Step down therapy

[Lubeckd]

Hi, does anyone have the guidelines for step down therapy of antibiotics? I know in ashtma patients there is a step down therapy as well. Step down as in IV to oral form.

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[Bostonredsox]

what antibiotics are you talking about?

COPD pts admitted and put on a respiratory FQ do not need a stepdown as they are 100% bioavailable PO. They just convert from 500IV daily levo to 500 PO daily. If they are on azithro its usually converted from 500 IV daily to 250 PO daily for the duration of what would be a zpak.

What i assume you are asking is what to do with the PNA pts on IV pip/taz or meropenem or the UTI pts with Ceftriaxone. The answer lies in their sensitivities and cultures if they have them. UTI that comes back sensi to keflex/bactrim/macrobid/cipro gets changed off their IV rocephin to one of those oral agents. PNA on pip/taz that comes back piperacillin sensi usually gets high dose amox or augmentin.

If you do not have sensis nor a positive culture then I would try to stick to an oral drun within the class they got better on. So the HCAP pt put on vanc + pip/taz + Azithro who did not have radiographic evidence of a staph PNA nor positive nares, I would send home on augmentin. probably continue the azithro for 5 days total for atypical coverage. Or send them home on resp FQ. Their are IDSA guidelines for this I suggest taking a gander at them.

 

[Lubeckd]

Thanks. Sorry for the confusion, I just meant antibiotics in general.
I gave a example of ashtma for patients on advair diskus, which is a long acting beta and steroid together, when patient is on it for a long time without any ashtma attacks you can step down their advair to a steroid alone.

I was wondering what kind of antibiotics you discharge the patients on after empirical IV therapy. I guess to be simple, it is from a broad spectrum to narrow spectrum right? I was hoping to see some websites that can help me with this. But thank you for the ISDA recommendation 🙂.

 

[Praziquantel86]

Thanks. Sorry for the confusion, I just meant antibiotics in general.
I gave a example of ashtma for patients on advair diskus, which is a long acting beta and steroid together, when patient is on it for a long time without any ashtma attacks you can step down their advair to a steroid alone.

I was wondering what kind of antibiotics you discharge the patients on after empirical IV therapy. I guess to be simple, it is from a broad spectrum to narrow spectrum right? I was hoping to see some websites that can help me with this. But thank you for the ISDA recommendation 🙂.

The rule of thumb is given culture data, step-down to the narrowest therapy possible for as short a duration as possible. Obviously this isn't possible for empiric therapy, given the lack of culture data. Most of the time you don't need to step down empiric therapy, as no infection is identified and you can just stop antibiotics.

If you're talking about definitive therapy without an organism identified, as is often the case with pneumonia, you step down to oral therapy that is likely to cover the causative organisms (S. pneumo, H. flu, M. cat, atypicals). Something like culture-negative osteo is a different beast, and really should be done in consult with someone knowledgeable about ID to ensure that it truly is culture-negative osteo (often because antibiotics were started prior to blood cultures/biopsies) and not something that might look similar (malignancy).