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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, 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:

I. Antimicrobial Team & the Pharmacy Department

 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:

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
 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 decrease the absorption of
the oral formulation of quinolones and doxycycline
♦ 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 by 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).

 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

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


See appendix A for sample

 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.

II. 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).

____________________________________________ _________ _____________


Signature (printed name) Date Pager #

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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