The other day I received a call about whether a patient could be sent home on self-administered IV antibiotics. The patient had an E. coli septic arthritis and had been on IV Ceftriaxone for 2 weeks. They were no longer febrile, their joint was no longer painful, and their peripheral blood white
cell count and CRP had improved considerably. The E. coli was sensitive to Ceftriaxone and Ciprofloxacin.
I gave advice to switch the patient from IV Ceftriaxone to oral Ciprofloxacin for a further 4 weeks. From the silence that followed it was clear that this wasn’t the advice that was expected. On discussion it became apparent that the team had wanted IV antibiotics because they felt these were better than orals!?
It seems many people believe that IV antibiotics are better than orals, be they the general public or healthcare professionals. I’m unsure where this myth arises but it is not true.
cell count and CRP had improved considerably. The E. coli was sensitive to Ceftriaxone and Ciprofloxacin.
I gave advice to switch the patient from IV Ceftriaxone to oral Ciprofloxacin for a further 4 weeks. From the silence that followed it was clear that this wasn’t the advice that was expected. On discussion it became apparent that the team had wanted IV antibiotics because they felt these were better than orals!?
It seems many people believe that IV antibiotics are better than orals, be they the general public or healthcare professionals. I’m unsure where this myth arises but it is not true.
Let me explain…
For any infection the best treatment is the most
narrow spectrum antibiotic given by the simplest and most effective route.
There are certain situations where IV antibiotics must be used, and when oral antibiotics are never appropriate:
• Sepsis, meningitis, encephalitis and other severe infections. In these situations you want to get antibiotics into the patient as fast as possible (IVs are the fastest route) and any delay (e.g. waiting for the patient to absorb an oral antibiotic) could prove disastrous
• When there is no oral equivalent. Some IV antibiotics do not have an equivalent oral preparation such as 3rd generation cephalosporins, carbapenems, glycopeptides and aminoglycosides
• When the bacterium itself has developed resistance to oral antibiotics such as Pseudomonas spp. resistant to Ciprofloxacin, or ESBL positive E. coli with co-resistance to oral antibiotics. The antibiotics to which they remain sensitive are only available IV
• The patient cannot absorb oral antibiotics (e.g. if they have had large amounts of bowel removed surgically or they have other conditions that affect absorption)
• The patient is unable to take medications by mouth
(e.g. they have an unsafe swallow which leads to a risk that anything they try and swallow goes in to their lungs not their stomach)
• The patient is morbidly obese and therefore it is impossible to get therapeutic antibiotic levels with normal oral dosing. These patients often need IV antibiotics that can be dosed per kg of body weight (normal oral doses are generally based on 60-70kg “normal” body weight)
Other than the above exceptions in every other instance it should be possible to treat the patient just as effectively with oral antibiotics.
The benefits of using oral antibiotics include:
• No need for IV access which is a potential source of serious blood stream infections
• Decreased medical resource for administration
• Easier to manage patients in the community
– Reduced risk of healthcare-associated infections
– More acceptable for the patient
• Reduced cost from:
– Reduced inpatient stays
– Reduced need for trained staff to administer IVs
– Oral antibiotics are almost always cheaper than
their IV equivalents
However, in order to achieve antibiotic levels similar to that of IVs, oral antibiotics need to have good oral bioavailability (e.g. they are easily absorbed from the gastrointestinal tract). Antibiotics considered as having excellent oral bioavailability, so very rarely require IV administration,
include:
• Clindamycin
• Ciprofloxacin and all of the quinolone antibiotics
• Metronidazole
• Doxycycline
• Linezolid
• Rifampicin
• Fusidic Acid
As for the patient I was called about, I explained this reasoning behind choosing an oral antibiotic to the SHO...
• Their patient had an microorganism sensitive to an oral antibiotic (Ciprofloxacin)
• The oral antibiotic (Ciprofloxacin) has excellent bioavailability
• Their patient has no problem with their swallow or ability to absorb oral antibiotics
• Their patient still needs a further 4 weeks of antibiotics
but an unnecessary IV catheter is a risk factor for a blood stream infection
• Oral antibiotics give equal, if not better, treatment (e.g.
the patient can go home, costs are reduced, there is less potential for complications, etc)
Bearing all of this in mind, the choice of how to treat this patient is clear; the patient went home on PO Ciprofloxacin and made a full recovery.
Although there are times when it is essential to treat patients with IV antibiotics, the majority of patients can be treated more effectively with oral antibiotics. So Switch IV to orals as soon as safe to do so.
For any infection the best treatment is the most
narrow spectrum antibiotic given by the simplest and most effective route.
There are certain situations where IV antibiotics must be used, and when oral antibiotics are never appropriate:
• Sepsis, meningitis, encephalitis and other severe infections. In these situations you want to get antibiotics into the patient as fast as possible (IVs are the fastest route) and any delay (e.g. waiting for the patient to absorb an oral antibiotic) could prove disastrous
• When there is no oral equivalent. Some IV antibiotics do not have an equivalent oral preparation such as 3rd generation cephalosporins, carbapenems, glycopeptides and aminoglycosides
• When the bacterium itself has developed resistance to oral antibiotics such as Pseudomonas spp. resistant to Ciprofloxacin, or ESBL positive E. coli with co-resistance to oral antibiotics. The antibiotics to which they remain sensitive are only available IV
• The patient cannot absorb oral antibiotics (e.g. if they have had large amounts of bowel removed surgically or they have other conditions that affect absorption)
• The patient is unable to take medications by mouth
(e.g. they have an unsafe swallow which leads to a risk that anything they try and swallow goes in to their lungs not their stomach)
• The patient is morbidly obese and therefore it is impossible to get therapeutic antibiotic levels with normal oral dosing. These patients often need IV antibiotics that can be dosed per kg of body weight (normal oral doses are generally based on 60-70kg “normal” body weight)
Other than the above exceptions in every other instance it should be possible to treat the patient just as effectively with oral antibiotics.
The benefits of using oral antibiotics include:
• No need for IV access which is a potential source of serious blood stream infections
• Decreased medical resource for administration
• Easier to manage patients in the community
– Reduced risk of healthcare-associated infections
– More acceptable for the patient
• Reduced cost from:
– Reduced inpatient stays
– Reduced need for trained staff to administer IVs
– Oral antibiotics are almost always cheaper than
their IV equivalents
However, in order to achieve antibiotic levels similar to that of IVs, oral antibiotics need to have good oral bioavailability (e.g. they are easily absorbed from the gastrointestinal tract). Antibiotics considered as having excellent oral bioavailability, so very rarely require IV administration,
include:
• Clindamycin
• Ciprofloxacin and all of the quinolone antibiotics
• Metronidazole
• Doxycycline
• Linezolid
• Rifampicin
• Fusidic Acid
As for the patient I was called about, I explained this reasoning behind choosing an oral antibiotic to the SHO...
• Their patient had an microorganism sensitive to an oral antibiotic (Ciprofloxacin)
• The oral antibiotic (Ciprofloxacin) has excellent bioavailability
• Their patient has no problem with their swallow or ability to absorb oral antibiotics
• Their patient still needs a further 4 weeks of antibiotics
but an unnecessary IV catheter is a risk factor for a blood stream infection
• Oral antibiotics give equal, if not better, treatment (e.g.
the patient can go home, costs are reduced, there is less potential for complications, etc)
Bearing all of this in mind, the choice of how to treat this patient is clear; the patient went home on PO Ciprofloxacin and made a full recovery.
Although there are times when it is essential to treat patients with IV antibiotics, the majority of patients can be treated more effectively with oral antibiotics. So Switch IV to orals as soon as safe to do so.
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