Antimicrobial Stewardship Report: 11 th August 2016 Issue: As part of ensuring compliance with the National Safety and Quality Health Service Standards (NSQHS), Yea & District Memorial Hospital is required to participate in benchmarking and quality improvement activities in relation to the prescribing and use of antibiotics. Background: Inappropriate use of antimicrobials leads to the emergence of resistant bacteria, an increase in the risk of patient harm from avoidable adverse reactions and interactions with other drugs, infection with multiresistant bacteria or Clostridium difficile, and unnecessary costs. Most importantly, inappropriate antimicrobial use increases the risk to patients of colonisation and infection with resistant organisms and subsequent transmission to other patients. The consequences of this are now well known patients with infections due to resistant bacteria experience delayed recovery, treatment failure and even death. Research indicates that twice as many patients with antimicrobial-resistant infections died than patients infected with nonresistant organisms. When multiresistant pathogens are prevalent, clinicians are forced to use broader spectrum and usually more expensive agents to treat seriously ill patients. All of these effects contribute to increasing healthcare and societal costs. Further studies show that up to half of antimicrobial regimens prescribed in Australian hospitals are considered inappropriate. Compared with northern Europe, Australian hospitals have a higher overall rate of inpatient antimicrobial use. Further work is required to optimise the use of antimicrobials in hospitals. 1
Antimicrobial Stewardship An effective approach to improving antimicrobial use in hospitals is an organised antimicrobial management program known as antimicrobial stewardship (AMS). AMS involves a systematic approach to optimising the use of antimicrobials. It is used by healthcare institutions to reduce inappropriate antimicrobial use, improve patient outcomes and reduce adverse consequences of antimicrobial use (including antimicrobial resistance, toxicity and unnecessary costs). Effective hospital AMS programs have been shown to decrease antimicrobial use and improve patient care. Along with infection control, hand hygiene and surveillance, AMS is considered a key strategy in local and national programs to prevent the emergence of antimicrobial resistance and decrease preventable healthcare associated infection. Comprehensive AMS programs have demonstrated an overall reduction in antimicrobial use by 22 36% and substantial pharmacy cost savings. Successful programs have been shown to improve the appropriateness of antimicrobial use, and reduce institutional resistance rates, morbidity, mortality and healthcare costs. NAPS program The Hospital National Antimicrobial Prescribing Survey (Hospital NAPS) assists in the auditing of antimicrobial prescribing practices within Australian hospitals. It is coordinated by a multi-disciplinary team of clinicians within the Guidance Group at the National Centre for Antimicrobial Stewardship, based at the Doherty Institute in Melbourne. The survey is designed to provide a standardised data collection tool which allows participants to audit prescribing within their facility and to receive useful reports and national benchmarking data. Yea & District Memorial Hospital actively began collecting antimicrobial data for Yea Hospital inpatients and Nursing Home and Hostel residents in November 2015. This data has been collected, reviewed and submitted to the NAPS program for review. A submission of all antibiotics prescribed and used for inpatients from November 2011 to July 2016 was provided to the NAPS program and reviewed by their pharmacist. 2
Summary of findings It was noted approximately 58% or more of orders did not meet the guidelines for compliance with: Therapeutic guidelines Local guidelines Allergy mismatch Microbiology mismatch Incorrect dose / frequency Incorrect route Incorrect duration Spectrum too broad Spectrum too narrow Indication does not require any antimicrobials If restricted: approval given Summary of Issues Yea Hospital Acute Nov 2015 July 2016 1 Optimal 16 12.7% 2 - Adequate 37 29.3% 3 - Suboptimal 24 19% 4 - Inadequate 40 31.7% 5 Not assessable 9 7.1% Total 126 3
Issue Summary 1 Cephalothin Cephalothin is used rather than cefazolin. Cephalotin has not been recommended for some time as it has a very short half-life and therefore needs to be given every 4 hours to be effective. It is also not very effective on gram negative coverage and as such usually not effective for UTI s and many other infections which would be more adequately treated by cefazolin. Most organisations have removed this from their formulary 2 Accuracy of diagnosis For the audit results to be accurate we need to document specific indications as listed in the guidelines. For example `Pleurisy or even `Respiratory tract infection are not recognised indications for antibiotic use. We need to be much more specific, for example `Community acquired pneumonia moderate severity. It was also noted that the diagnosis of pneumonia should be made by performing a chest x-ray 3 Use of Roxithromycin The use of roxithromycin for chest infections is no longer indicated. It is not effective against any typical infections and little cover for pneumonia. Most organisations have removed this from their formulary and use amoxicillin or doxycycline instead. 4 Ceftriaxone dose The standard dose is now recommended to be 1 gram daily not 1 gram BD (unless obese) 5 Allergy information It is very important to clearly document any reaction or sensitivity information. If no reaction is specified then it is assumed that the reaction would be severe and the drug should not be given. 6 Cefazolin for infected wounds Recommended Cefazolin dose for infected wounds is 2g 8 hourly not 1g 7 Norfloxacin Norfloxacin is the least preferred option for acute cystitis and should only be used when resistant or allergic to other antibiotics. Recommendations 1. Continue to submit the NAPS forms into the program and provide an annual summary report through participation in the national benchmarking survey that opens in September 2. Assist with any education, information or resources required 3. Adjust the formulary of stocked antimicrobials as per recommendations from the NAPS pharmacists 4
Summary In conclusion, the information gathered and feedback received by the NAPS pharmacists is to be seen as a valuable quality improvement exercise for the organisation. Ongoing involvement with the National Antimicrobial Prescribing Service will provide us with the opportunity to access expert advice to ensure that we are optimising the prescribing of antibiotics for our patients and residents. Appendix 1: NAPS review form Appendix 2: Guidelines to assist with the assessment of appropriateness Appendix 3: Indications list 5
Appendix 1 6
Appendix 2 7
Appendix 3 8
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