By Henrylito D. Tacio
Dr. Gideon Lasco is a physician and medical anthropologist who writes a column for Philippine Daily Inquirer. In his recent column, he wrote about one of his memorable patients named “Tatay Leonardo.” He had diabetes and was admitted into the Internal Medicine ward at the Philippine General Hospital for diabetic foot.
“Just when we were beginning to make progress with Tatay Leonardo, he developed a cough and fever, and after two days we diagnosed him with hospital-acquired pneumonia,” Lasco recalled. “Because the bacteria that thrive in hospitals are difficult to treat, we had to prescribe for him an intravenous (IV) antibiotic.”
He told the patient and his wife that the treatment must be done immediately. “The antibiotics must be started right away so we could prevent the pneumonia from worsening,” he told them.
“Bacterial infections can be mild, moderate, or severe cases,” explained Dr. Jozald Tuballa, who is with the Emergency Medicine at the Royal Prince Alfred Hospital in Sydney, Australia. “A mild to moderate infection can have oral antibiotics but a severe case needs immediate IV antibiotics.”
Antibiotics versus bacteria
But that’s going ahead of the story. An antibiotic is a type of antimicrobial substance active against bacteria. It is the most important medication for fighting bacterial infections.
Antibiotics kill bacteria or prevent them from reproducing and spreading. Common antibiotics include gentamicin, cephalexin, ertapenem, erythromycin, ciprofloxacin, and metronidazole. Penicillin, the first natural antibiotic, was discovered by British scientist Alexander Fleming in 1928.
However, as the term implies, antibacterials are used against bacteria, and thus aren’t effective against viral infections, such as the common cold, flu, sore throat, bronchitis, and most coughs.
Most antibiotics can be taken orally. This means the drug enters the body through the mouth. “The oral route is the most convenient and usually the safest and least expensive,” said Dr. Jennifer Lee, of the Skaggs School of Pharmacy and Pharmaceutical Sciences at the University of California in San Diego. “It is the one most often used. However, it has limitations because of the way a drug typically moves through the digestive tract.”
Generally, most drugs are usually absorbed from the small intestines. “The drug passes through the intestinal wall and travels to the liver before being transported via the bloodstream to its target site,” Dr. Lee said. “The intestinal wall and liver chemically alter (metabolize) many drugs, decreasing the amount of drug reaching the bloodstream.”
Intravenous anibiotics
But there are instances where antibiotics must be administered intravenously. “Intravenous (IV) antibiotics are antibiotics that are administered directly into a vein to enter the bloodstream immediately and bypass the absorption in the gut,” explains the website of Florida-based Infectious Disease Associates of Tampa Bay (IDATB)
IV antibiotics are generally used for bacterial infections in one of the following areas: lungs, hearts, bones, soft tissue and/or brain.
“Intravenously given antibiotics are also much better for those patients with decreased sensorium, cannot tolerate oral route, or oral cannot be accessed,” said Dr. Mec Haradji Elino, an internal medicine physician at the Southern Philippines Medical Center.
The IDATB lists the following infections and bacterial diseases that can be treated with IV antibiotics: respiratory infections, bacterial skin infections, heart valve/endocarditis, fungal infections, gastrointestinal infections, infections of wounds, Lyme disease, meningitis, post-operative infections, sinus infections, and urinary tract infections.
“Most of the time, IV antibiotic treatment is provided in a hospital,” IDATB says. “However, antibiotic therapy can effectively treat patients at home or another healthcare facility when it is safe and appropriate.”
This is how IV antibiotics are administered, according to IDATB: “The antibiotic is administered through a small narrow flexible tube called a catheter or IV line, inserted into a vein using a needle. The needle is removed, and the IV line is left in place and secured by a dressing.”
There are different types of IV lines available, and the one chosen for a patient’s treatment depends on his or her veins and how long the patient needs the antibiotics.
Dr. Francis Lagudas, a doctor who works in a government hospital in Saranganni Province, prescribed IV antibiotics to his patients who cannot tolerate oral medications due to nausea and vomiting. “Then I shift to the oral route once I observe some improvements from my patients after a few days,” he added.
The same intervention is done by Dr. Tuballa. “If very unwell, I preferred intravenously initially then continue with orals to finish the course,” he pointed out.
Oral versus IV
Now, a new study showed that oral antibiotics “may be a safe alternative to receiving prolonged IV antibiotics,” wrote Brittany Vargas for Medscape Medical News. Her source of information is the observational study published in JAMA Network Open.
Researchers analyzed observational data from 914 patients who received antibiotics through an IV line risk developing a secondary infection. They enrolled patients with uncomplicated gram-negative bacteremia who received care in four hospitals in Denmark between 2018 and 2021.
“The outcomes of patients who switched to oral antibiotics within 4 days after a positive blood culture were compared with those who continued to receive IV antibiotics for at least 5 days after the blood culture,” Vargas wrote. The patients in both groups received antibiotics for 7-14 days.
Researchers assessed mortality rates over a 90-day window and used a target trial emulation method to conduct the study, which was based on data from electronic health records. Complicated cases and people who were not stabilized by day 4 were excluded from the analysis.
Below are the findings of the study, as reported by Vargas in her report:
· About 14.3 of patients who received prolonged IV treatment died. In comparison, only 6.9% died in the oral antibiotics group.
· In an intention-to-treat analysis, patients who were switched to oral antibiotics had a 22% lower risk for death within 90 days of initiation of treatment.
· In a per-protocol analysis, patients who switched to the oral route had 1% lower odds of dying within 90 days.
“Individuals who were switched to oral antibiotic treatment were younger than those who continued to receive antibiotics via the IV route (median age, 73 vs 76 years, respectively), had fewer comorbidities (four vs five), and were more likely to have community-acquired gram-negative bacteremia (89.4% vs 80.9%),” Vargas noted.
“These findings suggest that the mortality associated with early antibiotic stepdown treatment is comparable to that associated with receiving prolonged IV antibiotic treatment for individuals with uncomplicated gram-negative bacteremia,” wrote the authors of the study, which was led by Dr. Sandra Tingsgard of the Center of Research & Department of Infectious Diseases at Copenhagen University Hospital.
“Selecting the most appropriate route of administration is part of the quality use of medicine,” wrote Kate McCarthy, an Australian infectious disease physician and microbiologist, and Minyon Avent, an advanced pharmacist, in their paper, “Oral or intravenous antibiotics?” which was published online in Australian Prescriber.
“For many patients with bacterial infections who require treatment with an antibiotic, an oral formulation is the most appropriate choice,” they further wrote. “However, patients in hospitals are often given intravenous antibiotics. While there are clinical circumstances when parenteral administration is indicated, for some infections oral therapy can be equally efficacious.” – ###
