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    Why you should take CAP patients off IV antibiotics

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    Vincent Tam
    Switching community-acquired pneumonia patients as quickly as possible from intravenous to oral antibiotics reduces hospital stays and improves the quality of care, according to many studies. One recent study suggests that even patients with severe CAP may be safely moved to oral antibiotics early in their stay. Health-system pharmacists should be aggressive in promoting that switch, say several clinical pharmacists.

    "Pharmacists play a key role in this," said Vincent Tam, Pharm.D., assistant professor at the University of Houston College of Pharmacy and a clinical pharmacist at St. Luke's Episcopal Hospital in Houston, specializing in infectious diseases. "We have a unique role in the drug [treatment] part in any disease state, and certainly antibiotic administration."

    Professional guidelines published by the American Thoracic Society and the Infectious Diseases Society of America recommend that CAP patients be switched from IV antibiotics to oral ones as soon as they are clinically stable and oral intake is possible, even when there is a positive blood culture for continued CAP infection.

    A recent study by researchers from the University Medical Centre in Utrecht, Netherlands, examined the effectiveness of switching from IV to oral antibiotics after three days, comparing it with a standard seven-day course of IV administration. The results were published in the Nov. 7, 2006, edition of the British Medical Journal.

    According to the authors, the early switch did not result in clinical deterioration and decreased hospital stays by an average of two days. "Patients admitted to hospital with severe CAP can be managed more efficiently by an early switch from IV to oral drugs—81% of patients could be switched to oral antibiotics on day three," the authors concluded.

    Research establishing the efficacy and safety of moving patients as quickly as possible to oral antibiotics is important to clinicians and payers, said Annie Wong-Beringer, Pharm.D., an associate professor at the University of Southern California School of Pharmacy and a clinical pharmacist specializing in infectious diseases at Huntington Hospital in Pasadena, Calif.

    "Managed care organizations are bringing pressure to discharge patients from the hospital to an ambulatory setting as early as possible," said Wong-Beringer. Pharmacists should be assertive in promoting the switch. "Physicians are drawn in many directions, involved with scans, X-rays, and so on, but pharmacists focus on drug administration, leaving the pharmacist as the best person suited to ensure optimal drug treatment," said Tam.

    At St. Luke's Episcopal, clinical pharmacists go on rounds with physicians and, therefore, have an opportunity to provide immediate verbal comment. "This is optimal, but even when it doesn't happen, no provider is as aware of the drug regimen for any single patient as the pharmacist," Tam concluded.

    The eight-step conversion program

    Moving patients as quickly as possible from IV antibiotics to oral administration is both cost-effective and clinically preferable, according to several studies. Pharmacists, who are in a distinct position to monitor drug therapy, can help implement a program to develop standardized, systemwide conversion protocols, as outlined by Annie Wong-Beringer, Pharm.D., an associate professor at the University of Southern California School of Pharmacy, Pasadena, Calif. Here are the eight steps she recommends:

    1. Identify drugs suitable for switching from IV to oral administration.

    2. Determine prescribers' baseline knowledge about the rationale for switching from IV to oral administration, as well as the pharmacologic and cost issues regarding targeted drug and related agents.

    3. Tailor educational efforts to prescribers' needs. This can include in-service presentations and informational posters.

    4. Clearly define the pharmacists' role and how prescribers will be informed when a patient is determined to be eligible for switching. Communication can include intervention forms, flowcharts, written chart notes, and telephone calls.

    5. Communicate with all prescribers, pharmacists, and healthcare team members before a program begins, explaining its rationale and objectives.

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    Martin Sipkoff
    Martin Sipkoff is a healthcare writer living in Gettysburg, Pa.

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