Conversion of Intravenous-to-Oral Antimicrobial Therapy in South Indian Population

Abstract

Background: In general, Mostly 48 hours free of fever following the start of IV antimicrobial therapy as an
indication that “IV to Oral” switch may take place. In recent years many studies had advocated regimen of
relatively short intravenous therapy i.e. for 2-3 days followed by oral treatment for the remaining course. The
Objective of the Study was an assessment of the conversion based on the eligibility criteria and impact of the
intervention provided. Methods: All the inpatients admitted to the study site during the study period in which
the prescription should have at least one IV antimicrobial were included in the study. A prospective study was
conducted at a 450-bedded multi specialty tertiary care private hospital for a period of 6 months in General
medicine department. Results: The total number of patients admitted in the study site during the study period
was found to be 126. Group I: General medicine, control (n=90), Group II: General medicine – intervention was
provided (n=36). The average costs were Rs 2217 ± 1757 and Rs 1959 ± 2352 in Group I and Group II
respectively. The average length of stay was 6.81 ± 2.69 and 6.21 ± 2.40 days in Group I and Group II
respectively. Conclusion: The results demonstrated that clinical pharmacy activities, which can play a pivotal
role when trying to influence and change the antimicrobial prescription (IV to Oral conversion) and also it, may
reduce the cost on different departments in the hospital.

Full text

Vol. 2 (3) Jul – Sep 2011 www.ijrpbsonline.com 1258
International Journal of Research in Pharmaceutical and Biomedical Sciences
ISSN: 2229-3701
______________________________________________________________________Research Paper
Conversion of Intravenous-to-Oral Antimicrobial Therapy in
South Indian Population
Palanisamy.A1*, Narmatha.M.P1, Rajendran.N.N1, Rajalingam.B2 and Sriram.S2
1Department of Pharmacy Practice, Swamy Vivekanandha College of Pharmacy,
Tiruchengode, Namakkal. TamilNadu, India.
2Department of Pharmacy Practice, College of Pharmacy, SRIPMS, Coimbatore,
TamilNadu, India.
___________________________________________________________________________________________
Abstract
Background: In general, Mostly 48 hours free of fever following the start of IV antimicrobial therapy as an
indication that “IV to Oral” switch may take place. In recent years many studies had advocated regimen of
relatively short intravenous therapy i.e. for 2-3 days followed by oral treatment for the remaining course. The
Objective of the Study was an assessment of the conversion based on the eligibility criteria and impact of the
intervention provided. Methods: All the inpatients admitted to the study site during the study period in which
the prescription should have at least one IV antimicrobial were included in the study. A prospective study was
conducted at a 450-bedded multi specialty tertiary care private hospital for a period of 6 months in General
medicine department. Results: The total number of patients admitted in the study site during the study period
was found to be 126. Group I: General medicine, control (n=90), Group II: General medicine – intervention was
provided (n=36). The average costs were Rs 2217 ± 1757 and Rs 1959 ± 2352 in Group I and Group II
respectively. The average length of stay was 6.81 ± 2.69 and 6.21 ± 2.40 days in Group I and Group II
respectively. Conclusion: The results demonstrated that clinical pharmacy activities, which can play a pivotal
role when trying to influence and change the antimicrobial prescription (IV to Oral conversion) and also it, may
reduce the cost on different departments in the hospital.
Key words: Conversion, Antimicrobials, patient, cost
__________________________________________________________________________________________
INTRODUCTION
Oral ingestion is the most common method of drug
administration. It is also the safest, most convenient
and most economical1. Switch to appropriate oral
therapy should be made as soon as possible. Mostly
48 hours free of fever following the start of
antimicrobial therapy as an indication that “IV to
Oral switch may take place”.2 Parenteral therapy is
associated with a greater risk of severe adverse
effects, a much higher drug cost, additional cost of
syringes and needles, a risk of infection from
contaminated equipment and additional time and
expertise to administer3.
Antimicrobials are the most commonly used and
costly drug group in hospital. Oral antimicrobials
are believed and promoted particularly for general
practice and parenteral agents for hospital practice4,
_______________________________________
*Address for correspondence:
E-mail: amirpalanisamy@yahoo.co.in
because it was considered to be the standard of care
for patients with serious infections.5 On an average
one third of the patients receive antimicrobial
therapy and 40% of who receive it as intravenous
(IV) agents. Prescriptions up to 40% were
incorrectly prescribed or inappropriate and often
reflecting over-use of expensive broad-spectrum
IVagents.6 Ana.I.Pablos et al 7 reported that the
antimicrobial treatment costs account for 25% of
the drug budget in the hospitals and 1.5-4.5% of
total health care costs. So the Development and
implementation of protocol/guidelines for an
effective and early conversion of antimicrobial
therapy may be required to reduce the length of
hospitalization and IV drug cost.
METHODS
A Prospective study was carried out in a 450
bedded multi specialty private hospital from June
2006 to Nov 2006. A regular ward round
participation was performed daily with the chief,
senior, junior physicians in general, special and

Vol. 2 (3) Jul – Sep 2011 www.ijrpbsonline.com 1259
International Journal of Research in Pharmaceutical and Biomedical Sciences
ISSN: 2229-3701
deluxe wards of the study site were carried out in
order to collect the data of inpatients who got
admitted. These data were transferred to a
previously designed data entry format and
thoroughly studied to identify the possibilities of
conversion.
Patients
Inclusion Criteria
All the inpatients admitted to the study site during
the study period in which the prescription should
have at least one IV antimicrobial were included in
the study.
Exclusion criteria
All the out patients, children, terminally ill patients
and ICU patients were excluded from the study.
Criteria for Conversion
The following are the criteria, which are considered
while the conversion from IV-to-oral therapy was
prepared. Patient’s clinically improving.
Patient’s Temperature (36 -37C >24Hours).
Patient’s Pulse (Heart Rate) (<100 bpm for at least
12 hours).
Patient’s ability to tolerate Food or Fluid or any
oral preparations.
Availability of suitable oral alternative.
No ongoing problems with gastrointestinal
absorption. Patient’s immunocompromised status.
(Shouldn’t be an immunocompromised)
Patient’s culture sensitivity test if any (reported
negative in the last 48 hours).
Intervention
An intervention form was designed in order to get a
clarified conversion and the same was used to
provide intervention for the conversion of the
therapy with the doctors. The form consist of the
criterias which decides the conversion of the
therapy and also it has a space to inform the
physician about the conversion which was possible
and also the suitable oral alternative with the dose.
Analysis of cost effectiveness and length of stay
The cost and length of stay for the different groups
were calculated and the impact also assessed.
RESULTS
The total number of patients admitted in the study
site during the study period were found to be 126.
Group I: General medicine, control (n=90),
Group II: General medicine - intervention was
provided for IV to oral conversion (n=36). An
overall Gender distribution indicates predominant
male population (56%) in the study site. The
average age of overall study population was found
to be 48.98±17.95 (13 to 86) years. The overall
results revealed that 24.15% patients were suffering
from LRTI. 55.55% of overall study population’s
prescription contains minimum 6-10 drugs in their
prescription. 1.86±0.78 (1 to 6) antimicrobials per
prescription were found in overall study
population, 1.83±0.79 (1 to 6) in Group I and
1.96±0.78 (1 to 4) antimicrobials in Group II were
also found. 51.58% (n=126) of patients were
eligible for conversion from IV-to-oral
Antimicrobial therapy. The possible reasons for
being not eligible for IV-to-oral conversion in the
study population was GIT intolerance &
Intolerance of food and unavailability of suitable
oral alternative. The average costs of IV
Antimicrobials were Rs 2217 ± 1757 and Rs 1959
± 2352 in Group I and Group II respectively. The
average length of stay were 6.81±2.69 and
6.21±2.40 days in Group I and Group II
respectively.
DISCUSSION
The reduction in the average cost of IV and the
length of stay in Group II may be due to the
intervention provided by the pharmacist. One study
calculated the health care costs for treating lower
respiratory tract infections in the hospital as 52 %
less after introduction of the sequential
antimicrobial therapy protocol and the savings per
patient calculated was approximately £ 1200. They
also reported that early conversion to oral
antimicrobials leads to decreased treatment. 8
So the development and implementation of
protocol/guidelines for an effective and early
conversion of antimicrobial therapy may be
required to overcome. Some of the barriers and
can be overlooked by active participation of the
management and its action which in turn effect all
levels of the staff, reorganization of restricted
antimicrobial prescriptions if any and clinical
pharmacist activities in the ward. A limitation of
the present study is possible because of bias,
differences in the demographics, cost of and length
of stay in the hospital.
One study found approximately 46% were not
switched to oral antibiotics with in 48 hours even
after they were eligible for conversion. It also
suggests implementation of strategies will help to
reduce the number of patients who were on IV
antibiotics.9 So there is a need of simple locally
developed guidelines may facilitate more
appropriate use of IV antimicrobials in early
conversion which may reduce the cost of
hospitalization and length of stay in the hospital.
The clinical pharmacist’s potential role in
promoting and maintaining the appropriate use of
antimicrobials, especially through development of
guidelines/protocols for automatic conversion was
very well understood.

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International Journal of Research in Pharmaceutical and Biomedical Sciences
ISSN: 2229-3701
CONCLUSION
The study can be concluded, as the present study
was an attempt to understand the impact of
conversion program at preliminary levels. The
results demonstrated that clinical pharmacy
activities, which can play a pivotal role when trying
to influence and change the antimicrobial
prescription (IV to Oral conversion) and also it,
may reduce the cost on different departments in the
hospital.
Key Points:
 Various studies reported about IV to oral
conversion and their implications in practice.
But this study was done in South Indian
population in a particular department of
Private hospital.
 Group II (n=36) patients were benefited due to
the intervention provided by the Clinical
pharmacist in this study.
 In India, there is a need of protocol/guidelines
to the physician/clinical pharmacist in order to
convert the IV to Oral Antimicrobial therapy
that may reduce the cost of IV Antimicrobials
and length of stay in the hospital.
 The Clinical Pharmacist can keep updated
electronic data bases which automatically
suggest IV-to-oral conversion therapy which
may contain information like listing of drug
classes, alternatives to be used and patients,
clinical criteria used to determine the
eligibility and appropriate timing for
conversion.
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