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Coenen I, Vander Elst L, Spriet I, Gijsen M, Foulon V, De Lepeleire J, Latour K, Cossey V, Schuermans A, Stroobants N, Quintens C. Check of APpropriaTeness of Antimicrobial therapy In Nursing homes (CAPTAIN):a point prevalence study in Belgium. JAC Antimicrob Resist 2024; 6:dlae101. [PMID: 38974942 PMCID: PMC11227214 DOI: 10.1093/jacamr/dlae101] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 06/13/2024] [Indexed: 07/09/2024] Open
Abstract
Objectives The overall prevalence of antimicrobial therapy (AMT) in nursing homes is well described. However, less is known about the appropriateness of AMT in nursing home residents. Therefore, the Check of APpropriaTeness of antimicrobial therapy in nursing homes (CAPTAIN) study aimed to assess both prevalence and appropriateness of AMT in Belgian nursing homes. Methods In a prospective, observational, point prevalence study, researchers documented prevalence and identified potentially inappropriate prescriptions (PIPs) by evaluating accordance of AMT with national guidelines. The severity of inappropriateness was assessed by a modified Delphi expert panel. Results Eleven nursing homes, including 1178 residents, participated in this study. On the survey day, 8.0% of residents took systemic AMT, primarily for urinary tract infections (54.2%), respiratory tract infections (36.5%), and skin and skin-structure infections (6.3%). About half of these prescriptions were used in prophylaxis (52.1%). Registration of indication and stop date was missing in 58.3% and 56.3% of AMTs, respectively. In 89.6% of the systemic AMTs, at least one discordance with national guidelines was identified, resulting in a total of 171 PIPs, with 49 unique PIPs. Of all unique PIPs, 26.5% were assessed with a high severity score (≥4). According to the expert panel, most inappropriate practice was starting AMT for cough without other symptoms. Inappropriate timing of time-dependent AMTs was common, but assessed as 'moderately severe'. One-third of systemic AMT exceeded the recommended duration. Conclusions AMT in nursing homes is often not prescribed according to national guidelines, highlighting the need for future interventions to promote the rational use of AMT in this setting.
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Affiliation(s)
- Indira Coenen
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | | | - Isabel Spriet
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- University Hospitals Leuven, Pharmacy Department, Leuven, Belgium
| | - Matthias Gijsen
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
- University Hospitals Leuven, Pharmacy Department, Leuven, Belgium
| | - Veerle Foulon
- KU Leuven, Department of Pharmaceutical and Pharmacological Sciences, Leuven, Belgium
| | - Jan De Lepeleire
- KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
| | - Katrien Latour
- KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
- Sciensano, Department of Epidemiology and Public Health, Brussels, Belgium
| | - Veerle Cossey
- University Hospitals Leuven, Department of Infection Control and Epidemiology, Leuven, Belgium
| | - Annette Schuermans
- KU Leuven, Department of Public Health and Primary Care, Leuven, Belgium
- University Hospitals Leuven, Department of Infection Control and Epidemiology, Leuven, Belgium
| | - Nele Stroobants
- University Hospitals Leuven, Department of Infection Control and Epidemiology, Leuven, Belgium
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Caubergs V, Van den Broucke E, Mertens B, Gijsen M, Peetermans WE, Van Wijngaerden E, Desmet S, Lagrou K, Declercq P, Quintens C, Spriet I. Evaluation and implementation of optimized antimicrobial dosing strategies in obese and underweight patients. Infection 2024:10.1007/s15010-024-02279-w. [PMID: 38967768 DOI: 10.1007/s15010-024-02279-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 04/21/2024] [Indexed: 07/06/2024]
Abstract
PURPOSE We aimed to develop and implement dosing recommendations for antimicrobials in obese and underweight patients within an academic hospital, and assess their impact on antibiotic prescribing. METHODS A multi-step approach project was performed. First, obese and underweight patient prevalence and antimicrobial prescription frequency was determined in a point prevalence study. Second and third, a literature review and e-survey provided dosing evidence. Fourth, a consensus meeting was organized to formulate dosing recommendations. Fifth, these were implemented in our clinical validation service as six clinical rules continuously screening patients' records for potentially inappropriate prescriptions (PIPs). Uptake was evaluated by documenting the number of advices and acceptance rate. Last, an interrupted time series analysis (ITS) compared pre- and post-implementation periods to measure the impact of the intervention on residual PIPs/day. A residual PIP was defined as a PIP which persisted up to 48 h. RESULTS First, 41% of 15.896 hospitalized patients received antimicrobials over 20 days; of which 12% were obese and 9% underweight. Antibiotics were predominantly prescribed according to standard dosing regimens, adjusted to renal function. Next, six dosing recommendations, derived from literature, survey, and consensus, were implemented. In the fifth step, during an 18-week period, 219 advices were given, with 86% acceptance rate. Last, in the ITS analysis, at preintervention, a median of 75% residual PIPs/day existed, reduced to 0% postintervention. Use of clinical rules resulted in a significant immediate 84% relative reduction in residual PIPs (95% CI 0.55-0.94). CONCLUSION After conducting a literature review, e-survey, and seeking consensus from a panel of experts, dosing recommendations for antimicrobial treatment in both obese and underweight patients were developed. These recommendations have been successfully implemented into clinical practice, addressing the specific needs of these patient populations.
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Affiliation(s)
| | - Evelyne Van den Broucke
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium.
| | - Beatrijs Mertens
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
| | - Matthias Gijsen
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of General Internal Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Eric Van Wijngaerden
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Department of General Internal Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Stefanie Desmet
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Clinical Department of Laboratory Medicine, UZ Leuven, 3000, Leuven, Belgium
| | - Katrien Lagrou
- Department of Microbiology, Immunology and Transplantation, KU Leuven, 3000, Leuven, Belgium
- Clinical Department of Laboratory Medicine, UZ Leuven, 3000, Leuven, Belgium
| | | | | | - Isabel Spriet
- Pharmacy Department, UZ Leuven, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, 3000, Leuven, Belgium
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Van De Sijpe G, Hublou W, Declercq P, Metsemakers WJ, Sermon A, Casteels M, Foulon V, Quintens C, Spriet I. Bedside check of medication appropriateness (BED-CMA) as a risk-based tool for bedside clinical pharmacy services: A proof-of-concept study at the trauma surgery ward. Comput Struct Biotechnol J 2023; 22:58-65. [PMID: 38022766 PMCID: PMC10656193 DOI: 10.1016/j.csbj.2023.10.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/10/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Background Bedside clinical pharmacy prevents drug-related problems, but is not feasible in many countries due to limited resources. Hence, clinical rules using structural information in the electronic health record can help identifying potentially inappropriate prescriptions (PIPs). We aimed to develop and implement a risk-based clinical pharmacy service and evaluate its impact on prescribing at the trauma surgery ward. Methods The proportion of residual PIPs per day, i.e. the number of PIPs that persisted up to 24 h after pharmacist intervention divided by the number of PIPs at T0, was evaluated before and after implementation of the intervention in an interrupted time series analysis. The pre-intervention cohort received usual pharmacy services, i.e. a 0.3 FTE clinical pharmacist trainee. Fifteen clinical rules, targeting antimicrobial, anticoagulant and analgesic therapy were implemented in the post-intervention period. The pre-intervention period was compared to two post-intervention scenarios: A) clinical rule alerts reviewed by a 0.3 FTE clinical pharmacist trainee; and B) clinical rule alerts reviewed daily for approximately 1 h by a clinical pharmacist trainee. Results Pre-intervention, a median proportion of 67% (range 0%-100%) residual PIPs per day was observed. Scenario A showed an immediate relative reduction of 14% (p = 0.72) and scenario B a significant immediate relative reduction of 85% (p = 0.0015) in residual PIPs per day. In scenario A, recommendations were provided for 19% of clinical rule alerts, of which 67% was accepted by the surgeon within 24 h. In scenario B, recommendations were given for 56% of alerts, of which 84% was accepted. Conclusions Using clinical rules is an effective approach to organize bedside clinical pharmacy services and improves prescribing at the trauma surgery ward. Advanced training and daily follow-up of the clinical rules are two requirements to be considered.
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Affiliation(s)
- Greet Van De Sijpe
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Wencke Hublou
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - An Sermon
- Department of Trauma Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Minne Casteels
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Veerle Foulon
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Charlotte Quintens
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
- Clinical Pharmacology and Pharmacotherapy, Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
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Quintens C, Coenen M, Declercq P, Casteels M, Peetermans WE, Spriet I. From basic to advanced computerised intravenous to oral switch for paracetamol and antibiotics: an interrupted time series analysis. BMJ Open 2022; 12:e053010. [PMID: 35396281 PMCID: PMC8995958 DOI: 10.1136/bmjopen-2021-053010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Early switch from intravenous to oral therapy of bioequivalent drugs has major advantages but remains challenging. At our hospital, a basic clinical rule was designed to automatically alert the physician to review potential intravenous to oral switch (IVOS). A rather low acceptance rate was observed. In this study, we aimed to develop, validate and investigate the effect of more advanced clinical rules for IVOS, as part of a centralised pharmacist-led medication review service. DESIGN AND SETTING A quasi-experimental study was performed in a large teaching hospital in Belgium using an interrupted time series design. INTERVENTION A definite set of 13 criteria for IVOS, focusing on the ability of oral absorption and type of infection, was obtained by literature search and validated by a multidisciplinary expert panel. Based on these criteria, we developed a clinical rule for paracetamol and one for ten bioequivalent antibiotics to identify patients with potentially inappropriate intravenous prescriptions (PIVs). Postintervention, the clinical rule alerts were reviewed by pharmacists, who provided recommendations to switch in case of eligibility. PRIMARY AND SECONDARY OUTCOME MEASURES A regression model was used to assess the impact of the intervention on the number of persistent PIVs between the preintervention and the postintervention period. The total number of recommendations, acceptance rate and financial impact were recorded for the 8-month postintervention period. RESULTS At baseline, a median number of 11 (range: 7-16) persistent PIVs per day was observed. After the intervention, the number reduced to 3 (range: 1-7) per day. The advanced IVOS clinical rules showed an immediate relative reduction of 79% (incidence rate ratio=0.21, 95% CI 0.13 to 0.32; p<0.01) in the proportion of persistent PIVs. No significant underlying time trends were observed during the study. Postintervention, 1091 recommendations were provided, of which 74.1% were accepted, resulting in a total 1-day cost saving of €4648.35. CONCLUSIONS We showed the efficacy of advanced clinical rules combined with a pharmacist-led medication review for IVOS of bioequivalent drugs.
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Affiliation(s)
- Charlotte Quintens
- Pharmacy department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Marie Coenen
- Pharmacy department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Peter Declercq
- Pharmacy department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Minne Casteels
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of General Internal Medicine, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Isabel Spriet
- Pharmacy department, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, Katholieke Universiteit Leuven, Leuven, Belgium
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D'hulster E, Quintens C, Bisschops R, Willems R, Peetermans WE, Verbakel JY, Luyten J. Cost-effectiveness of check of medication appropriateness: methodological approach. Int J Clin Pharm 2022; 44:399-408. [PMID: 35013878 DOI: 10.1007/s11096-021-01356-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/10/2021] [Indexed: 01/17/2023]
Abstract
Background Adverse drug events following inappropriate prescribing in the hospital cause a substantial and avoidable medical and economic burden to hospitals, payers and patients alike. A clinical rule-based, pharmacist-led medication-review service, the 'Check of Medication Appropriateness' (CMA) was implemented in the University Hospitals Leuven. The CMA is shown to be effective in reducing potentially inappropriate prescriptions. Aim This study investigated whether this centralised clinical pharmacy service is cost-effective. Method We performed a cost-effectiveness analysis of three clinical rules of the CMA, targeting adverse drug events at three levels of severity: A) persistent opioid-induced constipation, B) ketorolac-induced gastrointestinal bleeding and C) drug-induced Torsade de Pointes. A decision tree was developed for each clinical rule. Both intervention costs as well as total costs associated with the occurrence of an adverse drug event were considered. The outcomes were reported in the form of an incremental cost-effectiveness ratio, expressed as an incremental cost per adverse drug event avoided. Results Applying clinical rules to avoid persistent opioid-induced constipation and ketorolac-induced gastrointestinal bleeding were cost-saving. Implementation of a medication check to avoid drug-induced Torsade de Pointes costed €8,846 per Torsade de Pointes avoided. Conclusion Our study provides strong indications that the CMA is worth its investment for clinical rules targeting (very) common adverse drug events, that can be avoided with limited expenses. Further research is required to assess the full CMA. The proposed model may be useful to perform cost-effectiveness analyses of other centralised clinical pharmacy services targeting inappropriate prescribing, at the level of individual adverse drug events.
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Affiliation(s)
- Erinn D'hulster
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Unit H, B-3000, Leuven, Belgium.
| | - Charlotte Quintens
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.,Pharmacy Department, University Hospitals Leuven, Leuven, Belgium
| | - Raf Bisschops
- Department of Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium.,Department of Gastroenterology and Hepatology, University Hospitals Leuven, Leuven, Belgium
| | - Rik Willems
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Willy E Peetermans
- Department of Microbiology, Immunology and Transplantation, KU Leuven, Leuven, Belgium.,Department of General Internal Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Jan Y Verbakel
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Unit H, B-3000, Leuven, Belgium.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeroen Luyten
- Department of Public Health and Primary Care, KU Leuven, Kapucijnenvoer 7, Unit H, B-3000, Leuven, Belgium
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