IV PO Conversion P&P.V2

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Automatic IV to PO Conversion of Antimicrobial Agents by The Antimicrobial Team and Department of Pharmacy Background: Many intravenous agents have equivalent oral preparations. The administration of oral medications relies upon a functioning gastrointestinal tract for adequate absorption of the medication. Early switch from intravenous agents to the equivalent oral preparation offers several benefits: decreased total cost of therapy, therapy, decreased potential for line associated infections, a potential for decreased length of  stay and patient preference. A key factor in the conversion from IV to PO therapy is the bioavailability of the oral preparation. Bioavailability is expressed as a percentage of the d rug concentration of the oral route compared to the IV route in the systemic circulation. An oral agent that is well absorbed is considered equivalent. Additionally, Additionally, patient specific factors are also important determinants de terminants in the decision to switch from IV to PO therapy. Policy: I.

Anti Antimi micr crob obia iall Team eam & the the Phar Pharma macy cy Depa Depart rtm ment ent 

The Antimicrobial Team Team and/or the Clinical Pharmacists will assess patients ability to co nvert to oral antimicrobial therapy on the basis of the following criteria: Table I: Inclusion And Exclusion Criteria  Patient Inclusion Criteria  The patient is receiving an oral medication (PO, PEG, NG) that relies upon gastrointestinal absorption for efficacy diet  The patient is receiving an oral diet  The patient is receiving tube feeds of at least 50% of their goal rate  Patient Exclusion Criteria  Patients who are hemodynamic unstable  Patients designated NPO for any reason  Patients receiving scheduled antiemetics  Patients with mucositis and/or receiving chemotherapy that causes mucositis  Patients who are being treated for active GI bleed

Table II: Cautions  Drug/Food Interactions with Oral Quinolones and Doxycycline ♦ Certain medications and enteral feeding/dairy products can de crease the absorption of  the oral formulation of quinolones and dox ycycline ♦ The administration time between oral quinolones/doxycycline and these medications must be separated by two hours ♦ The administration time between oral quinolones/doxycycline and enteral feeding/dairy  products must be separated from the dose b y two hours pre and two hours post. ♦ Interacting medications include: antacids, iron salts, sucralfate, zinc salts, didanosine and bismuth subsalicylate

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The Antimicrobial Team and/or the Clinical Pharmacists will convert patients meeting the above criteria from IV to equivalent oral dose and frequency (listed in table III).

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The Antimicrobial Team and/or the Clinical Pharmacist will write the conversion order per  P&T policy and will be effective the following day (order must include instructions on administration time of the interacting medications/enteral feeding/dairy products if applicable). See appendix A for sample

Table III: Antimicrobials Agents With Equivalent IV to PO Bioavailability Drug IV normal daily Cost* /day PO normal daily Cost*/day dose (IV) dose (PO) Azithromycin 500 mg Q24H $18 500 mg Q24H $5 Ciprofloxacin 400 mg Q12H $49 500 mg Q12H $6 Doxycycline 100 mg Q12H $10 100 mg Q12H $0.20 Gatifloxacin 400 mg Q24H $18 400 mg Q24H $6 Fluconazole 200-400 mg Q24H $64-$128 200-400 mg Q24H $9-$18 Levofloxacin 500 mg Q24H $28 500 mg Q24H $6 Linezolid 600 mg Q12H $113 600 mg Q12H $84 Metronidazole 500 mg Q8H $5 500mg Q8H $1 Rifampin 600 mg Q24H $61 600mg Q24H $1 Trimethoprim/ 15-20mg /kg/day $27 15-20mg /kg/day $1 Sulfamethoxazole (TMP component) (TMP component) in in 3-4 divided doses 3-4 divided doses * Cost based on acquisition price of drug at University of Maryland Medical Center 

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A progress note will be written in the chart to indicate the conversion. See appendix A for sample

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The physician must contact the Antimicrobial Team for approval if medical necessity warrants continued IV therapy within this period. If approval is granted, the Antimicrobial Team will notify Pharmacy. Such patient shall be re-evaluated by the Antimicrobial Team/Clinical Pharmacist for oral conversion in 48 hours.

Nursing Staffs  Nursing will honor the conversion orders as a medication order and transcribe the orders onto the medication administration records. 3. Medical Staffs Upon review of the automatic conversion order, the Physician may rescind the conversion order, but must contact the Antimicrobial Team for approval to continue the IV therapy.

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Appendix A Example of Automatic Conversion from IV to Oral Antimicrobials- Progress Notes Automatic Conversion from IV to Oral Antimicrobials The Pharmacy and Therapeutics Committee (P&T) has an approved policy for automatic conversion of  selected antimicrobials to an equivalent oral dose. Your patient is receiving____________________, which is one of the antimicrobials covered by this policy. By chart review the patient is tolerating an oral diet (or enteral feeding) and/or oral medication. Your patient will be converted to_____________________, effective ________per approved P&T policy. Please contact us if you have any questions (refer to pager below).

 

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Signature (printed name)

_________

Date

Sample of automatic conversion order set : Automatic Conversion from IV to Oral Antimicrobial per P&T Policy .

D/C IV______________________  Start:_____________________________________________  Drug

Dose

Route

Frequency

First dose to start on: __________________  Date/time  ___________________________________________________________  Date Time Signature Beeper number 

Revised Nov-01

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