Daily review of all IV antimicrobials is essential.
Any patient that fulfils Sepsis 6 criteria will receive IV antimicrobials as part of their initial treatment, but only very few will have an infection that can only be treated with IVs or excludes from early IVOST.
See IVOST criteria guidance here.
This guidance only applies if there are no previous culture results indicating resistance to the proposed oral agent and no positive cultures are available for the current infective episode.
If the current agent is available in an oral formulation, a direct conversion is possible - with the exception of PO vancomycin; it is not absorbed from the GI tract and the PO formulation is therefore only indicated for treatment of C. difficile infection.
Details on the bioavailability of oral antimicrobials is available here.
In pregnant patients, ciprofloxacin and doxycycline are contraindicated - discuss appropriate empirical choices with an infection specialist.
| IV agent | PO agent |
| Meropenem |
Co-amoxiclav oral 625mg 8 hourly If penicillin allergic: ciprofloxacin oral 500mg 12 hourly |
| Piperacillin-tazobactam | Co-amoxiclav oral 625mg 8 hourly |
| Vancomycin | Doxycycline oral 200mg on day 1 and 100mg once daily thereafter |
| Gentamicin | See combination regimens below |
In pregnant patients, ciprofloxacin and co-trimoxazole are contraindicated.
| IV regimen | PO regimen |
|
Amoxicillin + Gentamicin + Metronidazole or Vancomycin + Gentamicin + Metronidazole |
Co-trimoxazole oral 960mg 12 hourly + Metronidazole oral 400mg 8 hourly Co-trimoxazole contains trimethoprim and sulfamethoxazole. Do not use this agent in pregnancy. Trimethoprim is contraindicated in the first trimester of pregnancy due to a risk of neural tube defects; sulfamethoxazole can cause neonatal haemolysis and methaemoglobinaemia in the last trimester. In pregnancy, use co-amoxiclav oral 625mg 8 hourly. If penicillin allergic, discuss with an infection specialist. |
|
Gentamicin+/- Amoxicillin for biliary sepsis or Gentamicin +/- Vancomycin for biliary sepsis |
Co-trimoxazole oral 960mg 12 hourly Co-trimoxazole contains trimethoprim and sulfamethoxazole. Do not use this agent in pregnancy. Trimethoprim is contraindicated in the first trimester of pregnancy due to a risk of neural tube defects; sulfamethoxazole can cause neonatal haemolysis and methaemoglobinaemia in the last trimester. In pregnancy, use co-amoxiclav oral 625mg 8 hourly. If penicillin allergic, discuss with an infection specialist. |
| Temocillin + Amoxicillin for SBP |
Co-trimoxazole oral 960mg 12 hourly If on SBP prophylaxis with co-trimoxazole use: co-amoxiclav oral 625mg 8 hourly. |
|
Gentamicin +/- Amoxicillin for urosepsis or Gentamicin +/- Vancomycin for urosepsis |
Co-trimoxazole oral 960mg 12 hourly Co-trimoxazole contains trimethoprim and sulfamethoxazole. Do not use this agent in pregnancy. Trimethoprim is contraindicated in the first trimester of pregnancy due to a risk of neural tube defects; sulfamethoxazole can cause neonatal haemolysis and methaemoglobinaemia in the last trimester. Only if low risk of C. difficile infection and suitable for early IVOS and discharge: ciprofloxacin oral 500mg 12 hourly. Nitrofurantoin does not achieve therapeutic serum or tissue levels and is only used for treatment of uncomplicated lower UTI. It is not an appropriate agent for upper or bacteraemic UTI. Do not use as IV-to-oral switch in urosepsis. In pregnancy, use co-amoxiclav oral 625mg 8 hourly. If penicillin allergic, discuss with an infection specialist. |
|
Co-trimoxazole + Gentamicin for HAP |
Co-trimoxazole oral 960mg 12 hourly; stop gentamicin after 72 hours or at time of IVOS, whichever is earlier. Co-trimoxazole contains trimethoprim and sulfamethoxazole. Do not use this agent in pregnancy. Trimethoprim is contraindicated in the first trimester of pregnancy due to a risk of neural tube defects; sulfamethoxazole can cause neonatal haemolysis and methaemoglobinaemia in the last trimester. |
|
Vancomycin + Ciprofloxacin for neutropenic sepsis |
Ciprofloxacin oral 500mg 12 hourly |