Guideline for the intravenous to oral switch of antibiotic therapy
VersionDate ratified
Review date
Ratified by········

2.0
December 2008
December 2010
NUH Antibiotic Guidelines Committee
NUH Drugs and Therapeutics Committee
Annette Clarkson (Microbiology pharmacist, City campus)
Dr Vivienne Weston (Consultant Microbiologist, QMC)Tim Hills (Microbiology pharmacist, QMC campus)·Members of Nottingham University Hospitals Antibiotic Guidelines
Committee.

Evidence Base··Inclusion Criteria
Exclusion Criteria··Published evidence from studies.
Recommended best practice based on clinical experience ofguideline developers.
Adult patients on intravenous antibiotic therapy
Paediatrics, Patients with chemotherapy­related neutropenia and/orbone marrow transplant patients
Directorate Audit Plans as appropriateThis policy has been adapted from one written by the North west
antibiotics pharmacist network advisory group
NUH antibiotic website
http://nuhnet/diagnostics_clinical_support/antibioticsConsultants via
trust e­mail.
NUH EDL website
Dr Vivienne Weston, Consultant Microbiologist, QMC
Ext 64179
E­mail vivienne.weston@nuh.nhs.ukAuthors

Consultation:

Audit·
Acknowledgements ·Distribution

Local Contacts·····

This guideline has been registered with the Trust. However, clinical guidelines are ‘guidelines’
only. The interpretation and application of clinical guidelines will remain the responsibility ofthe individual clinician. If in doubt consult a senior colleague or expert. Caution is advisedwhen using guidelines after the review date.

Nottingham University hospitals Antibiotic Guidelines Committee

December 2008

Review December 20101

Introduction
IV to oral switch is the prompt conversion of IV antibiotic therapy to oral. Patients may beconsidered candidates for switching from IV to oral therapy once the patient has shown
clinical improvement and is medically stable.
Rationale
The majority of patients with a severe infection who are adequately absorbing oral
medication and initially require IV therapy can be safely switched to oral therapy within 48
hours. There are a number of advantages to support the prompt switch from IV to oral
therapy these are as follows1,2,3:
Ø Reduction in the likelihood of hospital acquired bacteraemia and infected/phlebitic
IV lines.
Ø Saves both medical and nursing time.
Ø Reduces discomfort for patients and enables improved mobility and the possibilityof earlier hospital discharge.
Ø Potential to significantly reduce treatment costs.
Ø Patient is more likely to receive antibiotics at the correct time.
Ø Potential reduction in the risk of adverse effects; errors in preparation are
significantly higher with parenteral drugs, compared to oral formulation.
Considerations for the early switch to oral therapy COMS1,2,3,4(review at 24­48 hours)

CO

Clinical improvement observed
Oral route is not compromised (vomiting, malabsorptive disorder, NBM,swallowing problems, unconscious, severe diarrhoea)
NB: if NG/PEG feeding then please consult your pharmacist
Suitable oral antibiotic option available (see flow chart)

M

Markers showing a trend towards normal: Patient should be apyrexial for thelast 24 hours (Temp>36oC and <38oC) and NOT have more than one of thefollowing, heart rate>90/min, resp rate>20/min, BP unstable, WCC<4 or>12
White cell count should show a trend towards normal; absence of suchshould not impede the switch if all other criteria are met and not neutropenic.

S

Specific indication/deep­seated infection (Prior to switch refer to table 1)

Nottingham University hospitals Antibiotic Guidelines Committee

December 2008

Review December 20102

High risk/deep­seated infections
Certain infections may appear to respond promptly to intravenous therapy, but warrant
prolonged IV therapy. This is to ensure that adequate drug levels are attained at the siteof infection and to optimise the response and prevent relapse.
Discuss with Microbiology before switching patients with a high risk/deep seated
infection to oral therapy.
Table 1
Deep seated infections that may
require an initial two weeks of IVtherapy

High risk infections requiring
prolonged IV therapy

Staphylococcus aureus
bacteraemia· Severe necrotising soft tissue
infections· Severe infections duringchemotherapy related
neutropenia· Infected implants/prosthesis·· Meningitis/encephalitis·· Intracranial abscesses· Mediastinitis· Endocarditis· Exacerbation of cystic fibrosis/
bronchiectasis· Inadequently drained
abscesses or empyema
Certain multi­resistant organisms often require treatment with agents that are only available
in an intravenous form, please seek advice from microbiology regarding the length oftreatment.
···

Liver abscessOsteomyelitis,Septic arthritis(N.B. high­dose oral
Clindamycin may beappropriate once patient isstable, see memo appendix A)
EmpyemaCavitating pneumonia

References
1.

2.
3.
4.

Sevinc F et al. Early switch from intravenous to oral antibiotics: guidelines andimplementation in a large teaching hospital. Journal of Antimicrobial
Chemotherapy 1993 43:601­606
Guidance for intravenous antibiotic ‘switch’ therapy. 2004. North West Antibiotic
Pharmacists Network Advisory Group.
www.bsac.org/pyxis
McLaughlin C et al. Pharmacy­implemented guidelines on switching fromintravenous to oral antibiotics: an intervention study. Q J Med 2005;98:745:752

Nottingham University hospitals Antibiotic Guidelines Committee

December 2008

Review December 20103

Guideline for the intravenous to oral switch of antibiotic therapy

Does intravenous therapy need to continue? (see COMS, Box 2)

YESNOContinue with IV antibiotics

Switch to oral therapy (see Box 1), add
indication and intended stop date (seestop/review date policy) Check for any
interactions/allergies

Continue to monitor closely
If in doubt seek advice froma pharmacist/microbiology

Review need for IV therapy
again after 24 hours (marknew review date on chart)

Monitor patient’s progress
following switch to oral
therapy

BOX 1­ recommended empiric oral alternatives
N.B. Check for allergy/interactions/microbiology
results:

IV

Oral

Amoxicillin 500mg­1g tds

Amoxicillin 500mg­1g tds

Cefuroxime 750mg­1.5g
tds plus metronidazole
500mg tds
Cefuroxime 750mg­1.5gtds
Clarithromycin 500mg bd
Flucloxacillin 2g qds
Clindamycin 600mg qds

Co­amoxiclav 375mg tds
plus amoxicillin 250mg tds

Ciprofloxacin 400mg bdCo­amoxiclav 1.2g tds
Tazocin, meropenem,imipenem, vancomycinCo­amoxiclav 375mg plus
amoxicillin 250mg tds
Clarithromycin 500mg bd
Flucloxacillin 1g qds
Clindamycin 300­450mg
qds can use a maximumof 600mg qds if severe
infection (see appendixA).
Ciprofloxacin 500mg bd(750mg bd recommended
for Pseudomonas sp.)Co­amoxiclav 375mg plus
amoxicillin 250mg tds
Seek advice frommicrobiology

od = once daily bd= twice daily tds= 3 times/day qds =4times/dayBOX 2
Considerations for IV to oral switch
COMSCClinical improvement
O

Oral route not compromised­Vomiting­NBM­Unconscious­Mechanical swallowing disorder­Malabsorptive disorder
NB: if NG/PEG feeding then please consult your pharmacist
Suitable oral antibiotic option available

M

Markers showing a trend towards normal

Apyrexial: Temp>36 and <38oC
Plus not more than one of­HR >90 beats/min­Resp rate >20 breaths/min­BP stable­WCC <4 OR >12 (if abnormal, a trend towards thenormal range and without neutropenia isacceptable)
S
Specific indication/deep­seated infection(eg meningitis/encephalitis, endocarditis, mediastinitis, deep
seated abscess/empyema, bone/joint infection, Staph.
aureus bacteraemia/CF/bronchiectasis, implant/prosthesis

Nottingham University hospitals Antibiotic Guidelines Committee

December 2008

Review December 20104

Appendix A: IV to oral switch of clindamycin
Intravenous clindamycin is a restricted agent for the treatment of serious streptococcal and staphylococcal
soft tissue infections unresponsive to the penicillins, or in those who are penicillin allergic and in those withbone and joint infections who are penicillin allergic. All other cases require approval from a medical
microbiologist. If approval obtained please ensure that this is documented in the medical notes. The price ofIV clindamycin is significantly greater than oral clindamycin (see table). As clindamycin has an oral
bioavailability of 90%1,2,3, the antibiotic guidelines committee is recommending the use of oral clindamycin
where appropriate. For all those patients requiring treatment with clindamycin oral treatment should beprescribed first line, except in the following cases:
EXCEPTIONS WHERE IV THERAPY IS RECOMMENDED
Ø Oral route compromised eg vomiting, malabsorptive disorder, NBM, swallowing problems
Ø Necrotising fasciitis
Ø Acute Osteomyelitis and Septic arthritis (change to oral when medically stable)
Ø Sepsis (Fever, confusion, tachycardia, tachypnoea, hypotension, oliguria, acidosis)
Ø Severe soft tissue infections unresponsive to penicillins
Ø Prolonged rupture of membranes if penicillin allergic
Ø Microbiology approval required for other uses
NB Clindamycin is not recommended for the treatment of erythromycin resistant streptococcal andstaphylococcal infection.
Dosing
The maximum oral licensed dose is 450mg qds. However, higher oral doses of 600mg qds have been
documented in the literature for a variety of different indications 1,4. Therefore in severe infection an oral
dose of 600mg qds can be used. Please note that this is an unlicensed dose and therefore responsibility lies
with the prescriber. If using the higher dose, patients should be carefully monitored and the appearance ofmarked diarrhoea should be regarded as an indication that the product should be discontinued immediately3.
Patients with swallowing difficulties
It is not recommended that the capsules are opened as they have a poor taste and give off an offensive
smell when opened. The paediatric suspension has been discontinued within the UK but there is an oralsuspension available, which can be imported via IDIS. However, due to the cost of the suspension and thevolume required for adult dosing, it is recommend that where clindamycin is indicated that the IV route isused in this patient group.

COST COMPARISONS OF CLINDAMYCIN PREPARATIONSFORMULATION
Cost for one day treatment(600mg qds)
Clindamycin capsules£4.80
Clindamycin oral
£23.60suspension 75mg/5ml
Clindamycin 75mg/5ml oral £34.40
powderClindamycin injection£43.41(600mg qds)
1.Drugdex System:Klasco RK (Ed): Drugdex® System.Thompson Micromedex, Greenwood Village, Colorado, USA, Available at:
http://www.thomsonhc.com accessed <16 June 2006>
2.Gilbert D et al. The Sanford guide to antimicrobial therapy 2006, Antimicrobial Therapy INC, Sperryville, VA, USA
3.Summary of product characteristics for clindamycin. Available at http://www.medicines.org.uk/ accessed<13 July 06>
4.Recommendations from the CDC, the national institutes for health, and the HIV medicines association/Infectious Diseases
society of America. Treating opportunistic Infections Among HIV­Infected Adults and Adolescents ­ December 17, 2004

Nottingham University hospitals Antibiotic Guidelines Committee

December 2008

Review December 20105