Effectiveness of antimicrobial stewardship interventions on early switch from intravenous-to-oral antimicrobials in hospitalized adults: A systematic review


      • This systematic review summarized the evidence available on ASPs to improve IV-to-PO antimicrobial switch therapy.
      • All interventions on IV-to-PO antimicrobial switch reported in the literature were listed and described.
      • The study demonstrated that all the interventions shown to be effective and safe.
      • Interventions on IV-to-PO antimicrobial switch were associated with a significant reduction in costs.



      This review aimed to summarize the available evidence on the effectiveness and safety of antimicrobial stewardship interventions to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults.


      Following the PRISMA guidelines, we searched Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE/PubMed, and Scopus from inception to September 1, 2020, for original articles investigating any interventions aimed to improve the practice of IV-to-PO antimicrobial switch therapy in hospitalized adults with infectious diseases. We included randomized controlled trials (RCTs) and quasi-experimental studies. Studies were excluded if they evaluated drugs other than antimicrobials, head-to-head comparison of interventions, included pediatrics or oncology patients.


      Of 506 unique citations identified, 36 studies met the inclusion criteria. The 36 included studies reported 92 interventions as a single (n = 10) or a bundle of interventions (n = 26). The most common interventions used were guideline/protocol/pathway (n = 25), audit and feedback (n = 20), and education (n = 17).


      This review provides health care providers with a comprehensive summary on the interventions to promote IV-to-PO antimicrobial switch. While no one intervention could be identified as the safest and most effective as most of the included studies used a bundle of interventions, all interventions resulted in optimizing antibiotic use and reducing health care expenditures without compromising the clinical outcomes. As such, each hospital should design and utilize interventions that are applicable based on available resources and expertise.

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        • Sevinç F
        • Prins JM
        • Koopmans RP
        • et al.
        Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital.
        J Antimicrob Chemother. 1999; 43: 601-606
        • Porto APM
        • Goossens H
        • Versporten A
        • et al.
        Global point prevalence survey of antimicrobial consumption in Brazilian hospitals.
        J Hosp Infect. 2020; 104: 165-171
        • Ingram PR
        • Seet JM
        • Budgeon CA
        • Murray R.
        Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital.
        Intern Med J. 2012; 42: 719-721
        • Erbay AE
        • Colpan A
        • Bodur H
        • Cevik MA
        • Samore MH
        • Ergonul O.
        Evaluation of antibiotic use in a hospital with an antibiotic restriction policy.
        Int J Antimicrob Ag. 2003; 21: 308-312
        • Abubakar U.
        Antibiotic use among hospitalized patients in northern Nigeria: a multicenter point-prevalence survey.
        Bmc Infect Dis. 2020; 20: 1-9
        • Zeng SS
        • Wang D
        • Yan YL
        • et al.
        Single-center analysis of the potential inappropriate use of intravenous medications in hospitalized patients in China.
        Clin Ther. 2019; 41: 1631-1637
        • Mahatumarat T
        • Pinmanee N
        • Injai W
        • Chaiwarith R.
        Inappropriateness of intravenous antibiotic prescriptions at hospital discharge at a tertiary care hospital in Thailand.
        Drug Healthc Patient. 2019; 11: 125-129
        • Kawanami GH
        • Fortaleza CMCB.
        Factors predictive of inappropriateness in requests for parenteral antimicrobials for therapeutic purposes: A study in a small teaching hospital in Brazil.
        Scand J Infect Dis. 2011; 43: 528-535
        • Cyriac JM
        • James E.
        Switch over from intravenous to oral therapy: A concise overview.
        J Pharmacol Pharmacother. 2014; 5: 83-87
        • Ramirez JA
        • Vargas S
        • Ritter GW
        • et al.
        Early switch from intravenous to oral antibiotics and early hospital discharge - A prospective observational study of 200 consecutive patients with community-acquired pneumonia.
        Arch Intern Med. 1999; 159: 2449-2454
        • Fine MJ
        • Pratt HM
        • Obrosky DS
        • et al.
        Relation between length of hospital stay and costs of care for patients with community-acquired pneumonia.
        Am J Med. 2000; 109: 378-385
        • Davey P
        • Marwick CA
        • Scott CL
        • et al.
        Interventions to improve antibiotic prescribing practices for hospital inpatients.
        Cochrane Database Syst Rev. 2017; 2CD003543
        • Dellit TH
        • Owens RC
        • McGowan JE
        • et al.
        Infectious diseases society of America and the society for health care epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship.
        Clin Infect Dis. 2007; 44: 159-177
      1. Iosifidis E, Quattrocchi A, Monnet D, Weist K, Catchpole M. Proposals for EU guidelines on the prudent use of antimicrobials in humans, ECDC. 2017;16:64.

        • CDC
        Core Elements of Hospital Antibiotic Stewardship Programs.
        US Department of Health and Human Services, CDC, Atlanta, GA2019
        • Mertz D
        • Koller M
        • Haller P
        • et al.
        Outcomes of early switching from intravenous to oral antibiotics on medical wards.
        J Antimicrob Chemoth. 2009; 64: 188-199
        • Berrevoets MAH
        • Pot J
        • Houterman AE
        • et al.
        An electronic trigger tool to optimise intravenous to oral antibiotic switch: a controlled, interrupted time series study.
        Antimicrob Resist Infect Control. 2017; 6: 017-0239
        • Beeler PE
        • Kuster SP
        • Eschmann E
        • Weber R
        • Blaser J.
        Earlier switching from intravenous to oral antibiotics owing to electronic reminders.
        Int J Antimicrob Ag. 2015; 46: 428-433
        • Vouloumanou EK
        • Rafailidis PI
        • Kazantzi MS
        • Athanasiou S
        • Falagas ME.
        Early switch to oral vs intravenous antimicrobial treatment for hospitalized patients with acute pyelonephritis: a systematic review of randomized controlled trials.
        Curr Med Res Opin. 2008; 24: 3423-3434
        • Park TY
        • Choi JS
        • Song TJ
        • Do JH
        • Choi SH
        • Oh HC.
        Early oral antibiotic switch compared with conventional intravenous antibiotic therapy for acute cholangitis with bacteremia.
        Digest Dis Sci. 2014; 59: 2790-2796
        • Omidvari K
        • de Boisblanc BP
        • Karam G
        • Nelson S
        • Haponik E
        • Summer W.
        Early transition to oral antibiotic therapy for community-acquired pneumonia: duration of therapy, clinical outcomes, and cost analysis.
        Resp Med. 1998; 92: 1032-1039
        • Malaisri C
        • Phuphuakrat A
        • Wibulpolprasert A
        • Santanirand P
        • Kiertiburanakul S.
        A randomized controlled trial of sitafloxacin vs. ertapenem as a switch therapy after treatment for acute pyelonephritis caused by extended-spectrum β-lactamase-producing Escherichia coli: A pilot study.
        J Infect Chemother. 2017; 23: 556-562
        • Lee RWW
        • Lindstrom ST
        Early switch to oral antibiotics and early discharge guidelines in the management of community-acquired pneumonia.
        Respirology. 2007; 12: 111-116
        • Kohno S
        • Yanagihara K
        • Yamamoto Y
        • et al.
        Early switch therapy from intravenous sulbactam/ampicillin to oral garenoxacin in patients with community-acquired pneumonia: a multicenter, randomized study in Japan.
        J Infect Chemother. 2013; 19: 1035-1041
        • Sallach-Ruma R
        • Phan C
        • Sankaranarayanan J.
        Evaluation of outcomes of intravenous to oral antimicrobial conversion initiatives: a literature review.
        Expert Rev Clin Phar. 2013; 6: 703-708
        • Schuts E.C.
        • Hulscher M.E.
        • Mouton J.W.
        • et al.
        Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis.
        Lancet infect dis. 2016; 16: 847-856.
        • Gasparetto J
        • Tuon FF
        • Oliveira DD
        • et al.
        Intravenous-to-oral antibiotic switch therapy: a cross-sectional study in critical care units.
        Bmc Infect Dis. 2019; 19: 650
        • Shrayteh ZM
        • Rahal MK
        • Malaeb DN.
        Practice of switch from intravenous to oral antibiotics.
        Springerplus. 2014; 3: 1-8
        • KM K
        Intravenous To Oral Therapy Conversion. Competence Assessment Tools For Health-System Pharmacies.
        American Society of Health System Pharmacists, Bethesda, MD. USA2008: 347-360
        • Hermsen ED
        • Shull SS
        • Richter LM
        • Qiu F
        • Rupp ME.
        Failure of a pharmacist-initiated antimicrobial step-down protocol to impact physician prescribing behaviour or patient outcomes: A quasi-experimental cross-over study.
        J Hosp Adm. 2013; 2: 63-70
        • Beyene Berha AA-O
        • Kassie GM
        Current practice and barriers to an early antimicrobial conversion from intravenous to oral among hospitalized patients at jimma university specialized hospital: prospective observational study.
        Interdiscip Perspect Infect Dis. 2019; 20197847354
        • Moher D
        • Liberati A
        • Tetzlaff J
        • Altman DG
        • Prisma G.
        Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement.
        PLoS medicine. 2009; 6e1000097
      2. Effectiveness of Antimicrobial Stewardship Interventions on Early Switch from intravenous-to-Oral Antimicrobials in Hospitalized Adults: A Systematic Review [Internet].
        PROSPERO, 2020 (Accessed June 13, 2022)
      3. Tufanaru C, Munn Z, Aromataris E, Campbell J, Hopp L. Chapter 3: Systematic reviews of effectiveness. In: Aromataris E, Munn Z, eds. JBI Manual for Evidence Synthesis. JBI; 2020:74–134.

        • McGowan J
        • Sampson M
        • Salzwedel DM
        • Cogo E
        • Foerster V
        • Lefebvre C.
        PRESS Peer Review of Electronic Search Strategies: 2015 Guideline Statement.
        J Clin Epidemiol. 2016; 75: 40-46
        • Ahmed SA
        • Kumar A
        • Sethi P
        • Kapil A
        • Pandey RM
        • Wig N.
        Effectiveness of education and antibiotic control programme at All India Institute of Medical Sciences, New Delhi.
        National Medical Journal of India. 2018; 31: 262-267
        • Al-Eidan FA
        • McElnay JC
        • Scott MG
        • Kearney MP
        • Corrigan J
        • McConnell JB.
        Use of a treatment protocol in the management of community-acquired lower respiratory tract infection.
        J Antimicrob Chemother. 2000; 45: 387-394
        • Bartlett JM
        • Siola PL.
        Implementation and first-year results of an antimicrobial stewardship program at a community hospital.
        Am J Health Syst Pharm. 2014; 71: 943-949
        • Bonella GF
        • Fontes AM
        • Jorge MT
        • Silveira AB
        Assessment of an intervention aimed at early discontinuation of intravenous antimicrobial therapy in a Brazilian University hospital.
        Braz J Infect Dis. 2016; 20: 462-467
        • Carratalà J
        • Garcia-Vidal C
        • Ortega L
        • et al.
        Effect of a 3-step critical pathway to reduce duration of intravenous antibiotic therapy and length of stay in community-acquired pneumonia: a randomized controlled trial.
        Arch Intern Med. 2012; 172: 922-928
        • Dunn K
        • O'Reilly A
        • Silke B
        • Rogers T
        • Bergin C.
        Implementing a pharmacist-led sequential antimicrobial therapy strategy: a controlled before-and-after study.
        Int J Clin Pharm. 2011; 33: 208-214
        • Ehrenkranz NJ
        • Nerenberg DE
        • Shultz JM
        • Slater KC.
        Intervention to discontinue parenteral antimicrobial therapy in patients hospitalized with pulmonary infections: effect on shortening patient stay.
        Infect Control Hosp Epidemiol. 1992; 13: 21-32
        • Fazylov R
        • Peyko V
        • Burney S
        • Cohen H.
        Prospective evaluation of a novel treatment algorithm for health care-associated pneumonia.
        Infectious Diseases in Clinical Practice. 2017; 25: 82-87
        • Gibbons JA
        • Smith HL
        • Kumar SC
        • et al.
        Antimicrobial stewardship in the treatment of skin and soft tissue infections.
        American Journal of Infection Control. 2017; 45: 1203-1207
        • Ho BP
        • Lau TTY
        • Balen RM
        • Naumann TL
        • Jewesson PJ.
        The impact of a pharmacist-managed dosage form conversion service on ciprofloxacin usage at a major Canadian teaching hospital: a pre- and post-intervention study.
        Bmc Health Services Research. 2005; 5: 1-8
        • Hulgan T
        • Rosenbloom ST
        • Hargrove F
        • et al.
        Oral quinolones in hospitalized patients: an evaluation of a computerized decision support intervention.
        Journal of Internal Medicine. 2004; 256: 349-357
        • Kim M
        • Song KH
        • Kim CJ
        • et al.
        Electronic alerts with automated consultations promote appropriate antimicrobial prescriptions.
        PLoS One. 2016; 11: e0160551
        • Kuti JL
        • Le TN
        • Nightingale CH
        • Nicolau DP
        • Quintiliani R.
        Pharmacoeconomics of a pharmacist-managed program for automatically converting levofloxacin route from i.v. to oral.
        Am J Health-System Pharma. 2002; 59: 2209-2215
        • Lesprit P
        • Landelle C
        • Girou E
        Brun-Buisson C. Reassessment of intravenous antibiotic therapy using a reminder or direct counselling.
        J Antimicrob Chemother. 2010; 65: 789-795
        • McCallum AD
        • Sutherland RK
        • Mackintosh CL.
        Improving antimicrobial prescribing: implementation of an antimicrobial i.v.-to-oral switch policy.
        J R Coll Physicians Edinb. 2013; 43: 294-300
        • Mouwen AMA
        • Dijkstra JA
        • Jong E
        • Buijtels P
        • Pasker-de Jong PCM
        • Nagtegaal JE
        Early switching of antibiotic therapy from intravenous to oral using a combination of education, pocket-sized cards and switch advice: A practical intervention resulting in reduced length of hospital stay.
        Int J Antimicrob Agents. 2020; 55: 27
        • Nowak MA
        • Nelson RE
        • Breidenbach JL
        • Thompson PA
        • Carson PJ.
        Clinical and economic outcomes of a prospective antimicrobial stewardship program.
        Am J Health Syst Pharm. 2012; 69: 1500-1508
        • Rizan C
        • Phee J
        • Boardman C
        • Khera G.
        General surgeon's antibiotic stewardship: climbing the rogers diffusion of innovation curve-prospective cohort study.
        Int J Surg. 2017; 40: 78-82
        • Rodrigues RM
        • Fontes AM
        • Mantese OC
        • Martins RS
        • Jorge MT.
        Impact of an intervention in the use of sequential antibiotic therapy in a Brazilian university hospital.
        Rev Soc Bras Med Trop. 2013; 46: 50-54
        • Schouten JA
        • Hulscher ME
        • Trap-Liefers J
        • et al.
        Tailored interventions to improve antibiotic use for lower respiratory tract infections in hospitals: a cluster-randomized, controlled trial.
        Clin Infect Dis. 2007; 44: 931-941
        • Senn L
        • Burnand B
        • Francioli P
        • Zanetti G.
        Improving appropriateness of antibiotic therapy: randomized trial of an intervention to foster reassessment of prescription after 3 days.
        J Antimicrob Chemother. 2004; 53: 1062-1067
        • Stirling AL
        • Belliveau P
        • Maas B
        • Rothman A
        • Bercume R
        • Esposito M.
        Experience with a decentralized IV to PO ofloxacin conversion program.
        Formulary. 1999; 34: 688
        • Swamy A
        • Sood R
        • Kapil A
        • et al.
        Antibiotic stewardship initiative in a Medicine unit of a tertiary care teaching hospital in India: A pilot study.
        Indian J Med Res. 2019; 150: 175-185
        • Sze WT
        • Kong MC.
        Impact of printed antimicrobial stewardship recommendations on early intravenous to oral antibiotics switch practice in district hospitals.
        Pharm Pract. 2018; 16: 17
        • van Niekerk AC
        • Venter DJ
        Boschmans SA. Implementation of intravenous to oral antibiotic switch therapy guidelines in the general medical wards of a tertiary-level hospital in South Africa.
        J Antimicrob Chemother. 2012; 67: 756-762
        • Waagsbø B
        • Sundøy A
        • Paulsen EQ.
        Reduction of unnecessary i.v. antibiotic days using general criteria for antibiotic switch.
        Scand J Infect Dis. 2008; 40: 468-473
        • Weingarten SR
        • Riedinger MS
        • Hobson P
        • et al.
        Evaluation of a pneumonia practice guideline in an interventional trial.
        Am J Respiratory Crit Care Med. 1996; 153: 1110-1115
        • Willemsen I
        • Cooper B
        • van Buitenen C
        • Winters M
        • Andriesse G
        • Kluytmans J.
        Improving quinolone use in hospitals by using a bundle of interventions in an interrupted time series analysis.
        Antimicro Agents Chemother. 2010; 54: 3763-3769
        • Yen YH
        • Chen HY
        • Wuan-Jin L
        • Lin YM
        • Shen WC
        • Cheng KJ.
        Clinical and economic impact of a pharmacist-managed i.v.-to-p.o. conversion service for levofloxacin in Taiwan.
        Int J Clin Pharmacol Ther. 2012; 50: 136-141
        • Zamin MT
        • Pitre MM
        • Conly JM.
        Development of an intravenous-to-oral route conversion program for antimicrobial therapy at a Canadian tertiary care health facility.
        Ann Pharmacother. 1997; 31: 564-570
        • Emerson C.R.
        • Antonopoulos M.S.
        • Marzella N.
        • Grossman S.S.
        Economic impact of implementing pneumonia treatment guidelines for intravenous to oral conversion.
        Hospital Pharm. 2008; 43: 886-894
        • del Pozo-Ruiz J.J.
        • Martín-Pérez E.
        • Malafarina V.
        Pharmacoeconomic and clinical aspect of a sequential intravenous to oral therapy plan in an acute geriatric ward.
        Euro Geriatr Med. 2016; 7: 70-76
        • Davis S.L.
        • Delgado Jr, G.
        • McKinnon P.S.
        Pharmacoeconomic considerations associated with the use of intravenous-to-oral moxifloxacin for community-acquired pneumonia.
        Clin Infect Dis. 2005. 2005; 41: S136-S143
        • Laing RB
        • Mackenzie AR
        • Shaw H
        • Gould IM
        • Douglas JG.
        The effect of intravenous-to-oral switch guidelines on the use of parenteral antimicrobials in medical wards.
        J Antimicrob Chemother. 1998; 42: 107-111
        • Riordan DO
        • Walsh KA
        • Galvin R
        • Sinnott C
        • Kearney PM
        • Byrne S.
        The effect of pharmacist-led interventions in optimising prescribing in older adults in primary care: A systematic review.
        Sage Open Med. 2016; 4
        • Charani E
        • Edwards R
        • Fau - Sevdalis N
        • et al.
        Behavior change strategies to influence antimicrobial prescribing in acute care: a systematic review.
        Clin Infect Dis. 2011; 7: 651-662
        • Davey P
        • Peden C
        • Charani E
        • Marwick C
        • Michie S.
        Time for action-Improving the design and reporting of behaviour change interventions for antimicrobial stewardship in hospitals: Early findings from a systematic review.
        Int J Antimicrob Agents. 2015; 45: 203-212
        • Talkhan H
        • Stewart D
        • McIntosh T
        • et al.
        The use of theory in the development and evaluation of behaviour change interventions to improve antimicrobial prescribing: a systematic review.
        J Antimicrob Chemother. 2020; 75: 2394-2410