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4CPS-067 Pharmacist interventions in sequential antimicrobial therapy inside an antimicrobial stewardship programme (ASP)
  1. L Fructuoso,
  2. P Torrano Belmonte,
  3. J Ibañez Caturla,
  4. P Pacheco Lopez,
  5. MA Carvajal-Sanchez,
  6. S Clavijos Bautista,
  7. C Fernández Zamora,
  8. M Hernandez Sanchez,
  9. JA Gutierrez Sanchez
  1. Hospital Morales Meseguer, Servicio de Farmacia, Murcia, Spain


Background and importance Early switching of intravenous (IV) to oral (PO) antimicrobials is not only possible but highly recommended. Once patients are clinically stable it can reduce the risk of infection of the IV catheter, increase comfort and mobility for the patient, decrease the risk of thrombophlebitis, and reduce the length of hospitalisation and lower associated costs. Changes from IV to PO antimicrobial therapy resulted in equal clinical efficacy compared with patients administered the full parenteral course.

Aim and objectives Encourage and register pharmacists’ interventions in sequential antimicrobial therapy inside an antimicrobial stewardship programme.

Material and methods The study was an interventional, prospective study conducted in a 405-bed academic hospital in Spain from January to May 2021. Using an app called WASSP we preselected patients eligible for IV–PO switch: in treatment with good absorbed antimicrobials (levofloxacin, ciprofloxacin, amoxicillin/clavunate, metronidazole, clindamycin, linezolid, trimethoprim-sulfamethoxazole, fluconazole, voriconazole, isavuconazole) for 3 or more days. Then, each individual case was studied with these criteria: aged 18 years and above, IV–PO switch diagnosis (upper urinary tract infection, bacteraemia, intra-abdominal infection, skin and soft tissue infection, febrile neutropenia, osteoarticular infection, community-acquired pneumonia, pelvic inflammatory disease), received an IV antibiotic for more than 72 hours, body temperature <37.8°C for the past 24 hours, tolerating orally and showing clinical improvements from signs of infection. Finally, we communicated to doctors which patients were appropriated for the switch using an emergent note in our electronic prescription system and we followed-up those patients.

Results In this study, from all the patients individually analysed (292) pharmacists informed that 18.15% of all patients who started on IV antibiotics were candidates for an early IV–oral switch. Doctors agreed on early switch in 33/53 cases, which constitutes 62.26% of the acceptance rate of the intervention. Broken down this represents 37.14% to metronidazole, 17.14% to ciprofloxacin, 14.28% to linezolid, 8.57% to levofloxacin, 5.71% to amoxicillin/clavunate, 2.85% to clindamycin and 2.85% to trimethoprim-sulfamethoxazole.

Conclusion and relevance We must highlight the metronidazole IV–oral switch because surprisingly few prescribers knew that almost 100% of the drug is orally absorbed.

This study may be used as a template for the introduction of further pharmacist-led antimicrobial stewardship initiatives.

Recommendations initiated by pharmacists do improve the timeliness of the IV–PO switch.

Conflict of interest No conflict of interest

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