Criteria-based antimicrobial i.v. to oral conversion program

Collaborative efforts among several departments and the P & T Committee resulted in an IV to oral conversion program for select antimicrobials in our 580-bed county teaching hospital. This criteria-based program was designed to monitor and educate physicians on the appropriateness of parenteral antimicrobial prescribing, ensure rapid transition from IV to oral therapy, and contain costs. In the first 2 months of the program, 78 patients were converted from IV to oral administration with an estimated savings of $12,935. Of the ordering physicians, 66 (84.6%) accepted the interventions. All patients who switched administration routes were successfully treated with an oral agent. This program also has had a positive effect on patient outcomes and physician prescribing habits.     

Pharmacoeconomics of a pharmacist-managed program for automatically converting levofloxacin route from i.v. to oral.

The economic and clinical outcomes of a pharmacist-managed proactive program that used predetermined clinical criteria for converting levofloxacin therapy from i.v. to oral without physician approval were examined. A prospective observational study (POS) assessing the standard of care was conducted over two months and was compared with a proactive conversion program (PCP). A cost-minimization analysis was performed from the provider's perspective. The analysis was divided into cost levels 1, 2, and 3. During the POS and PCP, 49 and 82 patients were evaluated, respectively. The percentage of patients meeting conversion criteria in each group was similar (61% POS versus 65% PCP) (p = 0.827). Candidates met criteria for conversion on day 2 in both groups. The average days that conversion occurred during the POS and PCP were days 7 and 3, respectively (p = 0.010). In those patients, the length of stay was significantly shorter for the PCP (6 versus 9.5 days) (p = 0.031). Level-1, level-2, and level-3 costs were significantly less during the PCP than during the POS for patients who met conversion criteria ($77 versus $133, $91 versus $151, and $13,931 versus $17,198, respectively). Two patients in the PCP were switched back to i.v. levofloxacin due to noninfection-related complications. The overall clinical success rate for evaluable conversion candidates was 100% during the PCP. A pharmacist-managed proactive program that used predetermined clinical criteria for converting levofloxacin therapy from i.v. to p.o. without physician approval reduced length of stay and institutional health care costs without compromising clinical outcomes.     

Pharmacist intervention program focused on i.v. ranitidine therapy

A staff pharmacist intervention program designed to modify inappropriate dosage intervals for i.v. ranitidine and promote timely conversion to oral therapy is described. Records of patients who were receiving i.v. ranitidine were reviewed for eight weeks to determine whether the dosage interval was appropriate and whether they began receiving oral ranitidine within 24 hours of an order for an oral diet or other oral medications. Pharmacists were then asked to determine the proper i.v. ranitidine dosage interval based on creatinine clearance and the oral dosage that would be appropriate when i.v. therapy was no longer indicated. The information was used to complete an intervention form that was placed in the patient's chart. During the baseline phase the i.v. dosage interval was inappropriate for 49 of 139 patients; 617 i.v. doses costing $4214 were administered to 62 patients for whom oral therapy was indicated; conversion to oral therapy occurred appropriately for 39 of 68 patients (57%). In the intervention phase 138 patients received i.v. ranitidine. Pharmacists made 51 recommendations for adjusting the i.v. dosage interval, and 18 were implemented within 24 hours. All six recommendations to convert immediately to oral therapy were also implemented within 24 hours. A total of 280 inappropriate i.v. doses costing $1912 were given to 30 patients for whom oral therapy was indicated. Conversion to oral therapy occurred appropriately for 53 of 76 patients (70%). A simple program of monitoring and intervention by staff pharmacists when i.v. ranitidine therapy is begun can save money and promote the appropriate use of this drug.     

A continuous quality improvement program for phenytoin i.v

The P & T Committee at Latrobe (Pa.) Area Hospital conducted a drug use review of i.v. phenytoin, which lead to revised guidelines for the use of i.v. loading doses of this agent. The reasons for the study, its results, and the actions taken are presented below.     

Pharmacist-based i.v. theophylline therapy.

With the support and guidance of the medical staff, a protocol for IV theophylline dosing and monitoring has been implemented. The patients' theophylline needs are individually determined by pharmacists using clinical criteria and historical data determined for each patient. Ongoing monitoring and dosage adjustments are provided. The protocol is described where a therapeutic range of 10-20 mcg/mL was maintained 84% of the time as verified by quality assurance audits.     

Productivity and quality assessment associated with conversion from i.v. to oral ranitidine

At a university teaching hospital, a study was undertaken to evaluate the appropriateness of the intravenous form of ranitidine in adult patients. The assessment of the cost and quality considerations involved in the conversion of ranitidine therapy from intravenous to oral forms is presented here.     

Cost control of therapy for i.v. catheter infections

Intravenous catheter sepsis is an important challenge for physicians because it is associated with a high incidence of complications, and treatment can be very costly. Significant complications occur in about 25% of cases and include septic shock, suppurative thrombophlebitis, metastatic infection, and endocarditis. The risk of such complications is increased when catheter removal or appropriate antibiotic therapy is delayed, when Staphylococcus aureus is the pathogen, and probably when a prosthetic heart valve or pulmonary artery catheter is present. The optimum duration of antibiotic therapy for intravenous catheter sepsis has not been established and depends on the pathogen and on the presence of other risk factors for complications. A treatment duration of 1 week may be adequate for pathogens, such as coagulase-negative staphylococci or Candida, that are unlikely to cause complications, while > or = 2 weeks of antibiotic therapy is warranted for S aureus. Recent approaches that may help to reduce costs include shortening the duration of parenteral antibiotic treatment either by giving oral agents for part of the treatment period or by using a synergistic combination of antibiotics. Also, for infections in subcutaneously tunneled catheters, intraluminal administration of small volumes of highly concentrated antibiotics often is an effective alternative to prolonged systemic antibiotic therapy.     

Implementation of an i.v. morphine infusion program in a community hospital.

Pharmacy departments play a role in helping to design and implement a pain management program in community hospitals. The history, documentation of need, and benefits of the program are presented. Protocol guidelines for the intravenous infusion of morphine are outlined, and specific job functions of the nurse and pharmacist members of the pain management team are defined. In addition, the results of a pain management study are reported, which describe the efficacy of the treatment protocol in 22 patients.     

Population pharmacokinetic approach to compare oral and i.v. administration of etoposide

The antitumor effect of etoposide (ETO) may be related to duration of exposure to a relatively low serum level while myelosuppression may be dependent on peak ETO serum levels. With regard to such therapeutic ranges, duration of exposure to predefined plasma ETO concentration ranges and the related AUC (expressed as percent of total AUC, pAUC) were used to compare pharmacokinetic profiles after oral and short time i.v. (1 h infusion) administration of identical ETO doses (100 mg/m2). Patients included in this study received i.v. (18 patients, short-term infusions) or oral (16 patients) ETO on different treatment schedules. Plasma ETO concentrations were determined by HPLC and population pharmacokinetic parameters were calculated (P-Pharm 1.4). Despite an 'apparent bioavailability' of 59%, oral administration of ETO was associated with the same time of exposure to a predefined 'therapeutic range' of 0.5-3 mg/l and a significantly higher pAUC compared to i.v. administration. By contrast, time of exposure to the probably more myelotoxic concentration range above 3 mg/l was significantly shorter and the related pAUC was highly significantly lower after oral than after i.v. administration. These findings demonstrate that oral ETO therapy is at least equivalent to short time i.v. therapy in terms of achieving specific target concentration ranges and avoiding peak concentrations.     

Maintenance therapy after i.v. administration of disopyramide with an oral sustained release preparation, a pharmacokinetic study.

The blood levels in 20 patients were studied during the change from parenteral administration of disopyramide to an oral sustained release preparation containing the same active substance. From this study it is concluded that 100 mg i.v. bolus injection of disopyramide can safely be followed by the immediate administration of one sustained release tablet containing 250 mg disopyramide. In case of an i.v. infusion (0.4 mg kg-1h-1) it seems wise not to start earlier with the administration of the sustained release preparation than at the moment of stopping the infusion.     

A review of the Manitoba home i.v. antibiotic program.

The Manitoba Home IV Antibiotic Program was reviewed after 12 years of operation. Patient selection and the steps involved in sending a patient home on the program are outlined. The types of infections treated and the incidence of complications and therapeutic failures are presented. The drugs and supplies used are described and total costs are discussed. The data presented is based on 748 patient admissions to the program and 15,366 patient days of experience. The review concludes that the program is safe and effective and provides a viable alternative to hospitalization for patients with chronic infections.     

Cost-effectiveness issues for home i.v. therapy in the United States

The popularity of home infusion therapy is increasing as it becomes recognized as a cost-effective alternative to hospitalization with the added benefit of improving patient quality of life. Selection of appropriate candidates for home i.v. therapy requires consideration of many variables pertaining to the medical and psychosocial suitability of the patient. Innovations in drug delivery devices have created opportunities for patients to receive parenteral therapy at home who would otherwise be considered inappropriate candidates for this treatment option. The cost of providing home IV therapy is mainly attributable to pharmacy and nursing services. Other contributing cost factors include the expense of ancillary supplies, supply delivery and management, and those costs created by administrative and regulatory requirements. When appropriately managed, home administration of IV medications can be a cost-effective way of delivering safe, effective, and quality care to an increasing population of patients.     

Implementation and evaluation of a flexitime program involving pharmacy i.v. admixture technicians.

The purpose of this article is to describe the implementation of a flexitime program involving i.v. admixture personnel and to evaluate its impact on three work-related behaviors. Flexitime, also known as flex-time, is an alternative to the standard work schedule. Flexitime programs have been shown to have a positive effect on productivity, overtime, turnover, tardiness, absenteeism, and job satisfaction in various work settings. The i.v. admixture technicians and interns chose a flexitime program called the variable day. During both the baseline and the flexitime period, three work-related behaviors were measured: absenteeism, tardiness, and satisfaction. Tardiness was almost eliminated during the flexitime program; absenteeism decreased from 4.61% during the baseline period to 2.66% during the flexitime program, although this difference was not statistically significant. General job satisfaction did not significantly change during the flexitime program. Overall, all of the technicians favored the flexitime program and suggested that it be expanded to include the unit dose technicians. If future investigations support the usefulness of flexitime programs, pharmacy managers should consider its implementation as an additional strategy for reducing departmental costs.     

Patient-teaching program for home intravenous antimicrobial therapy

The development of a home i.v. antimicrobial therapy program and associated procedures for patient teaching are described. The pharmacy department at a 940-bed, acute-care, general medical-surgical teaching hospital participated with four other departments in the development of standardized teaching methods for a home i.v. antimicrobial therapy program. The pharmacy and nursing departments each developed sections of a home antimicrobial therapy manual. Over a 16-month period, i.v. antimicrobial therapy was prescribed for 37 patients who were discharged from the hospital. Most patients or their care-givers were able to prepare and administer the medications. After the patient was discharged, the pharmacy department offered services such as supplying medications, coordinating pharmacokinetic dosing, providing drug information, and acting as a patient contact. Hospitals that provide home i.v. antimicrobial therapy should coordinate the resources of the various departments involved to develop standardized patient-teaching methods.     

Opportunities for i.v. to oral switch in the management of infections: the role of quinolones

Quinolones are an important group of drugs for the oral treatment of severe infections. We have shown that in patients with bacteremia the serum levels of fleroxacin are high enough to treat Gram-negative infections with one single oral dose per day. Thus for severe, quinolone-sensitive infections, such as bacteremic pyelonephritis, the switch from i.v. to oral may be done even on the first day of infection if the patient is not in shock and able to take oral medication. Staphylococcal infections have been successfully treated in animal models and non-randomized human studies with the combination of quinolone and rifampin. We have studied the influence of rifampin on the pharmacokinetics of fleroxacin in normal volunteers and no dose adjustment appears necessary. A single daily oral dose of fleroxacin (400 mg) and rifampin (600 mg) appears to be a promising therapeutic approach for staphylococcal infections and is the basis for an ongoing prospective randomized clinical trial comparing early switch to oral bitherapy with standard i.v. therapy. In conclusion, fleroxacin as a single drug or in combination with rifampin is a promising approach for switch from i.v. to oral therapy of severe Gram-negative and possibly staphylococcal infections.