Oral to IV Conversion

• The optimal time to consider switching a patient to oral therapy is after 2 to 4 days of intravenous therapy.T
• his period of time allows the clinician to evaluate the patient’s microbiology results and assess their response to treatment. 
• A large number of clinical trials support the early switching to oral antibiotics after this period of time with equal treatment efficacy and no adverse effects on patient outcome
• A patient must meet a number
  of criteria prior to switching:
  • Display signs of clinical improvement (Box 1)
  • Able to tolerate oral therapy (Box 2)
  • Not have a condition in which higher concentrations of antibiotic are required in the tissue/prolonged course of IV therapy is essential(Box 4)
• There are a number of conditions in which a switch to oral therapy should be considered including:
  • Pneumonia
  • Skin and soft tissue infections
  • Urinary tract infections
  • Uncomplicated Gram negative bacteraemia
  • Intra-abdominal infection without deep seated collections

References:

1. Intravenous to Oral Switch Guideline for Adults Patients –can antibiotics S.T.O.P. South Australian expert Advisory Group on Antibiotic Resistance (SAAGAR)
2. Focus on Converting from IV to PO Antibiotic Therapy. 

IV to Oral Conversion: Ceftriaxone

Rationale

• Unnecessarily prolonged courses of IV antibiotics are also associated with increased length of hospital stay, increased costs of nursing, pharmacy and medical time in the insertion of IV lines, preparation, dispensing and administration of IV agents and the increased morbidity and mortality associated with IV line infections
• To optimise antibiotic use, a switch from IV antibiotics to oral therapy in the appropriate patient has a number of advantages

When to Switch

• The optimal time to consider switching a patient to oral therapy is after 2 to 4 days of intravenous therapy.
• This period of time allows the clinician to evaluate the patient’s microbiology results and assess their response to treatment.
• A large number of clinical trials support the early switching to oral antibiotics after this period of time with equal treatment efficacy and no adverse effects on patient outcome

Agent of Choice

• Recommendations for oral conversion are provided based on initial IV therapy.
• The choice of oral antibiotics may be influenced by results of microbiologic studies, favoring more-narrow spectrum agents when possible.
• Recommendations have been made to convert intravenous ceftriaxone, a third generation cephalosporin, to oral cefuroxime, a second-generation cephalosporin.
• Intravenous ceftriaxone has no definitive oral equivalent and conversion to cefuroxime (Ceftin®) should be adequate following initial therapy with ceftriaxone.
• If a specific pathogen is identified, therapy should be modified accordingly.

Pulmonary Infections

• unstable patients (low severity CAP who require hospital admission for other reasons, such as unstable co-morbid illnesses or social needs) with CAP are suitable candidates for early switch therapy
• consists of rapid initiation of 1-2 days of intravenous therapy followed by 5 days of oral therapy, with early hospital discharge after the administration of 1-2 doses of oral antibiotic (Augmentin or Cefuroxime)
• patients treated with Ceftriaxone and Azithromycin can be downgraded to oral Azithromycin if indicated (or Doxycycline).

Intra-Abdominal Infections

• Conversion to oral therapy with ciprofloxacin/metronidazole was as effective as continued intravenous therapy with ceftriaxone and oral metronidazole in patients who were able to tolerate oral feeding

IV	ORAL
Ceftriaxone 1g daily	Amoxycillin-clavulanate 875/125mg 12-hourly or Cefuroxime 500mg12-hourly (if respiratoryinfection)
Antimicrobial Stewardship Service, Melbourne Health
Ceftriaxone 1g-2g daily	Amoxycillin 875mg with clavulanic acid 125mg bd*
Intravenous to Oral Switch Guideline for Adults Patient can antibiotics S.T.O.P.
Ceftriaxone 1 g IV daily 1,5+Azithromycin 500 mg PO x 1, then 250 mg PO daily x 4 more days	Cefuroxime (Ceftin) 500 mg PO Q12h(7 days total) and/or Azithromycin 250 mg PO daily (5 days total) Or Levofloxacin 500 mg PO daily (7 days total)
Guidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia (CAP) and IV to PO Conversion
*Consider patient allergy status when converting to a penicillin. #Some drug doses may need to be reduced with decreased renal function.

References:

1. Guidelines for the Empiric Management of Adult Patients with Community-Acquired Pneumonia (CAP) and IV to PO Conversion
2. Intravenous-to-Oral Switch Therapy. http://emedicine.medscape.com/article/237521-overview
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4320166/
4. ATS/IDSA Guidelines for HAP/VAP: AJRCCM 2005;171:388.
5. Intravenous to Oral Switch Guideline for Adults Patients –can antibiotics S.T.O.P.
6. A Quick Guide to Switch. Southern Health Therapeutics Committee

Apixaban : Perioperative

1.    Stop apixaban two days before the procedure (off apixaban for one day before the procedure and the day of the procedure).

2.    No bridging.

3.    Resume apixaban the day after the procedure, after at least 24 hours have elapsed when hemostasis secured. If the patient requires polyp removal, delay resumption of apixaban for one to two more days.

4.    Before resume the treatment, PT, APTT, signs and symptoms of bleeding should be monitored and assessed. If there is changes in these parameters delay resumption of apixaban at least 48 hours after the procedure.

5.    Bleeding risk should be assessed before doing any procedure. Table below shows the risk of bleeding for certain procedures :

                                                                                                                         

References

1.   Uptodate.com

2.  Guideline for patients receiving apixaban(eliquis) requiring emergency surgery or treatment for haemorrhage. (Nottingham University Hospital, NHS)

Anti-Tuberculosis: Dosing Adjustment in Obesity

 G Hall II, R. (2015). Evolving Larger: Dosing Anti-Tuberculosis (TB) Drugs in an Obese World. Current pharmaceutical design, 21(32), 4748-4751.

Pruritus: Differential Diagnosis

Table 1: Historical Findings That Suggest Etiologies for Pruritus

HISTORICAL FINDING	POSSIBLE ETIOLOGIES
New cosmetics or creams	Allergic contact dermatitis, urticaria, photodermatitis
New medications, supplements, or illicit drugs	Urticaria, fixed drug eruptions
Recent travel	Pediculosis, scabies infestation, photodermatitis, urticaria
Hobby or occupational exposure to solvents, adhesives, cleaners	Irritant contact dermatitis, xerosis, atopic dermatitis, eczema
New animal exposures	Flea infestation, allergic contact dermatitis, urticaria
Sick contacts, especially those with febrile diseases and rashes	Rubeola, mumps, varicella, scarlet fever, cellulitis, fifth disease, folliculitis
Unexplained weight changes, menstrual irregularity, heat/cold intolerance	Thyroid disease with secondary urticaria or xerosis
Unexplained weight loss, night sweats, unexplained fevers, fatigue	Lymphoma with secondary generalized pruritus
Malaise, nausea, decreased urine output	Renal failure with generalized pruritus

Table 2: Dermatologic Etiologies for Pruritus

ETIOLOGY	FEATURES
Allergic/irritant contact dermatitis	Sharply demarcated, erythematous lesion with overlying vesicles
	Reaction within two to seven days of exposure
Atopic dermatitis	Pruritic area where rash appears when scratched in patients with atopic conditions (e.g., allergic rhinitis, asthma)
	Involvement of flexor wrists and ankles, as well as antecubital and popliteal fossae
Bullous pemphigoid	Initially pruritic urticarial lesions, often in intertriginous areas
	Formation of tense blisters after urticaria
Cutaneous T-cell lymphoma (mycosis fungoides)	Oval eczematous patch on skin with no sun exposure (e.g., buttocks)
	Possible presentation of new eczematous dermatitis in older adults
	Possible presentation of erythroderma (exfoliative dermatitis)
Dermatitis herpetiformis	Rare vesicular dermatitis affecting the lumbosacral spine, elbows, or knees
Dermatophyte infection	Localized pruritus and rash characterized by peripheral scaling and central clearing
	Can occur on several sites, including the feet, scalp, trunk, and groin
Folliculitis	Pruritus out of proportion to appearance of dermatitis
	Papules and pustules at follicular sites on chest, back, or thigh
Lichen planus	Lesions often located on the flexor wrists
	Characterized by the six P's (pruritus, polygonal, planar, purple, papules, plaques)
Lichen simplex chronicus	Localized, intense pruritus
	Initial erythematous, well-defined plaques with excoriations lead to thickened, lichenified, violaceous patches if scratching continues
Pediculosis (lice infestation)	Occiput in school-aged children; genitalia in adults (sexually transmitted)
Psoriasis	Plaques on extensor extremities, low back, palms, soles, and scalp
Scabies	Burrows in hand web spaces, axillae, and genitalia
	Hyperkeratotic plaques, pruritic papules or scales
	Face and scalp affected in children but not in adults
Sunburn	Possible photosensitizing cause (e.g., with use of nonsteroidal anti-inflammatory drugs or cosmetics)
Urticaria (hives)	Intensely pruritic, well-circumscribed, erythematous, and elevated wheals
	Lesions may coalesce and wax and wane over several hours
Xerosis	Intense pruritus, often during winter months in northern climates
	Involvement of back, flank, abdomen, waist, and lower extremities
	More common in older persons

Table 3: Systemic Etiologies for Pruritus

Autoimmune

Dermatitis herpetiformis

Dermatomyositis

Linear immunoglobulin A disease

Sjögren syndrome

Hematologic

Hemochromatosis

Iron deficiency anemia

Mastocytosis

Plasma cell dyscrasias

Polycythemia vera

Hepatobiliary

Biliary cirrhosis

Chronic pancreatitis with obstruction of biliary tracts

Drug-induced cholestasis

Hepatitis, particularly hepatitis C

Sclerosing cholangitis

Infectious disease

AIDS

Infectious hepatitis

Parasitic disease (giardiasis, onchocerciasis, schistosomiasis, ascariasis)

Prion disease

Malignancy

Leukemia

Lymphoma

Multiple myeloma

Solid tumors with paraneoplastic syndrome

Metabolic and endocrine

Carcinoid syndrome

Chronic renal disease

Diabetes mellitus

Hyper/hypothyroidism

Hyperparathyroidism

Neurologic

Cerebral abscess

Cerebral tumor

Multiple sclerosis

Stroke

Other

Drug ingestion

Eating disorders with rapid weight loss

Neuropsychiatric disorders

Pregnancy

References:

1. American Family Physician: A Diagnostic Approach to Pruritus 

http://www.aafp.org/afp/2011/0715/p195.html

2. NCBI Chronic Pruritus and Treatment 

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3119985/