Intravenous-to-oral antimicrobial therapy conversion: clinicians’ knowledge, beliefs, acceptance and current practice at Jimma University Specialized Hospital

Abstract

The practice of early intravenous to oral antimicrobial therapy conversion has not received much emphasis, but if practiced to its full extent presents a unique and exciting opportunity to reduce costs significantly while improving the quality of patient care. Many studies had convincingly demonstrated the efficacy, safety and the economic impact of timely intravenous (IV) to oral (PO) route therapy conversion. This study was conducted to explore clinician’s baseline knowledge, beliefs, acceptance and current practice of IV to PO antimicrobial therapy conversion among hospitalized patients at medical and surgical wards of Jimma University Specialized Hospital, Southwest Ethiopia. Methods: A self-administered questionnaire was distributed among practicing physicians to assess their baseline knowledge, beliefs, acceptance and current practice on IV to PO antimicrobial conversion. Hospital based observational study was conducted to assess the practice and factors that influence IV to PO antimicrobial therapy conversion from March to June 2013 at medical and surgical wards of Jimma University Specialized Hospital. Patient cards, charts and medication records were also reviewed for appropriateness of IV to PO therapy conversion program at least every 24hrs using a pretested data collection format. The non-parametric tests, Kruskal-Wallis and Mann-Whitney tests were used to determine the clinicians on the differences of ratings for clinical factors and agreement to a set of practice statement. Independent-samples t-test was used to compare converted and non-converted patients. Two-tailed P values of <0.05 were regarded as significant. Results: A total of one hundred nine practicing clinicians were included in this study. The factors most highly rated for antimicrobial conversion were the ability to maintain oral intake (81.1%), normalized temperature (81.1%) and stabilization of co-morbid conditions (83.5%). Majority of the clinicians (85.3%) agreed with the traditional clinical rule that “patient should be afebrile for 24 hours before IV to oral conversion”. Senior physicians had the highest knowledge score among the clinicians. However, there was no considerable difference on opinion about a guideline being integrated into practice. 71 patients were included in the study, of this two third 48(67.6%) of the patient were eligible for IV to oral antimicrobial conversion. However, 20.9% were timely converted, while 45.8% of them were ii not converted and the IV therapy was stopped among the remaining 27.1% patients at point that conversion was possible. Significant minority, 6.3% of patients were converted from IV to PO therapy without fulfilling eligibility criteria. A shorter duration of IV therapy was recorded for converted (2.80±1.87) versus non-converted patients (8.50±6.32), (P=0.009).Clinicians’ barriers to an early conversion in clinically stable patients included presence of co-morbidity 28.6% (8/ 28), should receive a standard duration of intravenous antibiotics 25 %( 7/25), forgetting to convert to oral agents 21.4 %( 6/28). Conclusion: Clinicians believed that patients with moderate to severe infection could be converted from IV to oral antimicrobials once they are able to tolerate oral intake, the temperature had normalized and after stabilized co-morbid conditions. However, there was considerable variation in several antimicrobials practice belief. Hence, guidelines that are carefully developed are necessary to address the heterogeneity in the practice beliefs we observed. The converted patients had shortened IV duration than the non-converted one. Besides, the conversion from IV to oral antimicrobials is often unnecessarily delayed in patients hospitalized with moderate to severe infection due to different types of barriers.