H e a l i n g t h e B o d y E n r i c h i n g t h e M i n d N u r t u r i n g t h e S o u l Misericordia Community Hospital (MCH) Antimicrobial Stewardship Report July December 213 Second and Third Quarters 214
Table of Contents I. Introduction...2 II. CHASC Antimicrobial Utilization Reports...3 III. Executive Summary...5 IV. MCH Antimicrobial Utilization Reports...7 A. Total MCH Antimicrobial DDD and Expenditures.7 B. Emergency Department..11 C. Home Parenteral Therapy..14 D. Intensive Care Unit 17 E. Medical Day Ward...2 F. Medicine.23 G. Surgery...26 V. Glossary...29 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 1
Covenant Health Antimicrobial Stewardship Report MCH July December 213 I. INTRODUCTION Antibiotics are among the most commonly prescribed medications in acute care centers (Figure 1), yet can result in unintended patient toxicities, selection of pathogenic organisms, such as C. difficile, and promotion of antibiotic resistance. Antimicrobial Stewardship is an interdisciplinary activity that promotes the optimization of antibiotic selection, dose, route and duration in order to improve patient clinical outcomes and safety, minimize antibiotic adverse effects and toxicity, decrease the selection of pathogenic organisms and reduce antibiotic resistance rates. An effective Antimicrobial Stewardship Program (ASP) has been demonstrated to achieve the above outcomes and as of 213, has been mandated as a Required Organizational Practice by Accreditation Canada. Evaluation of the program has been scheduled for October 214. The Covenant Health Antimicrobial Stewardship Committee (CHASC) was developed in 213 and has since implemented several initiatives. Summary of CHASC Initiatives: 1. Formulary Restriction and Preauthorization As of October 7, 213 a restricted antibiotic preauthorization form must be completed in order for continued dispensing of the following six restricted antibiotics: daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline. The form ensures these antibiotics are being used in a guideline concordant manner and allows us to track their use for regular feedback and optimization of prescribing as necessary. These antibiotics were chosen because they are our six most broad and novel agents often serving as our last resort against multi-drug resistant (MDR) organisms, and should therefore be used only when necessary. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 2
2. Covenant Health Pocket Antibiogram In November 213, a pocket antibiogram was developed and distributed. The antibiogram informs prescribers about local resistance rates for common pathogens and assists in the selection of empiric antibiotics while awaiting culture and sensitivity data. 3. Prospective Audit and Feedback of Piperacillin-tazobactam In December 213, in response to persistently elevated piperacillin-tazobactam prescribing, the antibiotic stewardship pharmacists began auditing the use of this broad-spectrum antibiotic to ensure use was guideline concordant. 4. Development of a C. difficile (CDI) Preprinted Care Order (PPCO) with Prospective Audit and Feedback In December 213, CHASC in conjunction with the Covenant Health CDI Task Force developed a PPCO that standardizes and optimizes the management of CDI by ensuring prompt patient isolation, initiation of diagnostic tests and guideline concordant management. Additionally, the antimicrobial stewardship pharmacists audit medication use and attempt to discontinue unnecessary antibiotics or acid-suppressing agents, which are known to propagate CDI. 5. Collation of Antibiotic Utilization Data Collation of antibiotic utilization data will occur quarterly with distribution of reports and recommendations to stakeholders on a bi-annual basis. II. CHASC ANTIMICROBIAL UTILIZATION REPORTS Antibiotic use at Covenant Health acute care sites is collated and examined by CHASC on a quarterly basis in conjunction with data collected from prospective audit and feedback and the restricted antibiotic preauthorization form in order to: Identify any antibiotic utilization trends or areas in need of intervention on a site and service-specific basis. Ensure that the use of broad-spectrum antibiotics is guideline concordant. Generate bi-annual reports summarizing antibiotic trends and CHASC recommendations for prescribers as direct feedback on their antibiotic use. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 3
Methods Data on antibiotic use is extracted directly from Centricity (pharmacy computer system). When determining whether an antibiotic has been prescribed in a guideline-concordant fashion, clinical information acquired from the antibiotic preauthorization form and/or prospective audit and feedback performed by the Antimicrobial Stewardship pharmacists is compared to the provincial formulary recommendations. Drug utilization data is provided in both DDD (Defined Daily Dose) and expenditures and this first report details data for the period of July 1 to December 31, 213. DDD is a World Health Organization measure of drug consumption. The definition is the assumed average maintenance dose per day for a drug used for its main indication in adults. It relates all drug use to a standardized measure which is equivalent to one day s worth. DDD allows us to compare antibiotic use across different classes despite differences in potency and dosing. Examples: The usual dose of ertapenem is 1 g IV daily therefore every 1 gram of ertapenem is equivalent to one DDD. The usual dose of clindamycin is 6 mg IV every 8 hours therefore every 18 mg is equivalent to one DDD. In the near future, data will be presented as DDD/patient days to account for fluctuations in patient volume and therefore antibiotic prescribing. We are currently working closely with DIMR (Data integration, Measurement and Reporting) and Infection Prevention and Control to optimize the patient day denominator data prior to use. Summary of MCH Services included: Emergency Department Home Parenteral Therapy Intensive Care Unit Medical Day Ward (equivalent to an Intravenous therapy clinic) Medicine (Family, Geriatrics, Internal 3W, 4ALC, 4E, 7E, 7W) Surgery [Orthopedic, Other (General/Obstetrics & Gynecology/Urology) 5E, 5W, 6E, 6W, Surgical Day Ward] Antibiotic Groupings: Antibiotic utilization is provided in three graphical formats. 1. Total drug DDD and expenditures for the hospital and by service 2. Antibiotic classes as follows: Carbapenems - ertapenem, imipenem and meropenem Cefazolin Cephalosporins (3 rd generation) - ceftriaxone, ceftazidime and cefotaxime Clindamycin Fluoroquinolones - ciprofloxacin, levofloxacin and moxifloxacin Macrolides - azithromycin and erythromycin Piperacillin-tazobactam Vancomycin 3. Restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline) and piperacillin-tazobactam Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 4
III. Executive Summary Data on guideline concordance rates for the six restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem, and tigecycline) is available only from the time that the restricted antibiotic preauthorization form was implemented on October 7, 213. However, antibiotic utilization data is presented in this report from July to December 213 thereby capturing any trends in antibiotic utilization that could be attributed to the restricted antibiotic preauthorization form. Overall Antibiotic Use: Overall antibiotic use at MCH has remained stable during the period of July to December 213. Cephalosporins were the most frequently ordered IV antibiotic. Piperacillin-tazobactam use, although decreasing, remained high throughout the hospital. Restricted Antibiotics: Among the six restricted antibiotics, linezolid, meropenem and tigecycline have minimal usage. Although daptomycin use appeared higher than expected, the elevated DDD was attributed to a few patients that were deemed guideline concordant. Overall, use of the restricted antibiotics declined from October to December 213 with ertapenem being the most frequently ordered restricted antibiotic. In most instances, ertapenem was used appropriately (e.g. treatment of multi-drug resistant organisms); however, it was also being used in a guideline discordant manner for a few cases of surgical prophylaxis. Compliance with the Restricted Antibiotic Preauthorization Form and Formulary Concordance Rates: Since initiation of the restricted antibiotic preauthorization form on October 7, 213, compliance with form completion has been 81% and could be improved upon. The form is important as it: Ensures thorough data collection which is used to inform prescribers regarding extent of use and guideline concordance rates. Permits prospective audit and feedback by the Antimicrobial Stewardship committee if interventions in prescribing are required in real time. Is an effective strategy in an Antimicrobial Stewardship program and one of the tests for compliance during accreditation. Overall, prescribing of the six restricted antibiotics adhered to formulary guidelines in 59/72 (82%) of cases. Areas for improvement include surgical prophylaxis and empiric treatment of intra-abdominal infections (see surgery section of report). Recommendations: Continue to improve rates of compliance in filling out the restricted antibiotic preauthorization form Continue judicious use of the six restricted antibiotics by ensuring these broad-spectrum agents are only being used for formulary approved indications and are narrowed upon culture availability if possible. Antibiotic re-assessments should be performed 48-72 hours after initiation and de-escalated according culture availability and the patient s clinical status. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 5
is not recommended for surgical prophylaxis. Ensure that ertapenem is used according to the below guidelines: 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Piperacillin-tazobactam remains one of the most frequently prescribed antibiotics at MCH and will be the target of prospective audit and feedback by the Antimicrobial Stewardship pharmacists moving forward. Please ensure that piperacillin-tazobactam use adheres to the following formulary guidelines: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. Intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Ensure surgical prophylaxis is administered in a guideline concordant manner thereby ensuring adequate coverage for the more likely pathogens while at the same time minimizing side effects and selection of resistance associated with broad-spectrum antibiotics. A summary of the recently updated surgical prophylaxis guidelines, developed by the Provincial Antibiotic Stewardship committee, is attached for your reference. Please refer to the service-specific section of this report for further details. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 6
IV. MCH Antimicrobial Utilization Reports A. Total MCH Antibiotic DDD and Expenditures July December 213 (Figure 2) Overall, parenteral antibiotics were ordered more frequently than oral and accounted for the vast majority of expenditures. Cephalosporins were the most commonly ordered IV antibiotic but carbapenems accounted for the majority of costs followed by piperacillin-tazobactam. The use of linezolid, meropenem and tigecycline was low. Daptomycin use was higher than expected but may be related to the large orthopedic population in the context of vancomycin allergies. was the most frequently prescribed restricted antibiotic although there was a trend towards decreased use from October to December 213. Piperacillin-tazobactam was the most frequently used broad-spectrum antibiotic although its use declined from August to December 213. Compliance with the restricted antibiotic preauthorization form was 81% (58/72) and could be improved upon (Table 1). Overall, the restricted antibiotics were used in a guideline concordant manner in 82% (59/72) of cases (Table 1). A portion of formulary discordant orders originated from pre-operative prophylaxis in the surgical services. Recommendations: Improve rates of form compliance to: o Ensure thorough and accurate data collection for feedback to prescribers. o Permit necessary prospective audit and feedback to improve appropriate use of the six restricted antibiotics. Antibiotic re-assessments should be performed 48-72 hours after initiation and de-escalated according culture availability and the patient s clinical status. Improve ertapenem use and ensure that prescribing conforms to the below formulary guidelines: 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community-acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Address piperacillin-tazobactam prescribing and ensure that this broad-spectrum antibiotic is being used according to the below formulary guidelines: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. Intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 7
Focus on antibiotic surgical prophylaxis to ensure that guideline concordant antibiotics are being administered. A summary of the recently updated surgical prophylaxis guidelines, developed by the Provincial Antibiotic Stewardship committee, is attached for your reference Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 8
Figure 2. MCH Total Antibiotic Usage and Expenditures MCH Total DDD MCH Total Expenditures 8 7 6 5 4 3 2 1 Oral Parenteral $6 $5 $4 $3 $2 $1 $ Oral Parenteral 4 35 3 25 2 15 1 5 MCH DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $45 $4 $35 $3 $25 $2 $15 $1 $5 $ MCH Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH DDD MCH Expenditures 4 35 3 25 2 15 1 5 Daptomycin Imipenem Linezolid Meropenem Tigecycline $12 $1 $8 $6 $4 $2 $ Daptomycin Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 9
Table 1. Total MCH Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Service Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) Ambulatory 9 9 (1%) 8 (89%) Total 9 9 (1%) 8 (89%) ER 6 6 (1%) 5 (83%) Imipenem 1 1 (1%) (%) Meropenem 2 2(1%) (%) Total 9 9 (1%) 5 (56%) HPT 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) ICU 1 1 (1%) 1 (1%) Imipenem 4 4 (1%) 4 (1%) Meropenem 5 5 (1%) 5 (1%) Total 1 1 (1%) 1 (1%) Medicine 7 7 (1%) 6 (86%) Imipenem 6 5 (83%) 5 (83%) Linezolid PO 1 1 (1%) 1 (1%) Meropenem 4 3 (75%) 4 (1%) 1 (%) Total 18 16 (89%) 16 (89%) Surgery Daptomycin 1 1 (1%) 1 (1%) 14 5 (36%) 9 (64%) 5 (1%) Imipenem 9 7 (78%) 7 (78%) Meropenem 1 1 (1%) 1 (1%) Total 25 14 (56%) 18 (72%) Grand Total 72 59 (82%) 58 (81%) 6 (83%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 1
B. MCH Emergency Department (ED) Antibiotic Utilization (Figure 3) Drug utilization data was recorded as ED prescribed if the patient resided in the ED at the time of dispensing. Once the patient had been transitioned to an inpatient ward or the MCH Medical Day Ward/IV clinic, the drug was thereafter recorded as prescribed from the new location. Therefore, if patients were admitted but remained in the ED for prolonged periods of time on antibiotics, ED utilization data would be affected. Overall, antibiotic usage and expenditures have remained stable in the ED. Oral and parenteral antibiotics were being ordered at relatively equal rates although parenteral antibiotics were responsible for the vast majority of antibiotic expenditures. The majority of orders were for cephalosporins. Piperacillin-tazobactam use remained high and serves as an area for potential examination and improvement to determine if its use is warranted or if there are more streamlined options that would be equally effective. The six restricted antibiotics were prescribed at low rates and have been guideline concordant from October 7 December 31, 213 (Table 2). Compliance with completing the restricted antibiotic preauthorization form has been adequate at 83% (Table 2). Recommendations: The ED has been effective in controlling their use of the six restricted antibiotics and ensuring they are used in a guideline concordant manner. No further recommendations can be made at this time. Improving completion rates of the restricted antibiotic preauthorization form is encouraged to allow for more accurate data collection to inform ED prescribing. Address piperacillin-tazobactam prescribing and ensure that this broad-spectrum antibiotic is being used according to the below provincial guidelines: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. Intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 11
Figure 3. MCH ED Antibiotic Usage and Expenditures MCH ED Total DDD MCH ED Total Expenditures 1 $5 8 $4 6 $3 4 Oral $2 Oral 2 Parenteral $1 Parenteral $ 5 4 3 2 1 MCH ED DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $4 $35 $3 $25 $2 $15 $1 $5 $ MCH ED Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH ED DDD MCH ED Expenditures 5 4 3 2 1 Daptomycin Imipenem Linezolid Meropenem Tigecycline $12 $1 $8 $6 $4 $2 $ Daptomycin Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 12
Table 2. MCH ED Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) 6 6 (1%) 5 (83%) Imipenem 1 1 (1%) (%) Meropenem 2 2(1%) (%) Total 9 9 (1%) 5 (83%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 13
C. MCH Home Parenteral Therapy (HPT) Antibiotic Utilization (Figure 4) Home parenteral therapy enables patients to receive intravenous antibiotics at home. Patients can be enrolled in HPT through the Outpatient IV clinic or from an inpatient hospital unit at the time of discharge. Patients (or their drug coverage plan) are responsible for the cost of these antibiotics. HPT is often used when the duration of therapy is expected to be prolonged; therefore, overall patient numbers are low but due to these long courses of therapy, one patient can greatly influence the utilization of a particular antibiotic (e.g. one patient on ertapenem for 1 weeks results in an increased ertapenem DDD of 7). There were no identifiable trends in antibiotic use likely because the DDD and expenditures are greatly influenced by the number of patients in the program at any given time. Cefazolin was the most commonly prescribed antibiotic. Use of the six restricted antibiotics has been limited to a minority of patients; but due to long courses of therapy, has resulted in skewed graphs. For instance, although daptomycin use appeared high, its use was in one patient. Unfortunately, data on compliance with the restricted antibiotic preauthorization form and rates of guideline concordant use are lacking given the vast majority of patients were started on their restricted antibiotic as an inpatient or in the IV clinic and would therefore have been accounted for in that data set (Table 3). Recommendations: Prior to making recommendations, CHASC needs to reconcile HPT antibiotic use at the time of prescribing (e.g. on the ward or in the IV clinic) for better representation of guideline concordance rates. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 14
Figure 4. MCH HPT Antibiotic Usage and Expenditures MCH HPT Total DDD MCH HPT Total Expenditures* 1 $12 8 6 4 2 Oral Parenteral $1 $8 $6 $4 $2 Oral Parenteral $ MCH HPT DDD MCH HPT Expenditures* 8 7 6 5 4 3 2 1 Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $8 $7 $6 $5 $4 $3 $2 $1 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH HPT DDD MCH HPT Expenditures* 8 7 6 5 4 3 2 1 Daptomycin Imipenem Linezolid Meropenem Tigecycline $5 $4 $3 $2 $1 $ Daptomycin Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. *Note: Patient responsible for costs Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 15
Table 3. MCH Home Parenteral Therapy Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) 1 1 (1%) 1 (1%) Total 1 1 (1%) 1 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 16
D. MCH Intensive Care Unit (ICU) Antibiotic Utilization (Figure 5) MCH ICU drug utilization data pertains strictly to the Intensive Care Unit. Coronary care unit (CCU) data was collated separately but due to low antibiotic prescribing has not been incorporated into this specific report. If desired, please contact AntimicrobialStewardship@covenanthealth.ca for CCU antibiotic utilization data. Overall antibiotic usage and expenditures have remained steady in the ICU. Carbapenem use has been increasing since October, despite becoming restricted antibiotics, and may relate to an increase in patient acuity as all orders were guideline concordant (Table 4). Compliance with the restricted antibiotic preauthorization form has been excellent at 1% (Table 4). Recommendations: Use of the restricted antibiotics is appropriate in the MCH ICU and no further recommendations are necessary at this time. Piperacillin-tazobactam use remains high. Given the relative acuity and complexity of these critically ill patients, whom often require broad-spectrum empiric therapy at the time of admission, it is suspected that the use of piperacillin-tazobactam is warranted. Antibiotic re-assessments should be performed 48-72 hours after initiation and de-escalated according culture availability and the patient s clinical status. Further data acquired from ongoing prospective audit and feedback may shed further light on piperacillin-tazobactam use for future direction. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 17
Figure 5. MCH ICU Antibiotic Usage and Expenditures MCH ICU Total DDD MCH ICU Total Expenditures 5 4 3 2 1 Oral Parenteral $8 $7 $6 $5 $4 $3 $2 $1 $ Oral Parenteral MCH ICU DDD MCH ICU Expenditures 25 2 15 1 5 Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $45 $4 $35 $3 $25 $2 $15 $1 $5 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH ICU DDD MCH ICU Expenditures 6 5 4 3 Daptomycin Imipenem $2 $15 $1 Daptomycin Imipenem 2 1 Linezolid Meropenem Tigecycline $5 $ Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 18
Table 4. MCH ICU Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) 1 1 (1%) 1 (1%) Imipenem 4 4 (1%) 4 (1%) Meropenem 5 5 (1%) 5 (1%) Total 1 1 (1%) 1 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 19
E. MCH Medical Day Ward/Outpatient IV clinic Antibiotic Utilization (Figure 6) The MCH Medical Day Ward functions as an IV clinic where patients attend to receive IV antibiotics when they are well enough to be treated as an outpatient and do not qualify for home parenteral therapy. Infectious diseases physicians and ED physicians are the main prescribers. Overall antibiotic use appeared to be trending down. The most frequently prescribed antibiotic was cefazolin although carbapenems made up the majority of the Medical Day Ward antibiotic expenditures. use decreased from October to December and all orders during that time frame have been guideline concordant (Table 5). Completion of the restricted antibiotic preauthorization form has been good at 89% (Table 5). Recommendations: Continue to ensure that ertapenem use is decreasing or stable and adheres to the provincial formulary as follows: 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 2
Figure 6. MCH Medical Day Ward/IV Clinic Antibiotic Usage and Expenditures MCH Medical Day Ward Total DDD MCH Medical Day Ward Total Expenditures 7 6 5 4 3 2 1 Oral Parenteral $18 $16 $14 $12 $1 $8 $6 $4 $2 $ Oral Parenteral MCH Medical Day Ward DDD MCH Medical Day Ward Expenditures 7 6 5 4 3 2 1 Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $1 $8 $6 $4 $2 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH Medical Day Ward DDD MCH Medical Day Ward Expenditures 12 1 8 6 4 2 Daptomycin Imipenem Linezolid Meropenem Tigecycline $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Daptomycin Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 21
Table 5. MCH Medical Day Ward/IV Clinic Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) 9 9 (1%) 8 (89%) Total 9 9 (1%) 8 (89%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 22
F. MCH Medicine Antibiotic Utilization (Figure 7) In this context, Medicine applies to Internal Medicine, Family Medicine (cannot be separated due to shared inpatient units) and Geriatrics. The data reported does not include the Internal Medicine unit that has temporarily been relocated to the Royal Alexandra Hospital. Overall, antibiotic utilization from July to December 213 has remained unchanged. Cephalosporins were the most commonly prescribed antibiotic. Piperacillin-tazobactam use has been increasing over time and should be an area of focus. The restricted antibiotics have been used in a guideline concordant manner in 89% of instances (Table 6). Compliance with completion of the restricted antibiotic preauthorization form has been good at 89% (Table 6). Recommendations: Continue to use the restricted antibiotics in a guideline concordant manner Antibiotic re-assessments should be performed 48-72 hours after initiation and de-escalated according culture availability and the patient s clinical status. Usage of piperacillin-tazobactam has been increasing over the last six months and may be an area for improvement. Please ensure that piperacillin-tazobactam is being used according to the below formulary guidelines: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. Intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 23
Figure 7. MCH Medicine Antibiotic Usage and Expenditure MCH Medicine Total DDD MCH Medicine Total Expenditures 16 155 15 145 14 135 13 125 12 115 Geriatrics Family & Internal Medicine 12 1 8 6 4 2 Geriatrics Family & Internal Medicine MCH Medicine DDD MCH Medicine Expenditures 6 5 4 3 2 1 Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $7 $6 $5 $4 $3 $2 $1 $ Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH Medicine DDD MCH Medicine Expenditures 1 8 6 4 2 Daptomycin Imipenem Linezolid Meropenem $3 $25 $2 $15 $1 $5 Daptomycin Imipenem Linezolid Meropenem Tigecycline $ Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 24
Table 6. MCH Medicine Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) 7 7 (1%) 6 (86%) Imipenem 6 5 (83%) 5 (83%) Linezolid PO 1 1 (1%) 1 (1%) Meropenem 4 3 (75%) 4 (1%) 1 (%) Total 18 16 (89%) 16 (89%) 1 (%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 25
G. MCH Surgery Antibiotic Utilization (Figure 8) Surgical data incorporates orthopedics, general surgery, obstetrics and gynecology, urology and surgical day ward. Overall, antibiotic use has remained stable during this time period with cephalosporins being the most commonly ordered IV antibiotic. Piperacillin-tazobactam use continued to remain high but has declined since August. Regarding the restricted antibiotics, although daptomycin use appeared atypically high, this order pertained to one patient where it was deemed guideline concordant. use spiked in October but has since come down. Unfortunately, from October 7 to December 31, 213, ertapenem was used in a guideline concordant manner in only 5/14 (38%) and should be an area of focus (Table 7). Compliance with completion of the restricted antibiotic preauthorization form has been reasonable at 72% and could be improved upon. Recommendations: Improve compliance with completion of the restricted antibiotic preauthorization form to ensure more accurate data collection and timely feedback for prescribers. Focus on pre-operative surgical prophylaxis and ensure that the antibiotic selected adheres to the provincial guidelines. o A summary of the recently updated surgical prophylaxis guidelines, developed by the Provincial Antibiotic Stewardship committee, is attached for your reference. Of note, only patients with an anaphylactic penicillin allergy or a severe cephalosporin allergy should avoid cefazolin. In these circumstances, alternatives would include clindamycin/gentamicin or vancomycin/gentamicin (refer to attached form). is unnecessarily broad and exposes the patient to more adverse effects and selection of resistance. Ensure that ertapenem is being used in a guideline concordant manner as per the below guidelines: 1. Empiric therapy of polymicrobial complicated skin and soft tissue infections, including bite wounds 2. Therapy of infections due to Enterobacteriaceae producing inducible (AmpC) β-lactamases or ESBLs where there is resistance to first line agents and documented susceptibility to ertapenem 3. Empiric therapy for patients at high risk (e.g. previous ESBL infection, international travel history) of infections due to Enterobacteriaceae producing ESBLs 4. Therapy of community acquired intra-abdominal infections in patients intolerant or unresponsive to first line therapy (ceftriaxone + metronidazole) Ensure that piperacillin-tazobactam use adheres to the below formulary recommendations: Piperacillin-tazobactam 1. Empiric therapy of severe infections including sepsis of unknown source or suspected to be polymicrobial (eg. Intraabdominal, limb threatening diabetic foot) 2. Alone or in combination, empiric therapy of ventilator-associated pneumonia 3. Empiric therapy in high risk febrile neutropenic patients (oral temperature 38.3 C once or 38 C for 1 hour, absolute neutrophil count <.5 x 1 9 /L) +/- aminoglycoside NB: For monomicrobial infections due to Pseudomonas aeruginosa, options for therapy include ceftazidime, ciprofloxacin, piperacillin (still available), or aminoglycosides, according to susceptibility. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 26
Figure 8. MCH Surgery Antibiotic Usage and Expenditures MCH Surgery Total DDD MCH Surgery Total Expenditures 3 $3 25 $25 2 $2 15 1 5 Orthopedic Other $15 $1 $5 $ Orthopedic Other 18 16 14 12 1 8 6 4 2 MCH Surgery DDD Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin $18 $16 $14 $12 $1 $8 $6 $4 $2 $ MCH Surgery Expenditures Carbapenems Cefazolin Cephalosporins 3rd generation Clindamycin Fluoroquinolones Macrolides Vancomycin MCH Surgery DDD MCH Surgery Expenditures 18 16 14 12 1 8 6 4 2 Daptomycin Imipenem Linezolid Meropenem Tigecycline $8 $7 $6 $5 $4 $3 $2 $1 $ Daptomycin Imipenem Linezolid Meropenem Tigecycline DDD = Defined daily dose. Assumed average maintenance dose per day for a drug used for its main indication in adults. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 27
Table 7. MCH Surgery Compliance with Preauthorization Form and Guideline Concordance Rates October 7 to December 31, 213 Restricted Antibiotic Number of orders Guideline concordant Form Compliance Recommendations (Number & Percent Accepted) Daptomycin 1 1 (1%) 1 (1%) 14 5 (36%) 9 (64%) 5 (1%) Imipenem 9 7 (78%) 7 (78%) Meropenem 1 1 (1%) 1 (1%) Total 25 14 (56%) 18 (72%) 5 (1%) Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 28
V. Glossary of Terms ASP.Antimicrobial Stewardship Program CDI Clostridium difficile Infection CHASC... Covenant Health Antimicrobial Stewardship Committee DDD..Defined Daily Dose DIMR...Data integration, Measurement and Reporting ED...Emergency Department ESBL.....Extended spectrum beta-lactamase HPT..Home Parenteral Therapy ID... Infectious Diseases IMCU...Intermediate Care Unit MDR..Multi-drug resident MRSA. Methicillin resistant Staphylococcus aureus MSSA. Methicillin susceptible Staphylococcus aureus NB..Nota bene or Important, Note well NP Nurse Practitioner PAC...Pre-Admission Clinic PPCO.Preprinted Patient Care Order Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of July 213 December 213 29