Transition from intravenous to oral antimicrobial therapy in patients with uncomplicated and complicated bloodstream infections

Abstract

Background: The role of oral antimicrobial agents in the management of bloodstream infections (BSI) is currently evolving. Objectives: This narrative review summarizes and appraises clinical studies that examined transition from intravenous to oral antimicrobials or compared effectiveness of various oral agents for definitive therapy of uncomplicated and complicated BSI in adults. Sources: Relevant English-language studies from MEDLINE (since inception) and presented abstracts at international scientific meetings (since 2017). Content: Emerging data suggest potential utility of oral switch strategy, particularly to oxazolidinones, as an alternative to standard intravenous therapy in low-risk patients with uncomplicated Staphylococcus aureus BSI. Moreover, results of recent randomized clinical trials are promising that combination oral regimens may play a role in antimicrobial management of complicated Gram-positive BSI, including infective endocarditis, septic arthritis and osteomyelitis. Whereas oral fluoroquinolones have been used successfully for decades in both uncomplicated and complicated Gram-negative BSI, recent studies suggest that trimethoprim-sulfamethoxazole and aminopenicillins represent alternative oral options in uncomplicated Enterobacteriaceae BSI. Oral azoles have been used for definitive therapy of Candida species BSI and are currently recommended by the international management guidelines. Implications: Recent studies demonstrate that early transition from intravenous to oral therapy is a feasible and effective strategy in most patients with BSI due to Gram-negative bacteria, obligate anaerobic bacteria and Candida species. Oral antimicrobial combinations may be considered in select patients with complicated Gram-positive BSI after 10e14 days of intravenous therapy. Future studies will determine the role of oral agents for switch therapy in uncomplicated Gram-positive BSI.

Oral Fluoroquinolone or Trimethoprim-Sulfamethoxazole vs ß-Lactams as Step-Down Therapy for Enterobacteriaceae Bacteremia: Systematic Review and Meta-analysis

“…Several studies have indicated the safety and benefits of oral step-down therapy after an initial IV antibiotic course for the treatment of gram-negative bacteremia [13]. Fluoroquinolones are the most frequent choice for this purpose given their favorable pharmacokinetics and pharmacodynamics (PK/PD), that is, excellent bioavailability that enables high serum levels, coupled with concentration-dependent inhibition and killing.…”

Update on Acute Bone and Joint Infections in Paediatrics: A Narrative Review on the Most Recent Evidence-Based Recommendations and Appropriate Antinfective Therapy

“…Trials conducted by Peltola et al showed a failure rate under 1% at follow-up [ 64 ]. Trimethoprim/sulfamethoxazole (TMP/SMX) has been successfully used in oral treatment of BJI in children [ 72 , 73 , 74 ]. The duration of oral therapy in uncomplicated BJIs is frequently approximately 3–4 weeks with rigorous monitoring of inflammatory markers and drug tolerability [ 32 ].…”

Direct Measurement of Performance: A New Era in Antimicrobial Stewardship

“…Rather, it is based on effectiveness as derived from large clinical studies and involves receiving an appropriately dosed agent based on the primary source of infection, the patient’s renal and hepatic function, and the minimal inhibitory concertation of the clinical isolate. The antimicrobial should also be administered via the appropriate route based on severity of infection, reliability of the enteral route, and bioavailability of the agent [58,59,60].…”