International Journal of Clinical Pharmacy

, Volume 33, Issue 2, pp 208–214 | Cite as

Implementing a pharmacist-led sequential antimicrobial therapy strategy: a controlled before-and-after study

  • Katherine DunnEmail author
  • Audrey O’Reilly
  • Bernard Silke
  • Thomas Rogers
  • Colm Bergin
Research Article


Sequential antimicrobial therapy is an important part of antimicrobial stewardship and intends to improve the timeliness of switch to oral antimicrobials. The aim of this study was to assess the impact of the introduction of guidelines and criteria for switching to oral antimicrobials. Setting The study was conducted in a 753-bed academic hospital in Ireland. Methods The study was prospective and of controlled before and after design. Patients admitted under the care of a medical consultant were screened for inclusion. The study was divided into pre-intervention and post-intervention phases. Patients admitted and prescribed IV antimicrobials were enrolled into either a study group or control group. Post-intervention, the intervention to the study group consisted of application of stickers and criteria for switch to oral antimicrobial therapy to the drug chart. Pre-intervention in the study group and in both phases in the control group, conventional practice of clinical pharmacists reviewing drug charts and contacting prescribers to discuss a switch to an oral antimicrobial continued. The duration of intravenous treatment, the timeliness of switch to oral therapy, length of stay and cost savings were measured. Main outcome measure The duration of intravenous antimicrobial therapy in the pre-intervention and post-intervention phases in both study and control groups. Results Pre-intervention, 85 courses of IV antimicrobials were prescribed to study group patients, compared to 60 in the control group. Post-intervention, there were 92 courses in the study group and 53 in the control group. The duration of IV antimicrobial treatment reduced significantly in the study group post-intervention, compared to the control group (P = 0.02). The timeliness of the switch also improved significantly in the study group post-intervention (P = 0.017). No improvement occurred in the control group. The median length of stay was not reduced post-intervention. Antimicrobial costs reduced by a mean of €6.41 in the study group post-intervention. Conclusion This controlled before and after study demonstrates successful implementation of a pharmacist-led antimicrobial stewardship strategy. Duration of IV antimicrobial treatment reduced significantly and the timeliness of switch significantly improved. This study may be used as a template for the introduction of further pharmacist-led antimicrobial stewardship initiatives.


Antibiotic Antimicrobials Intravenous Therapy-switch Pharmacist Ireland Good prescribing practice 



I would like to thank Veronica Treacy and the staff of St James’s Hospital pharmacy department and Niamh McMahon and Dr Martin Henman of University of Dublin, Trinity College for their support. This work formed part of a research project submitted as a thesis for a taught Masters programme in University of Dublin, Trinity College.


No funding was received for this research.

Conflicts of interest

None of the authors have any conflicts of interest.


  1. 1.
    Davey P, Nathwani D. Sequential antibiotic therapy: the right patient, the right time and the right outcome. J Infect. 1998;37(suppl 1):37–44.PubMedCrossRefGoogle Scholar
  2. 2.
    Dellit TH, Owens RC, McGowan JE, Gerding DN, Weinstein RA, Burke JP, et al. Infectious disease society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis. 2007;44:159–77.PubMedCrossRefGoogle Scholar
  3. 3.
    Lelekis M, Gould IM. Sequential antibiotic therapy for cost containment in the hospital setting: why not? J Hosp Infect. 2001;48:249–57.PubMedCrossRefGoogle Scholar
  4. 4.
    Sevinc F, Prins JM, Koopmans RP, Langendijk PNJ, Bossuyt PMM, Dankert J, et al. Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. J Antimicrob Chemother. 1999;43:601–6.PubMedCrossRefGoogle Scholar
  5. 5.
    McLaughlin CM, Bodasing N, Boyter AC, Fenelon C, Fox JG, Seaton RA. Pharmacy-implemented guidelines on switching from intravenous to oral antibiotics: an intervention study. Q J Med. 2005;98:745–52.Google Scholar
  6. 6.
    Milkovich G. Intravenous to oral transition therapy in community-acquired pneumonia: the INOVA health system experience. Pharmacotherapy. 2001;21:83S–8S.PubMedCrossRefGoogle Scholar
  7. 7.
    Glemaud I. Use of a physician order entry system to identify opportunities for intravenous to oral levofloxacin conversion. Am J Health Syst Pharm. 2000;57:S14–6.PubMedGoogle Scholar
  8. 8.
    Oosterheert JJ, Bonten MJM, Scheider MME, Buskens E, Lammes JWL, Hustinx WM, et al. Effectiveness of early switch from intravenous to oral antibiotics in severe community acquired pneumonia: multicentre, randomised trial. BMJ. 2006;333:1193–8.PubMedCrossRefGoogle Scholar
  9. 9.
    Castro-Guardiola A, Viejo-Rodriguez AL, Soler-Simon S, Armengou-Arxe A, Bisbe-Company V, Penarroja-Matutuano G, et al. Efficacy and safety of oral and early-switch therapy for community-acquired pneumonia: a randomised controlled trial. Am J Med. 2001;111:367–74.PubMedCrossRefGoogle Scholar
  10. 10.
    Erard V, Lamy O, Bochud PY, Bille J, Commetta A, Calandra T. Full-course oral levofloxacin for treatment of hospitalised patients with community-acquired pneumonia. Eur J Clin Microbiol Infect Dis. 2004;23:82–8.PubMedCrossRefGoogle Scholar
  11. 11.
    Chan R, Hemeryck L, O’Regan M, Clancy L, Feely J. Oral versus intravenous antibiotics for community acquired lower respiratory tract infection in a general hospital: open, randomised controlled trial. BMJ. 1995;310:1360–2.PubMedGoogle Scholar
  12. 12.
    Laing RBS, Mackenzie AR, Shaw H, Gould IM, Douglas JG. The effect of intravenous to oral switch guidelines on the use of parenteral antimicrobials in medical wards. J Antimicrob Chemother. 1998;42:107–11.PubMedCrossRefGoogle Scholar
  13. 13.
    Ahkee S, Smith S, Newman D, Ritter W, Burke J, Ramirez JA. Early switch from intravenous to oral antibiotics in hospitalised patients with infections: a six month prospective study. Pharmacotherapy. 1997;17:569–75.PubMedGoogle Scholar
  14. 14.
    Ramsay C, Brown E, Hartman G, Davey P. Room for improvement: a systematic review of the quality of interventions to improve hospital antibiotic prescribing. J Antimicrob Chemother. 2003;52:76–771.CrossRefGoogle Scholar
  15. 15.
    British Thoracic Society Guidelines on community acquired pneumonia in adults. Thorax. 2001;56(suppl IV):1–64.Google Scholar
  16. 16.
    American Thoracic Society Guidelines for the management of adults with community acquired pneumonia. Am J Respir Crit Care Med. 2001;163:1730–54.Google Scholar
  17. 17.
    Davey P, Brown E, Fenelon L, Finch R, Gould I Hartman G et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005 Issue 4.Google Scholar

Copyright information

© Springer Science+Business Media B.V. 2011

Authors and Affiliations

  • Katherine Dunn
    • 1
    Email author
  • Audrey O’Reilly
    • 1
  • Bernard Silke
    • 2
  • Thomas Rogers
    • 3
  • Colm Bergin
    • 4
  1. 1.Pharmacy DepartmentSt James’s HospitalDublinIreland
  2. 2.Department of General MedicineSt James’s HospitalDublinIreland
  3. 3.Department of Clinical MicrobiologyTrinity College and St James’s Hospital, University of DublinDublinIreland
  4. 4.Department of Genitourinary and Infectious DiseasesSt James’s HospitalDublin 8Ireland

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