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
Dpartmnt of Mdicin & Griatrics (M&G), Unitd Christian Hospital (UCH) Th dpartmnt that spnds most mony for antibiotic prscriptions in UCH
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
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
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)
How w did it?
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.
. Distribution of pockt-sizd UCH Guidlins for Empiric Antibiotic Thrapy 8 (15/8/8)
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 Email 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
An xampl of mail alrt snt to M&G Mdical Staff
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.
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
All usful guidlins archivd on http://uch.hom/id&mb/ for rapid accss
Rsults Prscribing Bhaviour
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$ 139348 Expnditur of Diffrnt Prparation of Augmntin 18 16 14 Expnditur ($) 1 1 8 6 4 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 8 8 8 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 9 9 9 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: Email 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
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) 8 66 79763 1.8 4. days 9 475 9946 7.34.44 days Rduc 49817 injctions by nurss
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
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 $.64 Total cost for stting up IV accss for injction of IV augmntin 8: HK$ 7956 9: HK$ 48811 Sav HK$ 344 in 9 (c.f. 8)!!!
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 1945 51133 7791.5796 HK$45,157 Normal salin for injction 79763 9946 49817.558 HK$5,197 1ml syring 3481 8759 17.747 HK$1,63 5ml syring 79763 9946 49817.64 HK$3,19 ml syring 498 1187 895.1985 HK$5,577 Ndl (1 gaug) 498 1187 895.16 HK$4,495 TOTAL HK$85,157 Sav HK$ 85157 in 9 (c.f. 8)!!!
Impact of Augmntin Early IV-to-PO switch programm (9 vs 8) Sav HK$ 139348 for drug cost Rduc 49817 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$ 85157 for consumabl itms usd for administration of IV augmntin
Significantly dcrasd xpnditur on PO azithromycin; slightly incrasd xpnditur on PO clarithromycin Comparison of Macrolid Expnditur 5 Expnditur ($) 15 1 Azithromycin (PO) Azithromycin (IV) Clarithromycin (PO) 5 y 8 J anuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 8 J un J ul y 8 8 8 8 8 8 A ugust S pt mbr O ct obr y N ovmbr D cmbr 9 J anuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 9 J un J ul y 9 9 9 9 9 9 A ugust S pt mbr O ct obr N ovmbr D cmbr 6/1/9: Email alrt rcommnd PO clarithromycin (daily cost HK$ 3) instad of PO azithromycin (daily cost HK$ 7) for cost-ffctiv covrag of atypical pnumonia
Significantly dcrasd xpnditur on quinolons (both IV and PO) Comparison of IV and PO Quinolon Expnditur 45 4 35 Expnditur ($) 3 5 15 1 Quinolon (IV) Quinolon (PO) 5 y 8 J anuar F br u ar y 8 M ar c h 8 A pr il 8 M ay 8 8 J un J ul y 8 8 8 8 8 8 A ugust S pt mbr O ct obr y N ovmbr D cmbr 9 J anuar F br u ar y 9 M ar c h 9 A pr il 9 M ay 9 9 J un J ul y 9 9 9 9 9 9 A ugust S pt mbr O ct obr N ovmbr D cmbr 15/8/8: Distribution of UCH antibiotic pamphlt for Empiric Antibiotic Thrapy 8
Significantly dcrasd xpnditur on ticarcillin-clavulanat (timntin), pipracillintazobactam (tazocin), cfoprazon-sulbactam (sulprazon), cfpim and mropnm Expnditur of Big-Guns 18 16 14 PIPERACILLIN + TAZOBACTAM TIMENTIN Expnditur ($) 1 1 8 6 4 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: Email 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: Email 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
Rsults Ovrall impact
Expnditur of Antibiotics in M&G 1 3 4 5 6 7 8 9 1 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 ($) Total Expns of Big Guns Total Antibiotic Expns Total Expns of Non-Big Guns Expns of IV Augmntin 9 vs 8 Ovrall dcras in xpnditur on all antibactrial drugs: HK$ 4198189 Dcrasd xpnditur on big gun antibiotics Dcrasd xpnditur on non-big gun antibiotics Espcially IV augmntin -HK$ 4198189 (9 vs 8)
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 ($) 1 9 8 7 6 5 4 3,5 3,,5, 1,5 Total no. of In-patint Total Expns of Antibiotics Total Expns of Big Guns Total Expns of Augmntin Total no. of In-patint 3 1, 5 1 J a n uar y 8 F b r u a ry 8 M ar c h 8 A pr il 8 M ay 8 Ju n 8 J ul y 8 8 A ugust S p t m br 8 O ct o b r 8 8 N ovmbr D c m br 8 J a n uar y 9 F b r u a ry 9 M ar c h 9 A pr il 9 M ay 9 Ju n 9 J ul y 9 9 A ugust S p t m O ct o b r 9 9 9 N ovmbr D c br m br 9
Rduction in th avrag lngth of inpatint stay (for all M&G inpatints): 15.1% (9 vs 8) This shortning of avrag lngth of inpatint stay (days) is significantly corrlatd with th rductions in xpnditur on antibiotics (spcially big-gun broad spctrum intravnous antibiotics) Rlationship of Total Expnss of Antibiotics, Big Guns and Augmntin with Avrag IP Lngth of Stay 1 6. Exp nditur ($) 9 8 7 6 5 4 3 1 r=.768, p<.1 r=.85, p<.1 r=.738, p<.1 5. 4. 3.. 1. 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 8 8 8 8 8 8 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 9 9 9 9 9 9 A ugust S p t mbr O ct obr N ovmbr D cmbr r= Sparman s rank corrlation
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 ($) 1 9 8 7 6 5 4 3 1 8.% 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 8 8 8 A ugust S pt mbr O ct o b r 8 8 8 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 9 9 9 A ugust S pt mbr O ct o b r 9 9 9 N ovmbr D cmbr
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
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
Succss nds to b sustaind
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