Discussion

We describe increased proportion of oral azithromycin and doxycycline administered before and after implementation of prescriber-facing IV to PO alert, leading to cost- and waste-savings.

Beique et al describe concerns about IV to PO conversion, including not understanding the benefit of conversion, misconceptions that PO dosage form yields lower concentration, patients have better clinical outcomes with IV therapy, intensive care unit admission, or presence of a feeding tube. ^{Reference Beique and Zvonar16} We attempted to mitigate concerns with the verbiage in our alert and by offering oral capsule or tablet as well as oral solution dosage form selection options, when available.

Various methods of IV to PO conversion have been implemented with earlier interventions involving pharmacists contacting providers to discuss recommendations, which can be time-consuming and require dedicated personnel. ^{Reference Przybylski, Rybak and Martin17,Reference Teich, Petronzio and Gerner18} One example by Akhloufi et al describe an IV to PO switch alert report generated at 84 hours after prescribing and sent to pharmacists for assessment. The pharmacist contacted prescribers to change from IV to PO or stop antibiotic, if appropriate. Only about 10% of alerts led to a change in therapy. ^{Reference Akhloufi, Hulscher and van der Hoeven19} In contrast, Quintens et al describe implementation of more advanced clinical rules for screening patients for IV to PO switches. Clinical pharmacists reviewed patients, and communicated recommendations via electronic health record notes. A significant and sustained effect was demonstrated with a 79% reduction in IV prescriptions. ^{Reference Quintens, Coenen and Declercq20}

The introduction of pharmacy collaborative practice agreement has streamlined the IV to PO process and decreased IV utilization and cost. ^{21–Reference Kuti, Le and Nightingale23} However, these protocols depend on restriction criteria set forth by hospitals including patient characteristics, clinical parameters, and required documentation of changes. In contrast to our study where patients may receive initial PO antibiotics, most protocols typically require receipt of at least one IV dose or improvement in infectious signs or symptoms. Jaggar et al describe an increase in IV to PO conversion and cost reduction when a preexisting protocol was modified to be less restrictive to increase eligibility for the intervention. ^{Reference Jaggar, Cleveland and Twilla24}

Prescriber-facing alerts are a strategy for IV to PO initiatives with implementation of computerized provide order entry systems. ^{Reference Fischer, Solomon, Teich and Avorn25,Reference Galanter, Liu and Lambert26} However, the rate of conversion is lower in comparison to pharmacist-managed protocols. Concern about alert fatigue and bypassing alerts based on location and acuity of patients have been previously described. Galanter et al observed a low overall compliance rate of 19% with only 15% in the intensive care units in comparison to 21% in the medical-surgical wards. ^{Reference Galanter, Liu and Lambert26} In contrast, although our study did not evaluate compliance rate, we did see a significant reduction in IV utilization postimplementation of the alert. This may be due to the nature of the alert with the IV fluid shortage and the option for prescribers to change to oral therapy from the alert without additional steps. Additionally, IV azithromycin is included on sepsis order-sets and likely selected more often for initial therapy, leading to potential greater impact when the prescriber-facing alert was implemented compared to doxycycline.

Our study is not without limitations. We described our health-system experience, which may not translate to other practice areas. We could not assess the number of alerts not resulting in IV to PO change. The adoption of the alert during national shortage may have been led to higher acceptance earlier during the shortage. We did not assess durability of PO switch. Although previously described in the literature, we could not assess clinical outcomes of the IV to PO switch. ^{Reference Wald-Dickler, Holtom and Phillips4–Reference Li, Zhou and Fan6}

In conclusion, a prescriber-facing IV to PO alert resulted in decrease utilization of IV formulation, acquisition cost, and waste generated. With the observed benefits of the IV to PO alert, our institution is working on adjusting the alert language following the resolution of the large-volume IV fluid shortage. A work group has also been tasked in evaluating other medications that may qualify for the prescriber-facing alert.