IV → PO antibiotic switch (discharge / step-down)
Adults · verify locally
Inpatient / outpatient
Switch criteria
- Afebrile ≥24–48 h, clinical improvement, functioning GI tract, no shock/severe malabsorption.
- No indication for mandatory parenteral therapy: endocarditis, meningitis, febrile neutropenia, unstable sepsis.
- After 48–72 h of effective IV therapy; oral choice per antibiogram and local protocol (IDSA, NICE, Sanford Guide).
| Inpatient (IV) | Outpatient (PO) | |
|---|---|---|
Cefuroxime Axetine → Zinnat | 750 mg–1.5 g IV tid | Cefuroxime axetil 500 mg PO bid |
Ciprofloxacin Ciphin | 200 mg IV bid | 500 mg PO bid |
Levofloxacin | 500 mg IV once daily | 500 mg PO once daily |
Fluconazole Medoflucon / Mycomax | 200–400 mg IV once daily | 200–400 mg PO once daily |
Metronidazole Efloran → Entizol | 500 mg IV tid | 250–500 mg PO tid |
Amoxicillin/clavulanate Augmentin / Amoksiklav | 1.2 g IV tid | 625 mg PO tid or 1000 mg PO bid |
Ampicillin/sulbactam Bitammon | 1.5 g IV tid | Sultamicillin 375 mg PO bid |
Cefotaxime | 1–2 g IV tid | Cefixime (Suprax) 200 mg PO bid or 400 mg once daily |
Clarithromycin Klacid SR | 500 mg IV once daily (if IV needed) | 500 mg SR PO once daily or 250–500 mg bid |
Clindamycin | 600 mg IV tid | 300–450 mg PO qid |
Co-trimoxazole Biseptol | 480/960 mg IV bid | 480 mg PO bid or forte 960 mg bid |
Piperacillin/tazobactam Tazocin | 4.5 g IV q6–8h | No direct PO form — switch by antibiogram |
Meropenem | 1000 mg IV tid | No direct PO form — switch by antibiogram |
Colistin Kolomycín | 1 million IU IV tid | No direct PO form — switch by antibiogram |
Vancomycin (systemic MRSA) | 15–20 mg/kg IV q8–12h + TDM | Linezolid 600 mg PO bid |
Rifaximin Normix | — | 200 mg PO tid |
Notes
- High oral bioavailability agents (metro, fluconazole, levofloxacin): PO dose equals or approximates IV.
- Lower bioavailability (ciprofloxacin): PO dose higher than IV.
- Pip/tazo, meropenem, colistin: switch to a different agent per susceptibility.
- Adjust for renal/hepatic function and allergy.
- • IDSA antimicrobial stewardship (2016)
- • NICE NG15 / IV-to-oral switch (2015)
- • Sanford Guide — oral bioavailability (2024)