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 and outpatient care
Restrictive opioid prescribing with indication and intended treatment duration
The most commonly used, high-acting opioids are morphine, fentanyl, oxycodone, and buprenorphine (1). In 2024, more than 1.1 million people received an opioid through the public pharmacy (2). Although the total number of benefits in kind fell slightly compared to 2023, the number of prescriptions from the hospital actually increased slightly (3). A first dose of a high-acting opioid included an average of 9 days of medication in 2024 (3), while acute pain due to trauma or surgery often requires only 48 hours of strong opioid pain relief (4). Prescribing opioids for too long increases the risk of dependence and also leads to unnecessary environmental impact.
Research shows that the amount of opioids that patients receive at discharge influences their actual use (5). As recovery progresses, the need for opioids decreases rapidly; four days are sufficient for most patients. This is in line with international recommendations that recommend a duration of 3 - 7 days (6-8). The guideline of the Dutch Association of Anesthesiology (NVA) also recommends appropriate use of opioids through restrictive prescribing (up to 7 days) tailored to the pain experienced (9).
Another bottleneck is that the intended treatment duration and indication of opioids at discharge or outpatient dispensing are not always explicitly stated or shared with patients and primary care providers. As a result, GPs and pharmacists often lack crucial information to continue treatment responsibly or to phase it out in time. This increases the risk of unnecessarily long use, and thus unnecessary environmental impact and risk of dependency.
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 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).
Outpatient care
Climate-aware prescription of inhalation medication
Inhalation medications are used in the treatment of asthma and COPD. In the Netherlands, more than 1.4 million people use inhalation medications every year, including bronchodilators, such as short- and long-acting β2 sympathomimetics and parasympatholytics, and inhaled corticosteroids (1). There are various types of inhalers available, including dose aerosols, powder inhalers, and soft mist inhalers. These vary greatly in environmental impact because dose aerosols contain propellants, such as HFA-134a, which has a 1500 times stronger greenhouse effect than CO₂ (2).
In some countries, powder inhalers are already prescribed more often. For example, the proportion of dose aerosols is lowest in Sweden (± 10%), highest in England (± 70%) and around 50% in the Netherlands (2, 3). If the Netherlands were to follow the Swedish example, a significant amount of CO₂ emissions could be prevented (2, 3). This is feasible because powder inhalers and soft mist inhalers are an effective alternative for most adult asthma and COPD patients, provided the inhalation technique is used correctly (4). In addition, more and more dose aerosols based on more sustainable propellants will come on the market in the coming years. This can also reduce the greenhouse gas emissions of inhalation medication.
To encourage doctors and pharmacists to prescribe climate-friendly inhalation medication, the Tranmural guideline for climate-aware prescribing of inhalation medication was developed by the Health Institute in collaboration with GPs, pulmonologists, paediatricians, pharmacists and the Lung Fund (4). To make a real impact, the guideline still requires inclusion in local formularies, so that the large-scale, unnecessary use of environmentally harmful inhalation medications can be reduced.
