What is the best oral medication to switch to from cefepime (Cefepime)?

Best Oral Medication Switch from Cefepime

The best oral medication to switch from cefepime is a fluoroquinolone (levofloxacin 750mg or ciprofloxacin 500mg twice daily) when treating Pseudomonas aeruginosa infections, as these provide the most reliable oral coverage against Pseudomonas species. 1, 2

Selection Algorithm Based on Suspected Pathogen

For Pseudomonas aeruginosa infections:

• First choice: Levofloxacin 750mg daily or Ciprofloxacin 500mg twice daily 1, 2
  • These are the only reliable oral options for Pseudomonas coverage
  • Levofloxacin 750mg daily is preferred for better compliance

For non-Pseudomonal infections:

1. Community-acquired pneumonia:

   • Moxifloxacin 400mg daily or Levofloxacin 500mg daily 1
   • Alternative: Amoxicillin-clavulanate 875mg twice daily 1

2. Intra-abdominal infections:

   • Ciprofloxacin 500mg twice daily + Metronidazole 500mg three times daily 1
   • Alternative: Amoxicillin-clavulanate 875mg twice daily 1

3. Urinary tract infections:

   • Ciprofloxacin 500mg twice daily or Levofloxacin 750mg daily 1
   • Alternative: Trimethoprim-sulfamethoxazole DS tablet twice daily 1

Considerations for Specific Pathogens

Organism	Preferred Oral Option
Pseudomonas aeruginosa	Ciprofloxacin 500mg BID or Levofloxacin 750mg daily [1,2]
ESBL-producing organisms	Fluoroquinolones (if susceptible) [1]
Streptococcus pneumoniae	Moxifloxacin 400mg daily (highest antipneumococcal activity) [1]
Staphylococcus aureus (MSSA)	Amoxicillin-clavulanate 875mg BID [1]
Acinetobacter baumannii	No reliable oral options; consider prolonged IV therapy [1]

Important Clinical Considerations

1. Timing of switch: Only switch to oral therapy when the patient:

   • Has clinical improvement in symptoms
   • Is afebrile for at least 24 hours
   • Has a functioning gastrointestinal tract
   • Has decreasing white blood cell count 1

2. Duration of therapy:

   • Community-acquired pneumonia: 5-7 days 1
   • Hospital-acquired pneumonia: 7-10 days 1
   • Complicated intra-abdominal infections: 5-10 days 1
   • Bloodstream infections: 10-14 days 1

3. Pitfalls to avoid:

   • Don't use oral cephalosporins (like cefixime) for Pseudomonas coverage as they lack reliable activity 3
   • Fluoroquinolone resistance is increasing in many regions; check local susceptibility patterns 1
   • Consider the risk of C. difficile infection with prolonged fluoroquinolone use
   • For difficult-to-treat resistant Pseudomonas, oral options are limited; may need to continue IV therapy 1

Special Populations

• Patients with bronchiectasis: Ciprofloxacin 750mg twice daily for 14 days, followed by inhaled antibiotics if chronic colonization 1, 2
• Patients with cystic fibrosis: Higher doses of ciprofloxacin (750mg twice daily) may be needed 2
• Elderly patients: Consider dose adjustment for fluoroquinolones based on renal function

Remember that cefepime has excellent activity against Pseudomonas aeruginosa 4, 5, 6, and finding an oral equivalent with similar coverage is challenging. Fluoroquinolones represent the only reliable oral option for Pseudomonas coverage, but their efficacy may be compromised by increasing resistance rates.