What oral (per oral) medication can be used as an alternative to ertapenem (intravenous) IV push?

Oral Alternatives to Ertapenem for Patients Unable to Receive IV Push

For patients who cannot receive ertapenem IV push, amoxicillin-clavulanate is the preferred oral alternative medication based on spectrum of coverage and clinical efficacy. 1

Recommended Oral Alternatives to Ertapenem (in order of preference)

1. First choice: Amoxicillin-clavulanate

   • Dosage: 875/125 mg PO twice daily
   • Rationale: Provides broad-spectrum coverage including many Enterobacteriaceae and anaerobes
   • Duration: 5-7 days (depending on infection type and clinical response)

2. Alternative options (if amoxicillin-clavulanate contraindicated):

   • Moxifloxacin 400 mg PO once daily 1
   • Levofloxacin 500-750 mg PO once daily 1

Clinical Decision-Making Algorithm

1. Assess infection type and severity:

   • For moderate infections previously treated with ertapenem: Use amoxicillin-clavulanate
   • For diabetic foot infections: Amoxicillin-clavulanate is recommended for mild-moderate infections 1

2. Consider patient-specific factors:

   • Penicillin allergy: Use moxifloxacin or levofloxacin
   • Renal impairment: Adjust dosing of amoxicillin-clavulanate
   • Risk of C. difficile: Consider risk factors before using fluoroquinolones

3. Consider pathogen coverage needs:

   • If MRSA coverage needed: Add doxycycline 100 mg PO twice daily 2
   • If enhanced anaerobic coverage needed: Consider metronidazole addition 1

Evidence Summary

Ertapenem is a carbapenem antibiotic with broad-spectrum activity against Gram-positive, Gram-negative, and anaerobic bacteria, particularly Enterobacteriaceae 3, 4. When IV administration is not possible, oral alternatives must provide similar coverage.

The IDSA guidelines for diabetic foot infections recommend amoxicillin-clavulanate as an appropriate oral agent for mild to moderate infections that would otherwise be treated with ertapenem 1. Clinical studies have shown that amoxicillin-clavulanate provides adequate coverage against many of the same pathogens targeted by ertapenem, particularly in community-acquired infections.

Fluoroquinolones (moxifloxacin, levofloxacin) represent alternative options with once-daily dosing advantages 5. Moxifloxacin has demonstrated non-inferiority to ertapenem in clinical trials for intra-abdominal infections with clinical success rates of 89.4% vs 93.4% respectively 1.

Important Considerations and Pitfalls

• Spectrum gaps: No oral antibiotic perfectly matches ertapenem's spectrum. Amoxicillin-clavulanate has the closest coverage profile but may have gaps against some resistant Enterobacteriaceae.

• Resistance concerns: Local antibiotic resistance patterns should guide therapy. In areas with high ESBL prevalence, oral options may be limited.

• Monitoring: Reassess within 48-72 hours to ensure clinical improvement. If no improvement occurs, consider broadening coverage or returning to parenteral therapy.

• Bioavailability: Oral antibiotics generally achieve lower tissue concentrations than IV formulations. Consider this limitation for deep-seated or severe infections.

• Avoid fluoroquinolones in patients with risk factors for tuberculosis as they may delay diagnosis and increase resistance risk 1.

By following this approach, you can select the most appropriate oral alternative to ertapenem based on the patient's specific infection, comorbidities, and local resistance patterns.