More clinical questions pt. 4

[GravityBeetle]

1) I've seen many ID physicians recommend treating a patient with IV antibiotics for a certain amount of days before switching to PO. Even when we're using like a fluoroquinolone with nearly 100% bioavailability and even when patient seems to be able to tolerate PO. Is there any specific reason for this?
2) Are there any guidance on dosing and duration of PO antibiotics for bacteremia? I've seen physicians want to switch from IV to PO after a certain amount of time to finish their course. However I can't find dosing info for this anywhere - IV is always suggested for the entire course.
3) What our thoughts on albumin replacement following paracentesis? Some doctors do it, some don't. I'm being told by everybody that there is no proven benefits. I've also seen albumin replacement ordered every 14 days for someone getting paracentesis every 7 days. Does that make any sense? Only thing I can think of, is that the half-life of albumin is about 14 days...

---

Members don't see this ad.

 

[Dred Pirate]

1) I've seen many ID physicians recommend treating a patient with IV antibiotics for a certain amount of days before switching to PO. Even when we're using like a fluoroquinolone with nearly 100% bioavailability and even when patient seems to be able to tolerate PO. Is there any specific reason for this?
2) Are there any guidance on dosing and duration of PO antibiotics for bacteremia? I've seen physicians want to switch from IV to PO after a certain amount of time to finish their course. However I can't find dosing info for this anywhere - IV is always suggested for the entire course.
3) What our thoughts on albumin replacement following paracentesis? Some doctors do it, some don't. I'm being told by everybody that there is no proven benefits. I've also seen albumin replacement ordered every 14 days for someone getting paracentesis every 7 days. Does that make any sense? Only thing I can think of, is that the half-life of albumin is about 14 days...

1. Nope - no reason other than people think "IV are better" We allow one day then do an auto sub to PO abx if they meet criteria to change.
2. total coarse of 7-10 days - regardless of what is IV and what is po - you want to get to PO as soon as the possible as often the IV abx is the only thing keeping the pt in the hospital
3. don't know this one - we usually replace the albumin based on the amount removed from paracenesis. and replace it every time

 

[PharmDBro2017]

Dred can you post the criteria you use for IV to PO switch?

 

[El Trombopag]

1. Nope - no reason other than people think "IV are better" We allow one day then do an auto sub to PO abx if they meet criteria to change.
2. total coarse of 7-10 days - regardless of what is IV and what is po - you want to get to PO as soon as the possible as often the IV abx is the only thing keeping the pt in the hospital

I think #2 is going to depend a lot on bacteremia source, what bug is isolated, and degree of source control. Gram negative bacteremia associated with pyelo is a different beast from a partially debrided infected joint that is shedding S.aureus into the bloodstream. 7 days is usually fine with the former, the latter is almost always going to get a 2-4 week minimum. But in general I agree, continued increasing support for shorter overall durations, faster PO switches. We auto sub as well and just know which physicians you should ‘check with’ first.

 

[rxkrafted]

1. A lot of the ID physicians here want the patient to be clinically improving (afebrile, WBC decreasing, and hemodynamically stable) before switching to oral. As for fluoroquinolones, I know some elderly patients have a difficult time swallowing the big Levaquin tablets so some doctors keep that mind too.

 

[Dred Pirate]

Dred can you post the criteria you use for IV to PO switch?

we don't have one for steroids = we focus on abx and acid suppression agents - mainly because that is either where we can save money, or we can help alleviate shortages. If steroids fit one of these buckets, I am sure we would re-address.

 

[Dred Pirate]

1. A lot of the ID physicians here want the patient to be clinically improving (afebrile, WBC decreasing, and hemodynamically stable) before switching to oral.

This is our criteria - afebrile x 24 hours, wbc <15k, and hemodynamically stable

 

[BidingMyTime]

Dred can you post the criteria you use for IV to PO switch?

The criteria our hospital uses is, if the pt is getting nutrition by mouth (PO, enteral, etc.), then they are auto-switched. Our protocol is only for certain drugs and they are all antibiotics. We might pester/suggest a doc change other drugs to PO, especially when we see the pt is taking all their meds PO except for 1. Unless a drug has bad oral bioavailability, like vanco, it's going to be rare that there is any compelling reason to take it IV instead of PO.

 

[GravityBeetle]

1. Nope - no reason other than people think "IV are better" We allow one day then do an auto sub to PO abx if they meet criteria to change.
2. total coarse of 7-10 days - regardless of what is IV and what is po - you want to get to PO as soon as the possible as often the IV abx is the only thing keeping the pt in the hospital

What do you do for dosage? Very rarely can I find information on PO dosages for bacteremia, unless it is on our IV to PO protocol

 

[Dred Pirate]

What do you do for dosage? Very rarely can I find information on PO dosages for bacteremia, unless it is on our IV to PO protocol

same as IV - for a positive cutlure we do have to get a MD"s order to change thou