It is my understanding that intravenous BPI treatment does not come cheaply; thus, it never fails to amaze me how the high costs of intravenous BPI treatment are so cavalierly dismissed by the more enthusiastic members of this board. If memory serves me, 2 out of 3 HMOs operated in the red in 1997 and I am willing to guess that cutting costs is of paramount concern to these health care providers. If BPI is approved, it will have a role, but I have trouble believing that it will be utilized to the extent envisioned by some on this board. The 4 part article below pertains to the above and an excerpt follows:
Correcting erroneous concepts
If intravenous-to-oral switch therapy is an economically attractive proposition that makes perfect
sense, why is it not used by everyone?
Misconception: Infectious diseases need intravenous treatment
The main obstacle to use of switch programs is the preconceived notion that oral antibiotic
therapy is somehow not equivalent to intravenous therapy. This misunderstanding can be
remedied by educational programs and, of course, through studying the literature (1,2).
In the past, clinicians were taught to look at infectious diseases as best treated only by
intravenous antibiotics. This is an erroneous concept but one that is widely adhered to. It is
essential to think in terms of effective antibiotic therapy regardless of the route of administration.
If orally administered antibiotics are well absorbed, have excellent bioavailability, and provide
blood and tissue levels that are virtually the same as those attained by intravenous administration,
then there is no difference therapeutically between oral and intravenous antibiotics. And, indeed,
this is the case.
Of course, only antibiotics that have the characteristics just mentioned lend themselves to switch
programs. Antibiotics that are equally efficacious when administered intravenously or orally (table
3) include doxycycline (Doryx, Vibramycin, Vibra-Tabs), metronidazole (Flagyl, Protostat),
trimethoprim-sulfamethoxazole (TMP-SMX) (Bactrim, Cotrim, Septra), clindamycin
hydrochloride (Cleocin), minocycline, and the oral quinolones (eg, levofloxacin, ciprofloxacin).
Thus the notion that certain diseases require intravenous therapy needs to be moderated.
Intravenous therapy is necessary only if the patient is unable to tolerate oral administration of the
drugs, not because of the inherent nature of the infectious disease being treated (6-8).
Table 3. Antibiotics with excellent
bioavailability both orally and
intravenously*
Amoxicillin
Doxycycline
Minocycline HCl
Trimethoprim-sulfamethoxazole (TMP-SMX)
Azithromycin
Metronidazole
Chloramphenicol (Chloromycetin)
Levofloxacin
Ciprofloxacin
Clindamycin HCl
*See text and table 2 for drug brand names
not listed here.
Misconception: The same agent must be used both ways
Another common misconception is that the antibiotics chosen for a switch regimen must be of the
same type or class. This is not the case at all. The only requirement is that the agents cover
essentially the same spectrum and have the same characteristics of tissue penetration. For
example, if intravenous ampicillin is being used, oral ampicillin would not be appropriate in a
switch program because it does not give anything close to the blood and tissue levels achieved
by intravenous administration. For another example, intravenous ceftriaxone has no oral
equivalent, but oral TMP-SMX provides exactly the same spectrum of activity and tissue
penetration; even though the two drugs are from dissimilar classes and work by different
mechanisms, they are therapeutically equivalent. Clearly, it is not necessary that both oral and
intravenous forms of a given agent be available to use in switch therapy. As noted, the task is to
be sure that the spectrum of activity and the pharmacokinetics of intravenous and oral drugs are
similar. Examples are provided in table 4.
Table 4. Agents used in empirical intravenous-to-oral switch therapy at
Winthrop-University Hospital, Mineola, New York
Infection
Intravenous agent*
Oral agent*
Acute bacterial meningitis
Ceftriaxone sodium
Chloramphenicol
Community-acquired
pneumonia
Intra-abdominal sepsis
(excluding biliary tract)
Biliary tract sepsis
Urosepsis
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