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Research Research Prescribing Trends Before and After Implementation of an Antimicrobial Stewardship Program

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Research Research Prescribing Trends Before and After Implementation of an Antimicrobial Stewardship Program Research Research Prescribing trends before and after implementation of an antimicrobial stewardship program Kelly A Cairns p to 50% of antimicrobial BPharm, Abstract GradDipClinPharm, agents prescribed to hospital Objectives: Antimicrobial stewardship programs are recommended to reduce Antimicrobial Stewardship 1 inpatients are considered to be Pharmacist U antimicrobial resistance by reducing inappropriate use of antimicrobials. We inappropriate,1,2 and this excess use implemented an antimicrobial stewardship program and aimed to evaluate its Adam W J Jenney effect on broad-spectrum antimicrobial use. MB BS, FRACP, FRCPA, has been associated with increased Infectious Diseases mortality, adverse drug reactions and Design, setting and participants: Observational study with historical control Physician and using interrupted time series analysis conducted in a tertiary referral hospital. Microbiologist1,2 the development of resistant bacte- ria.3,4 The Australian Commission on Hospital inpatients prescribed restricted antimicrobials for non-standard Iain J Abbott indications, where approval had expired or without approval. MB BS, Safety and Quality in Health Care 1 Intervention: Baseline period of 30 months immediately followed by an Microbiology Registrar recently published recommendations 18-month intervention period commencing January 2011. Matthew J Skinner for hospital-based antimicrobial stew- Main outcome measures: Number and type of interventions made by MB BS, FRACP, ardship programs.2 A variety of General Physician1,3 antimicrobial stewardship team; monthly rate of use of broad-spectrum approaches are available to imple- antimicrobial agents (in defined daily doses/1000 occupied bed-days). Joseph S Doyle ment these recommendations, MB BS, MSc, FRACP, Results: The antimicrobial stewardship team made 1104 recommendations in Infectious Diseases including dissemination of guidelines, 779 patients during the 18-month intervention period. In 64% of cases, the 1 Physician education, restricting antimicrobial recommendation was made to cease or de-escalate the antimicrobial therapy, Michael Dooley availability and postprescribing audit or to change from intravenous to oral therapy. The introduction of the BPharm, and review. intervention resulted in an immediate 17% (95% CI, 13%–20%) reduction in Director of Pharmacy,1 and broad-spectrum antimicrobial use in the intensive care unit and a 10% (95% CI, Professor of Clinical We aimed to evaluate changes in Pharmacy, Centre for 4%–16%) reduction in broad-spectrum antimicrobial use outside the intensive Medication Use and Safety2 antimicrobial prescribing after the care unit. Reductions were particularly seen in cephalosporin and glycopeptide implementation of an antimicrobial use, although these were partially offset by increases in the use of -lactam–- Allen C Cheng lactamase inhibitors. MPH, PhD, FRACP, stewardship program in a specialist Deputy Head, Infection tertiary referral hospital. Conclusions: The introduction of an antimicrobial stewardship program, Prevention and Hospital including postprescription review, resulted in an immediate reduction in broad- Epidemiology Unit,1 and Associate Professor of spectrum antimicrobial use in a tertiary referral centre. However, the effect of Infectious Diseases Methods this intervention reduced over time. Epidemiology2 Setting 1 Alfred Health, full-time pharmacist was appointed in macist and either an ID registrar and/ Melbourne, VIC. Alfred Health is a health service com- January 2011. Before this, authorisa- or an ID physician, on weekdays) com- 2 Monash University, prising three hospitals in metropolitan tion to prescribe restricted antimicro- menced in January 2011. Each round Melbourne, VIC. 3 Sir Charles Melbourne. The largest campus, the bial agents required approval from comprised a focused review of clinical Gairdner Hospital, Alfred Hospital, is a 430-bed tertiary infectious diseases (ID) registrars, but notes and results of investigations Perth, WA. teaching hospital with medicine, sur- auditing had suggested poor compli- aimed at establishing the indication, allen.cheng@ gery and trauma services. It includes ance. In the new system, online planned duration, appropriateness, monash.edu immunocompromised populations approval could be obtained to use and alternatives to the use of restricted (including patients with HIV, cystic restricted antimicrobials for pre- antimicrobial agents. Recommenda- MJA 2013; 198: 262–266 fibrosis and heart/lung transplantation, approved indications that were tions were discussed with the treating doi: 10.5694/mja12.11683 and haematology and bone marrow included in national or local consen- team and documented in writing; the transplantation) and is supported by a sus guidelines. Short-term approval final decision regarding patient man- 35-bed intensive care unit (ICU). was granted for other indications agement was the responsibility of the The Medical Journal of Australia ISSN: 0025- specified by the clinician (non-stand- treating team. Patients who required 729X 18 March 2013 198 5 262-266 Antimicrobial stewardship program ard indications). Pharmacists could more in-depth management advice ©The Medical Journal of Australia 2013 www.mja.com.auWe have previously described the pre- alert the antimicrobial stewardship were referred to the ID consult service. Research liminary activities of the antimicrobial team of unauthorised antimicrobial Patients were reviewed by the stewardship team.5 A web-based use exceeding 24 hours (pharmacist stewardship team if they were antimicrobial approval system (Guid- alerts). receiving at least one restricted anti- ance MS, Melbourne Health) was Non-ICU antimicrobial stewardship microbial for a non-standard indica- rolled out from October 20106 and a ward rounds (by the stewardship phar- tion, where approval had expired, or 262 MJA 198 (5) · 18 March 2013 Research 1 Existing infectious diseases services and antimicrobial stewardship interventions augmented this from January 2011 introduced during the study with all patients reviewed routinely. In December 2010, there was also a Existing infectious diseases services change to empirical ICU guidelines Antimicrobial stewardship interventions introduced during this study for health care-acquired sepsis, from Intensive care Heart/lung transplantation ticarcillin/clavulanate or cefepime Surgical specialties Haematology/bone (for early and late sepsis, respec- Rehabilitation General medicine marrow transplantation tively) to piperacillin/tazobactam Acute geriatric care Other medical specialties Cystic fibrosis (regardless of onset), in all cases Community hospital Emergency department Burns combined with an aminoglycoside, Increasing patient acuity except when combined with qui- nolone in specified situations. Rec- Existing ID ommendations for vancomycin use support Telephone- Routine ID based support Formal ID consultation on request ward rounds did not change. service Outcome measures We compared trends in the rate of use Audit and Antimicrobial stewardship rounds feedback of antimicrobial classes before stew- ardship implementation (January Antimicrobial Web-based antimicrobial approval 2008 to December 2010) and after restriction implementation (January 2011 to June 2012). Antimicrobial consumption quantities were converted into where a pharmacist alert had been received a formal ID consult, or were defined daily doses (DDD) per 1000 created. At our hospital, 13 restricted admitted under lung transplant/ occupied bed-days (OBD) as part of antimicrobial agents require web- cystic fibrosis, haematology and the National Antimicrobial Utilisation based approval: amikacin, azithro- bone marrow transplant, or burns Surveillance Program.7,8 Total broad- mycin, cefepime, ceftazidime, ceftri- services, where ID physicians per- spectrum antimicrobial use was axone, ciprofloxacin, meropenem, formed regular ward rounds (Box 1). defined as the sum of usage for all moxifloxacin, piperacillin/tazo- For several years in the ICU, the classes except for aminoglycosides, bactam, teicoplanin, ticarcillin/cla- microbiology registrar has discussed which are regarded as narrow-spec- vulanate, tobramycin and results and antimicrobial treatments trum antibiotics. Antimicrobial use is vancomycin. Patients were not with ICU teams daily (supported by based on pharmacy purchasing data reviewed by the antimicrobial stew- an ID physician three times per and inpatient stock distribution ardship team if they had already week). The stewardship pharmacist (excluding hospital in the home and 2 Change in antimicrobial use before and after implementation of antimicrobial stewardship interventions Before intervention After intervention Change Trend Trend Change Immediate change Change in trend Antimicrobial class/setting Use* (%/month)† Use* (%/month)† in use† (95% CI)‡ (95% CI)§ Intensive care Total broad spectrum 1021.8 0 937.1 1.0% 8.3% 16.6% ( 19.9%, 13.2%) 1.0% (0.7%, 1.4%) Aminoglycosides 137.0 2.0% 75.2 0.5% 45.1% 20.3% ( 30.2%, 9.1%) 1.5% (0.4%, 2.7%) Antipseudomonal -lactam– 129.1 0.3% 191.3 0.6% 48.2% 34.2% (21.8%, 47.9%) 0.3% ( 0.5%, 1.1%) -lactamase inhibitor Carbapenems 113.8 0.4% 133.9 2.4% 17.6% 11.2% ( 20.7%, 0.6%) 2.1% (1.2%, 3.0%) Cephalosporins 219.2 0.8% 131.2 1.6% 40.2% 54.6% ( 59.0%, 49.7%) 0.8% ( 0.1%, 1.7%) (3rd/4th generation) Fluoroquinolones 318.3 0.7% 278.4 0.1% 12.5% 3.3% ( 10.1%, 4.0%) 0.7% (0.1%, 1.4%) Glycopeptides 241.4 0.2% 202.3 1.5% 16.2% 24.8% ( 31.1%, 18.0%) 1.7% (1.0%, 2.5%) General wards (excluding intensive care) Total broad spectrum 357.8 0.1% 333.4 0.3% 6.8% 9.9% ( 15.7%, 3.7%) 0.2% ( 0.4%, 0.8%) Aminoglycosides 63.7 1.0% 55.8 0.7% 12.5% 9.8% ( 6.7%, 29.1%) 0.3% ( 1.1%, 1.7%) Antipseudomonal -lactam– 50.5 0.4% 54.5 1.9% 8.1% 2.9% ( 18.5%, 15.7%) 2.3% (0.9%, 3.7%) -lactamase inhibitor Carbapenems 52.9 0.4% 53.5 0.1% 1.0% 6.7% ( 10.0%, 26.5%) 0.5% ( 0.9%, 2.0%) Cephalosporins 90.1 0.5% 80.3 0.7% 10.9% 22.4% ( 32.3%, 11.1%) 0.2% ( 1.0%, 1.4%) (3rd/4th generation) Fluoroquinolones 81.8 0 74.0 0.6% 9.6% 4.2% ( 16.7%, 10.3%) 0.6% ( 1.8%, 0.7%) Glycopeptides 82.5 0.3% 71.2 0.4% 13.8% 14.2% ( 25.6%, 1.2%) 0.7% ( 2.0%, 0.5%) * Defined daily doses per 1000 occupied bed-days.
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