St. Joseph s General Hospital Vegreville and Mary Immaculate Care Centre Antimicrobial Stewardship Report January to June 217
Introduction Antibiotics are among the most commonly prescribed medications in acute care centres, yet can result in unintended patient toxicities, selection of pathogenic organisms, such as C. difficile, and promotion of antibiotic resistance. Antibiotic 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. The Covenant Health Antimicrobial Stewardship Committee (CHASC) was developed in May 213 and has since implemented several initiatives including: 1. Formulary restriction and preauthorization for daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline 2. Prospective audit and feedback of piperacillin-tazobactam and other antimicrobials (site dependent) 3. Development of a C. difficile (CDI) Patient Medication Order Set (PMOS) 4. Collation of antibiotic utilization data with the development of semi-annual site utilization reports 5. Circulation of a Covenant Health Antimicrobial Stewardship e-newsletter (CHASE) quarterly 6. Wide distribution and posting of formulary guidelines for the carbapenems and piperacillintazobactam to promote guideline concordant use 7. Development of a Patient Medication Order Set (PMOS) for the combined use of cefazolin and probenecid for simple cellulitis in outpatient areas (site dependent) 8. Development of an evidence based S. aureus bacteremia care bundle CHASC Antimicrobial Utilization Reports Data on antibiotic use is extracted from the Meditech Pharmacy Computer System. Drug utilization data is provided in both DDD (Defined Daily Dose) and expenditures. 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. There are three graph formats provided: 1. Total utilization and expenditures for the site broken down into Emergency Department, Inpatient Medicine unit and Mary Immaculate 2. Antibiotic classes as follows: ertapenem, imipenem and meropenem Cephalosporins (3 rd generation) ceftriaxone, cefotaxime and ceftazidime Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 2
ciprofloxacin, levofloxacin and moxifloxacin Piperacillin-tazobactam 3. Restricted antibiotics (daptomycin, ertapenem, imipenem, linezolid, meropenem and tigecycline) and piperacillin-tazobactam Utilization Summary The antibiotic utilization and expenditures over the last number of quarters at St. Joseph s General Hospital and Mary Immaculate Care Centre has remained stable (Figure 1). Antibiotic utilization is similar between the inpatient medicine unit and the emergency department while Mary Immaculate by comparison uses a very small amount of antibiotics. The cephalosporins and fluoroquinolones are the most commonly used antibiotics across the site. The fluoroquinolone breakdown is approximately 7% ciprofloxacin and 3% levofloxacin. The restricted antibiotics are generally used in low amounts. There was an increase in piperacillin-tazobactam use noted in the last quarter. There were three restricted antibiotic orders in the January to March 217 quarter (Table 1) all of which were guideline concordant. Antibiotic use in the Emergency Department has been stable over the last number of quarters although a rise in use is noted in the April to June 217 quarter (Figure 2). The cephalosporins were prescribed most commonly. There were no restricted antibiotics or piperacillin-tazobactam in use in this reporting period. Antibiotic utilization in the inpatient medicine unit has been stable over the last number of quarters (Figure 3). The cephalosporins and fluoroquinolones were the most commonly prescribed antibiotics with ciprofloxacin making up approximately 78% of the fluoroquinolone use. The restricted antibiotic orders as outlined above were prescribed in the inpatient medicine unit. A rise in piperacillintazobactam use occurred in the April to June 217 quarter. Antibiotic use at Mary Immaculate Care Centre is minimal. The fluoroquinolones and cefazolin were the only antibiotics prescribed (Figure 4). Approximately two-thirds of the fluoroquinolone use was ciprofloxacin. This is a shift from the last reporting period where only one-third of the fluoroquinolone use was ciprofloxacin. There were no 3 rd generation cephalosporins or restricted antibiotics in use. Recommendations: 1. Continue to use the restricted antibiotics minimally and according to formulary guidelines. 2. As Health Canada has issued a safety warning for quinolone use, St. Joseph s General Hospital and Mary Immaculate Care Centre to ensure quinolones are used only when necessary. Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 3
Figure 1. Vegreville Total Antimicrobial Usage and Expenditures July 213 to June 217 Vegreville Total DDD by Service 6 5 4 3 2 1 Emergency Mary Immaculate Medicine Vegreville Total Expenditures by Service $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Emergency Mary Immaculate Medicine Vegreville Total DDD 9 8 7 6 5 4 3 2 1 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 4
Vegreville Total Expenditures $12 $1 $8 $6 $4 $2 $ Vegreville Total DDD 14 12 1 8 6 4 2 Meropenem $7 $6 $5 $4 $3 $2 $1 $ Vegreville Total Expenditures Meropenem Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 5
Table 1. Vegreville Compliance with Preauthorization Form and Guideline Concordance Rates January to June 217 Date Service Antibiotic Guideline Concordant February 16, 217 February 23, 217 March 2, 217 Form Indication Compliance Medicine Yes No Polymicrobial pancreatic pseudocyst including Enterobacter. Transfer from RAH to complete therapy Medicine Yes Yes Diabetic foot infection, history of Enterobacter. Telephone advice from ID Medicine Yes No MRSA bacteremia with septic knee, acute kidney failure on vancomycin. Patient transferred from UAH to complete therapy Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 6
Figure 2. Vegreville ED Antimicrobial Usage and Expenditures July 213 to June 217 Vegreville ED DDD 4 35 3 25 2 15 1 5 Vegreville ED Expenditures $9 $8 $7 $6 $5 $4 $3 $2 $1 $ Vegreville ED DDD 14 12 1 8 6 4 2 Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 7
Vegreville ED Expenditures $7 $6 $5 $4 $3 $2 $1 $ Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 8
Figure 3. Vegreville Medicine Antimicrobial Usage and Expenditures July 213 to June 217 Vegreville Medicine DDD 5 45 4 35 3 25 2 15 1 5 Vegreville Medicine Expenditures $35 $3 $25 $2 $15 $1 $5 $ Vegreville Medicine DDD 4 35 3 25 2 15 1 5 Meropenem Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 9
$4 $35 $3 $25 $2 $15 $1 $5 $ Vegreville Medicine Expenditures Meropenem Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 1
Figure 4. Mary Immaculate Antimicrobial Usage and Expenditures July 213 to June 217 Mary Immaculate DDD 14 12 1 8 6 4 2 Mary Immaculate Expenditures $5 $45 $4 $35 $3 $25 $2 $15 $1 $5 $ Prepared by the Covenant Health Antimicrobial Stewardship Committee (CHASC) for the period of Jan-Jun 217 11