Spectrum: Local Antimicrobial Stewardship, for Markham Stouffville Hospital

Switch Therapy

Notes

Oral antimicrobial has rapid absorption and high oral bioavailability systemically, that is comparable to IV administration route.

Antimicrobials with excellent oral bioavailability should be given PO as long as the patient is stable, has a functioning gastrointestinal tract and there are no drug or food interactions with the enteral form.

Patient with exclusions referenced on the previous screen, should NOT receive oral anitmicrobials.

Appropriate for Switch Therapy

Azithromycin

Bioavailability: 37% - Azithromycin rapidly moves into tissues resulting in low serum concentrations, but high and persistent tissue concentrations, which makes it suitable for an IV to PO conversion.

| IV Dose

| PO Dose

250 mg q24h

| 250 mg q24h |
|500 mg q24h

| 500 mg q24h |

Ciprofloxacin

Note: Do not administer via jejunostomy tube (J-tube) as it bypasses the main site of absorption. Do not use ciprofloxacin with any tube as it may clog them.

Bioavailability: 70-89%

| IV Dose

| PO Dose

400 mg q12h

| 500 mg q12h |
|400mg q8h

| 750mg q12h |

Clindamycin

Bioavailability: 90%

| IV Dose

| PO Dose

600-900 mg q8h

|300-450 mg q6h-q8h |

Doxycycline

Bioavailability: Greater than 90%

| IV Dose

| PO Dose

100 mg q12h

|100 mg q12h |

Fluconazole

Bioavailability: Greater than 90%

| IV Dose

| PO Dose

100mg q24h

| 100mg q24h|
|150mg q24h

| 150mg q24h |

|200 mg q24h

| 200 mg q24h |

|400 mg q24h

| 400 mg q24h |

|800 mg q24h

| 800 mg q24h |

Linezolid

Bioavailability: 100%

| IV Dose

| PO Dose

600 mg q12h

|600 mg q12h |

Metronidazole

Bioavailability: 100%

| IV Dose

| PO Dose

500 mg q8h

|500 mg q8h |
|500 mg q12h

|500 mg q12h |

Moxifloxacin

Bioavailability: 90%

| IV Dose

| PO Dose

400 mg q24h

|400 mg q24h |

TMP-SMX

Note Dose variable based on indication

Bioavailability: 90-100%

IV Dose
10 mL q6h of TRIMETHOPRIM 160 mg/mL and
SUFAMETHOXAZOLE 800 mg/mL injection

PO Dose
1 DS q12h

Voriconazole

Bioavailability: 96%

| IV Dose

| PO Dose

200 mg (4mg/kg) q12h

| 200 mg q12h |