Guidance

Antimicrobial IVOS decision aid for paediatrics: text alternative

Updated 25 October 2024

Based on the National Antimicrobial IVOS Criteria.

Why use this IVOS decision aid

Intravenous-to-oral switch (IVOS) is an important antimicrobial stewardship intervention (1, 2 and 3). Research evidence confirms several IVOS benefits, including decreased risk of bloodstream and catheter-related infections, reduced equipment costs, carbon footprint and hospital length-of-stay, increased patient mobility and comfort, and released nursing time to care for patients (4 and 5). Most oral antibiotics have good bioavailability in children note 1. Success of IVOS in children with serious infections relies on adequate dose and choice of oral antibiotic.

When to use this IVOS decision aid

The audit standard recommended for the implementation of this decision aid is that all children on intravenous (IV) therapy should be reviewed promptly from first dose of IV antimicrobial with formal review completed within 48 hours and daily thereafter, unless clearly documented exemptions. This IVOS decision aid is not for use in children for whom an appropriate dose of oral antibiotics should be initially started, or for whom suspicion of a bacterial infection is low (for these children antibiotics should be stopped at 48 hours once microbiology or virology results are available or earlier at discretion of senior decision makers).

IVOS decision aid

Does your patient have an infection that may require special consideration?

Infections that may require special consideration include:

• deep-seated infections

• infections

• infections requiring immediate or persistently high blood or tissue concentration not achievable via oral antimicrobials

• confirmed bacterial infections in severely immunocompromised children or in young infants (28 days of age and under) or in children being managed on a paediatric intensive care unit or with critical infections with high risk of mortality (for example sepsis requiring inotropes or ventilation)

To note: on specialist advice, an IVOS within 48 hours may still be indicated for some patients with these infections.

Infections for special consideration include, but are not limited to:

• bloodstream infection
• pleural empyema
• endocarditis
• meningitis
• exacerbation of cystic fibrosis or bronchiectasis
• osteomyelitis
• severe or necrotising soft tissue infection
• septic arthritis
• undrained abscess
• central venous catheter-associated infection

If ‘yes’ to any of the above infections, then check for clearly documented plan or seek specialist advice, with the aim to switch if appropriate.

If ‘no’ to all of the above infections, then continue through decision aid.

1. Enteral route

1.1 Is the patient’s gastrointestinal tract functioning with no evidence of malabsorption?

1.2 Is the patient’s swallow or enteral tube administration safe?

1.3 Has the patient been free from vomiting for the past 24 hours?

1.4 Is there a tolerable oral antibiotic available (taste or frequency of dosing)? Rather than offering large volumes of suspensions, has pill swallowing training been offered?

1.5 Is the patient expected to adequately adhere to oral treatment?

If ‘no’ to any of those questions, continue IV and reassess patient in 24 hours.

If ‘yes’ to all of those questions, continue through decision aid.

Note 1. Oral bioavailability: amoxicillin 70%, azithromycin 60 to 90%, cefalexin 95%, ciprofloxacin 70 to 80%, clarithromycin 50 to 55%, clindamycin more than 90%, co-amoxiclav 70%, flucloxacillin 80%, fluconazole more than 90%, linezolid 100%, metronidazole 90 to 95%, rifampicin 90 to 95% (6)

2. Clinical signs and symptoms

2.1 Are the patient’s clinical signs and symptoms of infection improving?

2.1 Is the patient’s Early Warning Score (EWS) decreasing?

2.3 Has the patient’s temperature been between 36 and 38°C for the past 24 hours?

If ‘no’ to any of those questions, continue IV and reassess patient in 24 hours.

If ‘yes’ to all of those questions, continue through decision aid.

3. Infection markers (if available)

3.1 Is the patient’s white cell count (WCC) trending towards the normal range?

3.2 Is the patient’s C-reactive protein (CRP) decreasing?

If ‘no’ to either of those questions, continue IV and reassess patient in 24 hours.

If ‘yes’ to both those questions, prompt or assess for switch.

To note: These infection markers could also indicate inflammation or be affected by, for example, steroid treatment. ‘Prompt for switch’ or ‘Assess for switch’ may still be considered if the CRP or WCC are not falling or have not been repeated in a child that is improving clinically.

Prompt for switch and document rationale

Nursing or pharmacy teams to prompt prescriber or infection specialist to consider IV to oral switch.

Assess for switch and document rationale

Paediatric team or infection specialist to consider IV to oral switch. Identify whether a suitable oral switch option is available, considering, for example, microbiology results, oral bioavailability, any clinically significant drug interactions, patient allergies or contra-indications.

At the bottom of the decision aid, there is space for the user to write:

• intravenous antimicrobial initiation date, time, name of assessor
• IVOS first assessment (daily thereafter) – date, time, name of assessor
• IVOS – date, time, name of assessor

References

1. Goff DA, Bauer KA, Reed EE and others. ‘Is the “low-hanging fruit” worth picking for antimicrobial stewardship programs?’ Clinical Infectious Diseases 2012: volume 55, issue 4, pages 587-592
2. UK Health Security Agency. ‘Start Smart – Then Focus: Antimicrobial stewardship toolkit for English hospitals’ 2015 (viewed March 2024)
3. McMullan, BJ, Andresen, D, Blyth, CC and others. ANZPID-ASAP group. ‘Antibiotic duration and timing of the switch from intravenous to oral route for bacterial infections in children: systematic review and guidelines’ Lancet Infectious Diseases 2016: volume 16, issue 8, pages e139-e152
4. Nguyen AD, Mai-Phan TA, Tran MH and others. ‘The effect of early switching from intravenous to oral antibiotic therapy: a randomized controlled trial’ Journal of Pharmacy and Pharmacognosy Research 2021: volume 9, issue 5, pages 695-703
5. Schuts EC, Hulscher M, Mouton JW and others. ‘Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis’ Lancet Infectious Diseases 2016: volume 16, issue 7, pages 847-856
6. Electronic medicines compendium (viewed April 2024)

Additional resources

BSAC Paediatric Pathways and UK-PAS Antimicrobial Paediatric Summary

Guide to swallowing tablets

This accessible form is Version 1, dated July 2024.