Medicine sustainability interventions
Clinical care
Treatment with oral antibiotics when bioavailability is good
Timely conversion from intravenous (IV) to oral antibiotics is an important intervention within appropriate and sustainable care. Within the national antimicrobial stewardship program, as developed by SWAB, it is recommended to re-evaluate the route of antibiotic administration daily and switch to oral therapy as soon as possible once the patient is clinically stable and oral intake is possible (1). Switching to oral therapy contributes to shortening hospital stays, reduces complications from IV administration such as line infections and phlebitis, decreases the time spent preparing and administering infusions, and reduces material usage (2).
The Dutch Healthcare Institute explicitly states in its improvement report on Lower Respiratory Tract Infections that, where possible, a switch to oral antibiotics should be made for community-acquired pneumonia (CAP) (3). This recommendation has been translated into a target of 80% IV-to-oral switch, as included in the implementation agenda for Healthcare Evaluation and Appropriate Use (4). The Antimicrobial Stewardship Monitor (AMSM), which provides feedback on prescribing behavior to local A-teams, shows that this target percentage is often not yet achieved in practice (5).
Besides CAP, there is increasing evidence for IV-to-oral switch in other indications. A systematic review shows that in clinically stable patients with osteomyelitis, bacteremia, and endocarditis, an early switch to oral antibiotics leads to a clinically equivalent, but safer treatment, including a shorter hospital stay (6). For bone and joint infections, it has been shown that oral therapy during the first six weeks of treatment is non-inferior to intravenous therapy (7). It also appears that in patients with cellulitis, a switch to oral treatment, once the spread of the infection has stopped, leads to a non-inferior treatment (8).
Timely switching to oral treatment offers not only clinical benefits but also sustainability gains. For example, for penicillin use in pneumonia, based on the baseline situation in Denmark, it has been shown that timely completion of oral treatment leads to a reduction in climate impact of approximately 56%, increasing to 94% with fully oral treatment (9). For ciprofloxacin, a recent study has shown that one oral dose has a climate impact of 12.6 grams of CO2-equivalent, while an IV dose corresponds to a climate impact of almost 900 grams of CO2-equivalent (10).
Intervention
Switching to oral antibiotic treatment as soon as possible when the patient is clinically stable and oral intake is possible.
Environmental impact
Measured in CO2-emissions by reducing the number of IV antibiotic administrations.
Method
1. Define the population and formulate an objective
- Identify patients for whom an IV-to-oral switch is possible, i.e., clinically stable patients who can take medication orally, for example, patients with CAP, bone and joint infections, bacteremia, endocarditis, or cellulitis.
- Review the current policy for the selected patient group(s).
- Evaluate, using the AMSM or administration data from the EMR and the environmental impact calculation tool, what proportion of patients complete their treatment orally and the time until oral completion.
Note: the AMSM reports this for CAP or for the total number of patients. If focusing on a different indication or if a hospital does not participate in the AMSM, the intervention can be evaluated using administration and DBC data from the EMR.
- Formulate a SMART objective together with the A-team and (the green team of) the relevant department(s). For example: for ≥80% of patients with moderate/severe CAP, a switch to oral antibiotics occurs within 72 hours.
2. Implementation
- Define and implement clear switch criteria in the local antibiotic policy, for example, ≥24 hours fever-free, ability to take oral medication, decreasing infection parameters, and an effective oral alternative. Stipulate that reassessment routinely takes place on day 2 and/or 3 of intravenous therapy and embed this in protocols and order sets.
- Ensure reassessment is embedded in the care process by:
- automatic stop or reassessment moments in the EHR (e.g., “review IV antibiotics after 48 hours”).
- inclusion of IV-to-oral switch as a standard part of ward rounds.
- clear division of tasks (e.g., physician responsible for decision, pharmacist/alert system for reminder).
- Facilitate implementation via the A-team:
- training of physicians and nurses on indications and safety of switching.
- development of practical tools (decision tree, checklist).
- make IV-to-oral switch an explicit component of local improvement programs.
3. Monitoring and evaluation
- Monitor implementation using the environmental impact calculation tool by comparing the proportion of IV to oral administrations, see ‘‘Method for evaluating a drug intervention’.
- Discuss (interim) results regularly, for example, (bi-)monthly. Analyze any variation between departments. Also provide feedback to the A-team and/or the involved department(s), such as during handovers, team meetings, and/or educational sessions.
- Reflect on results in relation to the stated goal, identifying hindering and facilitating factors. Adjust interventions if necessary.
- At the end of the follow-up period (e.g., 6 months), evaluate whether the objective(s) has/have been achieved and how the change is sustained.
How is this measured?
The environmental impact of the intervention can be determined by the reduction in IV administrations adjusted for differences in patient numbers between the pre- and post-measurement, see ‘Methodology for evaluating a drug intervention’.
Note: for this intervention, patient numbers must be adjusted due to strong seasonal fluctuations.
When is implementation considered successful?
Based on the reduction in the proportion of IV versus oral antibiotic administrations, as described in the previous paragraph, determine when the implementation is considered successful, and reflect on the stated objective.
References
(1) SWAB. Antibiotic Booklet: IV/oral switch criteria. Available at: https://adult.nl.antibiotica.app/node/9404. Accessed on May 4, 2026.
Based on: Akhloufi H, Hulscher M, Melles DC, Prins JM, van der Sijs H, Verbon A. Development of operationalized intravenous to oral antibiotic switch criteria. J Antimicrob Chemother. 2017;72:543–546.
(2) Johnstone Y, Proud E, Sharp E. Time to care: a comparative evaluation of IV versus oral antibiotic administration. JAC Antimicrob Resist. 2025;7(Suppl 4):dlaf230.098.
(3) Zorginstituut Nederland. Meaningful Care – Improvement Report Lower Respiratory Tract Infections. 2021. Available at: https://www.zorginstituutnederland.nl/documenten/2021/12/06/zinnige-zorg-verbetersignalement-onderste-luchtweginfecties.
(4) Healthcare Evaluation and Appropriate Use. Community-acquired pneumonia: antibiotic prescription (ZZ-LWI-001). Available at: https://zorgevaluatiegepastgebruik.nl/implementatieagenda/zz-lwi-001/community-acquired-pneumonia-voorschrijving-antibiotica.
(5) SWAB. Antimicrobial Stewardship Monitor. Available at: https://swab.nl/nl/antimicrobial-stewardshipmonitor. Accessed on May 4, 2026.
(6) Wald-Dickler N, Holtom P, Phillips M, et al. Oral is the new IV: challenging decades of blood and bone infection dogma. Am J Med. 2021;135:369–379.e1.
(7) Li HK, Rombach I, Zambellas R, et al. Oral versus intravenous antibiotics for bone and joint infection. N Engl J Med. 2019;380:425–436.
(8) Aboltins CA, Hutchinson AF, Sinnappu RN, et al. Oral versus parenteral antimicrobials for the treatment of cellulitis: a randomized non-inferiority trial. J Antimicrob Chemother. 2015;70:581–586.
(9) Olsen RWF, Johansen KB, Ayivee F, Gislason S, Arnspang Pedersen S, Cimpan C. The greener prescription: life cycle environmental impact of oral and IV penicillin treatments. Sustain Chem Pharm. 2026;50:102346.
(10 De Jaegher N, De Greef J, Briquet C, et al. Environmental benefits of switching from intravenous to oral administration of ciprofloxacin Open Access. Journal of Antimicrobial Chemotherapy. 2026;81(6).
Attachments
- https://farmacopedia.nl/artikelen/intraveneus-orale-switch-antibiotica/
- On www.oralia.nl you can find which medications/antibiotics can be administered via a feeding tube.
View our other interventions
Clinical care
Paracetamol should be administered orally instead of intravenously
To treat postoperative pain, intravenous (IV) acetaminophen is usually administered. However, research shows that oral (PO) administration is equally effective and more sustainable in most patients. A systematic review of 14 studies shows that there is no convincing difference in the analgesic effect between IV and oral acetaminophen at different times after surgery (1). However, the environmental impact varies considerably: CO2 emissions from IV administration are up to 16x higher (2). Where an oral administration of 1 gram of acetaminophen from a blister results in the emission of approximately 38 grams of CO₂ eq., this can be up to 628 grams when administered IV, depending on the packaging and administration material (2).
In most patients, acetaminophen can be administered orally, as described in the NVZA Monograph 'Paracetamol' (3). The paracetamol challenge demonstrated that IV acetaminophen administration can be reduced by at least 25%, saving staff time, costs and environmental impact (4). These results underline deployment at a larger scale.
Clinical care
Sharing the indication and intended treatment duration of multiple anticoagulant therapies with primary care
The prescription of multiple anticoagulant therapy (e.g. double or triple therapy with anticoagulants and antiplatelet agents) is complex and associated with an increased risk of bleeding. Patients often use these combinations temporarily, for example after acute coronary syndrome, percutaneous coronary intervention, or concomitant atrial fibrillation and stent implantation (1). European and Dutch guidelines therefore emphasize that double or triple therapy is never indicated for life, but always has a limited treatment period, depending on the clinical situation and the individual balance between the risk of bleeding or an ischemic event (1).
In practice, however, it appears that these drugs are regularly used for too long or are continued without a current indication, which significantly increases the risk of serious, preventable bleeding. For example, research in Dutch pharmacies showed that 14— 23% of patients who used dual anticoagulation no longer had a valid indication (2). During hospitalization, it was found that more than 40% of patients with multiple anticoagulant therapies used these combinations incorrectly (3). This risks bleeding complications, and thus unnecessary hospital admissions (4), but also contributes to unnecessary costs and environmental impact.
To prevent this, clear communication during dismissal and transfer is crucial. Explicitly sharing the indication and the intended treatment duration with primary care (general practitioner and pharmacist) enables follow-up care providers to continue treatment responsibly or to stop it in time. This contributes to medication safety, reduces the risk of complications and prevents unnecessary drug use.
Clinical care
Administer antiemetics orally and/or rectally instead of intravenously
Antiemetics, such as 5HT3 antagonists (e.g. ondansetron and granisetron) and dopamine antagonists (e.g. metoclopramide), are widely used in clinical care to prevent and treat nausea and vomiting, for example postoperatively or during chemotherapy. Research shows that antiemetics administered enterally (e.g., orally or rectally) at an equivalent dose usually have a similar effectiveness and safety to those administered intravenously (IV) (1-2).
The oral/rectal route contributes to greater comfort and autonomy. In addition, the use of oral/rectal medication is more cost-effective and sustainable, because fewer disposable materials are required than intravenous administration (3). In situations where oral administration is not feasible, such as severe nausea or vomiting, rectal administration may sometimes still be chosen. IV administration is only eligible if this is not possible. This is further detailed in the NVZA monographs (4-6).
Clinical care and outpatient care
Discontinuation of proton pump inhibitors without a current indication
Proton pump inhibitors (PPIs) are antacids that are frequently used. Pantoprazole (1.3 million users) and (es) omeprazole (1.2 million users) were among the top 3 most used medicines in 2023 (1). However, it appears that a large number of these drug users have no indication for PPI use (2). In short-term use, more than half of the patients appeared to have no indication (3); in chronic use, this figure is even 87% (4). Overtreatment with PPIs risks side effects, such as an increased risk of bone fractures and vitamin B12 deficiency, but also leads to unnecessary costs and environmental impact (2).
The NHG 'Stomach Disease (NL)' guideline and the NVMDL guideline 'Gastroesophageal Reflux Disease (NL)' provide recommendations to prevent overtreatment with PPIs (5.6). These guidelines recommend that patients with stomach problems or disorders with a temporary indication for PPIs should reduce a PPI within three months. Only patients with grade C and D4 reflux esophagitis, Barrett's oesophagus and Zollinger-Ellison syndrome should use a PPI for life (5 - 7). A PPI for stomach protection should be stopped when a patient stops taking the medication for which it was prescribed (8).
The Proton Pump Inhibitors Knowledge Paper (NL) explains the consideration for reducing or discontinuing proton pump inhibitors when using PPIs chronically (7). Reducing appears to be successful in approximately 40 - 70% of the patients, depending on the intervention that is chosen (9). In this way, any long-term side effects of PPIs can be prevented and costs and environmental impact can be saved (5 - 7).
