Guidance

Antimicrobial IVOS decision aid for adults: text alternative

Updated 4 April 2024

This antimicrobial intravenous-to-oral switch (IVOS) decision aid was co-produced through a UK-wide consensus process involving 279 multidisciplinary participants.

Why use this IVOS decision aid

IVOS is an important antimicrobial stewardship intervention (1 and 2). Research evidence confirms several IVOS benefits, including decreased risk of bloodstream and catheter-related infections, reduced equipment costs, carbon footprint and hospital length-of-stay, increased patient mobility and comfort, and released nursing time to care for patients (3 and 4).

When to use this IVOS decision aid

The audit standard recommended for the implementation of this decision aid is that all patients on intravenous (IV) therapy should be reviewed promptly from first dose of IV antimicrobial with formal review completed within 48 hours and daily thereafter, unless clearly documented exemptions.

IVOS decision aid

Does your patient have an infection that may require special consideration?

Infections that may require special consideration include: deep-seated infections, infections requiring high tissue concentration, infections requiring prolonged intravenous antimicrobial therapy or critical infections with high risk of mortality.

To note: on specialist advice, an IVOS within 48 hours may still be indicated for some patients with these infections.

Infections for special consideration include, but are not limited to:

• bloodstream infection
• empyema
• endocarditis
• meningitis
• osteomyelitis
• severe or necrotising soft tissue infection
• septic arthritis
• undrained abscess

If yes to any of the above infections, then check for clearly documented plan or seek specialist advice.

If no to any of the above infections, then continue through decision aid.

1a. Enteral route

1.1 Is the patient’s gastrointestinal tract functioning, for example, no evidence of malabsorption?

1.2 Is the patient’s swallow or enteral tube administration safe?

If no to any of those questions, reassess patient in 24 hours.

If yes to any of those questions, continue through decision aid.

1b. Enteral route continued

1.3 Are there any significant concerns over patient adherence to oral treatment?

1.4 Has the patient vomited within the last 24 hours?

If yes to any of those questions, reassess patient in 24 hours.

If no to any of those questions, continue through decision aid.

2. Clinical signs and symptoms

2.1 Are the patient’s clinical signs and symptoms of infection improving?

If no to this question, reassess patient in 24 hours.

If yes to this question, continue through decision aid.

3. Infection markers

3.1 Has the patient’s temperature been between 36 to 38°C for the past 24 hours? There is a space next to the question for the user to write the temperature.

3.2 Is the patient’s Early Warning Score (EWS) decreasing? There is a space next to the question for the user to write the EWS.

3.3 Is the patient’s white cell count (WCC) trending towards the normal range? There is a space next to the question for the user to write the WCC.

3.4 Is the patient’s C-reactive protein (CRP) decreasing? There is a space next to the question for the user to write the CRP.

If yes to question 3, prompt or assess for switch.

If no to questions 3, reassess in 24 hours.

Prompt for switch

Nursing or pharmacy teams to prompt prescriber or infection specialist to consider IVOS.

Assess for switch

Prescriber or infection specialist to consider IVOS. Identify whether a suitable oral switch option is available, considering for example oral bioavailability, any clinically significant drug interactions, patient allergies or contra-indications.

At the bottom of the decision aid, there is space for the user to write the following:

• intravenous antimicrobial initiation: date, time, name of assessor

• IVOS first assessment (daily thereafter): date, time, name of assessor

• IVOS: date, time, name of assessor

To note: These infection markers could also indicate inflammation or be affected by for example, steroid treatment, ‘Prompt for switch’ or ‘Assess for switch’ may still occur if they are the only markers not met.

This form is Version 1, dated January 2023.

References

1. Goff DA, Bauer KA, Reed EE, and others. Is the ‘low-hanging fruit’ worth picking for antimicrobial stewardship programs? Clinical Infectious Diseases, 2012. 55(4): pages 587 to 592

2. Public Health England. Start Smart – Then Focus: Antimicrobial stewardship toolkit for English hospitals. 2015 (date accessed: August 2022)

3. Nguyen AD, Mai-Phan TA, Tran MH, and others. The effect of early switching from intravenous to oral antibiotic therapy: a randomized controlled trial. Journal of Pharmacy and Pharmacognosy Research, 2021. 9(5): pages 695 to 703

4. Schuts EC, Hulscher M, Mouton JW, and others. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. The Lancet Infectious Diseases, 2016. 16(7): pages 847 to 856