The Three R s Rethink..Reduce..Rocephin By: Alisa Cuff RN,BN,CIC and John Bautista B.Sc. (Chem), B.Sc.Pharm, M.Sc.Pharm IPAC National Conference 2017 Newfoundland and Labrador Regional Health Authorities (RHA) Population Estimates 2011 Labrador-Grenfell 36,394 Western 77,983 Central 93,906 Eastern 306,253 Total 514,536 Population - O ctober 1, 2016 530,376 1
Accreditation Canada ROP The organization has a program for antimicrobial stewardship to optimize antimicrobial use. Central Health Antimicrobial Stewardship Committee 2012 Senior Management, Lab Personnel, Front line Nursing Pharmacy, Physician, ICP Our Goals To optimize the use of antimicrobials to achieve the best patient outcomes, reduce the risk of infections, reduce or stabilize levels of antibiotic resistance, and promote patient safety. To ensure patients receive the right antibiotics only when they need them. Concern: Increased amounts of ceftriaxone being distributed to rural centers compared to the two referral centers. Once daily dosing Broad spectrum of activity Public s view that I.V. medications are better than oral medications Concern of inappropriate use may lead to resistance and other untoward effects in clients. 2
Intervention Audit Retrospective data Ensure compliance at site Audit Dose ordered Indication for use Date administered Once data was collected, the indications for use were compared to the 2010 Anti Infective Guidelines for Community Acquired Infections. 1 1. Anti-infective Review Panel. Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse; 2010. 3
Summary of outpatient usage of ceftriaxone from, October 2011 to October 2012 at a rural hospital Indication Respiratory Tract Infection (includes Chest Infection or Respiratory Infection Sinus Infection and Sinusitis Number of doses Total Number of vials used Number of patients administered 154 282 31 Urinary Tract Infection 16 32 4 Skin and Soft tissue infection (includes: Wound Infection, Cellulitis, Abscess and 64 113 11 Coccyx Abscess Infected Tooth 5 10 1 Scrotal Infection 3 6 1 Not specified 15 30 6 TOTAL 257 473 54 Audit and Feedback Concerns Only indication for ceftriaxone at this site that was consistent with the guidelines was cellulitis. Classification of the cellulitis was not documented on the audit form. Assuming that all patients who received ceftriaxone for cellulitis was consistent with the guidelines, 77% still received it inappropriately. If all patients who received ceftriaxone did not have either: - Uncomplicated, severe, non-facial cellulitis - Facial cellulitis or - Diabetic foot then noncompliance was 100%. 4
Audit Limitations Inadequate documentation of indication for use on the audit form. No mention of previous oral antibiotic use prior to ceftriaxone. Physical chart not accessible to obtain history of presenting illness/infection. Interventions Education has to be provided to the HCWs Revise Audit form Communication Results of the audit has to be shared throughout the region, especially to the medical advisory committees Future audits to be completed at this site Consider restrictions or pre-authorization forms for broadspectrum antibiotic orders Intervention: Audit and Feedback Re-auditing of ceftriaxone use at Site 7 Health Centre and distribution of the results as an intervention. July 2013 September 2014 November 2016 5
Intervention: Revised Audit Form Audit 2016 Reported Indication (n=7) Oral Antibiotics within the previous 30 days Use of Ceftriaxone consistent with guidelines 1 Use of Ceftriaxone as Per Guidelines in the context of the Reported Indication 1,2 Female with UTI with Amoxicillin Yes Ceftriaxone is recommended Decreased renal function as second-line parenteral therapy in severe cases of complicated UTI. UTI with cellulitis (location None Yes See above. not specified; considered Ceftriaxone is recommended for admission but no bed as second-line for severe available; probenecid not non-facial, uncomplicated available) cellulitis Cellulitis (finger) None; also prescribed No Ceftriaxone is recommended cephalexin PO while as second-line for severe receiving IV therapy non-facial, uncomplicated cellulitis Pneumonia (considered for Concomitant clarithromycin Yes Ceftriaxone is recommended admission but no beds for severe pneumonia available) requiring hospitalization or in Pneumonia Amoxicillin/Clavulanate No the presence of Pneumonia Clarithromycin No comorbidities, in combination Pneumonia Concomitant azithromycin Yes with ONE of clarithromycin, azithromycin, or doxycycline 1. Anti-infective Review Panel. Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse; 2013. 2. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27 Summary of Outpatient Usage of Ceftriaxone at Site 7 Health Centre Audit Period Percentage of Patients who received Ceftriaxone Inconsistent with Guidelines* October 1/11 to October 31/12 (Baseline) 77% Feb 1/13 to April 30/13 88% July 2/16 to September 30/16 43% *Anti-infective Review Panel. Anti-infective guidelines for community-acquired infections. Toronto: MUMS Guideline Clearinghouse; 2013. 6
Lessons Learned Audit tools may require revision to target what you are trying to measure. Audit and feedback were able to achieve some improvement in the appropriateness of our ceftriaxone use, but other methods may be necessary to increase adherence. We Love Thee Frozen Land 7