic therapy from intravenous to oral using a combination of education, pocket-sized cards and switch advice: A practical intervention resulting in reduced length of hospital stay

OBJECTIVES

To assess the effectiveness of a combined intervention on the timing and rate of switching from intravenous (IV) to oral antibiotic therapy.

MATERIALS AND METHODS

The study used a historically-controlled prospective intervention design. Interventions consisted of educating physicians, handing out pocket-sized cards and providing switch advice in the electronic patient record (EPR). All patients hospitalized at the surgery department who were treated with IV antibiotics for at least 24 h and who fulfilled the switch criteria within 72 h of IV treatment were included. Outcomes before and during the intervention were compared.

RESULTS

An early IV to oral switch took place in 35.4% (35/99) of the antibiotic courses in the baseline period and in 67.7% (42/62) of the antibiotic courses in the intervention period (odds ratio [OR] 3.84, 95% confidence interval [CI] 1.96-7.53). Duration of IV therapy was significantly reduced from 5 to 3 days (P<0.01). Length of hospitalization was reduced from 6 to 5 days (P<0.05).

CONCLUSIONS

The interventions were effective in promoting an early IV to oral antibiotic switch by shortening the length of IV therapy and hospital stay.

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.

Promoting oral potassium administration in a tertiary care hospital: An eleven-year study

INTRODUCTION

Potassium is used to treat or prevent hypokalemia and exhibits all the characteristics of an intravenous to oral therapy conversion program. Despite this, the intravenous route for potassium replacement seems frequently unjustified.

OBJECTIVES

To determine the impact of a conversion program on the use of intravenous and oral galenic forms in a university tertiary care hospital.

METHODS

Two promotion campaigns were conducted in 2006 and 2009. The following years this was completed by pharmacist interventions during prescription analysis and face-to-face discussions with physicians during ward rounds. The consumption of products containing potassium was obtained by analyzing the hospital's financial database.

RESULTS

The proportion of the oral route increased from 18% in 2006 to 22% in 2011, and from 25% in 2012 to 44% in 2016; the increase was significantly greater in the second period (P<0.0001). In 2016, in emergency, pulmonology, infectious diseases, and cardiology departments, the proportion of oral use ranged from 57% and 82%. The greatest progression from 2006 to 2016 was found for intensive care (4% vs. 12%) and visceral surgery departments (9% vs. 34%) that increased approximately four-fold, followed by the emergency department (28% vs. 57%) that increased approximately two-fold.

CONCLUSION

Promoting the oral route for potassium replacement modifies prescriber habits and is followed by a notable increase in the proportion of potassium administered orally irrespective of department type.

Strategies for reduction in the duration of intravenous drug use: Interest of drug tracers as quality indicators to improve intravenous to oral switch

RATIONALE, AIMS, AND OBJECTIVES

Intravenous (IV) to oral (PO) drug switch is a challenge for tertiary care institutions for several reasons: catheter-related infections, patient's pain and discomfort or higher costs, and overuse of IV drugs considered as an irrational use of medicines. The objective was to evaluate yearly acetaminophen and proton-pump inhibiters' (PPIs) IV/PO ratios from 2011 to 2015 and to determine their correlation with all drugs IV/PO ratios and their relevance as drug tracers. A secondary objective was to estimate costs savings associated with a IV to PO switch improvement.

METHODS

Data on IV and PO consumptions and impact on costs were presented to physicians yearly, followed by the development of a computerized tool and pharmaceutical validation of prescriptions. Intravenous and PO drug consumptions were extracted yearly for all drugs, acetaminophen, and PPIs from 2011-01-01 to 2015-12-31. Acetaminophen and PPIs' IV/PO ratios were compared to IV/PO consumptions for all drugs. Costs savings associated with this switch were calculated yearly by multiplying the difference in average cost per dose by the total number of doses delivered (fixed purchase prices, euros) for both routes.

RESULTS

All drugs IV/PO ratio decreased every year to achieve a 16.3% reduction between 2011 and 2015. Acetaminophen and PPIs also decreased respectively by 35.5% and 16.5%. Same tendency of decrease of ratios year by year was noted for all drugs, PPIs, and acetaminophen. Savings for both acetaminophen and PPIs IV/PO switch were over 98 000€ for 5 years.

CONCLUSIONS

This study demonstrated that acetaminophen IV/PO ratio, easily produced in routine, was a relevant tracer to follow IV/PO switch improvement as it was correlated with all drugs IV/PO ratio. Direct cost savings associated with IV/PO switch improvements were consequent and illustrate well the impact of our approach on the efficiency of therapeutics' management.

Antimalarial prescription in a public hospital outpatient setting in Kenya: A best practice implementation project

BACKGROUND

Important gaps still exist in malaria case management despite implementation of the World Health Organization parasitological diagnosis before treatment recommendation. This calls for evidence-based strategies to improve health providers' adherence to these guidelines.

OBJECTIVE

The goal of this project was to improve adherence of confirmed parasitological diagnosis prior to antimalarial prescription in the outpatient department.

METHODS

The Joanna Briggs Institute Practical Application of Clinical Evidence System program was used to facilitate collection of baseline and post-audit data. The Getting Research into Practice program was also utilized to analyze the potential barriers and for designing the intervention strategies. This study was done during a 7-month period in an outpatient department of public health facility in Kenya.

RESULTS

Baseline and post-implementation audit results comparison indicate that there was a clinically significant improvement in all three criteria. One hundred percent of health providers underwent training on malaria case management, an improvement from 24% at baseline. Almost all (98%) suspected cases for malaria were tested for malaria parasite, and 98% doses of antimalarial drug dispensed had documentation indicating that the malaria test result was positive, an increase of 74%.

CONCLUSION

This study successfully increased the adherence to malaria parasitological confirmation before the treatment recommendation. The interdepartmental collaboration facilitated improvements that led to a reduction in presumptive prescription of antimalarial drugs, antimalarial medication costs, and potentially the emergence of drug resistance.

Development of operationalized intravenous to oral antibiotic switch criteria

OBJECTIVES

Despite huge overlap in suggested criteria for a safe intravenous (iv)-to-oral antibiotic switch, there is considerable variation in their operationalization. The objective of this study was to develop a set of measurable conditions that should be met in adult hospitalized patients for a safe iv-to-oral switch.

METHODS

A RAND-modified Delphi procedure was performed to develop a set of operationalized iv-to-oral switch criteria. Switch criteria and their accompanying suggested measurable conditions were extracted from the literature and appraised by a multidisciplinary expert panel during two questionnaire rounds with a face-to-face meeting between these two rounds. In a final step, the experts could approve the set of developed operationalized switch criteria.

RESULTS

Seven switch criteria and 41 accompanying measurable conditions extracted from the literature were appraised. Sixteen measurable conditions that operationalize six switch criteria were selected: (i) stable systolic blood pressure; and the absence of (ii) fever, (iii) temperature <36°C, (iv) malabsorption syndrome, (v) short bowel syndrome, (vi) severe gastroparesis, (vii) ileus, (viii) continuous nasogastric suction, (ix) vomiting, (x) (severe) sepsis, (xi) fasciitis necroticans, (xii) CNS infection, (xiii) Staphylococcus aureus bacteraemia, and (xiv) endovascular infection. In addition, (xv) the patient should be cooperative and (xvi) adequate antimicrobial concentration should be achievable at the site of infection by oral administration.

CONCLUSIONS

These operationalized criteria can be used in daily clinical practice. Future use of these criteria in audits and as rules in clinical decision support systems will facilitate the performance and evaluation of iv-oral switch programmes.

Assessment of an intervention aimed at early discontinuation of intravenous antimicrobial therapy in a Brazilian University hospital

Many interventions demonstrate success in adapting the duration of intravenous antibiotic therapy, but few studies have been conducted in developing countries. The aim of this study was to evaluate the effectiveness of an intervention in the induction of early discontinuation of intravenous antimicrobial therapy and/or its switch to oral therapy. The study employed a before–after intervention design that consisted of displaying a message in the computerized prescription on the third day and suspension of the prescription on the fifth day of intravenous antimicrobial therapy. A total of 465 patients were followed during the control period (CP) and 440 in the intervention period (IP). The intravenous therapy was switched to oral therapy for 11 (2.4%) patients during the CP and 25 (5.7%) in the IP (p = 0.011), and was discontinued for 82 (17.6%) patients during the CP and 106 (24.1%) in the IP (p = 0.017). During the IP there was a significant increase of patients who had their antimicrobial treatment discontinued before the seventh day of intravenous treatment, 37.40% (49/131) in the IP and 16.13% (15/93) in the CP (p = 0.0005). The duration of intravenous antimicrobial therapy decreased by one day, but it was not significant (p = 0.136). It is concluded that the proposed intervention is effective in promoting the early discontinuation of antimicrobial treatment and/or switch to oral therapy. As long as a computerized system for prescription already exists, it is easy and inexpensive to be implemented, especially in hospitals in developing countries.

[Medication errors with concentrated potassium intravenous solutions: Data of the literature, context and prevention]

Accidental direct intravenous injection of a concentrated solution of potassium often leads to patient death. In France, recommendations of healthcare agencies to prevent such accidents cover only preparation and intravenous infusion conditions. Accidents continue to occur in French hospitals. These facts demonstrate that these recommendations are insufficient and ineffective to prevent such deaths, especially those occurring during a catheter flushing. This article reviews the measures able to reduce the number of accidents. Countries which removed concentrated ampoules from ward stocks observed a decrease of the number of accidental deaths. This withdrawal, recommended by the World Health Organization, is now part of standards in studies aimed at determining the safety of care in hospitals. However, removal alone is insufficient to eliminate the risk. The combination with other measures should be considered. These measures are the provision of a combination of diluted intravenous ready to use solutions, the promotion of the oral route with tablets and oral solutions for potassium replenishment and to make available products with safeguards to prevent single shot intravenous injection. Studies aimed at determining the consequences on preventing concentrated potassium accidents of a widespread distribution of isotonic sodium chloride pre-filled ready-to-use syringes for catheter flushing should be performed.

Earlier switching from intravenous to oral antibiotics owing to electronic reminders

Paper-based interventions have been shown to stimulate switching from intravenous (i.v.) to oral (p.o.) antibiotic therapies. Shorter i.v. durations are associated with a lower risk of iatrogenic infections as well as reduced workload and costs. The purpose of this study was to determine whether automated electronic reminders are able to promote earlier switching. In this controlled before-and-after study, an algorithm identified patients who were eligible for i.v.-to-p.o. switch 60 h after starting i.v. antimicrobials. Reminders offering guidance on the re-assessment of initial i.v. therapy were displayed within the electronic health records in 12 units during the intervention period (year 2012). In contrast, no reminders were visible during the baseline period (2011) and in the control group (17 units). A total of 22863 i.v. antibiotic therapies were analysed; 6082 (26.6%) were switched to p.o.

THERAPY

In the intervention group, 757 courses of i.v. antibiotics were administered for a mean ± standard deviation duration of 5.4 ± 8.1 days before switching to p.o. antibiotics in the baseline period, and 794 courses for 4.5 ± 5.5 days in the intervention period (P = 0.004), corresponding to a 17.5% reduction of i.v. administration time. In contrast, in the control group the duration increased; 2240 i.v. antibiotics were administered for a mean duration of 4.0 ± 5.9 days in the baseline period, and 2291 for 4.3 ± 5.8 days in the intervention period (P = 0.03). Electronic reminders fostered earlier i.v.-to-p.o. switches, thereby reducing the duration of initial i.v. therapies by nearly a day.

Implementing criteria-based early switch/early discharge programmes: a European perspective

Early switch (ES) from intravenous (IV) to oral antibiotic therapy programmes is increasingly included as a component of hospital antimicrobial stewardship initiatives that aim to optimize antimicrobial therapy while limiting toxicity and resistance. In terms of prioritizing the most cost-effective stewardship interventions, ES has been seen as a 'low-hanging fruit', which refers to selecting the most obtainable targets rather than confronting more complicated issues. Administration of highly bioavailable oral antibiotics should be considered for nearly all non-critically ill patients and has been recommended as an effective and safe strategy for over two decades. However, to accrue the most benefit from ES, it should be combined with an early discharge (ED) plan, protocol, or care pathway. Benefits of this combined approach include improved patient comfort and mobility, reduced incidence of IV-line-related adverse effects, reduced IV antimicrobial preparation time, decreased hospital stays, reduced antimicrobial purchasing and administration costs, decreased patient deconditioning, and shortened recovery times. Results from published studies document decreases in healthcare resource use and costs following implementation of ES programmes, which in most studies facilitate the opportunity for ED and ED programmes. Barriers to the implementation of these programmes include clinician misconceptions, practical considerations, organizational factors, and a striking lack of awareness of IV to oral switch guidance. These and other barriers will need to be addressed to maximize the effectiveness of ES and ED programmes. As national antimicrobial stewardship programmes dictate the inclusion of ES and ED programmes within healthcare facilities, programmes must be developed and success must be documented.

Pharmacists' interventions on intravenous to oral conversion for potassium

BACKGROUND

Guidelines recommend use of the oral route whenever possible to treat or prevent hypokalemia. Although a myriad of papers have been published regarding intravenous to oral (IV to PO) therapy conversion programs and about clinical pharmacy services provided in hospitals, little is known on the role of hospital pharmacists in promoting the oral route for potassium administration.

OBJECTIVE

The aim of this work was to describe the frequency of interventions related to IV to PO potassium therapy conversions performed by hospital pharmacists. Setting French hospitals recording pharmacist's interventions on the website tool of the French Society of Clinical Pharmacy.

METHODS

From the pharmacist's interventions (PI) dataset recorded we extracted all interventions related to potassium IV to PO conversion. We assessed the acceptance rate of these PI by prescribers. Additional free text information in the dataset was analysed.

MAIN OUTCOME MEASURES

IV to PO potassium therapy conversions related to potassium chloride.

RESULTS

From January 2007 to December 2010, 87 hospitals recorded 1,868 PIs concerning IV to PO therapy conversion. Among these, 16 (<1 %) concerned potassium chloride. They were recorded by four hospitals (4.6 %) with respectively 12, 2, 1 and 1 PIs. Six PIs were accepted by physicians and the prescriptions were modified.

CONCLUSION

PIs to promote the administration of potassium by the oral route are extremely rare. Our results and scarce previously published data reveal that this field of practice remains almost unexplored. These findings highlight an important gap in the field of intravenous to oral therapy programs. This situation must be regarded as unsatisfactory and should lead to setting up more education and research programs.

An outpatient antibacterial stewardship intervention during the journey to JCI accreditation

Background

Antibacterial overuse, misuse and resistance have become a major global threat. The Joint Commission International (JCI) accreditation standards include quality improvement and patient safety, which is exemplified by antimicrobial stewardship. There are currently few reports on interventions to improve the quality of outpatient antibacterial prescribing.

Methods

A before-after intervention study, aiming at antibacterial use in outpatients, was performed in a university-affiliated hospital with 2.8 million outpatient visits annually during the journey to JCI accreditation (March of 2012 - March of 2013). Comprehensive intervention measures included formulary adjustment, classification management, motivational, information technological, educational and organizational measures. A defined daily dose (DDD) methodology was applied. Pharmacoeconomic data and drug-related problems (DRPs) were statistically compared between the two phases.

Results

The variety of antibacterials available in outpatient pharmacy decreased from 38 to 16. The proportion of antibacterial prescriptions significantly decreased (12.7% versus 9.9%, P < 0.01). The proportion of prescriptions containing the restricted antibacterials was 30.4% in the second phase, significantly lower than the value of 44.7% in the first phase (P < 0.01). The overall proportion of oral versus all antibacterial prescriptions increased (94.0% to 100%, P < 0.01) when measured as defined daily doses. Statistically significant increases in relative percentage of DDDs of oral antibacterials (i.e., DDDs of individual oral antibacterial divided by the sum of DDDs of all antibacterials) were observed with moxifloxacin, levofloxacin, cefuroxime axetil, ornidazole, clindamycin palmitate, cefaclor, amoxicillin and clarithromycin. Occurrence rate of DRPs decreased from 13.6% to 4.0% (P < 0.01), with a larger decrease seen in surgical clinics (surgical: 19.5% versus 5.6%; internal medicine: 8.4% versus 2.8%, P < 0.01). The total expenditure on antibacterials for outpatients decreased by 34.7% and the intervention program saved about 6 million Chinese Yuan Renminbi (CNY) annually.

Conclusion

The one-year intervention program on outpatient antibacterial use during the journey to JCI accreditation reduced the expenditure on antibacterials, improved the appropriateness of antibacterial prescriptions. Quality improvements need integrated multifaceted intervention measures and long-term adherence to the antibiotic stewardship. Approach of i.v. to oral antibacterial switch, classification management, and motivational measures may play the most efficient role in changing antibacterial prescription practices.