Intravenous-to-oral antibiotic switch for neonates: the experience of early adopters in the UK
Overview
Organisation: Royal Devon University Healthcare NHS Foundation Trust
Organisation type: NHS Foundation Trust
This case study describes how the Royal Devon University Healthcare NHS Foundation Trust implemented a policy to enable babies on intravenous antibiotics for suspected early-onset neonatal infection to be switched to oral antibiotics and discharged home. It also refers to 2 other similar projects. It provides the key outcomes and learning from all 3 projects.
Neonatal intravenous-to-oral antibiotic switch pathways offer enormous potential to reduce neonatal bed days and associated costs. However, the priority is to avoid unnecessary antibiotic treatment in the first place, and to stop antibiotics if the clinical picture allows.
The switch from intravenous to oral antibiotics is for babies who genuinely need a full course of antibiotics but for whom intravenous antibiotics can be replaced with oral antibiotics. It is not a reason to extend treatment that could safely be stopped.
Neonatal oral antibiotics at home project
Inspired by the findings of the RAIN study (Keij et al. 2022), the Royal Devon University Healthcare NHS Foundation Trust ran a 6‑month project from June 2024 to facilitate neonatal teams at its Exeter site to switch from intravenous to oral antibiotics, where possible, for term babies with suspected early-onset infection who need treatment beyond 36 hours.
During the project, the change of practice was rigorously evaluated and refined. By the end of the 6 months, it was fully embedded into normal practice at the Exeter site and running smoothly. It was extended to the trust's Barnstaple site in February 2025.
Known as 'neonatal oral antibiotics at home' (NOAH), the project was completed before the May 2026 update of NICE's guideline on neonatal infection, which introduced new recommendations on switching to oral antibiotics. The NOAH project contributed to the guidance through expert witness evidence, which the guideline committee considered.
Under the change of practice, babies are eligible for oral switch if they are born at term, clinically well at 36 hours, have a peak C-reactive protein level below 50 that is falling, and have no positive blood or cerebrospinal fluid culture. These criteria were chosen with caution and are more restrictive than those described in the literature (Keij et al., Carlsen et al., Gyllensvärd et al.). They are also different to the criteria in NICE's guideline on neonatal infection.
Parents and carers of babies meeting these criteria are offered the option for their baby to be discharged home with a course of oral antibiotics. They are also given the contact details of the neonatal unit to call if they have any concerns.
The choice of oral antibiotic is amoxicillin at a dosage of 30 mg/kg three times daily for a total antibiotic course duration of 7 days. NICE's guideline on neonatal infection recommends up to 7 days.
Parents and carers of babies at home on oral antibiotics, as with all babies discharged from neonatal care, get a telephone call from a neonatal nurse on the day after discharge. They also receive a phone call from the neonatal team before their baby has completed their oral antibiotics. This is in line with NICE's guideline on neonatal infection, which recommends at least 2 follow-up consultations for parents and carers of babies on oral antibiotics.
Implementation
Before the project could get underway, the team of neonatal consultants at Exeter discussed the evidence for implementing NOAH and agreed to take the idea forward. External expertise provided reassurance that the principle of switching to oral antibiotics was sensible.
Engagement with other colleagues, including paediatric infectious diseases and microbiology colleagues, as well as nurses, midwives, general paediatricians and pharmacists followed. This involved email exchanges, formal and informal conversations and presentations at meetings.
Feedback from parents through the trust's maternity and neonatal voices partnership also played a part in the development of the project.
Another important early step involved creating a local guideline, circulating it for comments, and taking it to the appropriate governance meetings for ratification.
Finally, the change in practice was shared with all staff. This was done through formal teaching sessions, posters, emails and '5‑minute teaching sessions' delivered at staff handovers.
Other similar projects
By sharing the findings of the NOAH project at regional and national conferences and teaching events, 2 other projects implementing similar neonatal intravenous-to-oral antibiotic switch pathways were identified at:
-
St George's Hospital in London
-
6 hospitals across Kent, Surrey and Sussex.
Alignment with national policies
As well as aligning with NICE's guideline on neonatal infection, intravenous-to-oral switch is consistent with several national policy priorities, namely:
-
UK Health Security Agency's framework for intravenous-to-oral antibiotic switch, which supports early transition to oral antibiotics in appropriate patients across all age groups
-
NHS England's Getting It Right First Time neonatal recommendation to reduce mother-baby separation and improve the family experience of neonatal care
-
NHS 10-year plan's ambition to shift care out of hospital and into home settings, enabling well babies to complete treatment in their own environment rather than occupying a neonatal bed.
This page was last updated: