Drug Utilization and Evaluation of Restricted Anti-Microbials at CWM Hospital BY PHARMACY INTERNS 2007: ANNA ROSE PAVIHI MAKELESI COLATI VEEBHA CHAUHAN ANSHIL CHAND RAIJELI KAUYACA NAMRATA SINGH
INTRODUCTION v Use of Restricted Antimicrobials is rapidly increasing worldwide. v Inappropriate use results in: v increasing antimicrobial resistance v increasing health costs v To reduce such setbacks, regular monitoring and control of Restricted Antimicrobials is required.
The following are the Restricted Antimicrobials available at CWM hospital: ü Aciclovir 250mg IV ü Ceftriaxone 250mg & 1g IV ü Ciprofloxacin 500mg Tab. & 100mg/ 50ml IV ü Erythromycin 1g IV ü Metronidazole 500mg IV ü Piperacillin 2g IV ü Vancomycin 500mg IV
AIM v To review the current usage of Restricted Antimicrobials and to evaluate whether current prescribing corresponds with the Antibiotic Guidelines 2003/2004.
OBJECTIVES 1.To review the current usage of Restricted Antimicrobials at CWM Hospital as indicated in the Fiji Antibiotic Guidelines 2003/2004. 2.To find out whether Prescribers are adhering to the Standard Operating Procedure for acquiring Restricted Antimicrobials. 3.To determine the Consumption Rate and Estimated Cost per annum of Restricted Antimicrobials over the past 5 year period (2003-2007) at CWM Hospital.
METHOD Quantitative Retrospective and Prospective Review: v 6 month Retrospective (Aug. 2007 Jan. 2008) review was carried out for Ceftriaxone IV, Metronidazole IV, Vancomycin IV, Ciprofloxacin IV/ Tabs. v Exception : Erythromycin IV, Piperacillin IV & Aciclovir IV (previous 2 years). v 2 month Prospective (May June 2008) for all except Piperacillin. (no pts) Collection Tools and Reference Source: v Audit Sheets v Patients Information System (PATIS) v Restricted Antimicrobial Form (SOP) v Antibiotic Guidelines 2003 2004 2 nd Edition.
RESULTS and DISCUSSION OBJECTIVE 1 (a): Prescribing According To Antibiotic Guideline Retrospective Percentage of Indications According to Antibiotic Guideline Vancomycin 90 10 Piperacillin 57 43 Antimicrobial Erythromycin Metronidazole Aciclovir 80 96 100 20 4 Ciprofloxacin 89 11 Ceftriaxone 89 11 Percentage (%) Within Outside
Prospective No. of Requests According to Guideline Erythromycin IV 2 Aciclovir IV 4 Antimicrobial Vancomycin IV Metronidazole IV 2 70 6 Ceftriaxone IV 250 mg & 1 g 91 7 Ciprofloxacin IV/oral 20 1 0 15 30 45 60 75 90 No. of patients Within Outside
Objective 1(a) : Majority are prescribed according to Indications in the Antibiotic Guideline: Retrospective (84%) and Prospective (93%). Outside Indication pertain to the following reasons: No indication on the request form Unclear indications Writing of microbe name with no specific indication New indications
OBJECTIVE 1 (b) : Completion of Therapy Retrospective Percentage of Completed Treatment Antimicrobials Ceftriaxone IV 250mg & 1g Piperacillin IV Metronidazole IV Ciprofloxacin IV/Oral Erythromycin IV Vancomycin IV Aciclovir IV 79% 43% 61% 32% 75% 50% 95% 21% 57% 39% 68% 25% 50% 5% 0% 20% 40% 60% 80% 100% 120% Percentage (%) TX Complete TX Incomplete
Prospective Completion of Therapy Erythrom ycin IV 2 Antimicrobials Aciclovir IV Vancomycin IV Metronidazole IV Ceftriaxone IV 250 mg & 1 g Ciprofloxacin IV/oral 1 3 1 1 20 1 53 62 23 36 0 15 30 45 60 75 90 No. of Patients Tx Complete Tx Incomplete
Objective 1 (b): Completion of therapy: Treatment Incomplete Retrospective - 38% Prospective 33% The following applies to the Prospective data only Pt. Deceased (18) Pt. Discharged (15) Pt Switched to another Antimicrobial (8) Out of Stock (2) Others (23) * n=203
Objective 2 Not Adhering 21% Retrospective Adhering 79%
Objective 2: Adherence to Protocol Non Adherence: v Retrospective 21% v Prospective 26% v Reasons: - Patient details not specific e.g. NHN, age & weight for Peadiatrics - No justification given for Indications when outside the Antimicrobial Guidelline - Indication's not specified - Consultant did not sign - No sensitivity report - No pharmacy report
Objective 3: Consumption Rate Per Annum (2003-2007) Consumption Rate Per Annum For Piperacillin & Ciprofloxacillin IV/Oral No. of Units 1400 1200 1000 800 600 400 200 0 2003 2004 2005 2006 2007 Year Piperacillin IV Ciprof loxacin IV Ciprof loxacin Oral
Consumption Rate per Annum of Vancomycin IV/Metronidazole IV No. of Units 8000 7000 6000 5000 4000 3000 2000 1000 0 2003 2004 2005 2006 2007 Year Vancomycin IV Metronidazole IV
Consumption Rate per Annum of Erythromycin IV/Aciclovr IV No. of Units 700 600 500 400 300 200 100 0 2003 2004 2005 2006 2007 Year Erythromycin IV Acyclovir IV
Consumption Rate of Ceftriaxone 1g and 250mg per Annum 14000 12000 10000 No. of vials 8000 6000 4000 2000 Ceftriaxone 1g Ceftriaxone 250mg 0 2003 2004 2005 2006 2007 Year
Cost Per Annum Consumption Rate of IV Piperacillin, Erythromycin, Aciclovir ($) 8000 Cost per Annum 6000 4000 2000 0 2003 2004 2005 2006 2007 Year Piperacillin 2g Erythromycin 1g Aciclovir 250mg
Cost Per Annum Consumption rate of Vancomycin and Metronidazole ($) Cost per Annum 16000 14000 12000 10000 8000 6000 4000 2000 0 2003 2004 2005 2006 2007 Year Vancomycin IV (500mg) Metronidazole IV (500mg)
Cost Per Annum Consumption Rate of Ceftriaxone 250mg & 1g ($) Cost per Annum ($) 35000 30000 25000 20000 15000 10000 5000 Ceftriaxone 250mg Ceftriaxone 1G 0 2003 2004 2005 2006 2007 Year
Cost per Annum Consumption rate of Ciprofloxacillin Oral and IV ($) Cost per Annum 4500 4000 3500 3000 2500 2000 1500 1000 500 0 2003 2004 2005 2006 2007 Year Ciprofloxacillin 500mg Tablets Ciprofloxacillin IV 200mg
DISCUSSION: Objective 3 v Drastic increase in consumption and cost/annum in the period of 2006-2007 for : v Ceftriaxone 250mg and 1g IV v Metronidazole IV v Ciprofloxacin IV v Vancomycin IV
Patients per Discipline Erythromycin IV 2 Aciclovir IV 13 Antimicobials Vancomycin IV Metronidazole IV Ceftriaxone IV 250mg & 1g Ciprofloxacin IV/ Oral 2 17 18 16 678 49 10 64 Medical Surgical Paediatrics 0 15 30 45 60 75 90 No. of patients
RECOMMENDATIONS - R - Clarify -- Delegate a clinical pharmacist to monitor all pts. on restricted antimicrobials - Additional intervention is required to improve communication between the microbiology and pharmacy department. - Continuing education for all health professionals.
LIMITATIONS Time Constraints Unavailability of Sensitivity Report. Incomplete Pharmacy Reports. Limited Time frame for Prospective Study (2months)
CONCLUSIONS The principal aim of restricted antimicrobial protocols is to improve the quality of prescribing, which should lead to a reduction of resistance, decreased cost and improved patient care. he approach to appropriate prescribing and utilization of restricted antimicrobials should include: Adherence to Antimicrobial Guidelines and prescribing protocols. The overall results of the study was found to be inconclusive due to significant limitations mainly the lack of patient numbers and inadequate time frame in the prospective part.