Use of antibiotic agents in a large teaching hospital. The impact of Antibiotic Guidelines

Evaluation of the prescription and use of antibiotics in Brazilian children

INTRODUCTION

Inappropriate use of antibiotics leads to increased levels of bacterial resistance making it difficult to treat upper respiratory tract infections. The appropriate use of these drugs has a fundamental role in controlling resistance and in success of treatment of childhood infections. Therefore, the aim of this study was to assess the prescription and use of antibiotics for Brazilian children.

METHODS

The use of antibiotics in 160 children was monitored in two Primary Health Centers by questionnaires administered to parents and caregivers that assessed the social, demographic and clinical conditions of the children. Furthermore, the antibiotic use pattern was ascertained in these children and compared to the recommendations of the Brazilian and international guidelines.

RESULTS

The use of these drugs had an inverse relationship with children breast-fed to six months of age, showing that breast-fed children had a tendency to use less of these drugs. There was great variability in the amoxicillin doses used for upper respiratory infections ranging from 8.2 to 91.9mg/kg/day. The doses used in most treatments were far below the doses recommended in the Brazilian and international guidelines (50% and 97%, respectively).

CONCLUSION

Although there are guidelines for the use of these medications, compliance is still very low, leading to under dosage and therapeutic failures. It is essential for pediatricians to be aware of and comply with the guidelines, avoid personal decisions and take measures based on strong clinical evidence. The proper use of these medications, in addition to greater therapeutic success, decreases the possibility of the appearance of resistant microorganisms.

Point-prevalence study of inappropriate antibiotic use at a tertiary Australian hospital

A point-prevalence study at a tertiary Australian hospital found 199 of 462 inpatients (43%) to be receiving antibiotic therapy. Forty-seven per cent of antibiotic use was discordant with guidelines or microbiological results and hence considered inappropriate. Risk factors for inappropriate antibiotic prescribing included bone/joint infections, the absence of infection, creatinine level >120 µmol/L, carbapenem or macrolide use and being under the care of the aged care/rehabilitation team. In the setting of finite antimicrobial stewardship resources, identification of local determinants for inappropriate antibiotic use may enable more targeted interventions.

Antibiotic use in elderly hospital inpatients before and after the introduction of treatment guidelines

Objective

(1) To establish the pattern of antibiotic use in elderly hospital inpatients, using data to draw up antibiotic treatment guidelines; (2) To assess the short-term and longer-term impact of the guidelines on antibiotic use and their acceptability to medical staff.

Method

Antibiotic use was assessed in relation to suitability for site and severity of infection, appropriateness of drug choice, outcome of therapy and cost, before, immediately after and 10 months after guideline introduction. Acceptability to medical staff was gauged through a questionnaire.

Setting

Geriatric hospital inpatients in long-stay, assessment and GP-supervised wards in the Grampian region of Scotland (phase 1: 324 patients; phase 2: 302 patients; phase 3: 263 patients).

Key findings

The antibiotic prescribed was appropriate for site and severity of infection in 92 per cent of patients in phase 1, but was a policy drug in only 56 per cent. After guideline introduction, adherence to policy did not improve, but use of non-policy drugs without identified reason fell from 24 per cent in phase 1 to 13 per cent in phase 3. Adjustment of antibiotic dose for renal function increased from 73 per cent in phase 1 to 86 per cent in phase 3. Duration of treatment for a single infection was significantly reduced in phase 3, but outcome and cost were unchanged after guideline introduction. Medical staff were supportive of the guidelines and felt they had changed their prescribing practices.

Conclusion

Antibiotic treatment guidelines did not have a major impact on antibiotic use, although some positive trends were observed. New ways of promoting adherence to guidelines need to be explored.

The performance of junior doctors in applying clinical pharmacology knowledge and prescribing skills to standardized clinical cases

AIMS

Recent studies suggest a worryingly high proportion of final year medical students and new doctors feel unprepared for effective and safe prescribing. Little research has been undertaken on UK junior doctors to see if these perceptions translate into unsafe prescribing practice. We aimed to measure the performance of foundation year 1 (FY1) doctors in applying clinical pharmacology and therapeutics (CPT) knowledge and prescribing skills using standardized clinical cases.

METHODS

A subject matter expert (SME) panel constructed a blueprint, and from these, twelve assessments focusing on areas posing high risk to patient safety and deemed as essential for FY1 doctors to know were chosen. Assessments comprised six extended matching questions (EMQs) and six written unobserved structured clinical examinations (WUSCEs) covering seven CPT domains. Two of each assessment types were administered over three time points to 128 FY1 doctors.

RESULTS

The twelve assessments were valid and statistically reliable. Across seven CPT areas tested 51-75% of FY1 doctors failed EMQs and 27-70% failed WUSCEs. The WUSCEs showed three performance trends; 30% of FY1 doctors consistently performing poorly, 50% performing around the passing score, and 20% performing consistently well. Categorical rating of the WUSCEs revealed 5% (8/161) of scripts contained errors deemed as potentially lethal.

CONCLUSIONS

This study showed that a large proportion of FY1 doctors failed to demonstrate the level of CPT knowledge and prescribing ability required at this stage of their careers. We identified areas of performance weakness that posed high risk to patient safety and suggested ways to improve the prescribing by FY1 doctors.

Third generation cephalosporin use in a tertiary hospital in Port of Spain, Trinidad: need for an antibiotic policy

Background

Tertiary care hospitals are a potential source for development and spread of bacterial resistance being in the loop to receive outpatients and referrals from community nursing homes and hospitals. The liberal use of third-generation cephalosporins (3GCs) in these hospitals has been associated with the emergence of extended-spectrum beta- lactamases (ESBLs) presenting concerns for bacterial resistance in therapeutics. We studied the 3GC utilization in a tertiary care teaching hospital, in warded patients (medical, surgical, gynaecology, orthopedic) prescribed these drugs.

Methods

Clinical data of patients (≥ 13 years) admitted to the General Hospital, Port of Spain (POSGH) from January to June 2000, and who had received 3GCs based on the Pharmacy records were studied. The Sanford Antibiotic Guide 2000, was used to determine appropriateness of therapy. The agency which procures drugs for the Ministry of Health supplied the cost of drugs.

Results

The prevalence rate of use of 3GCs was 9.5 per 1000 admissions and was higher in surgical and gynecological admissions (21/1000) compared with medical and orthopedic (8 /1000) services (p < 0.05). Ceftriaxone was the most frequently used 3GC. Sixty-nine (36%) patients without clinical evidence of infection received 3Gcs and prescribing was based on therapeutic recommendations in 4% of patients. At least 62% of all prescriptions were inappropriate with significant associations for patients from gynaecology (p < 0.003), empirical prescribing (p < 0.48), patients with undetermined infection sites (p < 0.007), and for single drug use compared with multiple antibiotics (p < 0.001). Treatment was twice as costly when prescribing was inappropriate

Conclusions

There is extensive inappropriate 3GC utilization in tertiary care in Trinidad. We recommend hospital laboratories undertake continuous surveillance of antibiotic resistance patterns so that appropriate changes in prescribing guidelines can be developed and implemented. Though guidelines for rational antibiotic use were developed they have not been re-visited or encouraged, suggesting urgent antibiotic review of the hospital formulary and instituting an infection control team. Monitoring antibiotic use with microbiology laboratory support can promote rational drug utilization, cut costs, halt inappropriate 3GC prescribing, and delay the emergence of resistant organisms. An ongoing antibiotic peer audit is suggested.

Impact of an antibiotic policy on antibiotic use in a paediatric department. Individual based follow-up shows that antibiotics were chosen according to diagnoses and bacterial findings

Guidelines and clinical Cupertino for rational antibiotic use were implemented in a Norwegian paediatric department in 1994. From 1994 to 1998 the use of antibiotics and expenditures was reduced by 50%. There was an 80% decrease in the use of cloxacillin, a 74% decrease of aminoglycosides and a 59% decrease of cephalosporins. The use of penicillin V and G increased by 14% and ampicillins by 8%. Eight point prevalence studies showed that on average 23% (range 21-38%) of the patients were treated with antibiotics. Penicillins were used in 44% of courses, aminoglycosides in 35% of courses and cephalosporins in 9% of courses. Treatment was mostly adjusted to bacteriological findings. Compliance with guidelines was >90%. Guidelines for rational antibiotic policy and multidisciplinary co-operation lead to reduction in the use and expenses of antibiotics in a paediatric department.

The use of antimicrobials in ten Australian and New Zealand intensive care units. The Australian and New Zealand Intensive Care Multicentre Studies Group Investigators

A prospective standardized collection of clinical, microbiological and pharmaceutical information on antibiotic use was conducted in Australia and New Zealand intensive care units (ICUs) involving 481 consecutive critically ill patients who were receiving antibiotics for any reason while in ICU. Patients had a mean SAPS II score of 34.1 +/- 17.8 with an expected mortality of 15.6% (actual mortality 12%). Of these, 292 (60.8%) were admitted to the ICU within 72 hours of surgery. Among such surgical patients, 233 (79.9%) received antibiotics for "surgical prophylaxis" while in ICU (48% of sample population). The second largest group of patients treated with antibiotics in ICU included those with systemic inflammatory response syndrome and clinical suspicion of infection (38%). Antibiotics were prescribed for the treatment of clinically diagnosed infection in 268 patients. Clinical response was apparent in 62.6% and in most (71%) was achieved in the first 72 hours of treatment. The incidence of antimicrobial-related side-effects was 4%, mostly in the form of diarrhoea or rash (75% of all side-effects). The most commonly prescribed antimicrobials were gentamicin (n = 146), ceftriaxone (n = 98), vancomycin (n = 94) and metronidazole (n = 111). Three times daily prescription of aminoglycosides was uncommon (< 1%). Forty-one patients had a documented infection (positive culture) with a gram-negative organism. Of these, 17 received therapy with a single antibiotic and 24 received therapy with two antibiotics. Despite similar illness severity, there were six deaths in the former group and only two in the latter.

[The good use of antibiotics in intensive care: results of a program for rationalization of prescriptions]

OBJECTIVE

To assess the impact of an antibiotic prescribing programme in a intensive therapy unit.

TYPE OF STUDY

Prospective comparative study.

METHODS

We compared antibiotic prescriptions and bacterial susceptibility to antimicrobial agents before and after introduction of a programme focusing on injection control and therapeutic indications.

RESULTS

The introduction of the programme resulted in a major decrease in antibiotic administration. Moreover, the susceptibility of Pseudomonas aeruginosa to ticarcillin increased from 40 to 68%, and susceptibility of Staphylococcus aureus to methicillin increased from 55 to 73%.

CONCLUSIONS

Antibiotic control policies must be considered integral to any effort to decrease resistance and cost of therapy with antibiotics.

Impact of an educational program on antibiotic use in a tertiary care hospital in a developing country

A multi-cross-sectional study was conducted in a 2000-bed tertiary care university hospital in Bangkok, Thailand, from September 1993 to May 1994 to assess the effectiveness of an educational program on the use of antibiotics. Data on the study covered antibiotic usage both in-patients and out-patients. Data were collected for a 24-hour period every 2 weeks for 7 days for each 3-month period. The target population were residents, general practitioners, and sixth-year medical students. The educational program provided information derived from the data of inappropriate use of antibiotics during the pre-intervention period and guidelines on the use of antibiotics which were agreed to by a consensus among the faculty in all clinical departments. The study revealed: (1) the prevalence of antibiotic use and the cost of antibiotics during post-intervention period was significantly decreased by 20%; (2) the use of antibiotic prophylaxis for obstetrics patients and patients undergoing cataract surgery decreased significantly; (3) there was a shift from second or third generation cephalosporins to cefazolin for surgical prophylaxis; (4) the duration of perioperative antibiotic prophylaxis was reduced to under 2 days; (5) there was a shift from netilmicin or amikacin to gentamicin for the treatment of community acquired infection; and (6) the mortality, median length of hospital stay, and nosocomial infection rate among the patients who received antibiotics during the post-intervention period were not significantly different from those during the pre-intervention period. These results suggest that this educational program comprising information feedback and antibiotic usage guidelines was effective in improving antibiotic use at this tertiary care university hospital in Thailand.

Single- versus multiple-dose antimicrobial prophylaxis for major surgery: a systematic review

BACKGROUND

Single-dose antimicrobial prophylaxis for major surgery is a widely accepted principle; recommendations have been based on laboratory studies and numerous clinical trials published in the last 25 years. In practice, single-dose prophylaxis has not been universally accepted and multiple-dose regimens are still used in some centres. Moreover, the principle has recently been challenged by the results of an Australian study of vascular surgery. The aim of this current systematic review is to determine the overall efficacy of single versus multiple-dose antimicrobial prophylaxis for major surgery and across surgical disciplines.

METHODS

Relevant studies were identified in the medical literature using the MEDLINE database and other search strategies. Trials included in the review were prospective and randomized, had the same antimicrobial in each treatment arm and were published in English. Rates of postoperative surgical site infections (SSI) were extracted, 2 x 2 tables prepared and odds ratios (OR) [with 95% confidence intervals (95% CI)] calculated. Data were then combined using fixed and random effects models to provide an overall figure. In this context, a high value for the combined OR, with 95% CI > 1.0, indicates superiority of multiple-dose regimens and a low OR, with 95% CI < 1.0, suggests the opposite. A combined OR close to 1.0, with narrow 95% CI straddling 1.0, indicates no clear advantage of one regimen over another. Further subgroup analyses were also performed.

RESULTS

Combined OR by both fixed (1.06, 95% CI, 0.89-1.25) and random effects (1.04, 95% CI, 0.86-1.25) models indicated no clear advantage of either single or multiple-dose regimens in preventing SSI. Likewise, subgroup analysis showed no statistically significant differences associated with type of antimicrobial used (beta-lactam vs other), blinded wound assessment, length of the multiple-dose arm (> 24 h vs 24 h or less) or type of surgery (obstetric and gynaecological vs other).

CONCLUSIONS

Continued use of single-dose antimicrobial prophylaxis for major surgery is recommended. Further studies are required, especially in previously neglected surgical disciplines.

Hospital antibiotic prescribing successfully modified by 'immediate concurrent feedback'

1. To determine the effectiveness of ongoing immediate concurrent feedback (ICF) in minimizing 'inappropriate' sultamicillin or co-amoxiclav prescribing via the parenteral route (i.e. when the oral route was accessible and not contraindicated), a prospective controlled audit was carried out on hospital inpatients over a 20 month period. 2. After an education programme to promote oral rather than unnecessary intravenous (i.v.) use of sultamicillin, co-amoxiclav and certain other drugs, an ongoing ICF strategy was instituted. 3. ICF entailed issue of memos on the following day to prescribers of i.v. sultamicillin or co-amoxiclav for inpatients in whom this route was deemed 'inappropriate', by a specially trained nurse using strict objective criteria. The memos recommended oral prescribing (particularly of co-amoxiclav, currently the less expensive alternative). 4. After starting ICF, there were consistent, clinically and statistically significant reductions in the monthly proportions of (i) admissions prescribed i.v. sultamicillin or co-amoxiclav (38% P < 0.001), (ii) those in whom the route was 'inappropriate' (75%, P < 0.001), and (iii) corresponding ratios of i.v./oral usage and expenditure, oral sultamicillin/co-amoxiclav usage and expenditure, as well as total and per admission expenditure on i.v. forms (> or = 43%, P < 0.01). 5. For i.v. cefuroxime (for which there was no ICF) and its oral counterpart cefuroxime-axetil, there were no comparable changes in usage or expenditure. 6. This simple, ongoing ICF strategy was effective and well accepted; estimated net monthly savings being HK$26-30,000.

Monitoring of antibiotic use in a primary and tertiary care hospital

Prophylactic and curative use of antibiotics was studied prospectively in 87 consecutive medical and surgical cases of a tertiary care hospital and in 98 cases of a primary care hospital. Based on Kunins' criteria, antibiotic prophylaxis was found to be more inappropriate in the primary care hospital (49%) than in the tertiary care hospital (34%). Antibiotic therapy, however, was more appropriate at the primary level; 67% as opposed to 60% at the tertiary level. This resulted in a similar overall level of inappropriate antibiotic use in the two hospitals. Surgical prophylaxis was started postoperatively in 68% of the primary care hospital cases. Though prophylaxis was always perioperative in the tertiary care hospital, the postoperative duration was more than 7 days in one third of the cases. The nosocomial infection rate in those given prolonged prophylaxis was higher than those who received antibiotics for less than 72 hours. Antibiotics were started empirically in 78% of tertiary hospital care cases and 100% of cases in the primary hospital. Though culture sensitivity was done in 80% of the tertiary care cases, more than half the specimens were sent after multiple doses of antibiotics were started. The choice of antibiotic did not always correlate with the sensitivity report. Though cost-effective drugs were chosen in 50% of cases, in more than 20% of cases expensive drugs were started. The study highlights the need for an antibiotic audit and suggests the necessity of having an ongoing peer audit.

Audit of antibiotic usage in medium-sized general hospital over an 11-year period. The impact of antibiotic policies

The objective of the present study was to evaluate trends in antibiotic expenditure over an 11-year period (1982-1992) in a 370-bed district general hospital in Northern Ireland and to examine the impact of two separate antibiotic policies on antibiotic usage. A further objective was to examine the attitudes of prescribers to the second policy. Drug utilization review was used to collect information on antibiotic expenditure and usage before and after introduction of separate antibiotic policies in 1985 (not intensively monitored) and 1989 (intensively monitored). A main questionnaire was used to determine the attitudes of prescribers. The first policy (1985) showed no benefits with regard to the number of antibiotic entities stocked (45 before, 45 after), number of dosage units issued (9.3% increase) or expenditure (33.3% increase). The 1989 policy led to significant reductions in the number of antibiotic entities stocked (28.9%), number of antibiotics issued (11.9%) and expenditure (6.1%). Expenditure began to spiral upwards when active monitoring of the second policy was suspended. The majority of prescribers (87.2%) who responded to the questionnaire (56.5% response rate) felt that the 1989 policy made a positive contribution to antibiotic usage in the hospital.

Effect of including recommendations for antimicrobial therapy in microbiology laboratory reports

Innovative approaches are needed to improve cost-effective antibiotic use in hospitals. We established an algorithm to provide a recommendation for both a single oral and a single parenteral antimicrobic, including dosage, to be placed in the bacteriology laboratory report for therapy guidance of 174 episodes of lower respiratory infection in a group of "program" patients with no evidence of infection at other sites. The initial recommendation was based on the Gram-stained direct smear of secretions. The recommendation was updated when preliminary culture results were available, and again with final identification and susceptibility data. We compared the severity of illness, length of stay, and cost of therapy for 68 episodes in program patients who received the recommended therapy with 111 episodes in a control group of patients who received antimicrobial therapy but for whom no recommendations were reported. There was a significantly greater use of the recommendations for sicker patients. Antimicrobial therapy, in general, was more often used for the program patients than for the controls. There was no difference in length of stay or therapy cost. We recommend that this approach be used in settings where there is more problematic use of antimicrobics.

A decade of antibiotic use in a teaching hospital

A survey of the antibiotic agents that are being prescribed for inpatients in St Vincent's Hospital, Melbourne, has been carried out annually since 1976. This article describes the patterns of prescribing that were observed between 1976 and 1986 with special emphasis on the results since 1980, which was the year before the adoption of the hospital's antibiotic policy. The proportion of hospital inpatients who received antibiotic therapy as determined by prevalence studies varied from 25%-36%. Since the introduction of the antibiotic policy, 61%-70% of antibiotic courses were administered for the treatment of infection and 30%-39% of the courses were administered as prophylaxis. Amoxycillin and ampicillin were prescribed most frequently, followed by the cephalosporin agents and the other penicillins. In the area of the empirical treatment of infection, compliance with the hospital antibiotic policy improved and reached 76% of courses in 1986. In the area of prophylaxis, compliance improved a little and stood at 21% of courses in 1986.

Regional variation in the use of antibiotics in four Danish hospitals

The increasing use of antibiotics contributes to the selection of resistant bacteria and to the cost of health care. Large regional differences in the use of antibiotics between and within countries exist. This study describes such usage in four Danish hospitals, and includes a comparison with that of the average of 450 US hospitals. Compared to the Danish hospitals, the US hospitals used approximately double the amount of antibiotics in defined daily dosages (DDD)/100 bed days. In contrast to the comparison with the American hospitals no real differences were found comparing the four Danish hospitals. The four Danish hospitals differed in degree of specialization, presence of a clinical microbiological department or a hospital pharmacy. Use of antibiotics, in DDD/100 bed days, was highest in the hospital without a department of clinical microbiology, while the highest cost of antibiotics/admission was found in the hospital with the highest degree of specialization. Restraint in antibiotic usage calls for the joint efforts of the department of clinical microbiology, the hospital pharmacy and the local drug committee - the most important tools being: continuous education, audits of antibiotic use, provision of guidelines and recommendations, facilities for rapid diagnosis of infectious diseases, and limitation of the number of antibiotics used in routine sensitivity testing.

Changing antibiotic prescribing by educational marketing

A controlled cross-over study in 12 Victorian public hospitals was performed to examine the power of marketing techniques in influencing prescribing. The targeted prescribing behaviour was the use of antibiotic prophylaxis in surgery, and the criteria for judging the appropriateness of therapy were its duration and timing, as are detailed in the fourth edition of the booklet Antibiotic guidelines. The first intervention was mounted in 1985 in six hospitals (two metropolitan teaching hospitals, one suburban general hospital and three rural hospitals), and six matched hospitals acted as control hospitals. One year later, the intervention was mounted in the six hospitals that previously had been the control hospitals. The interventional campaign consisted of material that was similar to that which is used by the pharmaceutical industry, including an "academic" representative. Its effect was assessed by audits that were performed before and after the first interventional campaign and again, one year later, after the second interventional campaign. The proportion of antibiotic courses that were assessed as satisfactory in terms of duration increased significantly after the first campaign in the hospitals where the intervention was mounted. No significant changes in prescribing occurred in the control hospitals. In the hospitals which were control hospitals in 1985, and in which the intervention occurred in 1986, the proportion of antibiotic courses that were assessed as satisfactory also increased significantly after the interventional campaign. A fall-off in performance occurred during the 12 months after the campaign in the 1985-interventional hospitals. Calculated cost savings more than outweighed the costs of the campaign. We conclude that inappropriate prescribing behaviour in hospitals can be modified successfully by educational marketing techniques.

Educational antibiotic advertising

Antibiotic audits that were conducted within our hospital between 1978 and 1982 showed persisting patterns of inappropriate antibiotic use. A commercial advertising agency was commissioned to plan a campaign to change entrenched prescribing habits. Amoxycillin was chosen as the test drug because previous audits consistently had shown that its intravenous administration was prescribed more frequently than was that of benzylpenicillin in the treatment of primary pneumonia. In addition, amoxycillin given by mouth was prescribed six-hourly rather than eight-hourly in one-third of the patients who were surveyed. A three-month remedial campaign used direct mail (pads and pens), display stands and posters, all of which focused on the booklet Antibiotic guidelines. Educational material was placed wherever staff members congregated. At the end of the campaign, intravenously administered amoxycillin was used in only 8% of 50 patients with primary pneumonia and amoxycillin given by mouth was prescribed six-hourly in only 10% of 99 patients. These changed habits were sustained six months after the campaign but showed some fall-off 18 months after the campaign. The campaign costs of $10,000 were recouped within 12 months by savings on drug costs. It is concluded that educational advertising is an effective means of changing prescribing behaviour in a hospital.