Early Transition from Intravenous to Oral Antimicrobial Therapy

Abstract & Commentary

Synopsis: A comprehensive program led to significant cost savings by encouraging early transition from intravenous to orally administered levofloxacin.

Source: Wong-Beringer A, et al. Implementing a program for switching from i.v. to oral antimicrobial therapy. Am J Health Syst Pharm. 2001;58:1146-1149.

This article describes in detail how a pharmacist-initiated, i.v.-to-oral antimicrobial switching program was implemented at Huntington Memorial Hospital. This hospital is a full-service, 525-bed, community hospital in Pasadena, Calif, and is affiliated with 2 universities.

The pharmacy team took the approach of initially identifying a specific antimicrobial agent based upon pharmacologic properties and prescribing patterns. They also used the results of a survey that was sent out to prescribers. By their definition, the "ideal" antimicrobial agent was one with high bioavailability, low adverse-effect profile, minimal drug-drug interactions, long half-life, and low rate of documented resistance problems. They felt that levofloxacin met those criteria.

They then assessed the prescribing patterns in their hospital and found that 80% of the patients that were receiving levofloxacin intravenously would have potentially been candidates for oral therapy. They followed this with a questionnaire that was sent to the top 100 admitting physicians to determine the criteria prescribers were using in determining patient eligibility for switching from i.v. to oral. The questionnaire was also administered to the house staff and randomly distributed to attending physicians. Of the 49 responses that were received, 71% stated that patients were continued in i.v. therapy due to clinical instability, 39% had concern regarding patient’s gastrointestinal function, 39% had questions regarding which oral alternatives were appropriate, 37% had questions regarding the bioavailability of oral antimicrobials, 35% admitted that they were simply not thinking about it at the time it might have been appropriate, and 40% felt that i.v. therapy was required by third party payers to keep patients in the hospital.

The issue of third party payer reimbursement was thoroughly investigated by Wong-Beringer and colleagues and it was found that 85% of the patients receiving levofloxacin were being treated for respiratory-tract infections, which were primarily community-acquired pneumonia. The reimbursement mix was Medicare, Medicaid, and 3 independent physician organizations. Hospital admission, continuing stay, and discharge planning were governed by guidelines published by InterQual and Milliman & Robertson. Under the most up-to-date versions of these guidelines, i.v. and/or oral therapy are accepted criteria for hospital admission and continuing stay.

Realizing that the effectiveness of this project would require appropriate clinical educational programs, information was distributed, seminars presented, and the reimbursement staff inserviced. Working with the medical staff, the pharmacy developed criteria for patient eligibility. First, it was decided that patients could be evaluated for a switch from i.v. to oral only after they had been stable or improved for 48 hours. Secondly, to be eligible, patients had to meet 4 criteria: 1) be able to adequately absorb oral medications via the oral, nasogastric tube, or gastric tube route; 2) be able to eat or tolerate enteral feeding with minimal residuals (< 50% of hourly rate); 3) not have any nausea or vomiting; and 4) be clinically improving. Patients with meningitis or endocarditis were excluded.

With these criteria in hand, an intervention form was developed and a memorandum sent to all prescribers explaining the rational and objectives of the program and the pharmacists’ role. Internally, the pharmacy developed an algorithm to insure consistency among the pharmacy staff. Once pharmacy identified a potential patient for switch from i.v. to oral, the intervention form was left for the prescriber to decide whether to accept the recommendation. Under this program, there was a 31% conversion of i.v. to oral therapy which resulted in an annual cost savings of approximately $37,000 per year.

Comment by Thomas G. Schleis, MS, RPh

All providers and health care systems are being expected to do more for less. Shrinking reimbursement and rising drug costs have challenged pharmacists to reduce costs wherever possible. While some programs have been poorly implemented, others have followed a more rational and methodical path. The treatment of community-acquired pneumonia has been an area that has been targeted as one which is well-suited for a standardized treatment algorithm. Other programs similar to the one described above have been implemented throughout the country.1-4 Some of the "buzz terms" that are used in describing these programs are "Critical Pathways," "Clinical Pathways," "Transition Therapy," "Switch Therapy," and "I.V. to Oral." In all of the references cited here, levofloxacin was chosen as the workhorse quinolone, partly due to the aggressive pricing offered by the manufacturer, Ortho-McNeil.

The development of a program such as the one described above can only be successful if there is input from infectious diseases specialists and other prescribers, and if the physician is the ultimate decision maker. In all of the references cited here, antimicrobial resistance patterns for all appropriate antimicrobials were studied before levofloxacin was chosen. Even then, unless antimicrobial resistance patterns, prevalent organisms, and treatment efficacy are monitored on a regular basis, problems can occur down the road. It is only through a multi-disciplinary approach that efficacious and cost-effective patient care can be realized.

References

1. Feagan BG. A controlled trial of a critical pathway for treating community-acquired pneumonia: The CAPITAL study. Pharmacotherapy. 2001;21(suppl 7, Pt 2):S89-S94.

2. Milkovich G. Intravenous-to-oral transition therapy in community-acquired pneumonia: The INOVA health system experience. Pharmacotherapy. 2001;21(suppl 7, Pt 2):S83-S88.

3. Press RA. The use of fluoroquinolones as anti-infective transition-therapy agents in community-acquired pneumonia. Pharmacotherapy. 2001;21(suppl 7, Pt 2): S100-S104.

4. Moran GJ. New directions in antiinfective therapy for community-acquired pneumonia in the emergency department. Pharmacotherapy. 2001;21(suppl 7, Pt 2): S95-S99.