Economic impact of a rational use of antibiotics in intensive care

Drug utilization pattern in critical care unit in a tertiary care teaching hospital in India

Aims:

The aim of this study is to evaluate the drug utilization pattern and pharmacoeconomic analysis in critical care unit (CCU).

Materials and Methods:

Indoor case papers of patients admitted in CCU between January 2008 and December 2010 were analyzed for demographic variables; indications; duration of CCU stay; proportion of common drugs used. Use of antimicrobials was evaluated based on the culture report and empirical regimen used. Defined daily dose (DDD)/100 bed-days were calculated. Various World Health Organization prescribing indicators were evaluated. Cost of drugs was calculated from Indian Drug Review (2010).

Results:

A total of 397 cases were evaluated with a mean age of 44.62 years (95% confidence interval [CI]: 42.56-46.69). Average duration of CCU stay was 4.15 days (95% CI: 3.79-4.51). The average number of drugs prescribed per patient was 13.54 (95% CI: 13.05-14.04). Total drug utilization in terms of DDD/100 bed-days was 226.27. Metronidazole, cefotaxime, atropine, adrenaline, dopamine, dobutamine, deriphyllin, ranitidine, metoclopramide and furosemide were prescribed in more than 30% cases. Number of antimicrobials prescribed per patient was 2.50 (95% CI: 2.37-2.66). Cefotaxime + metronidazole (26.70%) were the most common empirical regimen used. Average cost of treatment per patient was Rs 3225.70 (95% CI: 2749.8-3701.6). Higher economic burden was noted among expired patients and admitted due to medical + surgical indication (P < 0.05).

Conclusion:

Poly-pharmacy and use of antimicrobials without culture report is a common problem in CCU.

Knowledge translation interventions for critically ill patients: a systematic review*

OBJECTIVE

We systematically reviewed ICU-based knowledge translation studies to assess the impact of knowledge translation interventions on processes and outcomes of care.

DATA SOURCES

We searched electronic databases (to July, 2010) without language restrictions and hand-searched reference lists of relevant studies and reviews.

STUDY SELECTION

Two reviewers independently identified randomized controlled trials and observational studies comparing any ICU-based knowledge translation intervention (e.g., protocols, guidelines, and audit and feedback) to management without a knowledge translation intervention. We focused on clinical topics that were addressed in greater than or equal to five studies.

DATA EXTRACTION

Pairs of reviewers abstracted data on the clinical topic, knowledge translation intervention(s), process of care measures, and patient outcomes. For each individual or combination of knowledge translation intervention(s) addressed in greater than or equal to three studies, we summarized each study using median risk ratio for dichotomous and standardized mean difference for continuous process measures. We used random-effects models. Anticipating a small number of randomized controlled trials, our primary meta-analyses included randomized controlled trials and observational studies. In separate sensitivity analyses, we excluded randomized controlled trials and collapsed protocols, guidelines, and bundles into one category of intervention. We conducted meta-analyses for clinical outcomes (ICU and hospital mortality, ventilator-associated pneumonia, duration of mechanical ventilation, and ICU length of stay) related to interventions that were associated with improvements in processes of care.

DATA SYNTHESIS

From 11,742 publications, we included 119 investigations (seven randomized controlled trials, 112 observational studies) on nine clinical topics. Interventions that included protocols with or without education improved continuous process measures (seven observational studies and one randomized controlled trial; standardized mean difference [95% CI]: 0.26 [0.1, 0.42]; p = 0.001 and four observational studies and one randomized controlled trial; 0.83 [0.37, 1.29]; p = 0.0004, respectively). Heterogeneity among studies within topics ranged from low to extreme. The exclusion of randomized controlled trials did not change our results. Single-intervention and lower-quality studies had higher standardized mean differences compared to multiple-intervention and higher-quality studies (p = 0.013 and 0.016, respectively). There were no associated improvements in clinical outcomes.

CONCLUSIONS

Knowledge translation interventions in the ICU that include protocols with or without education are associated with the greatest improvements in processes of critical care.

Antibiotic prescription patterns at admission into a tertiary level intensive care unit in Northern India

Context:

An audit of antibiotic prescribing patterns is an important indicator of the quality and standard of clinical practice.

Aims:

To study the (1) antibiotic prescription and consumption patterns at admission into the intensive care unit (ICU); (2) average costs of antibiotics prescribed; and (3) correlation of antibiotic usage and the costs incurred with age, severity of illness, and diagnosis.

Settings and Design:

A 13-bedded tertiary level ICU. A prospective, observational audit.

Materials and Methods:

Two hundred consecutive prescriptions on patients admitted to the ICU from August to October, 2008, were audited. The total number of drugs and antibiotics, the class, dose, route, and cost of antibiotics were noted and the Defined Daily Dose/100 bed-days (DDD/100 bed-days) of the 10 most frequently prescribed antibiotics were calculated. Statistical analysis used: Univariate analysis was performed using Epi Info software (version 8.0).

Results:

A total of 1246 drugs and 418 antibiotics were prescribed in the 200 patients studied, that is, an average of 6.23 (± SD 2.73) drugs/prescription and 2.09 (± SD 1.27) antibiotics/prescription. Antibiotics were prescribed on 190 patients (95%) at admission. There was a significant correlation between the number of patients prescribed three or more antibiotics and mortality rates (53% nonsurvivors vs. 33.5% survivors (P = 0.015). The average cost of the antibiotics was Rupees 1995.08 (± SD 2099.99) per patient and antibiotics expenditure accounted for 73.2% of the total drug costs.

Conclusions:

Antibiotics are commonly prescribed to most ICU patients at admission and contribute significantly to the total drug costs. Antibiotic restriction policies and a multidisciplinary effort to reduce usage are urgently required.

A strategy for reduction of antibiotic use in new patients admitted to a neonatal intensive care unit

BACKGROUND

In order to reduce the unnecessary use of and provide appropriate guidance for the administration of antibiotics, the neonatal bacterial infections screening score (NBISS) was developed to assess each new patient that is admitted to the neonatal intensive care unit (NICU).

METHODS

NBISS was designed based on maternal risk factors, clinical presentations, and laboratory data. The total score of each new patient is calculated at the time of admission. The first period of this study was an observational survey. Receiver operating characteristic (ROC) curves were used to determine the best cut-off NBISS for the diagnosis of bacterial infection (BI) and guide the use of antibiotics during the second period of this study.

RESULTS

Of 250 neonates who were admitted to the NICU, 237 (94.8%) received antibiotics during the first period of study. The initial total scores were not statistically different between the BI and non-BI groups (p = 0.155). We weighted C-reaction protein (CRP) (by 8×), the presence of a bulging fontanelle, pus from the ear canal, redness around the umbilicus, reduced movement, and being unable to feed (each by 5×) as significantly different between the BI and non-BI groups (p = 0.015). Weighted scores >8 points demonstrated the best diagnostic accuracy for indicating BI. After introducing NBISS for predicting BI in new patients admitted to NICU, the rate of antibiotic use significantly decreased from 94.8% to 60.3% between the two periods.

CONCLUSION

Using this simple screening strategy, we were able to clinically reduce the use of unnecessary antibiotics.

Antimicrobial stewardship: bridging the gap between quality care and cost

PURPOSE OF REVIEW

Antibiotic resistance continues to rise, whereas development of new agents to counter it has slowed. A heightened need exists to maintain the effectiveness of currently available agents. This review focuses on the need for better antimicrobial stewardship, expected benefits of well designed antimicrobial stewardship programs (ASPs), and provides suggestions for development of an effective ASP.

RECENT FINDINGS

Healthcare-associated infections (HAIs) are a significant cause of poor treatment outcomes and elevated healthcare and societal costs worldwide. HAIs are often caused by antibiotic-resistant pathogens; overuse of antibiotics has been linked with antibiotic resistance. Benefits of improved antimicrobial stewardship include reduced emergence of antibiotic resistance, limitation of drug-related adverse events, minimization of other consequences of antibiotic use (e.g., superinfection), and reduction of societal and healthcare-related costs. In 2007, the Infectious Diseases Society of America (IDSA) and the Society for Healthcare Epidemiology of America (SHEA) provided guidelines for the development of institutional programs to enhance antimicrobial stewardship. Experiences at The Ohio State University Medical Center (OSUMC) reinforce this message, while providing specific examples of ways to optimize ASP development and implementation. The focus of an ASP should be on improving quality of care, reducing drug resistance, and cost savings. When implementing an ASP, it is important to identify those most likely to resist the ASP, understand their concerns, and develop easy-to-understand messages that address these concerns and highlight the benefits of the proposed changes. Antibiograms play a key role in identifying local and interdepartmental trends in antibiotic susceptibility or resistance. These data are important not only in devising best-treatment practices for the institution, but also in evaluating the impact of a recently implemented ASP. Other measures of the impact of an ASP should include patient outcomes and overall costs or savings.

SUMMARY

Better antimicrobial stewardship is needed to limit the emergence of antibiotic resistance, prolong the effectiveness of currently available agents, improve patient outcomes, and reduce healthcare and societal costs associated with HAIs. Guidelines from the IDSA/SHEA and experiences at OSUMC provide examples of how best to develop an institutional ASP to accomplish these goals.

[Assessing the usefulness of a permanently opened clinical microbiology laboratory]

Since 2005, the clinical microbiology laboratory of the Angers teaching hospital has implemented after hours service requiring the overnight presence of a technician specialized in bacteriology. During that time, bacterial identifications and antibiotic susceptibility testing to antimicrobial agents can be performed for critical samples.

OBJECTIVES

The authors wanted to evaluate the impact of the after-hours service on the decrease of delay from sampling to results, and from sampling to the implementation of an appropriate antimicrobial therapy. A therapy could be initiated, changed for more efficient agents, or changed to narrower-spectrum agents (major benefits).

METHODS

A 4-month prospective study was made. All samples for which identification and/or susceptibility testing were performed during after-hours service (continued analyses) were included in the study. Delays observed were compared with theoretical delays estimated in the absence of the after-hours service.

RESULTS

A minimum 24 hour-decrease of the delay for results was observed for 97 % of the 430 samples included. Overall, a major benefit was obtained for more than 25 % of the analyses, representing a cumulated 111-day benefit in days of efficient treatments and a cumulated 27-day benefit in days of prescription of narrower-spectrum agents.

DISCUSSION

This organization, unique in French hospitals, is directly related to the improvement of antimicrobial treatments, like antibiotic practice guidelines or infection disease specialists. It was evaluated as a relevant strategy, potentially cost saving, with a significant impact on both the efficiency of treatments and microbial ecology.

[Impact of antibiotic use and prescribing policy in a Tunisian intensive care unit]

OBJECTIVE

The aim of this study was to assess the efficacy of local antibiotic policy in a Tunisian ICU. The predefined primary efficacy objectives were the decrease of antibiotic consumption, reduction of inappropriate antibiotic (ATB) use and antimicrobial resistance.

DESIGN

This prospective intervention study lasted from January 2002 to December 2004. In the first study period or the baseline phase (from January to December 2002) we focused on physician education for ATB prescription practice. The second period concerned intervention (control of all ATB use).

RESULTS

The number of infection episodes significantly decreased from 2002 to 2004; 198 infection episodes in 2002 (1.63+/-1.15 episodes/patient) versus 124 in 2003 (1.22+/-0.93) (P<0.0008) versus 121 in 2004 (1.23+/-0.8) (P1<0.0008). The number of ATB/prescription also significantly decreased from 1.85+/-1.3 in 2002 to 1.5+/-0.9 in 2003 (P=0.02) and 1.5+/-1.4 in 2004 (P1=0.05). Appropriateness of antibiotherapy improved during the intervention period: 65% in 2002 versus 86% in 2003 (P=0.0003) and 81% in 2004 (P1=0.02). The length of antibiotherapy in survivors was considerably reduced: 14.1+/-2.9 days in 2002 versus 11.9+/-1.2 days in 2003 (P<10(-5)) and 10.9+/-2.5 days in 2004 (P1<10(-5)) with a significant reduction of antibiotherapy cost and length of stay (20.4+/-9 days in 2002 versus 18.3+/-6 days in 2003 and 16.9+/-8 days in 2004; P=0.05; P1=0.02). There was a significant decrease of carbapenem resistant Enterobacteriaceae esbeta, Pseudomonas aeruginosa and Acinetobacter baumannii.

Evaluation of antibiotic use in intensive care units of a tertiary care hospital in Turkey

The object of this study was to evaluate the appropriateness of antibiotic use in relation to diagnosis and bacteriological findings in the intensive care units (ICUs) of a 1100-bed referral and tertiary care hospital with an antibiotic restriction policy in Turkey. Between June and December 2002, patients who received antibiotics in the medical and surgical ICUs were evaluated prospectively. Two infectious diseases (ID) specialists assessed the antibiotics ordered daily. Of the 368 patients admitted to the ICUs, 223 (60.6%) received 440 antibiotics. The most frequently prescribed antibiotics were first-generation cephalosporins (16.1%), third-generation cephalosporins (15.2%), aminoglycosides (12.1%), carbapenems (10.7%) and ampicillin-sulbactam (8.7%). Antibiotic use was inappropriate in 47.3% of antibiotics. ID specialists recommended the use of 47% of all antibiotics. An antibiotic order without an ID consultation was more likely to be inappropriate [odds ratio (OR)=13.2, P<0.001, confidence intervals (CI)=4.4-39.5]. Antibiotics ordered empirically were found to be less appropriate than those ordered with evidence of culture and susceptibility results (OR=3.8, P=0.038, CI=1.1-13.1). Inappropriate antibiotic use was significantly higher in patients who had surgical interventions (OR=3.6, P=0.025, CI=1.2-10.8). Irrational antibiotic use was high for unrestricted antibiotics. In particular, antibiotic use was inappropriate in surgical ICUs. Additional interventions such as postgraduate training programmes and elaboration of local guidelines could be beneficial.

Pneumopathies du sujet âgé

OBJECTIVE

We developed a prescribing guideline containing recommendations for the initial empirical antibiotic therapy in community or nosocomial pneumonia. The aim of the present study was to examine the impact of this measure.

METHOD

The prescribing guideline was implemented in May 1999. We retrospectively reviewed the charts of all patients>65 years with community-, or nursing home- or hospital-acquired pneumonia hospitalised in our department of acute geriatric care between May 1999 and November 2000. The criteria assessed were: consistence with the guideline, clinical effectiveness within 72 hours, adequation with the isolated germs and intra-hospital mortality.

RESULTS

Data were collected on 112 patients (63 women et 49 men; mean age=80 +/- 8 Years). The pneumonia was community-acquired in 52 cases (46%), nursing home acquired in 25 cases (22%) and hospital-acquired in 35 cases (31%). Antibiotic prescription was consistent with the guideline in 64 cases (57%). When the antibiotic therapy was consistent, the patients were more likely to improve within 72 hours (45/64 versus 23/48; p=0.01). Despite a tendency, the number of antimicrobial treatments adapted to the isolated microorganisms was not significantly higher in the consistent group (22/36 adapted treatments versus 10/20). The intra-hospital mortality (25%) was similar in the two groups consistent and not consistent with the guideline. SARM was the most frequent multiresistant bacteria that was isolated.

CONCLUSION

The use of a prescribing guideline might improve the efficiency of empirical probabilistic antibiotic therapies. The impact of the guideline use on overall antibiotic costs and microbiological flora remains to be determined.

Effect of a comprehensive, multidisciplinary, educational program on the use of antibiotics in a geriatric university hospital

OBJECTIVES

To assess the effect of a comprehensive, educational antibiotic management program designed to improve antibiotic use and reduce treatment costs in elderly patients with suspected urinary or respiratory tract infection.

DESIGN

Interventional cohort study with 12 cross-sectional drug utilization reviews of antibiotic use before, during, and after the multifaceted intervention.

SETTING

A 304-bed university hospital for geriatric patients.

PARTICIPANTS

A total of 3,383 elderly patients.

INTERVENTIONS

An educational program including distribution of guidelines on the diagnosis and treatment of urinary and respiratory tract infections; lectures on geriatric infectious diseases; weekly ward rounds for patients with suspected infection; and targeted, individual counseling on diagnosis and antibiotic treatment of infections.

MEASUREMENTS

Antibiotic utilization data were collected from the patients' records. Antimicrobial costs were calculated using 1998 hospital wholesale prices.

RESULTS

Of 3,383 screened patients, 680 (20%) received at least one antibiotic. During the study period, the mean number of prescribed drugs per patient increased from 5.9 to 7.6 (29%; P<.001). In contrast, a reduction of 15% was observed in the proportion of patients exposed to antibiotic agents (P=.08) and a drop of 26% in the number of antibiotics administered (P<.001). This resulted in a 54% decrease in cumulative daily antibiotic costs. In 83 (75%) of 110 surveyed patients, the guidelines were correctly implemented. The intervention had no measurable negative clinical effect.

CONCLUSION

A comprehensive, multifaceted educational program for treating urinary and respiratory tract infections in the elderly was a safe and practical method to change physicians' antibiotic prescribing practice and significantly reduce the consumption and costs of antibiotics in a geriatric hospital.

Judicious Use of Antimicrobials in the Critical Care Setting

This article reviews the judicious use of antibiotics in an intensive care setting. Risk factors for both infection and antimicrobial resistance are discussed. Various methods hospitals can apply to promote the optimal use of antibiotics also are reviewed. These methods include empiric therapy, antibiotic cycling, treatment guidelines and protocols, and antibiotic susceptibility monitoring.

Importance of nondrug costs of intravenous antibiotic therapy

Introduction

Costs are one of the factors determining physicians' choice of medication to treat patients in specific situations. However, usually only the drug acquisition costs are taken into account, whereas other factors such as the use of disposable materials, the drug preparation time and the staff workload are insufficiently taken into consideration. We therefore decided to assess true overall costs of intravenous (IV) antibiotic administration by performing an activity-based costing approach.

Methods

A prospective survey on costs and workload by means of a time and motion analysis and activity-based costing was performed in a 605-bed secondary referral centre with 20 intensive care unit beds. The subjects were 50 consecutive patients admitted to our hospital with community-acquired pneumonia or intra-abdominal infections requiring treatment with IV antibiotics. A time and motion analysis of 103 routine acts of preparing and administering IV antibiotics was performed in the intensive care unit and in the Department of Internal Medicine. To measure the entire process an inventory and work flowchart were made using detailed questionnaires completed by members of the nursing staff, the medical staff and the pharmacy staff. In addition, questionnaires were distributed to management and secretarial staff to determine additional overhead costs. The average costs for different methods of IV antibiotic administration were then compared by timing all steps in the process. Four different methods of drug administration were used: administration by volumetric pump, administration by syringe pump, administration by 'unaided' infusion bag, and administration by direct IV injection.

Results

The average times required for each of these procedures, including preparation and administration of the drug, were 4:49 ± 2:37, 4:56 ± 2:03, 5:51 ± 3:33 and 9:21 ± 2:16 min (mean minutes:seconds ± standard deviation), respectively. When the costs for expended staff time and materials (not including drug costs) were calculated this resulted in average costs of €5.65, €7.28, €5.36 and €3.83, respectively, for administration of each dose of antibiotics. These costs represent between 11% and 53% of the total daily costs of antibiotic therapy. Compared with the acquisition costs, these indirect costs ranged from 13% to 113%. Not included in this comparison is the time required for insertion of an IV catheter, which was found to be 10:15 ± 6:31 min with an average calculated cost of €9.17.

Conclusions

Total costs of IV antibiotic administration are formed not only by the costs of the drugs themselves, but also, to a substantial degree, by the time expended by medical and nursing staff, costs of disposable materials and overhead costs. Physicians making decisions regarding the use of specific medications in intensive care unit patients should take these factors into account. Use of IV antibiotics is associated with considerable workload and additional costs that can exceed the acquisition costs of the medications themselves.

Impact of a multidisciplinary approach to the control of antibiotic prescription in a general hospital

We examined the impact of a rational antibiotic prescription programme based on a multidisciplinary consultative approach in a 600-bed hospital. The programme involved four measures: (1). drawing up of a local prescribing consensus with all prescribers; (2). a restricted prescriptions policy for the most expensive antibiotics; (3.assessment of the prescription of these antibiotics by regular audits; and (4). institutional training and information for prescribers. The impact of the programme was assessed by comparing actual prescriptions with the criteria of the local consensus, compliance with the restrictive prescription policy, changes in the average daily cost of antibiotic therapy per inpatient and changes in the local ecology of methicillin-resistant Staphylococcus aureus (MRSA), Enterobacteriaceae producing extended-spectrum beta-lactamases (EPESB) and ceftazidime-resistant Pseudomonas species (CRP). Using a participatory consensual approach, 182 reference recommendations were established (104 for adults, 78 for children), corresponding to 85% of the clinical settings encountered in the hospital. Six audits, conducted since June 1997, show that the rate of unjustified prescriptions first fell significantly (from 6 to 0%, P<0.001), then increased significantly (from 0 to 3%, P<0.05) before stabilizing at 3%. The cost of antimicrobials per inpatient day fell significantly (from US dollars 13.8 in 1997 to US dollars 11 in 2000, P<0.001). The prevalence of MRSA and CRP remained stable, while that of EPESB fell significantly (P<0.001). This multidisciplinary consultative approach thus reduced antibiotic costs, contributed to infection control, and improved the quality of antibiotic prescription.

Implementing practice guidelines for appropriate antimicrobial usage: a systematic review

BACKGROUND

Antimicrobial resistance is increasing, apparently in part as a result of the inappropriate use of antimicrobial agents.

OBJECTIVES

To conduct a systematic review of guideline implementation studies for improving appropriate use of antimicrobial agents and to determine which implementation methods appear to improve the outcome of appropriate antimicrobial use.

RESEARCH DESIGN

The Medline database was searched for comparative studies on guideline implementation of appropriate antimicrobial use in common infections. Estimates of treatment effects and costs were included. The community-acquired infections selected were otitis media, respiratory illnesses, pharyngitis, and sinusitis. The nosocomial infections selected were urinary tract infections and surgical wound infections. Antiretroviral treatment studies and vancomycin usage studies were also included. Other computer-assisted antibiotic control studies not selected in the above topics were included.

RESULTS

Forty studies were found that documented the effectiveness of implementation methods in encouraging appropriate antimicrobial use. The available evidence showed that multifaceted implementation methods were most successful. Individual implementation methods that appeared to be useful were academic detailing, feedback from nurses, pharmacists, or physicians, local adaptation of a guideline, small-group interactive sessions, and computer-assisted care.

[Economic impact of rationalized antibiotic therapy in a general hospital]

PURPOSE

To evaluate the economic impact and the bacterial resistance rates after 2 years of a rationalized antibiotic prescription program in a 502-bed hospital.

CURRENT KNOWLEDGE AND KEY POINTS

Prescribing protocols were established by consensus in 1998 and were reinforced a year later by nominative dispensing of the most costly antibiotics. The impact of the program was assessed in terms of changes in the overall cost of antibiotics and in the pattern of bacterial resistance among pathogens isolated in the institution, during the period prior to the onset of the program (1997) and its realization (1998 and 1999).

FUTURE AND PROJECTS

The expenses for antibiotic drugs decreased by 46% in 2 years. Resistance rates among the different pathogens studied have remained stable. No increase of mortality was observed. Our rational policy in antibiotic therapy had a positive economic impact. However, new additional measures should be encouraged to prevent antimicrobial resistance.