Development and implementation of a national antimicrobial intravenous-to-oral switch criteria for early switching

The ‘English surveillance programme for antimicrobial utilisation and resistance 2020–2021’ report recorded an increased number of antibiotic-resistant infections compared with 2016​[1]​. Antimicrobial resistance (AMR) is exacerbated by antibiotic overuse, thus antimicrobial stewardship (AMS) efforts are crucial to ensure appropriate antibiotic prescribing and reduce avoidable AMR. 

Antimicrobial intravenous-to-oral switch (IVOS) is an important hospital AMS intervention, with patient safety and cost benefits, including the decreased risk of bloodstream and catheter-related infections, reduced equipment costs, carbon footprint and hospital length-of-stay, as well as increased patient mobility and comfort and released nursing time to care for patients​[2–8]​. Studies have shown that IVOS decisions do not negatively impact patient outcomes​[6]​. Pharmacist involvement in IVOS has been shown to improve quality of antibiotic prescribing and reduce medication costs by 34%​[7]​. IVOS initiatives led by ward pharmacists have also been shown to reduce use of hospital intravenous broad-spectrum antibiotics, including co-amoxiclav by 28% and cefuroxime by 47%​[5]​.

Most acute NHS hospitals have developed individualised local IVOS eligibility criteria for use in clinical practice. The evidence base underpinning the included criteria is not always apparent and widespread variation between hospitals exists.

Our project, which took place from September 2021 to September 2022, aimed to collate IVOS criteria from hospital policies; complete a systematic rapid review of the literature to evaluate these criteria; and undertake a four-step Delphi consensus-gathering process to agree evidence-based, UK-wide IVOS criteria for hospitalised adults​[9]​.  

Adult antibiotic IVOS policies were selected through stratified sampling of UK NHS trusts for collation of their IVOS criteria. Trust data included IVOS criteria from 45 IVOS policies; 42 from English acute hospital trusts, 2 from Scottish Health Boards and the All-Wales IVOS checklist. A rapid review literature search was also undertaken in Ovid Embase and Medline databases for articles published between January 2017 and December 2021​[9]​. Articles without IVOS criteria and those focusing on a specific antimicrobial or infection were excluded, to limit the results to generalisable IVOS criteria. Of 477 papers identified, 16 papers reported IVOS criteria. The IVOS criteria from trust policies and literature were extracted into Excel spreadsheets and synthesised into a five-section framework: One — timing of IV antimicrobial review; two — clinical signs and symptoms; three — infection markers; four — enteral route; five — special considerations. On combining trust and literature data, 41 IVOS criteria were formatted into five-point Likert scale questions​[9]​.

Criteria with the highest, or more than 50%, appearance in policies and literature were combined and informed the four-step Delphi process:

• Step 1: pilot/first round questionnaire to assess relevance and ease of application of criteria;    
• Step 2: virtual meeting to gain consensus on which criteria to move forward into step 3;
• Step 3: Second round questionnaire for UK-wide cascade to assess opinions of safety and effectiveness of criteria;
• Step 4: workshop to finalise criteria and discuss operationalisation.       

Through the four-step Delphi process, consensus was achieved for IVOS criteria from 279 multidisciplinary experts from across the UK (including 114 pharmacists, 107 doctors, and 37 nurses). The new national criteria and sample decision aid have been published and are available here. The findings from the rapid review and Delphi consensus process were submitted for peer review in September and December 2022, respectively (for preprints, see references)​[9,10]​.

Further research is needed to evaluate expanded AMS roles of pharmacy and nursing teams, and assess their impact. Validation of IVOS criteria in the paediatric population is also important, alongside international validation, as no standardised set of IVOS criteria was identified in any other country.

The nationally agreed IVOS criteria will need support to be operationalised in UK hospitals. NHS England regional teams are already working to promote implementation of the national IVOS criteria in clinical practice. In the east of England, for example, a multi-professional group of clinicians has developed and finalised a suite of regional resources, including a clinical decision support tool, available here. Posters, guidelines-on-a-page and evidence slide sets are also available on the FutureNHS Collaboration Platform. Nationally, the NHS England Commissioning for Quality and Innovatio(CQUIN) indicators and metrics, to be used as part of calculating the annual payment for NHS trusts and foundation trusts, under the NHS Payment Scheme, published on 23 December 2022 (currently out of consultation), includes an indicator for IVOS​[11]​. If approved, the CQUIN scheme will incentivise prompt switching of IV antimicrobial treatment to the oral route of administration as soon as patients meet the criteria developed by this project.

Eleanor Harvey, Chief pharmaceutical officer’s clinical fellow, UK Health Security Agency 2021/22

Kieran Hand, National pharmacy & prescribing clinical lead, NHS England

Diane Ashiru-Oredope, Lead pharmacist, HCAI & AMR and Chair of ESPAUR, UK Health Security Agency

For further details, contact: diane.ashiru-oredope@ukhsa.gov.uk