Antibacterial drugs choose intravenous or oral? It is enough to master these 6 principles!

For medical professionals only

How to make a reasonable conversion?

Antibacterial drugs, as one of the most widely used drugs in clinical practice, intravenous injection has a greater risk, so can it be replaced by oral intravenous injection, thereby reducing hospital costs and reducing the risk of patient medication?

In response to this problem, Jie XiaoYao briefly introduced the principles and indications for the use of oral antibacterial drugs.

1

Principles of oral drug use

The Guidelines for the Clinical Application of Antimicrobials mention that for most patients with mild and moderate infections, oral therapy should be given, and the variety of antimicrobials with good oral absorption should be selected, and intravenous or intramuscular injection (except in special cases) is not necessary [1].

In 2017, Prins JM[2] et al. published on "Establishment of Criteria for Intravenous to Oral Conversion of Antimicrobials" mentioned that adult inpatients should meet all of the following criteria when performing intravenous to oral (iv-to-po) conversion:

1. Vital signs should be good or improved

Systolic blood pressure should be stable and there is no inotropic or fluid resuscitation;

2. Signs and symptoms associated with the infection have been resolved or improved

In the absence of antipyretic drugs, the body temperature should be 36 ° C -38.3 ° C;

3. The gastrointestinal tract must be intact and functional

Absence of the following: malabsorption syndrome, short bowel syndrome, severe gastroparesis, intestinal obstruction, persistent nasogastric tube aspiration;

4. The oral route should not be disrupted

No vomiting, patients should cooperate;

5. There is no contraindicated infection

Oral administration of the drug does not achieve sufficient anti-infective concentrations at the site of infection. The following infections are absent:

a. (Severe) sepsis

b. Necrotizing fasciitis

c. Central nervous system (CNS) infections

d. Staphylococcus aureus

e. Intravascular infection (e.g., endocarditis)

6. Converted oral antibacterial drugs (which can be another antibacterial drug with appropriate anti-infective effects) must have good bioavailability (60%-90%).

2

Bioavailability of oral antimicrobials at a glance[3]

Table 1 β lactam oral antibacterial drugs

Note: This table is compiled from the "Fever: Sanford Antimicrobial Therapy Guidelines (50th Edition)" published by Peking Union Medical College Press in China, and there may be different dosages or oral absorption rates of drugs from different manufacturers, which are for reference only.

Table 2 Antimicrobials with high orally bioavailable non-β lactams[3]

Note: This table collates the "Fever: Sanford Antimicrobial Treatment Guidelines (50th Edition)" published by Peking Union Medical College Press, there may be different dosages or oral absorption rates of drugs from different manufacturers, for reference only.

3

What are the indications for oral antimicrobials?

Upper respiratory tract infections

Common pathogens are Streptococcus pneumoniae, Haemophilus influenzae, Moraxella catarrhalis, Escherichia coli, and Klebsiella pneumoniae, and ceftolampirate in the third generation of cephalosporins has a good antibacterial effect on these pathogens in vitro [4-5].

In the Japanese Guidelines for the Management of Respiratory Infectious Diseases in Children (2007), mild-to-moderate respiratory infections caused by Streptococcus pneumoniae and Haemophilus influenzae are recommended as options for oral ceftolampirate, ceftacatamate, and ceftorram ester [6].

Fig. 1 90% inhibitory concentration of four antimicrobial drugs on the main clinically isolated pathogens[4]

Fig. 2 Minimum bacteriostatic concentration of six antimicrobials and their proportion of drug resistance[5]

Urinary tract infections caused by Enterobacteriaceae bacteria (ESBL-E).

In the patient's eligibility, oral medications are sensitive to pathogens, the patient is afebrile, hemodynamically stable, the lesions of infection are controlled, gastrointestinal absorption is normal, nitrofurantoin and compound sulfamethoxazole are preferred for uncomplicated cystitis, and alternative therapy for cystitis is amoxicillin/clavulanate potassium, fosfomycin tromethamine [5].

Bloodstream infections (BSI) caused by ESBL-E

For bloodstream infections (BSI) caused by ESBL-E, clinicians should avoid oral step-down medications such as nitrofurantoin, fosfomycin, doxycycline, or amoxicillin/clavulanate potassium, as blood concentrations of fosfomycin and nitrofurantoin are low and amoxicillin/clavulanate potassium and doxycycline are unstable and therefore not recommended.

4

Orthopedic infection

In 2019, a study published in the New England Journal of Medicine compared the efficacy of oral versus intravenous antimicrobials for bone/joint infections [8].

The research team in this paper recruited adult patients who were treated for bone/joint infections at 26 UK medical centres.

The results proved that in the first 6 weeks, the clinical efficacy of oral antimicrobials was not inferior to that of intravenous antimicrobial therapy for complex orthopedic infections. At the same time, oral antimicrobial therapy has a shorter hospital stay and fewer complications than intravenous antimicrobials.

discuss

The above results show that clinicians can choose appropriate oral antibacterial drugs for patients with mild and moderate infections according to the actual situation of patients. Thereby reducing the total cost of patient treatment, but also reducing the risk of intravenous injection of antibacterial drugs, to achieve a "win-win" between doctors and patients.

If you have anything you want to talk about, let's talk about it in the comment area!

bibliography:

[1] Guiding Principles for Clinical Application of Antimicrobials: 2015 Edition/Editor-in-Chief of the Revised Working Group of guidelines for the Clinical Application of Antimicrobials.—Beijing: People's Medical Publishing House, 2015.

[2] Prins, J, M, et al. Development of operationalized intravenous to oral antibiotic switch criteria[J]. Journal of Antimicrobial Chemotherapy, 2017.

3] Fever: The Sanford Guidelines for Antimicrobial Therapy, 50th Edition.

[4] Li Jiatai, et al. Efficacy and safety of ceftolampiramide in the treatment of infectious diseases of respiratory system[J].Chinese Medical Journal,2003(05):42-45.

[5] JA Vázquez, E Martín, Galarza P , et al. In vitro susceptibility of Spanish isolates of Neisseria gonorrhoeae to cefditoren and five other antimicrobial agents[J]. International Journal of Antimicrobial Agents, 2007, 29(4):473-474.

[6] Japanese Guidelines for the Management of Respiratory Infectious Diseases in Children 2007 with focus on pneumonia[J]. Pediatrics International (2011) 53, 264–276.

Diagnosis and treatment of urinary tract infection in China. Expert Consensus on the Diagnosis and Treatment of Urinary Tract Infections in China (2015 Edition)——Complicated Urinary Tract Infections[J]. Chinese Journal of Urology, 2015, 36(004):241-244.

[8] Oral versus Intravenous Antibiotics for Bone and Joint Infection[J]. New England Journal of Medicine, 2019, 380(5):425-436.

Source: Clinical Pharmacy Channel of the Medical Community

Author: Radish White Cai

Editor-in-charge: Ling Jun

Proofreader: Zang Hengjia

Plate making: Xue Jiao