Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 1 Gen Med 5 East 7 / 8 / 54 M / F / U 74 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) Ceftriaxone iv 1g d Y CAP Y N N N N N N Y N N NA 3 Azithromycin iv 500 mg d Y CAP Y N N N Y N N Y N N NA 3 Allergies to antimicrobials * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Sputum normal upper respiratory tract flora Clinical notes/comments Fever, normal CXR, normal SaO2, cough with sputum Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit Doc:NAPS-DCFv4;20141006
Case 1. Explanatory notes: This is appropriate treatment for severe community acquired pneumonia. Although the team did not specify the severity of the pneumonia, this patient does not meet the requirements for severe community acquired pneumonia and would fit more with mild to moderate community acquired pneumonia. There is not also no need to be giving azithromycin intravenously when the patient could be taking it orally. If bacterial infection is suspected and antibiotics are warranted then treatment with amoxycillin or benzylpenicillin with or without doxycycline or clarithromycin is recommended by the Therapeutic Guidelines. This prescription has therefore been deemed suboptimal as it did not follow the Therapeutic Guidelines optimally, and there were no local guidelines available. Although these prescriptions were deemed to be too broad-spectrum based on the clinical notes, adequate information may not always be readily available. Hence the assessors may decide to give the prescribers the benefit of the doubt (ie the prescription is not excessive enough to be deemed inappropriate) and choose to mark this prescription as adequate or optimal.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 2 Gen Med Aged Care 26 / 1 / 35 M / F / U 62 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 17/11/13 Augmentin DF po 1 tab bd Y? UTI Y N N N N N Y N N N NA 3 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature sulphur rash Please provide any relevant result urine culture results pending Clinical notes/comments Admitted from Nursing Home confused chart specifies Augmentin DF bd for 3 days Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 2. Explanatory notes: Although Augmentin Duo Forte is an appropriate choice for an uncomplicated UTI, the Therapeutic Guidelines states that the course for women should be 5 days and not the specified 3 days that it is charted for. Therefore this was deemed to be suboptimal as the duration was too short.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 3 Gen Med Aged Care 26 / 1 / 35 M / F / U 62 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 15/11/13 Ceftriaxone iv 1g d Y? UTI /CAP Y N Y N Y N N N N N NA 3 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Amoxicillin - rash Please provide any relevant result Sputum normal upper respiratory tract flora Urine mixed flora, no white cells Clinical notes/comments Admitted from NH with nausea, vomiting and delirium Responded quickly and was eating and drinking on day 2 Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 3. Explanatory notes: As the team was unsure if the diagnosis was a urinary tract infection or community acquired pneumonia, it was difficult to assess the compliance with guidelines, therefore it was deemed not assessable. As the patient responded quickly to the prescribed therapy and it is day 7 of intravenous therapy and has been eating and drinking for 3 days, they should have been switched to oral therapy by now. The prescription was therefore deemed suboptimal as the route was incorrect. Note: There was a perceived allergy mismatch as the patient was prescribed a cephalosporin when there was a documented allergy to penicillin. As this was not an immediate hypersensitivity reaction and the patient was prescribed a cephalosporin rather than penicillin, the allergy mismatch was not thought to have been severe enough to contribute to the assessment of appropriateness.
Indication documented Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 19 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 4 Geriatrics 19 / 12 / 26 M / F / U Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. 04/11/13 Famciclovir po 250 mg 8 hrly Specify documented or presumed indication Y shingles Y N N N N N Y N N N NA 3 Appropriateness (1-5) Allergies to antimicrobials Microbiology * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Clinical notes/comments Admitted form home with pneumonia, developed shingles while in hospital, symptoms resolved quickly Awaiting nursing home placement Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 4. Explanatory notes: Although famciclovir was a correct choice for this patient, the Therapeutic Guidelines suggest 7 days of therapy for non immunocompromised patients. As the patient s symptoms had improved the famciclovir should have been ceased on day 7, whereas it is now day 15 of treatment and therefore the prescription was deemed suboptimal due to the incorrect duration of therapy.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 5 Respiratory 7 North / 68 / M / F / U 63 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) Ceftriaxone iv 1g d Y pneumonia Y N Y N N N N Y N N NA 4 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Penicillin - anaphylaxis Please provide any relevant result Sputum H. influenzae Clinical notes/comments Fever, consolidation on CXR, cough with sputum, confusion, SaO2 82% Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 5. Explanatory notes: In this scenario the team has only documented pneumonia and has not specified the type (for example, community acquired vs hospital acquired). It is therefore important to determine the nature of pneumonia. For this patient, pneumonia developed within 48 hours of admission to hospital and therefore determined to be community acquired pneumonia. Ceftriaxone is an appropriate medication for severe community acquired pneumonia and is consistent with the Therapeutic Guidelines. Note that it is reasonable for this patient not to be on azithromycin given that H. influenzae has been isolated in sputum. However, there is an obvious allergy mismatch in this patient with a documented immediate hypersensitivity allergy to penicillin being prescribed a cephalosporin. Therapeutic Guidelines would recommend moxifloxacin for this patient and as a result the prescription has been deemed inadequate.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 19 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 6 Urology Gen Med / 40 / M / F / U 64 15.3 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 17/11/13 1. Ceftriaxone iv 1g d Y pyelonephritis Y N N Y N N N N Y N NA 4 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Penicillin - rash Please provide any relevant result Urine - Klebsiella - ESBL Clinical notes/comments Pyelonephritis, fever, acute flank pain and vomiting Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 6. Explanatory notes: Although ceftriaxone would normally be appropriate therapy for severe pyelonephritis in a penicillin hypersensitive patient with poor renal function as per the Therapeutic Guidelines, unfortunately the bacteria that were cultured contained the extended spectrum beta-lactamase (ESBL) gene and would make this resistant to all penicillins and cephalosporins including ceftriaxone. This patient should be changed to a more appropriate antibiotic, such as meropenem or ciprofloxacin, depending on available sensitivities. This prescription was therefore deemed inadequate due to the choice having a microbiology mismatch and therefore being too narrow spectrum..
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 7 Respiratory 3 South 17 / 5 / 82 M / F / U 63 18 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. 05/05/13 Azithromycin o 500 mg 3 x wkly Specify documented or presumed indication N? Anti-inflammatory Y N N N N N N N N N NA 5 Appropriateness (1-5) 16/11/13 Ceftazidime iv 2g tds N? CF infective exacerbation Y N N N N Y N N N N N 2 16/11/13 Gentamicin iv 240 mg d N Y N N N N Y N N N N N 4 Allergies to antimicrobials * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Sputum P. aeruginosa Clinical notes/comments Cystic fibrosis patient with chronic Pseudomonas infection and a Surgical procedure performed Procedure: recent decrease in lung function, azithromycin prescribed as a presumed anti-inflammatory If prophylaxis given within the previous 24 hours, please include in audit
Case 7. Explanatory notes: Local guidelines: For infective exacerbation of chronic pseudomonal infection in CF patients ceftazidime 2g iv tds with gentamicin iv daily (dosage calculated) The indications for these prescriptions were not documented in the notes, but as this was a Cystic Fibrosis patient, it was presumed that the ceftazidime and gentamicin were prescribed for an exacerbation of the pseudomonal infection according to the local guidelines and the azithromycin was prescribed as an anti-inflammatory. Although the prescription of ceftazidime and gentamicin could be considered directed therapy, as they are consistent with the local guidelines for cystic fibrosis patients, this was chosen instead. Due to the patient having renal impairment (CrCl of 18mL/min), the ceftazidime should have been reduced to either 12 or 24 hourly and the gentamicin dose is very high for the patent s weight and renal function. The ceftazidime prescription was therefore deemed to be adequate as it was not an excessively high dose and the gentamicin prescription was deemed inadequate as this was a potentially toxic dose. The use of azithromycin as an anti-inflammatory therapy is currently still controversial. Macrolide antibiotics such as azithromycin have been shown to be effective in the treatment of chronic Pseudomonas aeruginosa infection. This therapy is now listed in the Therapeutic Guideless as a possible other suggested treatment of respiratory illnesses in cystic fibrosis patients. It would have to be decided by each hospital on an individual basis as to whether they would want to adopt this therapy as part of their guidelines. In this case the assessor was unable to decide on its appropriateness as there were no such guidelines available and it was deemed not assessable. Note: Although both ceftazidime and gentamicin are restricted antimicrobials in this scenario, approval had not been sought or given.
Indication documented Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 8 Colorectal Surg 17 / 9 / 37 M / F / U Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 13/11/13 Ceftriaxone iv 1g d Y Diverticulitis Y N N N N N N N N N NA 1 13/11/13 Metronidazole iv 500 mg 8 hrly Y Y N N N Y Y N N N N NA 2 Allergies to antimicrobials Microbiology * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Clinical notes/comments Uncomplicated diverticulitis but severe enough to warrant admission. No abscess Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 8. Explanatory notes: Local guidelines: For uncomplicated diverticulitis ceftriaxone 1g iv daily with metronidazole 400mg orally 12 hourly The Therapeutic Guidelines recommend ampicillin, gentamicin and metronidazole for diverticulitis or ticarcillin + clavulanate / piperacillin + tazobactam as an appropriate single agent to use if therapy is likely to be for greater than 72 hours. Ceftriaxone and metronidazole in combination is only suggested for those with a penicillin allergy without immediate hypersensitivity. In this case the local guidelines are for ceftriaxone and metronidazole as the choice of antimicrobials even without a penicillin allergy. The ceftriaxone prescription was deemed optimal as it is included in the combination according to local guidelines. Even though the route and dosage of the metronidazole was incorrect according to the local guidelines, it was thought that overall the prescription was adequate and perhaps some education was required if this was a common prescription error in the hospital or unit..
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 9 Gen Surg Surgical / 30 / M / F / U 98 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 19/11/13 Vancomycin iv 1.5g bd Y abscess Y N N N N Y N Y N N NA 3 Allergies to antimicrobials * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Swab of exudate Staphylococcus aureus Erythro/Clindamycin S Penicillin G R Methicillin R Vancomycin S Clinical notes/comments Steroid injection site, incision and drainage of small deltoid abscess. Trough level was 25 yesterday and dose unchanged. Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 9. Explanatory notes: Small uncomplicated skin abscesses with no systemic symptoms may be treated with incision and drainage alone. There was probably no indication for antibiotic therapy for this patient, but if therapy was thought necessary, then clindamycin should have been used instead of vancomycin which was deemed suboptimal as it was too broad spectrum agent for the sensitivity pattern of the Staphylococcus aureus. Of note, the dose of vancomycin was continued when it should have be adjusted (eg to 1g 12 hrly) as the trough level is too high (aim 15-20), so this was also recorded as an incorrect dose.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Spectrum too broad Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 10 Gen Surg Surgical 14 / 03 /52 M / F / U Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Piperacillin + tazobactam iv 4.5g 8 hrly Specify documented or presumed indication Post-op wound infection 1 Appropriateness (1-5) Metronidazole iv 500 mg 12 hrly 4 Allergies to antimicrobials * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Wound swab mixed flora including gram positive cocci, gram negative bacilli and anaerobes Clinical notes/comments Abdominal wound dehiscence Surgical procedure performed Procedure: cholecystectomy If prophylaxis given within the previous 24 hours, please include in audit
Case 10. Explanatory notes: Piperacillin + tazobactam is an appropriate single agent to use for a mixed surgical site infection and therefore deemed optimal. Metronidazole is not warranted in this scenario, as there is no extra beneficial coverage while on piperacillin + tazobactam. The metronidazole is not in concordance with the Therapeutic Guidelines and there are no local guidelines for this indication available, the metronidazole prescription was therefore deemed suboptimal in this setting, as being redundant. Note that not all of the grey boxes were filled in on this example as they are optional fields.
Indication documented Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) a National Antimicrobial Prescribing Survey Audit date: 21 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 11 Gen Surg Surgical 16 / 6 / 80 M / F / U Gen Surg Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 18/11/13 Ceftriaxone iv 1g d N Surgical prophylaxis Y Y N N N N Y Y N N NA 4 18/11/13 Metronidazole iv 500 mg bd N Y Y N N Y N Y N N N NA 4 Allergies to antimicrobials Microbiology * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Clinical notes/comments Surgical procedure performed Procedure: Appendicectomy Uncomplicated, given 3 days of antibiotics as per usual protocol, ceased at 12:00pm yesterday If prophylaxis given within the previous 24 hours, please include in audit
Case 11. Explanatory notes: Local guidelines: The local historical protocol by the colorectal surgeons is to administer ceftriaxone and metronidazole prophylactically for 3 days after all surgical procedures. This protocol is not endorsed by the hospital or drug and therapeutic committee and is not found on any intranet policy or procedure documents. Even though these two antimicrobials were ceased yesterday and there was no indication documented, they were still included in the survey as these were presumed to be for surgical prophylaxis (given the usual protocol) and had been administered in the previous 24 hours. As the surgical prophylaxis prescribed is not consistent with the Therapeutic Guidelines and there are no locally endorsed guidelines for this procedure, both antibiotics were deemed non-compliant with guidelines even though there are historical protocols used in the hospital. They were also both prescribed and administered for greater than 24 hours, therefore they were recorded as Surgical prophylaxis >24 hrs. The recommended prophylaxis according to the Therapeutic Guidelines for appendicectomy is for a single dose of metronidazole plus either cephazolin or gentamicin. Therefore the ceftriaxone was deemed too broad spectrum whilst the metronidazole was not. However, as both antibiotics were given for 3 days (ie surgical prophylaxis greater than 24 hours ), both prescriptions were therefore deemed inadequate
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 12 Urology 7 East / 54 / M / F / U 13 Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) 17/11/13 Gentamicin iv 80 mg stat Y removal of urinary catheter Y N N N Y 1 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Clinical notes/comments Surgical procedure performed Procedure: kidney transplant 14/11/2013 stat dose of gent for removal or urinary catheter as per protocol catheter removed and dose given,16:00 pm 17/11 If prophylaxis given within the previous 24 hours, please include in audit
Case 12. Explanatory notes: Local guidelines: The local historical protocol by the urologists is to give all patients with urinary catheters a stat dose of gentamicin prophylactically when the catheter is removed. This protocol is endorsed by the hospital s drug and therapeutic committee and appears in an intranet policy or procedure document. As this prescription is compliant with locally endorsed guidelines and is a reasonable dose for someone with renal insufficiency, this is deemed optimal therapy. Note: As recommended by the Therapeutic Guidelines, administration of antibiotics to cover the period of catheterisation and on removal is not recommended. This may be an issue you wish to highlight to the urology team and possibly the drug and therapeutic committee to attempt to have the protocol removed form hospital policy and procedure documents.
Indication documented Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 13 Neurosurgery HDU 30 / 1 / 44 M / F / U Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication 16/11/13 Cephazolin iv 1g tds while EVD present 4 Appropriateness (1-5) Allergies to antimicrobials Microbiology * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result Clinical notes/comments Surgical procedure performed Procedure: Craniotomy EVD inserted intraoperative If prophylaxis given within the previous 24 hours, please include in audit
Case 13. Explanatory notes: The local historical protocol by the neurosurgeons is to give all patients with external ventricular drains (EVD) cephazolin prophylactically while the drain is present. This protocol is not endorsed by the hospital or drug and therapeutic committee and not found on any intranet policy or procedure documents. As recommended by the Therapeutic Guidelines, although widely used, the value of routine prophylaxis for the insertion of shunts, ventricular drains or pressure monitors remains unproven. Ongoing prophylaxis for ventricular drains is not recommended. As there are no recommended guidelines for EVD prophylaxis longer than for possible insertion, this prescription was deemed inadequate. Note: The indication from the drop down list chosen should be Surgical prophylaxis.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B./Age yrs Gender Weight kg egfr/crcl ml/min Case 14 ICU ICU 19/ 11 / 38 M / F / U Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks Start date Antimicrobial Route Dose Freq. Specify documented or presumed indication Appropriateness (1-5) Vancomycin iv 125 mg 6 hrly Y severe C. difficile infection Y N N N Y N N N N N Y 4 * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant result C.difficile toxigenic strain DNA was detected by PCR Clinical notes/comments Long stay in ICU following MVA, multiple previous antimicrobials Surgical procedure performed Procedure: If prophylaxis given within the previous 24 hours, please include in audit
Case 14. Explanatory notes: Vancomycin in an acceptable choice for severe Clostridium difficile infection, however, the correct route is oral administration. Intravenous administration of vancomycin will result in insufficient drug concentrations at the site of infection to treat Clostridium difficile, therefore this has been deemed an inadequate prescription. Note: this prescription was approved for administration, as vancomycin is a restricted drug in this scenario. This prescription would therefore normally be deemed appropriate, but as there was severe mistake with the prescription it is clearly not optimal therapy and therefore this was deemed to be inadequate by the assessing team.
Indication documented Surgical prophylaxis >24 hrs Allergy mismatch Microbiology mismatch Incorrect route Incorrect dose/frequency Incorrect duration Therapeutic Guidelines Local guidelines * Non-compliant Directed therapy None available Not assessable Spectrum too broad Spectrum too narrow Antimicrobial not indicated If restricted: approval given (1 - optimal, 2 - adequate, 3 - suboptimal, 4 - inadequate, 5 - not assessable) National Antimicrobial Prescribing Survey - ARPEC Audit date: 18 /11 / 13 Patient identification no. Specialty Ward D.O.B. Gender Weight kg egfr/crcl ml/min Case 15 NICU NICU 11 / 11 / 13 M / F / U 2.8 32 Underlying diagnosis (up to 3 may be chosen) No Underlying Disease Compliance with guidelines (only fill one box) For NICU patients Birth weight kg Gestational age weeks 3.3 1 Start date Antimicrobial Route Dose Freq. Aciclovir iv 100 mg 8 hrly Specify documented or presumed indication (populates reason for treatment ) Y HSV Y N N N N Y N N N N NA 2 Appropriateness (1-5) * If local guidelines are the same as Therapeutic Guidelines, choose the Therapeutic Guidelines in preference Allergies to antimicrobials Microbiology Nil known Not documented Collected Not collected / Not assessable Present; please specify drug and nature Please provide any relevant results swab - HSVII on nucleic acid testing Clinical notes/comments Full term, normal vaginal delivery, mother had known HSVII Surgical procedure performed Procedure: Type of indication Type of treatment Ventilated A / B1 / B2 / B4 / B5 / C1 / C2 / C3 / D E / T I / NI / N If prophylaxis given within the previous 24 hours, please include in audit
Case 15. Explanatory notes: The Therapeutic Guidelines recommended dose for neonatal HSV is aciclovir 20mg/kg 8 hourly. The prescribed dose in this scenario should therefore have been 56mg and not 100mg. The frequency should also have been reduced to 12 hourly as opposed to the prescribed 8 hourly due to the mild renal insufficiency. Therefore this prescription was deemed adequate rather than suboptimal as the dose was not excessively high. As the assessors had difficulty deciding between the two categories, the more lenient option was chosen.