The advantages of stepping down from IV to oral therapy include lower cost, less administration time by nursing staff, decreased length of stay, and decreased potential for adverse events associated with IV therapy. One possible reason for the trend of decreasing oral usage may be the decline in hospital length of stay. Patients are typically switched to oral therapy just before discharge, and oral therapy continues on an outpatient basis; however, outpatient therapy was not included in this study. Another reason may be that patients who were admitted later in the study period were sicker, and their care was more complex, than patients admitted earlier in the study period.
Switching patients from IV to oral medications also has economic advantages. In 2002/2003, the ratio of IV to oral use of ciprofloxacin was 0.325, and NS provincial expenditures for ciprofloxacin were approximately $860 000. Lowering the rV—oral ratio to 0.25 would represent a cost avoidance of approximately $330 000. Similarly, if the ratio of IV to oral use of respiratory fluoroquinolones was decreased from 0.2, its reported level in 2002/2003, to 0.15, approximately $180 000 in cost avoidance could be realized. canadian cialis
If one assumes that each case of community-acquired pneumonia should be treated with 1 DDD of moxifloxacin or gatifloxacin and 2 DDDs of levofloxacin (the DDD of levofloxacin is 0.25 g [250 mg], which is half the usual dose of 500 mg once daily used in Canada to treat community- acquired pneumonia at the time of the study), the rate of use in facilities was high and increased over time. This suggests that respiratory fluoroquinolones were used to treat infections other than community-acquired pneumonia, which may be inappropriate. Zhanel and others reported that resistance to penicillin and macrolides increased over time in the Maritime provinces of Canada (i.e., Nova Scotia, New Brunswick, and Prince Edward Island), whereas fluoroquinolone resistance declined between 1997 and 1998 and then stabilized. The Canadian Bacterial Surveillance Network has reported stabilization of penicillin resistance in the Atlantic provinces (i.e., Nova Scotia, New Brunswick, Prince Edward Island, and Newfoundland and Labrador), but a decrease in high-level resistance and an increase in macrolide resistance from 1997 to 2001. A study of susceptibility results for invasive pneumococcal isolates collected in 2002 and 2003, at the end of the current study period, demonstrated rates of resistance to macrolides, penicillin, and fluoroquinolones similar to those of the study by Zhanel and others. This suggests that resistance rates did not go up in the last year of our study. However, even if resistance rates increased and the increasing use of fluoroquinolones was justified on the basis of macrolide and fi-lactam resistance, this would not explain why fluoroquinolone usage was greater than would be accounted for by all cases of community-acquired pneumonia in which hospital admission was required. The use of levofloxacin fell in the last year of the study, while the combined use of respiratory fluoroquinolones remained the same. One factor may be the reporting of Streptococcus pneumoniae resistance to levofloxacin in the literature, which may have led prescribers to switch to the newer respiratory fluoroquinolones. In support of this supposition, 3 of the DHAs changed the respiratory fluoroquinolone on their pneumonia pathways from levofloxacin to either moxifloxacin or gatifloxacin during the last year of the study. viagra soft