Ryan Mills, a pharmacist candidate, evaluated implementing a program at Charleston Area Medical Center to switch patients earlier from intravenous to oral antibiotics based on certain criteria. In a study of 25 patients with community-acquired pneumonia, 13 met criteria for early switch, which could have resulted in over $400 in direct cost savings annually. The goals of the program were to maintain or improve outcomes while decreasing costs of IV drugs and patient care. A follow-up evaluation of 30% of patients switched found 100% cure rates with average cost savings of $44 per patient and decreased length of IV therapy.

1. RYAN MILLS, PHARM.D CANDIDATE Pharmacist role in MTM at Charleston Area Medical Center Switching patients Intravenous to oral

2. Quick Overview Goals Background Information Drug Utilization Evaluation Policy and Procedures Follow-up Evaluation Conclusions Questions

3. Goals Maintain or improve patient outcomes Decrease overall cost of target IV drugs Decrease overall cost of patient care

4. Background Information Potential Benefits Decrease indirect costs Decrease direct costs Increase patient satisfaction Decrease risk iatrogenic disease Decreased risk adverse reactions to IV therapy Patients ambulate sooner Previous Programs Cure rates of 98-100% Decreased length of stay by 1.5-2 days Approximately 50% of patients on IV antibiotics may be eligible for early switch Direct and Indirect cost savings

5. Drug Utilization Evaluation 25 patients evaluated 1 month CAP 13 of the patients met criteria for early switch 9 would have been switched with the program Estimated $463.58 in direct cost savings Estimated $6700 per year for CAP 4 were converted early by physician Average length of stay 6.5 days Average length of IV therapy 4.5 days

6. Criteria for Switch Inclusion Adequate oral intake and absorption Afebrile for at least 24 hours Documented improvement in signs and symptoms White blood cells normalizing and <15/mm 3 Has Received 48 hours of IV antibiotics Exclusion Neutropenia or Immunocompromised Infections requiring prolong treatment with IV antibiotics Nausea/Vomiting Ileus or Bowel obstructions NPO orders ICU Admission

7. Switch Therapy IV antibiotics Ampicillin Amp/Sulbactam Cefazolin Cefuroxime Ceftazidime Ceftriaxone Ciprofloxacin Gatifloxacin Metronidazole Clindamycin Gentamicin Fluconazole PO antibiotics Amoxicillin Amoxicillin/Clav. Cephalexin Cefuroxime Ciprofloxacin Gatifloxacin Ciprofloxacin Gatifloxacin Metronidazole Clindamycin Ciprofloxacin Fluconazole

8. Policy and Procedures Proposal to P&T committee Medical Center Memorandum Medical Staff Council Scope of Practice Presentation at medical noon conference Physician Acceptance

9. Methods

10. Follow-up Evaluation 30% of 63 evaluated patients were switched 100% cure rates Average cost to treat CAP during DUE $130.60 Average cost to treat CAP with switch program $86.40 Average length of stay 6.4 days Average length of IV therapy 2.6 days Adverse outcomes

11. Limitations Limited duration of evaluation Confounding factors involved with length of stay Changes in formulary antibiotics potentially inflating cost savings Difficult to estimate indirect cost savings

12. Conclusion Maintenance of this program should result in direct cost savings for this institution Patient safety initially appears to be maintained Further evaluation over a year would be useful

13. References Ahkee Sunket. Early Switch from Intravenous to Oral Antibiotics in Hospitalized Patients with Infections: A 6-Month Prospective Study. Pharmacotherapy. 1997;17(3):569-575 Elbe Dean, et al. Use of cefixime in an IV to oral stepdwn program to reduce antimicrobial costs. Formulary. 1998;3354-63. Fraser Giles L., et al. Antibiotic Optimization: An Evaluation of Patient Safety and Economic Outcomes. Arch Intern Med. 1997;157:1689-1694. Przybylski Kevin G., et al. A Pharmacist-Initiated Program of Intravenous to Oral Antibiotic Convesion. Pharmacotherapy. 1997;17(2):271-276 Ramirez Julio A. Managing Antiinfective Therapy of Community-Acquired Pneumonia in the Hospital Setting: Focus on Switch Therapy. Pharmacotherapy. 2001;27(7Pt2):79S-82S