Automatic Therapeutic Conversion of IV Ceftriaxone, IV Azithromycin and IV Gatifloxacin Used

for Community Acquired Pneumonia to Equivalent Oral Antibiotic by the Antimicrobial Team and
the Department of Pharmacy

Background:
Many intravenous antimicrobial agents are not available in both intravenous and oral formulation.
However, therapeutically equivalent agents providing comparable spectrum of activity, clinical efficacy
and adverse effect profiles are available.
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, 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 drug 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, patient specific factors are also important determinants in the decision to switch from IV to
PO therapy.

Policy:
 Only patients receiving ceftriaxone(IV) and/or azithromycin(IV) and/or gatifloxacin(IV) for upper
and lower respiratory tract infection will be considered for oral therapy conversion

 The Antimicrobial Team and/or the Clinical Pharmacists will assess patients ability to convert to oral
antimicrobial therapy on the basis of the following criteria:

A. Determination of GI function

Table II: Inclusion and Exclusion Criteria

 Patient Inclusion Criteria
 The patient is receiving an oral medication (PO, PEG, NG) that relies upon gastrointestinal
absorption for efficacy
 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 hemodymatically 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

B. Clinical Efficacy
Patient must have received ceftriaxone(IV) and/or azithromycin(IV) and/or
gatifloxacin(IV) for at least 24 hours prior to consideration of oral conversion

Patient must have defervesced (temperature ≤ 38 °C), must have a RR ≤ 24/min,

HR ≤100 /minutes and negative blood culture for the past 16 hours

White blood cell count must be improving

Patient must be doing clinically better per Physician’s progress notes

 The Antimicrobial Team and/or the Clinical Pharmacists will convert patients meeting the above
criteria from ceftriaxone(IV) and/or azithromycin(IV) and/or gatifloxacin(IV) to equivalent oral
antimicrobial agent 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.
See appendix A for sample

Table III: Ceftriaxone ,Azithromycin and Gatifloxacin IV to Oral Conversion

IV Antimicrobial Therapy Cost of Equivalent Oral Antimicrobial Therapy Cost of
Therapy* Therapy*
Azithromycin 500mg IV Q24h $20.30 Azithromycin 500mg PO Q24h $11.44
Gatifloxacin 400mg IV Q24h $18 Gatifloxacin 400mg PO Q24h $6

Renal Dose Adjustment Renal Dose Adjustment

CrCl<40 ml/min 200mg Q24h CrCl<40 ml/min 200mg Q24h
Dialysis 200mg Q24h Dialysis 200mg Q24h
(administer dose after dialysis) (administer dose after dialysis)

Ceftriaxone 1 gram IV Q12-24h $28-$56 Cefpodoxime (Vantin®) $5.20

200mg Q12h
No renal dose adjustment needed Renal Dose Adjustment Dose
CrCl >30 ml/min 200mg Q12h
CrCl <30ml/min 200mg Q24h
Dialysis 200mg Q24h
(administer dose after dialysis)

*cost based on UMMC acquisition cost.

 A progress note will be written in the chart to indicate the conversion.

See appendix A for sample

Nursing Staffs
Nursing will honor the conversion orders as a medication order and transcribe the orders
onto the medication administration records.

Medical Staffs
Upon review of the automatic conversion order, the Physician may rescind or accept the
conversion order.

Appendix A
Example of Automatic Conversion from IV to Oral Antimicrobials- Progress Notes

Community Acquired Pneumonia (CAP) Pathway-Automatic IV to Oral Conversion

The Pharmacy and Therapeutics Committee (P&T) has an approved policy for automatic conversion of
intravenous ______________to oral _____________. By chart review the patient is tolerating an oral
diet (or enteral feeding) and/or oral medication and fulfilling the protocol criteria for oral therapy
conversion.
Your patient will be converted to_____________________, effective ________per approved P&T policy.
Please contact us if you have any questions (refer to pager below).

____________________________________________ _________ _____________

Signature (printed name) Date Pager #

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Sample of automatic conversion order set:

CAP Pathway-Automatic IV to Oral Conversion per P&T Policy.

D/C IV_ ____________________

Start:_____________________________________________
Drug Dose Route Frequency
First dose to start on: __________________
Date/time
___________________________________________________________
Date Time Signature Beeper number