Educational draft · awaiting clinical reviewThe full textbook explains uncertainty but does not replace live national or local guidance, specialist advice, or current prescribing information.
Review antimicrobial prescriptions as active clinical decisions, switching safely from intravenous to oral treatment when physiology, absorption, source, pathogen and available oral exposure all support the change.
Stewardship optimises the individual patient's outcome while reducing avoidable toxicity, Clostridioides difficile infection and resistance. It is not automatic restriction. The first prescription may need broad urgent cover; the quality test is whether the decision is documented, sampled appropriately and revisited when microbiology and clinical response improve certainty.
The switch decision has four domains: infection, patient, oral drug and care setting. The source must be controlled and suitable for oral treatment; the patient must be haemodynamically stable and able to absorb; the oral agent must cover the pathogen at an adequate dose; and follow-up must support adherence, monitoring and action on pending results.
Discharge can make a poor plan less visible. Reconcile total course length including inpatient doses, remove redundant duplicate therapy, communicate culture results and monitoring, and state who will review. Long courses need a clear indication, toxicity plan and stop date rather than an open-ended repeat prescription.
Improving physiology, afebrile or clearly improving fever, functioning gut, controlled source and an effective oral option together support route review.
Shock, escalating oxygen, persistent bacteraemia, vomiting, ileus, malabsorption or a high-risk deep focus argues against routine oral conversion.
Alternative diagnosis, contaminant culture, colonisation or resolved self-limited illness may justify stopping rather than finding an oral substitute.
A patient improving after source control may still have an inherited long end date; compare the total planned course with current syndrome guidance.
Check immediate beta-lactam allergy, renal function and indication; avoid using this example for meningitis, endocarditis or resistant organisms without specialist guidance.
Review pregnancy, oesophageal irritation, photosensitivity, hepatic disease and cation-containing antacids or supplements; take with water while upright and use syndrome-specific duration.
Review liver disease, neurological toxicity with prolonged use, alcohol advice and warfarin interaction; do not continue after adequate drainage without a supported indication.
If infection becomes unlikely, replacing intravenous treatment with oral treatment preserves an unnecessary diagnosis and exposes the patient to further harm.
An appropriately dosed high-bioavailability oral medicine can match systemic exposure, but infection site and evidence still determine whether switch is safe.
Continued intravenous treatment adds thrombosis, infection, mobility and discharge harms that must be weighed against any pharmacological benefit.
Count active treatment already received in hospital when writing discharge prescriptions, unless the guideline deliberately defines duration from source control or another event.
Switching because the cannula failed rather than because criteria are met.
Continuing broad dual therapy when one targeted oral agent is sufficient.
Using a normal CRP as the sole switch criterion or a raised CRP as the sole reason to continue.
Forgetting interaction and absorption checks when choosing an oral agent.
Issuing a fresh full course at discharge without counting inpatient treatment.
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A patient with uncomplicated pyelonephritis is haemodynamically stable, improving, eating normally and has a susceptible organism with an effective oral option. What is the best next step?
National guidance is shown before implementation-dependent detail. Typical adult dose examples remain subject to patient factors, contraindications and the live BNF or specialist protocol. Source check completed 27 Aug 2026; clinical approval remains outstanding.
Editorial contact: Doctor’s Passport editorial team. Source-check date is separate from clinical approval. Report a content problem · Content changes