Pediatric Guidelines for IV to PO Conversion of Antimicrobials
The Pediatric Subcommittee and P&T Committee approved guidelines for appropriate sequential
parenteral-enteral therapy (IV to PO conversion) for select antimicrobials in the neonatal and pediatric populations. The guidelines also were approved by Dr. Dan Keim, Pediatric Infectious Disease Section. An education program to aid practitioners in selecting and dosing alternative enteral antimicrobials will begin in October.
Advantages of early conversion from parenteral to enteral therapy may include a reduction in the period of venous cannulation and hospitalization, thus a reduction in the risk of nosocomial sepsis. Removal of an intravenous line also may reduce chemical or bacterial phlebitis, improve patient mobility and comfort, and improve the overall patient attitude. Conversion to enteral therapy may result in significant cost savings by reducing drug and supply costs, as well as pharmacy and nursing time spent preparing and administering the medication.
Several indications for sequential parenteral-enteral antimicrobial therapy have been well studied
and include suppurative skeletal infections, lower respiratory tract infections, and pyelonephritis.
Other common pediatric infections (e.g., otitis media, bacterial sinusitis, and urinary tract
infection) are routinely treated with enteral antibiotics.
Most neonates and children are eligible to receive enteral antimicrobials when they exhibit:
- Adequate absorption of enteral medications
Generally if a patient is tolerating an enteral diet and taking other enteral medications, conversion from IV to enteral antimicrobials is appropriate.
Many clinicians believe that infants poorly absorb enteral medications. However infants have been shown to absorb the same amount of drug as older children and adults, but at a slower rate. Slower absorption rate can affect the peak serum and tissue concentrations of various antimicrobials. However, the recommended dosing regimens for the selected agents have been shown to yield concentrations in serum and tissues in neonatal patients that are adequate for treating common infections.
- Clinical improvement in symptoms (e.g., reduction in cough and respiratory distress with pneumonia)
- Stable temperature 38C (i.e., afebrile) for at least 24 hours
- Improvement in laboratory markers of infection (e.g., decreasing WBC/CRP/ESR)
Please note that there will be situations in which the above criteria for enteral conversion are met, but in which clinical judgement suggests a longer course of parenteral therapy would be appropriate.
Enteral antimicrobials may not be acceptable for neonates and children with:
- Compromised drug absorption (vomiting, diarrhea, active colitis, short bowel syndrome)
- Difficult to treat infections (endocarditis, undrained abscess, meningitis, osteomyelitis, highly drug-resistant S. pneumoniae)
The above infections are not absolute contraindications to enteral antimicrobials after initial IV therapy (e.g., osteomyelitis); however, patients must be carefully selected.
- Leukopenia (WBC < 3500 cells/mm3)
- Special clinical considerations (active TB, cystic fibrosis)
- Drug-drug interactions that may impair antimicrobial absorption
Not an absolute contraindication, as long as drugs are separated (generally administer antimicrobial 2 hours before interacting med)
- Drug-food interactions that may impair antimicrobial absorption
Not an absolute contraindication, as long as drugs are separated from meal (generally administer antimicrobial 2 hours before interacting meal)
Antimicrobials included in the guidelines are the following:
PARENTERAL Dosage Form / ENTERAL Dosage Form / Daily Cost Difference (IV vs. PO)*Azithromycin (Zithromax) / Azithromycin (Zithromax) / $$
Ceftriaxone (Rocephin)** / Ceftibuten (Cedax) / $$
Cefuroxime (Zinacef)** / Cefuroxime (Ceftin) or Cefdinir (Omnicef) / $$
Ciprofloxacin (Cipro) / Ciprofloxacin (Cipro) / $$$
Doxycycline / Doxycycline (Vibramycin) / $$
Erythromycin / Erythromycin (E.E.S., Ery-Ped) / $$
Fluconazole (Diflucan) / Fluconazole (Diflucan) / $$$
Levofloxacin (Levaquin) / Levofloxacin (Levaquin) / $$
Linezolid (Zyvox) / Linezolid (Zyvox) / $$$
Metronidazole (Flagyl) / Metronidazole (Flagyl) / $
Rifampin (Rifadin) / Rifampin (Rifadin) / $$$
TMP/SMX (Bactrim) / TMP/SMX (Bactrim) / $$
*costs based on drug acquisition prices for standard adult doses; this figure does not reflect ancillary costs e.g., supplies (syringes, IV tubing), equipment (syringe pumps), pharmacy preparation time, nursing administration time, or IV administration fee charged to patient. $ = $0–6 per day, $$ = $8–16 per day, $$$ = $35–70 per day
**although therapy may be switched empirically, conversion to an enteral agent preferably should be based on C+S results
for UTI