Criteria to Achieve Safe Antimicrobial Intravenous-to-Oral Switch in Hospitalised Adult Populations: A Systematic Rapid Review

Abstract

Introduction: Antimicrobial stewardship and patient safety strategies include early intravenous-to-oral switch (IVOS) for antimicrobials. Aim: This rapid review aimed to assess and collate IVOS criteria from the literature to achieve safe and effective antimicrobial IVOS in the hospital inpatient adult population. Method: The rapid review follows the PRISMA statement and is registered with PROSPERO. Systematic literature searches were conducted. Articles of adult populations published between 2017-2021 were included. IVOS criteria from UK hospital IVOS policies were categorised to inform the framework synthesis of the literature criteria. Results: IVOS criteria from 45/164 (27%) UK IVOS policies were categorised into a 5-section framework: 1-Timing of IV antimicrobial review, 2-Clinical signs and symptoms, 3-Infection markers, 4-Enteral route, and 5-Infection exclusions. The literature search identified 477 papers, of which 16 were included. The most common timing for review was 48-72 hours from initiation of intravenous antimicrobial (n=5, 30%). Nine studies (56%) stated clinical signs and symptoms must be improving. Temperature was the most frequently mentioned infection marker (n=14, 88%). Endocarditis had the highest mention as an infection exclusion (n=12, 75%). Overall, 33 IVOS criteria were identified to go forward into the Delphi process. Conclusion: Through the rapid review, 33 IVOS criteria were collated and presented within 5 distinct and comprehensive sections. The literature highlighted the possibility of reviewing IVOS before 48-72 hours, and of presenting HR, BP and RR as a combination early warning score criterion. The criteria identified can serve as a starting point of IVOS criteria review for any institution globally, as no country or region limits were applied. Further research is required to achieve consensus on IVOS criteria from healthcare professionals that manage patients with infections.

A Delphi Process for Reaching Nationwide Consensus on Antimicrobial Intravenous-to-oral Switch Criteria and Development of an Antimicrobial Intravenous-to-oral Switch Decision Aid

“…The IVOS criteria introduced at Step One of the Delphi process were extracted from a combination of literature evidence, individual hospital IVOS policies and expert advice (see Supplementary Information). 20 The Delphi process is a widely accepted technique to achieve group consensus, 25 allows for participant anonymity and consideration of a breadth of expertise across wide geographical locations. 26…”

“…The IVOS criteria introduced at Step One of the Delphi process were extracted from a combination of literature evidence, individual hospital IVOS policies and expert advice (see Supplementary Information ). 20…”

“…Initial IVOS criteria identified from the published literature, 20 a purposive sample of UK hospitals and expert opinion, were formatted into questions with 5-point Likert scale responses using Microsoft Forms (see Supplementary Information ). Additional answer options included ‘Not applicable’ and ‘I don’t know’ The collated IVOS criteria were grouped into 5 sections: 1) Timing of intravenous (IV) antimicrobial review , 2) Clinical signs and symptoms , 3) Infection markers , 4) Enteral route , and 5) Infection exceptions .…”

“…18 Hospital care settings have developed individualised IVOS policies, 19 and within one country alone, criteria for timely IVOS varies considerably and lacks national consensus for standardisation. 20 The aim of this initiative was to achieve nationwide consensus on antimicrobial IVOS criteria for safe and effective timely switch in hospitalised adult patients (over 18 years of age) receiving intravenous antimicrobial therapy. A secondary objective was to design a decision aid to operationalise agreed IVOS criteria for use in the hospital care setting.…”

“…Hospital care settings have developed individualised IVOS policies, 19 and within one country alone, criteria for timely IVOS varies considerably and lacks national consensus for standardisation. 20…”