Oral Stepdown Research Articles

Randomized, open-label, parallel-group, multicenter study of the efficacy and tolerability of IV gatifloxacin with the option for oral stepdown gatifloxacin versus IV ceftriaxone (with or without erythromycin or clarithromycin) with the option for oral stepdown clarithromycin for treatment of patients with mild to moderate community-acquired pneumonia requiring hospitalization

Background: Empiric therapy for community-acquired pneumonia (CAP) requires the use of antibiotics with activity against a broad spectrum of respiratory pathogens and suitable pharmacokinetic properties to simplify IV-to-oral step-down therapy switches. Objective: The aim of this study was to compare the efficacy and tolerability of IV gatifloxacin with the option for oral stepdown gatifloxacin with a standard regimen of IV ceftriaxone (with or without erythromycin or clarithromycin) with the option for oral stepdown clarithromycin in patients with mild to moderate CAP requiring hospitalization. Methods: In a randomized, open-label, parallel-group, multicenter study, adults with CAP received 7 to 14 days of treatment with either IV gatifloxacin 400 mg QD with the stepdown option or IV ceftriaxone 1 or 2 g QD (with or without erythromycin 0.5 or 1 g QID or clarithromycin 500 mg BID) with the stepdown option. Results: One hundred seventy adults with CAP were included in the study. IV gatifloxacin was stepped down to oral gatifloxacin in 90.6% ( 77 85 ) of patients; IV ceftriaxone was stepped down to oral clarithromycin in 87.1% ( 74 85 ) of patients. Among clinically evaluable patients (n = 153), cure rates at 1 to 3 days after treatment were 97.4% in the gatifloxacin group ( 74 76 ) and 90.9% in the ceftriaxone group ( 70 77 ), with a 95% CI for the difference (−3.7% to 19.1%) indicating statistical equivalence. In patients in whom pathogens were isolated from pretreatment sputum cultures, bacteriologic eradication rates were 100.0% ( 29 29 ) and 90.9% ( 30 33 ), respectively. Both regimens were well tolerated; treatment-related adverse events occurred in 27.1% ( 23 85 ) and 21.2% ( 18 85 ) of patients, respectively. Conclusions: In the population studied, treatment with IV gatifloxacin with an option for oral stepdown gatifloxacin was as effective for achieving clinical cure as IV ceftriaxone (with or without concomitant IV erythromycin or clarithromycin) with an option for oral stepdown clarithromycin. Both regimens were well tolerated.

Antibiotic Stewardship, Calgary 1995‐1997: Regionalization, Restructuring and Retrenchment

Hospitals in the Calgary area have undergone a decade of change as a result of provincial and local initiatives to provide the same or better health care with fewer dollars. The new system includes 1850 beds at four hospitals, a continuing care sector coordinating nursing home and ambulatory care services, and population health and public health services. The reorganization is patient-ocused, using a “hospital without walls” concept to promote linkages and efficiencies in health care delivery. Before the elimination of individual hospital boards and the creation of one regional health board in 1994, each of the hospital groups had organized antibiotic utilization programs with the primary aims of making better use of antibiotics and taking efforts towards cost containment. Programs were more intensive and comprehensive at the teaching institutions. Community hospitals that adopted policies according to local needs. Being the primary teaching hospital in Calgary region, the Foothills Hospital practised a series of antimicrobial use and restriction guidelines via the Online Survey and Certification Reporting (OSCAR) hospital computer system. At the Calgary General and Alberta Children’s hospitals, the infectious diseases consultation service was used to restrict the excessive use of broad-spectrum and expensive antimicrobial agents. Four of the five hospitals had antibiotic utilization subcommittees that reported to pharmacy and therapeutics committees. Three part-time drug use evaluation (DUE) pharmacists (0.25 to 0.6 full-time equivalent) were available to monitor antimicrobial use and fulfill an educational function. Specific antibiotic stewardship activities included writing pharmacy newsletters, monitoring intravenous to oral stepdown, tracking antimicrobial costs, instituting therapeutic interchanges, standardizing antibiotic regimens, and reviewing cephalosporin, vancomycin, clindamycin and imipenem/cilastatin use. Individual cost cards indicating antimicrobial susceptibilities were updated annually by each hospital group. Plans for downsizing and reorganizing hospital services were made between 1991 and 1994. Three of seven hospitals were closed between 1995 and 1997. A $100 million renovation and building program was implemented and completed to upgrade remaining facilities. The hospital and community laboratory systems have been merged into a public/private service company, and all microbiology services have been consolidated into one central ‘core’ laboratory. While disadvantages may be associated with not having a microbiology laboratory in each of the hospitals, the centralized laboratory can provide important advantages withregard to tracking and monitoring antibiotic resistance. Further examples of the restructuring of hospital services include the consolidation of all pharmacies under one regional administration, and the reorganization of the individual antibiotic utilization subcommittees into one regional, antibiotic utilization, working group. Although the majority of antibiotic use policies have been retained during hospital consolidation, standardization is now taking place. The DUE pharmacist po-

Evaluation of the use of cefuroxime and cefuroxime axetil in an intravenous-oral stepdown program.

To characterize cefuroxime and cefuroxime axetil use under the influence of a parenteral-to-oral (iv-po) stepdown program. Open single-center retrospective review. Tertiary care teaching and referral Canadian hospital with 1100 beds. A random sample of 78 patients receiving cefuroxime was compared with a random sample of 50 patients receiving iv-po cefuroxime stepdown. During the first 6 months following formulary introduction, 1535 patients received cefuroxime. Stepdown to any oral antibiotic occurred in 22% of patients. Cefuroxime axetil was used as the stepdown agent in 64% of these cases. In a comparison of nonstepdown courses with stepdown courses, some differences were apparent. Nonstepdown treatment courses were primarily prophylactic, whereas stepdown courses were typically initiated as primary therapy for the 10-day management of respiratory tract infections (p < 0.001). Conversion to oral therapy typically occurred on day 5 of parenteral therapy and continued for 5 days. Stepdown was considered possible in 46% of treatment courses in which this process did not happen. When stepdown did occur, it was considered timely in 64% of cases, unnecessarily delayed in 32%, and premature in 4% of treatment courses. Stepdown did not appear to be associated with a negative impact on patient outcome. Mean +/- SD cost of drug therapy per day was less for the stepdown group (US $15.78 +/- $5.97) than the nonstepdown group (US $25.47 +/- $7.87; p < 0.001). As a result of this study we intend to maintain cefuroxime and cefuroxime axetil on the formulary and continue to judiciously promote the timely conversion to oral therapy.

Intravenous to Oral Antimicrobial Stepdown Therapy at the Victoria General Hospital, Halifax, Nova Scotia

Intravenous to Oral Antimicrobial Stepdown Therapy at the Victoria General Hospital, Halifax, Nova Scotia

Intravenous to Oral Antimicrobial Stepdown Therapy at the Henderson Hospital, Hamilton, Ontario

Intravenous to Oral Antimicrobial Stepdown Therapy at the Henderson Hospital, Hamilton, Ontario

Intravenous to Oral Antimicrobial Stepdown Implementation at the Calgary General Hospital, Calgary, Alberta

Intravenous to Oral Antimicrobial Stepdown Implementation at the Calgary General Hospital, Calgary, Alberta

Pharmaceutical, Pharmacokinetic and Other Considerations for Intravenous to Oral Stepdown Therapy

Parenteral to oral stepdown therapy represents an effective cost containment strategy which can minimize intravenous therapy associated morbidity and may facilitate earlier hospital discharge. Several oral anti‐infectives are available to the prescriber and there are as many opportunities to stepdown to the same agent as there are to other drugs of the same class or other classes. Recognition of the pharmacokinetic characteristics of these oral agents is essential lo successful therapy. Good bioavailability may not always be assured. A simple regimen will promote compliance.

Reducing Antibiotic Costs: The Ottawa General Hospital Experience of Cost Cutting, Including Intravenous to Oral Stepdown

Reducing Antibiotic Costs: The Ottawa General Hospital Experience of Cost Cutting, Including Intravenous to Oral Stepdown

Cost-effectiveness and value of an IV switch.

A few antibiotics (i.e. metronidazole, clindamycin and ciprofloxacin) are available in both parenteral and oral formulations, and have good bioavailability, ensuring equivalent systemic drug concentrations. During a 4-year period subsequent to the initiation of a parenteral to oral (IV-PO) stepdown programme for metronidazole and clindamycin, Vancouver General Hospital saved approximately $C85 000. However, many parenteral antibacterials lack an oral formulation, requiring oral stepdown to a different antibacterial with a similar spectrum of activity. Alternatively, the oral formulation of a parenteral antibacterial may have poor bioavailability (i.e. cefuroxime axetil, ampicillin, cloxacillin, erythromycin, and tetracycline) and it is not possible to maintain equivalent systemic drug concentrations. While rigid criteria are not applicable to all clinical scenarios, the general criteria for oral stepdown include the following: the patient 1) continues to need an antibiotic; 2) is clinically stable; 3) is capable of tolerating the oral dosage form; and 4) has no factors present (e.g. gastrointestinal abnormalities or drug interactions) that would adversely affect oral bioavailability. A review of subsequent IV-PO stepdown programmes at Vancouver General Hospital revealed that 1) not all patients receiving parenteral therapy are candidates for oral stepdown; 2) oral stepdown is delayed in a large proportion of treatment courses; 3) oral stepdown is not occurring in many patients for whom it is deemed appropriate; and 4) in a very few treatment courses stepdown may occur prematurely and may contribute to clinical deterioration.(ABSTRACT TRUNCATED AT 250 WORDS)

Intravenous to Oral Stepdown Antibiotic Therapy: Another Cost‐Effective Strategy in an Era of Shrinking Health Care Dollars

The rapid transition from intravenous to oral antimicrobial therapy in hospitalized patients is being catalyzed by the need to gain further efficiencies in health care delivery without Compromising patient cure. The successful transition to oral therapy reduces complication from intravenous access devices. reduces cost of therapy and facilitates early discharge. both older and newer antimicrobials can be used as stepdown therapy. Although there are gaps in our information base with regards to outcome studies. the application of newer “pharmacodynamic” principles of antimicrobials action and careful selection of antimicrobials based on in vitro activity and pharmacokinetics will maximize the effectiveness of stepdown treatment of infections.

Oral Tedizolid Phosphate Stepdown Therapy in Two Cases of Staphylococcus aureus Endocarditis in Intravenous Drug Abusers

This study examines the successful use of early oral stepdown therapy with tedizolid in 2 cases of Staphylococcus aureus endocarditis in intravenous drug users. While oxazolidinones are not recommended as initial therapy, tedizolid may offer convenient oral step-down therapy once the patient is stabilized with intravenous antibiotics and surgery.