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