Orchestrated Efforts to Optimize Antibiotic Prescriptions in a Medical Department

Transcription

1 Workshop on Antibiotic Stwardship Orchstratd Efforts to Optimiz Antibiotic Prscriptions in a Mdical Dpartmnt Dr. Eugn Tso Division of Infctious Disass Dpartmnt of Mdicin & Griatrics Unitd Christian Hospital 18 Jan 11

2 Dpartmnt of Mdicin & Griatrics (M&G), Unitd Christian Hospital (UCH) Th dpartmnt that spnds most mony for antibiotic prscriptions in UCH

3 Cor mmbrs Dpartmnt of Mdicin & Griatrics (M&G) Dr. Eugn Tso, Infctious Disass Physician Dr. Ng Woon Lung, Dputy COS Dr. Chu Chung Ming, COS Dpartmnt of Pathology Dr. Kitty Fung, Clinical Microbiologist & Infction Control Officr, Chairman of Antibiotic Stwardship Programm in UCH Dpartmnt of Pharmacy Ms. Janis Chan, Pharmacist

4 Why w nd to do it? Promot th prompt us of appropriat mpirical antibiotics Promot a targtd tratmnt approach for bactrial infction Rduc th inappropriat and unncssary us of broad spctrum Big gun antibiotic Promot arly hospital discharg By rducing unncssary hospital stay simply bcaus of th nd for antibiotic injction

5 Targtd Antibiotics Intravnous amoxicillin-clavulanat (Augmntin) Quinolons, azithromycin (po) Big gun broad-spctrum intravnous antibiotics Ticarcillin-clavulanat (Timntin) Cfoprazon-sulbactam (Sulprazon) Pipracillin-tazobactam (Tazocin) Cfpim Mropnm Imipnm-cilastatin (Tinm)

6 How w did it?

7 1. Promotion of Outpatint Parntral Antimicrobial Thrapy - parntral cftriaxon and rtapnm (Onc daily dosing) Our dpartmnt submittd th proposal and succssfully stockd rtapnm in th Hospital Authority Drug Formulary in May 8.

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9 . Distribution of pockt-sizd UCH Guidlins for Empiric Antibiotic Thrapy 8 (15/8/8)

10 3. Rgular mail alrts to doctors 5/1/9 Rcommndation on th appropriat uss of IV & PO Augmntin For mild cas and no contraindication for oral intak, PO augmntin is rcommndd Rcommndd oral augmntin with normal rnal function: Augmntin 1g bd (Syrup augmntin 64mg tds if put on Ryl s tub/peg tub) 6/1/9 Rcommndation on th us of PO clarithromycin (daily cost HK$ 3) instad of PO azithromycin (daily cost HK$ 7) for mpiric covrag of atypical pnumonia 8/1/9 Rcommndation on th us of onc-daily cftriaxon (rathr than cfotaxim) 6//9 Rcommndation on stpping down pipracillin/tazobactam (tazocin) to pipracillin if th organism is snsitiv to pipracillin 7/8/9 Rcommndation on monitoring optimal trough srum vancomycin concntrations for trating svr MRSA infction 9/8/9 mssag listing inappropriat antibiotic prscriptions and suggstd improvmnt 1/9/9 Appropriat uss of tazocin and carbapnm for ESBL infctions 8/9/9 Tratmnt of lowr urinary tract infction du to ESBL E coli 15/9/9 Collct spcimns for cultur and snsitivity bfor 1st dos of antibiotic

11 An xampl of mail alrt snt to M&G Mdical Staff

12 4. Implmntation of Augmntin arly IVto-PO switch programm (5//9) For cas put on IV augmntin, days of IV augmntin will b supplid by th pharmacy. If th cas MO dcids on continuation of IV augmntin for mor days, thy must rad th Augmntin IV-to-Oral Switch Rmindr Form and fill-in th indication.

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14 5. Distribution of UCH Guidlins for Empiric Antimicrobial Thrapy of Slctd Infctions in Adults 9 basd on latst UCH antibiotic suscptibility rsults (14/8/9) Pag 3

15 All usful guidlins archivd on for rapid accss

16 Rsults Prscribing Bhaviour

17 In 9 (compard with 8): w achivd a significant drop in xpnditur on IV augmntin and augmntin syrup (457mg/5ml); a slight ris in th xpnditur on Augmntin 1g bd and augmntin syrup (156mg/5ml). Rduction in ovrall augmntin xpnditur (9 vs 8): HK$ Expnditur of Diffrnt Prparation of Augmntin Expnditur ($) AUGMENTIN TABLET 375MG AUGMENTIN SYRUP 156MG/5ML AUGMENTIN INJECTION 6MG AUGMENTIN TABLET 1G AUGMENTIN SYRUP 457MG/5ML J a n uar y 8 F b r u a ry 8 M ar c h 8 A pr il 8 M ay 8 Ju n 8 J ul y A ugust S p t br m O ct o b r 8 8 N ovmbr 8 br D c m J a n uar y 9 F b r u a ry 9 M ar c h 9 A pr il 9 M ay 9 Ju n 9 J ul y A ugust S p t br m O ct o b r 9 9 N ovmbr 9 br D c m 15/8/8: Distribution of UCH antibiotic pamphlt for Empiric Antibiotic Thrapy 8 5/1/9: alrt rcommnd PO augmntin for mild cas, us cost-ffctiv PO augmntin prparations (1g tablt, 156mg/5ml syrup) 5//9: Implmntation of Augmntin arly IV-to-oral switch programm

18 Usag of IV Augmntin 9 Vs 8 Yar No. of cass givn IV augmntin No. of doss of IV augmntin givn Avrag no. of doss of IV augmntin givn for ach cas Avrag duration of IV augmntin (if givn q8h) days days Rduc injctions by nurss

19 Avrag tim takn for prparation and administration of IV Augmntin ~3-4 minuts Total tim rquird 8: 489 hrs 9: 88 hrs Sav 51 hours of nurss tim

20 Consumabl itms for stting up an IV accss G Angiocathtr x 1 $5.8 MicroCLAVE Connctor x 1 $4.87 Tgadrm x 1 $.74 Normal salin for injction x 1 $.558 5mL syring x 1 $.64 Total cost for stting up IV accss for injction of IV augmntin 8: HK$ : HK$ Sav HK$ 344 in 9 (c.f. 8)!!!

21 No. of consumabl itms usd for administration of IV augmntin No. usd in 8 No. usd in 9 Rduction in no. Pric (HK$) pr itm Rduction in xpnss (HK$) Watr for injction HK$45,157 Normal salin for injction HK$5,197 1ml syring HK$1,63 5ml syring HK$3,19 ml syring HK$5,577 Ndl (1 gaug) HK$4,495 TOTAL HK$85,157 Sav HK$ in 9 (c.f. 8)!!!

22 Impact of Augmntin Early IV-to-PO switch programm (9 vs 8) Sav HK$ for drug cost Rduc IV injctions by nurss Sav 51 hours of nurss tim for injctions Sav HK$ 344 for consumabl itms usd for stting up IV accsss Sav HK$ for consumabl itms usd for administration of IV augmntin

23 Significantly dcrasd xpnditur on PO azithromycin; slightly incrasd xpnditur on PO clarithromycin Comparison of Macrolid Expnditur 5 Expnditur ($) 15 1 Azithromycin (PO) Azithromycin (IV) Clarithromycin (PO) 5 y 8 J anuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 8 J un J ul y A ugust S pt mbr O ct obr y N ovmbr D cmbr 9 J anuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 9 J un J ul y A ugust S pt mbr O ct obr N ovmbr D cmbr 6/1/9: alrt rcommnd PO clarithromycin (daily cost HK$ 3) instad of PO azithromycin (daily cost HK$ 7) for cost-ffctiv covrag of atypical pnumonia

24 Significantly dcrasd xpnditur on quinolons (both IV and PO) Comparison of IV and PO Quinolon Expnditur Expnditur ($) Quinolon (IV) Quinolon (PO) 5 y 8 J anuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 8 J un J ul y A ugust S pt mbr O ct obr y N ovmbr D cmbr 9 J anuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 9 J un J ul y A ugust S pt mbr O ct obr N ovmbr D cmbr 15/8/8: Distribution of UCH antibiotic pamphlt for Empiric Antibiotic Thrapy 8

25 Significantly dcrasd xpnditur on ticarcillin-clavulanat (timntin), pipracillintazobactam (tazocin), cfoprazon-sulbactam (sulprazon), cfpim and mropnm Expnditur of Big-Guns PIPERACILLIN + TAZOBACTAM TIMENTIN Expnditur ($) SULPERAZON CEFEPIME TIENAM y 8 Ja nuar F br u ar y 8 M ar c h 8 A pr il 8 M a y 8 Ju n 8 J ul y 8 8 A ugust S p t m 8 8 br O ct obr 8 N ovmbr D c m br 8 y 9 Ja nuar F br u ar y 9 M ar c h 9 A pr il 9 M a y 9 Ju n 9 J ul y 9 9 A ugust S p t m 9 9 br O ct obr 9 N ovmbr D c m br 9 MEROPENEM 15/8/8: Distribution of UCH antibiotics pamphlt for Empiric Antibiotic Thrapy 8 to M&G doctors 5/1/9: alrt Rcommndation on th appropriat uss of IV & PO Augmntin. For mild cas and no contraindication for oral intak, PO augmntin is rcommndd 6//9: alrt stp down IV tazocin to IV pipracillin if th isolat is snsitiv to th lattr 14/8/9: Distribution of UCH Guidlins for Empiric Antimicrobial Thrapy of Slctd Infctions in Adults 9

26 Rsults Ovrall impact

27 Expnditur of Antibiotics in M&G J a n u a ry 8 F b ru a ry 8 M a rc h 8 A p ril 8 M a y 8 J u n 8 J u ly 8 A u g u s t 8 S p t m b r 8 O c to b r 8 N o v m b r 8 D c m b r 8 J a n u a ry 9 F b ru a ry 9 M a rc h 9 A p ril 9 M a y 9 J u n 9 J u ly 9 A u g u s t 9 S p t m b r 9 O c to b r 9 N o v m b r 9 D c m b r 9 Expnditur ($) Total Expns of Big Guns Total Antibiotic Expns Total Expns of Non-Big Guns Expns of IV Augmntin 9 vs 8 Ovrall dcras in xpnditur on all antibactrial drugs: HK$ Dcrasd xpnditur on big gun antibiotics Dcrasd xpnditur on non-big gun antibiotics Espcially IV augmntin -HK$ (9 vs 8)

28 Th rduction in xpnditur was achivd whil th numbr of M&G inpatints incrasd by 7.5% in 9 (c.f. 8) Rlationship of Total Expnss of Antibiotics, Big Guns and Augmntin with Total No. of In-patint Expnditur ($) ,5 3,,5, 1,5 Total no. of In-patint Total Expns of Antibiotics Total Expns of Big Guns Total Expns of Augmntin Total no. of In-patint 3 1, 5 1 J a n uar y 8 F b r u a ry 8 M ar c h 8 A pr il 8 M ay 8 Ju n 8 J ul y 8 8 A ugust S p t m br 8 O ct o b r 8 8 N ovmbr D c m br 8 J a n uar y 9 F b r u a ry 9 M ar c h 9 A pr il 9 M ay 9 Ju n 9 J ul y 9 9 A ugust S p t m O ct o b r N ovmbr D c br m br 9

29 Rduction in th avrag lngth of inpatint stay (for all M&G inpatints): 15.1% (9 vs 8) This shortning of avrag lngth of inpatint stay (days) is significantly corrlatd with th rductions in xpnditur on antibiotics (spcially big-gun broad spctrum intravnous antibiotics) Rlationship of Total Expnss of Antibiotics, Big Guns and Augmntin with Avrag IP Lngth of Stay 1 6. Exp nditur ($) r=.768, p<.1 r=.85, p<.1 r=.738, p< Avrag IP lngth of Stay (Days) Total Expns of Antibiotics Total Expns of Big Guns Total Expns of Augmntin Avrag IP lngth of stay (days). y 8 J anuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 Ju n 8 J ul y A ugust S p t mbr O ct obr y N ovmbr D cmbr 9 J anuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 Ju n 9 J ul y A ugust S p t mbr O ct obr N ovmbr D cmbr r= Sparman s rank corrlation

30 Th rduction in antibiotic xpnditur did not lad to an incrasd mortality rat Instad, th inpatint mortality rat dcrasd by 6.9% in 9 (cf. 8) Rlationship of Total Expnss of Antibiotics, Big Guns and Augmntin with IP Mortality Rat Expnditur ($) % 7.% 6.% 5.% 4.% 3.%.% 1.% IP Mortality Rat (%) Total Expns of Antibiotics Total Expns of Big Guns Total Expns of Augmntin IP Mortality rat (%).% y 8 Ja nuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 Ju n 8 J ul y A ugust S pt mbr O ct o b r y N ovmbr D cmbr 9 Ja nuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 Ju n 9 J ul y A ugust S pt mbr O ct o b r N ovmbr D cmbr

31 Incidnts of ndlstick injuris for nurss working in M&G Dpt 8: 4 incidnts A nurs got injury to hr Lt hand (dorsal aspct) whn withdrawing ndl from hparin block. Two nurss got injury to hr Lt middl fingr bcaus of patint movmnt during iv injction A nurs got injury to th fingr whn picking up usd ndl for injction from th kidny dish 9: Nil

32 Tips for succss Tamwork Within th M&G dpartmnt Collaboratd ffort by microbiologist and pharmacy Opn and clar communications/ducations Simpl, asily accssibl guidlin Rgular mail alrts Administrativ intrvntions to safguard abus

33 Succss nds to b sustaind

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36 This prsntation was also givn in:

37 Thank you