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IV to PO from an Inpatient Perspective: An Intervention Worth the Effort? · The SHEA Podcast

• 0:09
  SPEAKER_01: Welcome to our podcast series Antimicrobial Stewardship Popoy, brought to you by the Society for Healthcare Epidemiology of America, SHA, promoting the prevention of healthcare associated infections and antibiotic resistance, and seeking to advance the field of healthcare epidemiology and antibiotic stewardship.
• 0:25
  SPEAKER_01: This series will discuss communication techniques for antimicrobial stewardship, evaluate the opportunities and limitations of antimicrobial IV to PO conversion, and identify best practices in shortening durations of therapy.
• 0:38
  SPEAKER_01: I am Dr.
• 0:39
  SPEAKER_01: Whitney Buckle, System Antimicrobial Stewardship Pharmacist Manager for Intermountain Healthcare at Salt Lake City, Utah, and I will be your podcast moderator today.
• 0:47
  SPEAKER_01: Today is excited to launch this episode of the podcast series, which is entitled IV to PO from an inpatient perspective: an intervention worth the effort.
• 0:55
  SPEAKER_01: IV to PO conversion has immense potential to benefit patients by preventing unnecessary intravenous therapy associated with risks like prolonged length of stay, Lyme associated infections and excessive costs and inconvenience.
• 1:08
  SPEAKER_01: Although it is often listed as a low-hanging fruit for antimicrobial stewardship, there are many nuances to cover.
• 1:13
  SPEAKER_01: This podcast will discuss special cases, big successes, and gaps in our current understanding of IV to PO conversion.
• 1:20
  SPEAKER_01: I'm happy to introduce our two speakers for today.
• 1:23
  SPEAKER_01: First, we have Dr.
• 1:24
  SPEAKER_01: Megan Jeffries, Associate Professor in the Department of Clinical Pharmacy at University of Colorado and Chutes Medical Campus.
• 1:30
  SPEAKER_01: We also have Dr.
• 1:31
  SPEAKER_01: Shivani Sattel, System Antimicrobial Stewardship Lead for the Houston Methodist System in Houston, Texas.
• 1:37
  SPEAKER_01: Thank you both for joining us today.
• 1:39
  SPEAKER_02: Thanks.
• 1:40
  SPEAKER_02: Thrilled to be here.
• 1:41
  SPEAKER_02: Same.
• 1:42
  SPEAKER_02: Such an exciting topic.
• 1:43
  SPEAKER_01: First, will each of you describe your current practice setting and how you approach IV to PO?
• 1:48
  SPEAKER_01: Dr.
• 1:48
  SPEAKER_01: Jeffrey, would you like to start us off?
• 1:50
  SPEAKER_00: Yes, thank you.
• 1:51
  SPEAKER_00: My current practice is my clinical site is the University of Colorado Hospital in Aurora, Colorado, which is right next to Denver.
• 1:59
  SPEAKER_00: I round with internal medicine there with the School of Medicine.
• 2:03
  SPEAKER_00: And my approach to IV to PO is pretty aggressive.
• 2:06
  SPEAKER_00: I'm a big advocate of IV to PO switches early.
• 2:10
  SPEAKER_00: Getting people discharged out quickly is at the forefront of all of our practice right now because we have been overcapacitated at our hospital for months and months and months.
• 2:19
  SPEAKER_00: And so duration of stay is super important in terms of keeping flow through the ED without people sitting there.
• 2:25
  SPEAKER_00: So I am a pro-PO.
• 2:29
  SPEAKER_02: I love that.
• 2:31
  SPEAKER_02: So my site is the Houston Methodist Health System in Houston, Texas.
• 2:35
  SPEAKER_02: So I am the antimicrobial stewardship lead for the system.
• 2:38
  SPEAKER_02: So I oversee our seven campuses in terms of stewardship and commonality.
• 2:44
  SPEAKER_02: So IB2PO is something that we're trying to reinvigorate at our campus actively.
• 2:50
  SPEAKER_02: I think that everybody considers IV to PO is very low-hanging fruit for stewardship, but it actually has like a really big impact in terms of all the things we've kind of already talked about.
• 3:01
  SPEAKER_02: Lines out early, reduce phlebitis and thrombophitis, being engaged with infection control and preventing collapses.
• 3:09
  SPEAKER_02: And then, you know, just like Dr.
• 3:10
  SPEAKER_02: Jeffries talked about the length of stay, and I feel like this one's really close to my heart right now.
• 3:15
  SPEAKER_02: I think ASP programs that are really well established at this point have done all of the cost containment or cost avoidance that we can.
• 3:23
  SPEAKER_02: And so being able to de-escalate early and then convert to oral early to help facilitate and partner with case management and medical teams to get people out of the hospital have really, really tied us closely to quality and patient outcomes in the hospital.
• 3:39
  SPEAKER_02: And I think this is such an emerging role for stewardship, like really with that focus on length of stay.
• 3:44
  SPEAKER_01: Thank you, Dr.
• 3:44
  SPEAKER_01: Patel.
• 3:45
  SPEAKER_01: I am excited that you are invigorating your IB2PO approach.
• 3:48
  SPEAKER_01: And I'm excited that Dr.
• 3:49
  SPEAKER_01: Jeffries is so aggressive in the IV2PO switch because I think there's a lot of opportunity here.
• 3:54
  SPEAKER_01: And there are nuances to discuss.
• 3:57
  SPEAKER_01: You know, I think sometimes we think at face value this will be really easy, but then when we get into the weeds, there can be some common questions that come up.
• 4:04
  SPEAKER_01: So my next question for you is what are some common questions that you get about whether IV to PO is appropriate?
• 4:10
  SPEAKER_01: For example, those with GI conditions or multidrug resistant organisms, certain inspection types are that proverbial, it's required for inpatient admission comment that you might get.
• 4:20
  unknown: Dr.
• 4:20
  SPEAKER_01: Patel, do you want to start us off?
• 4:22
  SPEAKER_02: Yeah, I can.
• 4:23
  SPEAKER_02: So I think clinically there's two big things that consistently happen to me.
• 4:28
  SPEAKER_02: There is still this perception that IV is better, which I don't understand for the life of me.
• 4:33
  SPEAKER_02: You have highly bioavailable agents.
• 4:35
  SPEAKER_02: We have multiple studies looking at equal serum concentrations between IV and PO and equal efficacy.
• 4:42
  SPEAKER_02: And I feel like this kind of theory or myth or persona should be put to rest at this point.
• 4:47
  SPEAKER_02: And then the other question that I really get is, you know, physicians oftentimes have uh questions about efficacy.
• 4:53
  SPEAKER_02: How could IV really be as good as PO?
• 4:56
  SPEAKER_02: And can oral agents be used in like very specific settings, such as like MDROs and specific infection types?
• 5:05
  SPEAKER_02: So I feel like these conversations give me not just a good opportunity to be able to like say, okay, it's time for you know IV to PO, let's de-escalate, let's get this person off, but it really gives us a chance to have a bedside conversation in terms of factors such as selection of agent, clinical improvement, have we achieved source control?
• 5:23
  SPEAKER_02: And is this person a good candidate for IV to PO de-escalation?
• 5:27
  SPEAKER_02: And it transitions really nicely into some of the transitions of care things that people are doing across the country now in terms of, you know, okay, we're switching to oral antibiotics, but we only need three or four more days.
• 5:39
  SPEAKER_02: You're not going to discharge them on another 10 to 14.
• 5:42
  SPEAKER_02: And it's just a really nice avenue to be able to round out like the end part of stewardship for a patient as they're transitioning out of the hospital.
• 5:50
  SPEAKER_00: Totally agree with all of those points you just raised.
• 5:53
  SPEAKER_00: Like those are some essentially like some big picture things being sort of in the trenches on the internal med side of things, some of the other questions we get have to do with like patient-specific characteristics.
• 6:05
  SPEAKER_00: Patients that come in with maybe questionable absorption based on either their having a CHF exacerbation, or where they might have a demodus guts because of that, or cirrhosis, or the other area that we talk about a lot is bariatric surgery.
• 6:18
  SPEAKER_00: So, like even though we are have are confident that a PO antibiotic would work in terms of side of infection and pathogen of infection, is there absorption issues that are a part of this?
• 6:30
  SPEAKER_00: And so I have reluctantly spent more time in the literature than I would want, learning about all these sort of like PK nuances that happen in these days.
• 6:40
  SPEAKER_00: And ultimately, for the the short course lesson here is anything that is that affects the small intestine is of concern.
• 6:48
  SPEAKER_00: It's not really the stomach, it's really the small intestine.
• 6:51
  SPEAKER_00: So if patients get bariatric surgery that has eliminated a lot of their small intestine, like with a ruin Y or a bilioduct procedure that sort of reroutes the intestine and cuts a big part of the small intestine off, those are things that are important to look at.
• 7:07
  SPEAKER_00: In terms of edematous guts, that happens in acute illness a lot.
• 7:11
  SPEAKER_00: So in those scenarios, I often look for surrogate markers to indicate whether this person has a long-term edematous gut problem or absorption problems.
• 7:20
  SPEAKER_00: It's also within like diabetes with gastrocuresis, all these sort of like things.
• 7:23
  SPEAKER_00: And essentially you can almost always get some sort of surrogate marker like vitamin levels.
• 7:28
  SPEAKER_00: So like if a person has normal vitamin levels or does not anemic from like pernicious anemia from folate or you know, deficiencies, those are all little like clues in there that says, like, yeah, their guts might not be amazing to the patient concerning that, but that there's still absorption happening.
• 7:46
  SPEAKER_00: The other thing to think about is like, you know, in the setting of massive diarrhea, not necessarily C.
• 7:51
  SPEAKER_00: diff related, but you know, otherwise patients that are cirrhotic and have are on lactulose.
• 7:56
  SPEAKER_00: So, like, is the transit time enough, you know, to if you're having three to five bowels a day or bowel moments a day, is there enough time in the small intestine for absorption?
• 8:05
  SPEAKER_00: And all those things are essentially short answers.
• 8:08
  SPEAKER_00: Yes.
• 8:09
  SPEAKER_00: As long as there's a half an hour or so in the small intestine that most everything's gonna be absorbed.
• 8:14
  SPEAKER_00: But yeah, there's a lot of like poop investigations in my life that are not really what you would say is the normal day for lots of people, but it is.
• 8:24
  SPEAKER_02: Oh my goodness.
• 8:24
  SPEAKER_02: And I love those clinical pearls about the vitamin.
• 8:26
  SPEAKER_02: I'm gonna have to keep that on my short list.
• 8:28
  SPEAKER_02: That's a great surrogate marker.
• 8:31
  SPEAKER_00: Yeah, there's so many sort of acutely ill patients end up getting some sort of like vitamin panel or anemia panel.
• 8:37
  SPEAKER_00: And if those are within normal range, you know that that guts are working.
• 8:41
  SPEAKER_02: Yeah.
• 8:42
  SPEAKER_02: Another place where I get questions in this scenario or potential like people are a little bit uncomfortable, is with multidrug resistant organisms.
• 8:50
  SPEAKER_02: And, you know, specifically around like ESBL organisms and then pseudomonas or Voldemort, however you want to call it.
• 8:58
  SPEAKER_02: People don't like to say that word, I think.
• 9:00
  SPEAKER_02: But oral agents and conversion oral agents are really powerful in this setting as well, assuming that some of those basic principles of IV to PO are maintained.
• 9:08
  SPEAKER_02: Are they tolerating diet?
• 9:10
  SPEAKER_02: You know, some of the gut issues are squared away.
• 9:13
  SPEAKER_02: Are they clinically improving?
• 9:14
  SPEAKER_02: I feel like nitroferentolin and phosomycin have been really powerful tools for me in terms of ESBL cystitis and getting people out of the hospital without an IV line and IV antibiotics.
• 9:25
  SPEAKER_02: And then using not just CIPRO, but CIPRO appropriately dosed for pseudomonal infections and making sure that we've got adequate concentrations to be able to treat the infection with the oral agents that we have available to us.
• 9:37
  SPEAKER_01: Those are both great clinical pearls, and I appreciate your on the ground experience with answering these questions.
• 9:44
  SPEAKER_01: I think we're really empowered to be good advocates for IV to PO and the right patient, and it really does benefit our patients.
• 9:51
  SPEAKER_01: Speaking a little bit about the right dose of ciprofloxicin for conversion, are there any gaps in the data regarding IV to PO conversion that you'd like to have closed?
• 10:00
  SPEAKER_01: For example, specific drugs with less than 100% bioavailability, staph aureus bacteremia as another example.
• 10:07
  SPEAKER_00: Yeah, the area most common where I hedge in terms of recommendations, there are so many things that I'm pro switching to IB2PO and very brave in my approach and very clear in terms of a recommendation.
• 10:21
  SPEAKER_00: In the area of Staph aureus, being an MSSA or MRSA, it's a little bit murkier in terms of A, because Staph aureus is the absolute queen of infections and can destroy everything at her will anytime.
• 10:37
  SPEAKER_00: So they're I get more nervous about consequences of treatment of Staph aureus than I do.
• 10:44
  SPEAKER_00: You know, your run-of-the-mill E.
• 10:46
  SPEAKER_00: coli is different than the approach treatment for Staph aureus.
• 10:49
  SPEAKER_00: So when dealing with MRSA, I'm super comfortable switching to linazolid.
• 10:54
  SPEAKER_00: We've got really great data with Oviva and Poet that indicate that peeled linazolid is just as fine efficacy-wise.
• 11:01
  SPEAKER_00: And we know on the PK side that, you know, as long as there's not something abnormal in your guts, that's going to be 99% absorbed.
• 11:09
  SPEAKER_00: So in that situation, it's pretty easy to send people on the lanazolid.
• 11:12
  SPEAKER_00: Then they start having discussions about long-term lanazolid use and tolerance in the ADRs, which is fascinating in all in itself.
• 11:19
  SPEAKER_00: But that switch to PO linazol is an easy one.
• 11:22
  SPEAKER_00: Switching to PO beta-lactams for MSSA here is what I would say like a rather large gap in so many areas.
• 11:32
  SPEAKER_00: We have gaps for clinical data in terms of efficacy, and we have gaps for PK data.
• 11:37
  SPEAKER_00: Even though cephalexin is well absorbed, it's like 80%-ish, you know, bioavailable.
• 11:43
  SPEAKER_00: It's a dosing problem.
• 11:45
  SPEAKER_00: It's not an absorption problem, right?
• 11:47
  SPEAKER_00: So ANCF or cephasolin is dose one gram Q8 in-house or two grams Q8 in-house, depending on your sort of institutional specific.
• 11:55
  SPEAKER_00: So it's somewhere between three and six grams per day of this drug that we give.
• 12:00
  SPEAKER_00: And then when you switch to PO cephalexin, oftentimes the doses are like 500 Q12 or 500 Q8.
• 12:08
  SPEAKER_00: So you're going from a dose of three to six grams to one to one and a half grams a day.
• 12:13
  SPEAKER_00: And that is to me is the problem.
• 12:15
  SPEAKER_00: It's not the like bioavailability problem, it's the dosing problem.
• 12:19
  SPEAKER_00: And like that is not discussed enough.
• 12:21
  SPEAKER_00: Like so much emphasis is put on bioavailability, which is annoying because this is a basic like dosing problem.
• 12:29
  SPEAKER_00: But when you make recommendations like a gram of cephalxin QA, you know, and people are like, that sounds great.
• 12:36
  SPEAKER_00: Any PK data to support this?
• 12:38
  SPEAKER_00: And you're like, great question.
• 12:41
  SPEAKER_00: No.
• 12:43
  SPEAKER_00: But on paper, when I map it out, when I look at half-lifes and I look at serum concentrations, on paper, this is the regimen that makes sense for this.
• 12:52
  SPEAKER_00: And so I've got like back of the napkin scrawlings to sort of support my recommendation here, which is, I mean, it's works, but it's just not ideal, you know, when you want to like bring some really good evidence to the table.
• 13:04
  SPEAKER_00: Dr.
• 13:05
  SPEAKER_00: Patel, what about you?
• 13:06
  SPEAKER_00: Is this just a me conversation I'm having, or is this out in the field as well?
• 13:10
  SPEAKER_02: No, no, I am 100% the same.
• 13:13
  SPEAKER_02: I love your napkin scrawlings, I think you said.
• 13:16
  SPEAKER_02: I think it just shows the art of dosing here.
• 13:19
  SPEAKER_02: And this isn't just like a one size fits all thing.
• 13:21
  SPEAKER_02: I'm it you're really taking into consideration what is going on with the patient, the disease state you're trying to target and what is actually achievable with a tolerable side effect profile to make sure that you're getting somebody out on an appropriate regimen that's not going to allow the queen to rule and like set up colonies everywhere in somebody's body.
• 13:42
  SPEAKER_02: And so I 100% agree with you.
• 13:44
  SPEAKER_02: Something that's been interesting to me in the literature, and I'd love to get your take on this, is the role of boosters.
• 13:49
  SPEAKER_02: I've seen a number of papers here recently with preventicid.
• 13:52
  SPEAKER_02: And when I think about prevenicid, it's like way back even before my day, and I feel like I'm pretty old, in terms of boosting beta-lactam concentrations.
• 14:01
  SPEAKER_02: What do you think about that and potentially some of these types of agents filling the gap and allowing increased use of beta-lactams in this patient population?
• 14:10
  SPEAKER_00: I arguably have not really invested in this data.
• 14:14
  SPEAKER_00: And I would say that it's because the therapeutic range for beta-lactams is massive.
• 14:21
  SPEAKER_00: So I'm not nervous about giving more beta-lactam to somebody, right?
• 14:25
  SPEAKER_00: So it's we don't have a maximum tolerability PO-wise like Clinda does, right?
• 14:31
  SPEAKER_00: So like after 450, everyone barfs their guts up.
• 14:34
  SPEAKER_00: So there's like no way that we can get more Clinda in them.
• 14:37
  SPEAKER_00: But I've never had that outside of a mox clav, right?
• 14:40
  SPEAKER_00: So a mox clav definitely has definitely has a dose ceiling because of the significant diarrhea associated with clav.
• 14:47
  SPEAKER_00: But in terms of like oral cephalosporins, for instance, I'm totally comfortable giving them as much cephalosporin as possible.
• 14:55
  SPEAKER_00: Now, where you where probenicid could be a winner has to do with adherence, right?
• 15:00
  SPEAKER_00: So like if you've got a patient that can't do two or three times a day dosing, maybe that is where probenicid might be more helpful.
• 15:08
  SPEAKER_00: I recognize that like no one takes pills through two or three times a day, but I don't know if that's necessarily true for short-term meds, right?
• 15:16
  SPEAKER_00: So like for short-term meds, if you are still feeling sick, you are definitely going to take your antibiotics because you feel terrible.
• 15:25
  SPEAKER_00: And then honestly, if by the time that you feel okay and you forget to take your antibiotics, great, wonderful, shorter duration of care for you, better for the microbiome, better for the whole sort of like everyone getting back to wild type.
• 15:37
  SPEAKER_00: So those sort of things I'm fine with, but it's an interesting, like another sort of avenue to think about in terms of changing the PK.
• 15:45
  SPEAKER_02: No, absolutely.
• 15:46
  SPEAKER_02: And I'm really glad you brought up cephalosporins as well, because this is a particular research interest of mine.
• 15:51
  SPEAKER_02: You know, there's variable data about the cephalosporins and potential inferior activity, which ones you can use, which ones you can use.
• 15:59
  SPEAKER_02: And so this is like my jam right now, definitely.
• 16:03
  SPEAKER_02: So my standpoint is if we look at some of the trials that showed a failure and you look at some of the doses that were used in those studies, we're giving 500 VID of Keflex, which to me is 100% garbage dose.
• 16:15
  SPEAKER_02: I don't even know what's the point for treating an invasive infection, kind of getting back to what you were talking about with the Staph aureus bacteremia, right?
• 16:22
  SPEAKER_02: So what we actually did as a part of my wonderful resident, Sony Carr, she should definitely get a shout-out for this.
• 16:28
  SPEAKER_02: Her residency project this year is we looked at a multi-center retrospective propensity score-matched cohort to look at gram-negative bacteremias and step-down therapy to fluoroquinolones and bacterum, which are our traditional high bioavailability agents.
• 16:44
  SPEAKER_02: And then we also looked at third-generation cephalosporins because it kind of takes that dosing question out of it.
• 16:50
  SPEAKER_02: And we found non-inferiority.
• 16:52
  SPEAKER_02: There is no difference in outcomes in terms of 30-day readmissions or reinfections with our beta-lactam arm versus our fluoroquinolone bactrum arm.
• 17:01
  SPEAKER_02: And so I think that, you know, as people really start to look at these like oldy but goody drugs and how we can bring them back into play in a much bigger way.
• 17:11
  SPEAKER_02: I'm excited for more of this kind of data to come out to really kind of help us with our arsenal arm inventarium at the bedside and what we can use for people.
• 17:21
  SPEAKER_02: I'm an options kind of girl.
• 17:22
  SPEAKER_02: I like every option available if possible.
• 17:24
  SPEAKER_00: 100% right.
• 17:25
  SPEAKER_00: There's always the one patient that, like, you know, has an ampicill analogy.
• 17:29
  SPEAKER_00: So maybe I don't want to use Keflex, maybe I need to use a third gen cellusporin, speaking to my own favorite topic in the world.
• 17:36
  SPEAKER_00: The interesting thing here, also in terms of like dosing and matching PK of the IV equivalent, super important data is needed.
• 17:45
  SPEAKER_00: The other argument that I've had with folks is does it even matter?
• 17:50
  SPEAKER_00: So, like after you've had three to five days of antibiotics of IV antibiotics, is there a lot of importance on what has been called like mop-up therapy or sort of like leftover, you know, straggling bacteria in the, you know, around, or is it even needed at all and where the immune system is probably gonna just take care of this?
• 18:11
  SPEAKER_00: There's not really an antibiotic need, especially if there's resolutions in signs and symptoms, meaning that there's not an inoculum that's resulting in signs and symptoms, therefore the inoculum is low enough to where the immune system can handle it again.
• 18:23
  SPEAKER_00: So I think there's a decent amount of pushers is like you're up in arms about trying to match this Ivy version, and this is just like so much effort without needed, because none of this matters, anyways, because they've already received the efficacy, the big bulk of their treatment in the first three, five days, et cetera, of Ivy therapy.
• 18:43
  SPEAKER_00: And I think this applies to anything outside of the goddess Staph Warreus, right?
• 18:48
  SPEAKER_00: So she is arguably, there's no real mop-up therapy, I suppose, with her.
• 18:54
  SPEAKER_00: And that that is a really important thing.
• 18:56
  SPEAKER_00: But the other one, you know, simple gram negatives, cystitis, often, you know, like skin, right?
• 19:01
  SPEAKER_00: So, like those are sort of things where you're thinking, is this much ado about nothing?
• 19:04
  SPEAKER_00: Do I really need to get into a pickle?
• 19:06
  SPEAKER_00: And which is why we probably haven't been pushed for a ton of PK data in this area because clinical efficacy is really high for even garbage doses, as you said, for like 500 Q12 of a cephalosporin, that efficacy is still high.
• 19:21
  SPEAKER_00: And arguably it could be because that dosing works, or these antibiotics aren't even necessary.
• 19:27
  SPEAKER_02: And I feel like this is so supported by all of the shorter, it was better data coming out.
• 19:32
  SPEAKER_02: Trial after trial continues to say that shorter regimens are just as efficacious as longer ones.
• 19:38
  SPEAKER_02: We've got a piles of studies now supporting the duration.
• 19:42
  SPEAKER_02: And then specifically, if you look at like intra-abdominal infections and like the stop it trial, source control was the key.
• 19:48
  SPEAKER_02: You know, what is really three to four days of antibiotics post-removal of like an appendix or a dirty gallbladder really doing in the big scheme of things?
• 19:56
  SPEAKER_02: And especially with empiric therapy and using fluoroquinolones in some of those trials where we know that the empiric susceptibilities are garbage anyway.
• 20:05
  SPEAKER_02: So, you know, 60, 70%, what is it even doing anyway, without cultures to go along with it?
• 20:11
  SPEAKER_01: Right, absolutely.
• 20:13
  SPEAKER_01: I'm loving this discussion.
• 20:14
  SPEAKER_01: I think you've gone great detail about where, you know, we're missing some data about the nuances of you know which agent and what dose.
• 20:21
  SPEAKER_01: And I think you've addressed that really well.
• 20:23
  SPEAKER_01: And then you've also taken a step back and been like, okay, you know, I could get lost in the weeds here of the nuances of exactly this drug and this dose and and this population at a high level.
• 20:34
  SPEAKER_01: You know, we really are also needing to look at, you know, how long are they on IV, how much are they clinically improved.
• 20:40
  SPEAKER_01: And so I think we can have a lot of value in antimicrobial stewardship talking about IVPO in this bigger context of making sure that we we limit unnecessary therapy.
• 20:51
  SPEAKER_01: So it's not just efficacy, but now we're talking about safety, right?
• 20:55
  SPEAKER_01: Like these, but we we don't know if they're more effective to do these, but it clearly can increase harm for every additional day of unnecessary you know, antibiotics that we're giving.
• 21:05
  SPEAKER_01: And so I think it's a really valuable conversation.
• 21:07
  SPEAKER_01: In my experience, you know, we've implemented an automatic IV to PO protocol by pharmacists here, which can actually be more challenging than you would think to implement one of those.
• 21:17
  SPEAKER_01: You know, I think there's a still a desire to have a conversation with the provider.
• 21:21
  SPEAKER_01: But this is a really important topic to switch people from IV to PO early to avoid unnecessary IV therapy.
• 21:28
  SPEAKER_01: How have you implemented IV to PO conversion at your institution?
• 21:32
  SPEAKER_01: Any suggestions that you have?
• 21:34
  SPEAKER_01: Perhaps there's a big success intervening to switch patients to oral therapy that you'd like to share with us?
• 21:39
  SPEAKER_02: Dr.
• 21:40
  SPEAKER_02: Patel, would you like to go first?
• 21:42
  SPEAKER_02: I certainly can.
• 21:43
  SPEAKER_02: So we have implemented IV to PO, and I think the protocol probably looks like everybody else's protocol in the entire country.
• 21:50
  SPEAKER_02: Like there's not much like variation, right?
• 21:52
  SPEAKER_02: Like there's the list of drugs that are highly bioavailable.
• 21:55
  SPEAKER_02: You've got your list of clinical considerations that have to be met.
• 22:00
  SPEAKER_02: I think for me the bigger challenge is getting compliance with the protocols.
• 22:04
  SPEAKER_02: There are so many patients that we have the opportunity to switch that we don't take advantage of doing that conversion early enough.
• 22:12
  SPEAKER_02: And so I think two big successes for me.
• 22:15
  SPEAKER_02: One would be looking at our IB to PO conversion in disease states where we're not going to get cultures where we can just make equal switches and be able to move on.
• 22:26
  SPEAKER_02: I think pneumonia is a great example of that.
• 22:28
  SPEAKER_02: Our typical regimens are azithromyosin or a beta-lactam plus or minus azithromyosin.
• 22:34
  SPEAKER_02: And so both of those can be easily converted to something that the patient can finish up on and head out.
• 22:39
  SPEAKER_02: And, you know, the earlier we can do that, I think the better our patients off are cellulitis.
• 22:44
  SPEAKER_02: If they have risk factors for MRSA or their MRSA PCR is positive, there's why do we need to continue vain?
• 22:50
  SPEAKER_02: You know you're not going to get cultures for like a non-purulent cellulitis.
• 22:53
  SPEAKER_02: Go ahead and move them to Bactrum, Doxy, Linazolid, whatever is available to you.
• 22:58
  SPEAKER_02: And let's make that active conversion and get them out the door.
• 23:02
  SPEAKER_02: And I think those kinds of switches are really near and dear to me because it kind of goes back to the length of stay stuff that I was talking about.
• 23:08
  SPEAKER_02: Nobody cares about cost anymore.
• 23:10
  SPEAKER_02: And if we look at how much antibiotics cost, it, you know, I'd have to stop like a thousand pancomyosins to make any sort of dent in something, which I'm not going to do, right?
• 23:19
  SPEAKER_02: So, like my new focus is how can I improve patient safety and quality?
• 23:24
  SPEAKER_02: And my best way is to get them out the door on a streamlined regimen as much as humanly possible.
• 23:29
  SPEAKER_02: And that's really getting them back to these oral regimens and getting them out the door.
• 23:34
  SPEAKER_00: 104, like 100% on board with like duration, safety, quality being part of this, that being actually like the nugget of this conversation rather than this relatively simple intervention that I think can get overlooked.
• 23:49
  SPEAKER_00: We have the standard, you know, IB2PO protocol that includes GI H2 blockers, PPIs, some vitamins, and then anti-infectives in there.
• 23:58
  SPEAKER_00: I think it's probably underutilized as a tool because we have a relatively hands-on approach of clinical pharmacists that are have close interacting relationships and following patients within the team.
• 24:10
  SPEAKER_00: And so I think it's way more common for us to switch to PO through direct recommendation, either through secure chat or in person.
• 24:17
  SPEAKER_00: So that's almost always how it's done rather than using the intervention.
• 24:21
  SPEAKER_00: I think scope-wise, to better improve IB2PO switches, it wouldn't be to focus your efforts on the IB2PO protocol, but actually within the infectious treatment pathways.
• 24:33
  SPEAKER_00: So almost all institutions have a pathway that at least are on stewardship checkbox of CMS.
• 24:39
  SPEAKER_00: If you put the PO antibiotics in that pathway, you can empower prescribers to feel comfortable that regardless of how your patient is doing, you know, they might still have a fever.
• 24:49
  SPEAKER_00: That's fine.
• 24:50
  SPEAKER_00: PO antibiotics don't care if there is a fever.
• 24:53
  SPEAKER_00: They have not called in to say they're not working if in the setting of a fever.
• 24:57
  SPEAKER_00: They have not called to say they're not working in the setting of an elevated white count.
• 25:01
  SPEAKER_00: So like those sort of like clinical barriers that exist on, I think, most IB2PO conversions, like that makes no clinical sense.
• 25:09
  SPEAKER_00: PK doesn't care about that.
• 25:11
  SPEAKER_00: So in those settings, if you put them in the pathway, I think you can empower people that like PO antibiotics are just as good in this, you know, regardless of how your patient is sort of responding clinically, that you can switch them over to anything.
• 25:25
  SPEAKER_00: As long as, again, ideally based on you know data and PK, efficacy data and PK data.
• 25:31
  SPEAKER_00: But yeah, I think that's the intervention to really empower this or to really increase the scope of PO conversion is to put those in those treatment pathways.
• 25:40
  SPEAKER_01: Yeah, I completely agree.
• 25:41
  SPEAKER_01: I think we talk a lot in stewardship about integrating into the workflow.
• 25:45
  SPEAKER_01: You know, adding on the protocol sometimes just adds something else to the list.
• 25:48
  SPEAKER_01: It's not integrated into the workflow.
• 25:50
  SPEAKER_01: And so I love this discussion about integrating into clinical pathways, switched to oral therapy.
• 25:56
  SPEAKER_00: And that was a huge win for us when we switched over uh skin and pneumonia to where lanasolid was a first-line option for patients with mRSA risk factors or PCR, nasal MRSA, PCR positive patients, is that you can using lanazolid early, oftentimes they'll get like maybe a dose of IB in the ED, but we can switch those patients to PO immediately, you know, even in the setting of like being sick, like looking infected and acting infected.
• 26:26
  SPEAKER_00: So that has certainly helped.
• 26:27
  SPEAKER_00: And there's a trickle-down effect, right?
• 26:29
  SPEAKER_00: So like if this works, other PO antibiotics might also work in the setting.
• 26:33
  SPEAKER_00: So a lot of it's about confidence, sort of like faith, you know, that that this is going to happen, considering that we're working against, I don't know, 60 years of IV being the better choice and PO being the sort of like only for the not sick patients.
• 26:48
  SPEAKER_00: So yeah, we're fighting a lot of history here.
• 26:51
  SPEAKER_02: So glad you bring that up about this perception of sick patients.
• 26:55
  SPEAKER_02: Sick does not equal multi-drug resistant organisms that warrant continued IV therapy.
• 27:00
  SPEAKER_02: And I feel like this is a battle I am fighting all the time.
• 27:03
  SPEAKER_02: Like, just because they look wrecked does not mean that we continue Ivy antibiotics.
• 27:10
  SPEAKER_02: Like, is it a source control issue?
• 27:12
  SPEAKER_02: Like, what else is going on that is keeping this person this sick?
• 27:15
  SPEAKER_02: Because I promise it's nine out of 10 times it is not multidrug resistant organisms when we finally are able to isolate something.
• 27:22
  SPEAKER_02: It's because we didn't do the surgery or there was something there that we didn't know about.
• 27:26
  SPEAKER_02: And then they just de-escalate and do fine on very narrow and then oral regimens.
• 27:32
  SPEAKER_02: Completely agree.
• 27:33
  SPEAKER_01: I think that wraps up our time for today.
• 27:36
  SPEAKER_01: Thank you so much, Dr.
• 27:37
  SPEAKER_01: Jeffries and Patel, for such a great conversation.
• 27:40
  SPEAKER_01: It was a pleasure having both of you here today.
• 27:43
  SPEAKER_00: It was a pleasure and an honor to be asked as a Shea member and a listener to the podcast.
• 27:48
  SPEAKER_00: I couldn't be more excited to be like part of the crew that's putting out such great content.
• 27:53
  SPEAKER_02: Oh, absolutely.
• 27:54
  SPEAKER_02: Dr.
• 27:55
  SPEAKER_02: Jeffries, you are a rock star.
• 27:56
  SPEAKER_02: Dr.
• 27:57
  SPEAKER_02: Russell.
• 27:58
  SPEAKER_02: Thank you for giving me the opportunity to have such like a great just conversation about something that seems so simple, but is really not, and be able to kind of share some of the things that we've done around it.
• 28:09
  SPEAKER_02: So I've really enjoyed today.
• 28:10
  SPEAKER_02: I hope you guys did too.
• 28:11
  SPEAKER_01: Yes, for sure I did.
• 28:13
  SPEAKER_01: You can find more educational content like this podcast on Shay's Online Education Center, Learning CE, at www.learningce.shay online.org.
• 28:25
  SPEAKER_01: This concludes today's episode of the antimicrobial stewardship popery series.
• 28:28
  SPEAKER_01: Thank you for tuning in.