When to discharge a patient with intravenous (IV) antibiotics versus oral antibiotics?

From the Guidelines

The decision to discharge a patient with IV versus oral antibiotics should be based on the patient's clinical stability, ability to tolerate oral medications, and the severity of the infection, with a preference for oral antibiotics when possible, as supported by the most recent study 1. When considering discharge with antibiotics, several factors come into play. These include:

• Clinical stability: Patients who are clinically stable and have shown improvement on IV therapy are candidates for oral therapy at discharge.
• Ability to tolerate oral medications: Patients who can tolerate oral medications and have an infection that can be effectively treated with oral antibiotics are suitable for oral therapy.
• Severity of the infection: The severity of the infection and the need for continued parenteral therapy due to poor oral absorption or high-severity infection should guide the decision between IV and oral antibiotics.
• Reliable IV access: For IV therapy at discharge, patients should have a reliable IV access, such as a PICC line or midline catheter.
• Arrangements for home or outpatient IV administration: Patients should have arrangements for home or outpatient IV administration, including insurance coverage for home health services and follow-up arrangements. Some common oral antibiotics for discharge include amoxicillin, amoxicillin-clavulanate, cephalexin, doxycycline, and trimethoprim-sulfamethoxazole. For outpatient IV therapy, options include ceftriaxone, ertapenem, and daptomycin. The bioavailability of the antibiotic is crucial, with medications like fluoroquinolones and linezolid having excellent oral bioavailability, making them good oral options 1. It's also important to consider the duration of IV therapy, which should be limited to 1-2 weeks, until the patient is stable and culture results are known, as recommended by the most recent study 1. Patient factors, such as adherence capability and insurance coverage, must also be considered to ensure successful treatment completion. Key points to consider when switching from IV to oral therapy include:
• Clinical response: The decision to switch from IV to oral therapy should be based on an assessment of clinical response, evaluating symptoms such as cough, sputum production, dyspnea, fever, and leukocytosis.
• Serum levels: Agents that achieve comparable serum levels either intravenously or orally, such as doxycycline, linezolid, and most quinolones, can be switched to oral therapy without a decrease in serum levels 1.

From the FDA Drug Label

Patients could switch to oral therapy after a minimum of 4 days of IV treatment if clinical improvement was demonstrated. Patients could switch to oral therapy after clinical improvement was demonstrated (no minimum IV dosing was required)

The decision to discharge with IV antibiotics vs oral antibiotics should be based on clinical improvement.

• Patients can be switched to oral therapy after a minimum of 4 days of IV treatment if clinical improvement is demonstrated.
• Alternatively, patients can be switched to oral therapy after clinical improvement is demonstrated, with no minimum IV dosing required. 2 2

From the Research

Discharge Criteria with IV Antibiotics vs Oral Antibiotics

The decision to discharge a patient with intravenous (IV) antibiotics versus oral antibiotics depends on several factors, including the type of infection, the causative organism, and the patient's clinical response to treatment.

• Type of Infection: For patients with infective endocarditis, the American Heart Association recommends that patients be treated with IV antibiotics for at least 4-6 weeks 3, 4.
• Causative Organism: The choice of antibiotic and route of administration also depends on the causative organism. For example, patients with penicillin-sensitive viridans or nonenterococcal group D streptococcal endocarditis may be treated successfully with aqueous penicillin G alone for four weeks or with combined penicillin and streptomycin for two weeks 3, 4.
• Clinical Response: Patients who have had symptoms of enterococcal endocarditis for longer than three months or perhaps patients with mitral valve infection should receive at least six weeks of penicillin therapy together with an aminoglycoside 3.
• Antibiotic Regimens: Prolonged infusion of antibiotics has been shown to be associated with a reduction in all-cause mortality and improvement in clinical cure compared to intermittent infusion 5.
• Oral Antibiotics: There is limited evidence to support the use of oral antibiotics as a replacement for IV antibiotics in the treatment of infective endocarditis. However, oral antibiotics may be considered for patients who have completed a course of IV antibiotics and are clinically stable 4.

Considerations for Discharge

When considering discharge, the following factors should be taken into account:

• The patient's clinical response to treatment
• The presence of any complications or comorbidities
• The patient's ability to adhere to the treatment regimen
• The availability of follow-up care and monitoring

It is essential to note that the decision to discharge a patient with IV antibiotics versus oral antibiotics should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.