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JAC Advance Access originally published online on April 28, 2009
Journal of Antimicrobial Chemotherapy 2009 64(1):188-199; doi:10.1093/jac/dkp131
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© The Author 2009. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: journals.permissions@oxfordjournals.org
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Original research

Outcomes of early switching from intravenous to oral antibiotics on medical wards

Dominik Mertz1, Michael Koller2, Patricia Haller1, Markus L. Lampert3,4, Herbert Plagge5, Balthasar Hug6, Gian Koch6, Manuel Battegay1, Ursula Flückiger1,* and Stefano Bassetti1,7

1 Division of Infectious Diseases and Hospital Epidemiology, University Hospital Basel, Basel, Switzerland 2 Basel Institute for Clinical Epidemiology, University Hospital Basel, Basel, Switzerland 3 Division of Pharmacology and Toxicology, University Hospital Basel, Basel, Switzerland 4 Institute of Clinical Pharmacy, Department of Pharmaceutical Sciences, University of Basel, Basel, Switzerland 5 Hospital Pharmacy, University Hospital Basel, Basel, Switzerland 6 Department of Internal Medicine, University Hospital Basel, Basel, Switzerland 7 Department of Internal Medicine, Kantonsspital Olten, Olten, Switzerland

Received 18 September 2008; returned 19 December 2008; revised 23 January 2009; accepted 18 March 2009

* Corresponding author. Tel: +41-61-265-25-25; Fax: +41-61-265-31-98; E-mail: flueckigerU{at}uhbs.ch

Objectives: To evaluate outcomes following implementation of a checklist with criteria for switching from intravenous (iv) to oral antibiotics on unselected patients on two general medical wards.

Methods: During a 12 month intervention study, a printed checklist of criteria for switching on the third day of iv treatment was placed in the medical charts. The decision to switch was left to the discretion of the attending physician. Outcome parameters of a 4 month control phase before intervention were compared with the equivalent 4 month period during the intervention phase to control for seasonal confounding (before–after study; April to July of 2006 and 2007, respectively): 250 episodes (215 patients) during the intervention period were compared with the control group of 176 episodes (162 patients). The main outcome measure was the duration of iv therapy. Additionally, safety, adherence to the checklist, reasons against switching patients and antibiotic cost were analysed during the whole year of the intervention (n = 698 episodes).

Results: In 38% (246/646) of episodes of continued iv antibiotic therapy, patients met all criteria for switching to oral antibiotics on the third day, and 151/246 (61.4%) were switched. The number of days of iv antibiotic treatment were reduced by 19% (95% confidence interval 9%–29%, P = 0.001; 6.0–5.0 days in median) with no increase in complications. The main reasons against switching were persisting fever (41%, n = 187) and absence of clinical improvement (41%, n = 185).

Conclusions: On general medical wards, a checklist with bedside criteria for switching to oral antibiotics can shorten the duration of iv therapy without any negative effect on treatment outcome. The criteria were successfully applied to all patients on the wards, independently of the indication (empirical or directed treatment), the type of (presumed) infection, the underlying disease or the group of antibiotics being used.

Keywords: stewardship , policy , guidelines , antimicrobials , internal medicine


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