Results of an antimicrobial control program at a university hospital.

PURPOSE: The results of the first five years of an ongoing antimicrobial control program are reported. METHODS: In 1998, a multidisciplinary antimicrobial subcommittee of the pharmacy and therapeutics committee of a university hospital was formed and charged with making formulary interventions in an effort to reduce rising antimicrobial resistance rates and drug expenditures. In 1999, a number of measures were implemented for controlling antimicrobial use. Selected antimicrobials with the potential for inappropriate use or whose inappropriate use had been documented were placed in the control of physicians in the infectious diseases (ID) division. Prior approval by an ID physician was required before the pharmacy could dispense these agents. Other key interventions included removal of ceftazidime and cefotaxime from the formulary, restriction of vancomycin and carbapenem use, and replacement of ciprofloxacin with levofloxacin as the sole fluoroquinolone on the formulary. Data regarding antimicrobial use and expenditures between 1998 and 2002 were compared and analyzed. RESULTS: Antimicrobial use was reduced by 80% for third-generation cephalosporins and 15% for vancomycin following the implementation of the new antimicrobial policies. Antimicrobial-resistance patterns for many important gram-negative pathogens, including Pseudomonas aeruginosa, demonstrated a reversal of previous increases. In addition, the rate of methicillin-resistant Staphylococcus aureus decreased by an average of 3% each year from 1999 to 2002. Pharmacy expenditures for all antimicrobials, including antiviral, antifungal, and antibacterial agents, decreased 24.7%, with a cumulative cost saving of 1,401,126 US dollars, without inflation assumptions. CONCLUSION: The implementation of an antimicrobial control program decreased the use of selected antimicrobial agents and resulted in substantial reduction of expenditures for antimicrobials.     

Controlling cephalosporin and aminoglycoside costs through pharmacy and therapeutics committee restrictions

The cost-reducing effect of antibiotic restrictions imposed by a pharmacy and therapeutics (P & T) committee was evaluated. The pharmacy department developed guidelines restricting the use of second-generation cephalosporins and aminoglycosides in cooperation with the infectious disease division. The P & T committee approved the restrictions, and the pharmacy department disseminated information on the program to the hospital's physicians. Specific indications were developed for the use of amikacin, tobramycin, cefoxitin, and cefamandole. In order to prescribe a restricted antibiotic, physicians are required to write an approved indication on the physician's order form. Residents cannot prescribe restricted antibiotics for unapproved indications unless they acquire the signature of an attending physician. Pharmacy personnel closely monitor the restricted antibiotic use and enforce the established guidelines. The major impact of the restrictions was the reversal of a previous trend toward the use of more expensive second-generation cephalosporins and tobramycin to the use of first-generation cephalosporins and gentamicin. Injectable antibiotic expenses decreased by $193,172 in the first 12 months of the program. Antibiotic restrictions imposed by the P & T committee were effective in reducing the cost of antimicrobial therapy.     

某医院抗菌药物临床应用分析

目的从药物经济学角度分析医院抗菌药物的使用情况,为抗菌药物的合理应用和管理提供依据。方法对湖北仙桃市第一人民医院2012年使用的抗菌药物,从品名、规格、剂型、销售数量、销售金额、用药频度（DDDs）、日均费用（DDDc）进行统计、分析。结果该院使用的抗菌药物有92种,消耗金额占用药总金额的31.7%,用药频度排名前三位分别是头孢菌素类、大环内酯类和抗结核类。用药频度前十位的抗菌药物中,销售金额与用药频度同步性较好的占50%。价格〈10元·g-1的抗菌药品消耗金额比例最高,占全部抗菌药品的36.5%。结论该院抗菌药物兼顾了高、中、低3个价格层次,低价格层次抗菌药物种类居多,分布和使用较合理,基本上体现了经济适用的原则。     

Antibiotic restriction in hospitals associated with medical schools

Restriction of antibiotic use in 112 hospitals that are primary teaching facilities for medical schools was studied by mail questionnaire to pharmacy directors and infectious disease physicians. Questions involved whether use of certain antipseudomonal penicillins, aminoglycosides, and second- and third-generation cephalosporins was restricted, reasons for restrictions, existence of a formal education program on new antibiotics, whether the physician respondents agreed with the practice of antibiotic restriction, what percent of requests for use of restricted agents was denied, formulary status of the drugs, the procedure for authorizing dispensing of restricted agents, and the percent of drug expenditures represented by restricted agents. Direct control (specialist authorization or restricted indications for use) was used in 62 (57%) of 108 institutions responding. Nonformulary status indirectly controlled use in 35 institutions. No significant differences in the prevalence of restrictions were found for hospital size, ownership, physician's view of the restrictions, or presence of an education program. Most (85%) of the physicians agreed with restriction practices. Cost was the reason given most frequently for restriction of the penicillins and cephalosporins, while aminoglycosides were most frequently restricted because of bacterial resistance. The specialist's oral authorization was the most common method of approval for use of restricted agents. Expenditures for restricted drugs varied widely, suggesting that different levels of control were considered "restriction" by the responding institutions. Control of antibiotic use is common in these teaching hospitals associated with medical schools. No best method for antibiotic restriction was evident.     

药师主导的抗菌药物管理项目对新生儿ICU抗菌药物使用合理性的影响

目的：总结某院新生儿ICU（NICU）实施抗菌药物管理项目的经验与成效。方法：基于国际上施行的抗菌药物管理项目（antimicrobial stewardship program，ASP）策略目标，在某三级综合医院NICU病房实施综合干预措施，包括教育、医嘱点评和反馈、咨询和多学科病例讨论等。并对干预前和干预后的患者抗菌药物使用比例、抗菌药物使用天数、治疗失败率等相关指标进行评价。结果：采取干预措施后，特殊使用级抗菌药物病原学检查比例明显升高（83.55%vs 100%，P<0.001），使用万古霉素血药浓度监测率明显升高（23.08% vs 90.91%，P<0.001）；抗菌药物治疗天数（每千人日）较前下降3.54%，特殊使用级抗菌药物治疗天数（每千人日）较前下降31.05%。结论：药师主导的抗菌药物管理项目，提高了NICU抗菌药物合理使用水平。但还存在一些问题，包括干预过程信息化程度不高，缺乏对药物使用经济性的干预以及对患者预后和科室细菌耐药性长期影响的评估。     

Antibiotic surveillance: the results of a clinical pharmacy intervention program

One of the major goals of any medical center is to provide safe, cost-effective drug therapy. To ensure rational antimicrobial therapy and control hospital drug costs, a criteria-based antibiotic surveillance program was developed. This method of antibiotic restriction provided exceptional cost savings in our institution. Clinical pharmacy interventions resulted in physician education and an 18% increase in compliance with the program criteria producing in a one-year period a $43,000 cost avoidance for antibiotic expenditures.     

Clinical services provided by staff pharmacists in a community hospital

A program for developing staff pharmacists' clinical skills and documenting pharmacists' clinical interventions in a large community teaching hospital is described. A coordinator hired in 1984 to develop clinical pharmacy services began a didactic and experiential program for baccalaureate-level staff pharmacists. Fourteen educational modules are supplemented by journal and textbook articles and small-group discussions of clinical cases, and the clinical coordinator provides individual training on the patient-care units for each pharmacist. Monitoring of clinical pharmacy services began in June 1987; each intervention provided by a pharmacist is recorded on a specially designed form. A target-drug program is used to document cost avoidance achieved through clinical services. Information collected through these monitoring activities is used to educate the pharmacy staff, shared with the pharmacy and therapeutics committee, and used to monitor prescribing patterns of individual physicians. The data are used in the hospital's productivity-monitoring system. All pharmacists who were on staff in 1984 have completed the educational modules, and all new employees are in the process. Since monitoring began, the number of clinical interventions has averaged 2098 per month. Cost avoidance has averaged $9306 per month. Over a five-year period, the development of staff pharmacists' clinical services raised the level of professional practice, produced substantial cost avoidance, and increased the number of pharmacist interventions in medication use.     

我院临床药学工作现状与展望

介绍本院临床药学工作开展情况和展望。从临床药师查房、药品不良反应（事件）监测工作、药物咨询和合理用药宣传、抗菌药物合理使用监控、参与医院临床会诊、带教工作等方面,叙述了临床药学具体的工作内容。进一步开展上市药物的再评价、临床药学科研、临床中药师的培养工作。本院临床药学已经有了较好的开端,但是还要进一步努力。临床药学工作应该进一步与临床紧密结合,促进临床合理用药。     

Controversies in antimicrobial therapy: formulary decisions on third-generation cephalosporins

Factors affecting the admission of antimicrobial agents to hospital formularies are discussed, using third-generation cephalosporins as examples. Inappropriate antimicrobial therapy is costly in terms of wasted drugs, ineffective therapy, and drug toxicity. In 1984, 10 of the top 15 drug products (in sales to hospitals) were antimicrobial agents; these accounted for $1 billion in sales. Since third-generation cephalosporins are very similar in terms of spectra, clinical efficacy, and safety, they are useful in illustrating the process a hospital might use in deciding which individual agent to admit to a formulary. Five factors should be considered in formulary evaluations of antimicrobial agents: in vitro activity, pharmacokinetic disposition, adverse effects, clinical efficacy, and total economic impact. As applied to third-generation cephalosporins, this decision analysis leads to the conclusion that these agents should be considered therapeutic alternates. The decision would then rest solely on the institution-specific factors of microbial susceptibility patterns, patient case-mix, and acquisition costs. Antimicrobial agents account for the largest financial expenditure among hospital drug products; a set of these agents should be selected carefully to meet the needs of the individual institution.     

我院呼吸内科抗菌药物使用情况调查分析

目的分析我院呼吸内科抗菌药物使用情况,为临床合理用药提供依据。方法随机抽取2010年10月～2011年9月的呼吸内科出院病历360份,进行回顾性分析,调查抗菌药物使用情况,包括抗菌药物的种类、剂量、疗程、联合用药情况、药敏试验等。结果其中316例患者使用了抗菌药物,占调查病历的87.78%;共涉及13类45种,主要为喹诺酮类、头孢菌素类与β-内酰胺酶抑制剂配伍的复方制剂、头孢菌素类;使用频率排名前3的为左氧氟沙星、头孢哌酮钠-他唑巴坦、阿奇霉素;其中,二联用药居多（占71.52%）;不合理用药有28例（占8.86%）,主要为联合用药不适宜（占56.25%）。结论我院呼吸内科抗菌药物使用基本合理,基本符合安全有效的原则,但仍有一些不合理用药现象。     

Pharmacy-based antimicrobial-monitoring service.

A pharmacy-based antimicrobial-monitoring service at a university teaching hospital is described. The service was developed and implemented by the pharmacy department in 1987. Antimicrobial drugs that can be misused, that are expensive, or for which bacterial resistance is a concern were targeted. When a pharmacist receives an order for a targeted antimicrobial, an antimicrobial-monitoring card is completed. Monitored drugs meeting approved criteria are dispensed as ordered. When the antimicrobial does not meet the criteria, the pharmacist contacts the physician and suggests an alternative. If the alternative is not accepted, the infectious diseases service is contacted and then informs the pharmacy department about the status of the drug. The agent is dispensed if no response is received within two hours. Qualified staff pharmacists rotate through the position of antimicrobial pharmacist, whose responsibilities include reviewing antimicrobial use throughout the hospital, checking relevant laboratory test results, and recommending adjustments to regimens. From July 1989 to June 1990, 3546 orders for monitored antimicrobials were reviewed; of these, 86% met the criteria, 9% did not meet the criteria but were approved, 2% were for drugs that were replaced by alternative therapies, 1% were for agents that were dispensed because the pharmacist was not contacted, and 2% represented medical staff overrides or drugs dispensed inappropriately. Pharmacist and physician compliance with the monitoring policy has been high. A positive, constructive, and educational relationship exists between pharmacists and physicians vis-à-vis the service. A pharmacy-based antimicrobial-monitoring service has been accepted by pharmacists and physicians and appears to be having a positive impact on prescribing habits.     

Culture and antibiotic monitoring service in a community hospital

A culture-antibiotic monitoring service (CAMS) established by the pharmacy in a 254-bed community hospital is described. CAMS was offered as a clinical pharmacy consultation service to reduce the delay between availability of culture-report results in the laboratory and evaluation of these results by the physician. The pharmacist reviews culture results in conjunction with the patient's antibiotic therapy and clinical condition and contacts the physician regarding changes in therapy according to predetermined criteria. The pharmacist is also able to promote appropriate antibiotic prescribing and generate cost savings through interactions with physicians facilitated by CAMS. More than 98% of physicians agreed to participate in CAMS. During a one-year period, physicians implemented 87.1% of pharmacist-recommended changes in antibiotic therapy in 202 patients. The projected cost savings through a reduction in inappropriate prescribing of ceftazidime alone during a 10-month period enabled the pharmacy to easily justify hiring an additional clinical pharmacist. The culture-antibiotic monitoring service has enabled the pharmacy department to foster appropriate use of antibiotics and to realize substantial cost savings.     

Changing use patterns of plasma volume expanders through educational intervention

Use patterns of the plasma volume expanders albumin and hetastarch were evaluated before and after an educational program promoting the preferential use of hetastarch was implemented in a 700-bed teaching hospital. The high acquisition cost and periodic shortages of 5% albumin injection prompted the implementation in March 1985 of a target drug program that would encourage the use of 6% hetastarch injection in place of albumin whenever possible. Purchases of albumin and hetastarch were monitored from August 1984 to March 1985 and again from April to November 1985 to determine how much and where these agents were being used. Criteria and guidelines for the use of plasma volume expanders were developed by the pharmacy with physician input. Senior attending physicians who had been identified as primary decision makers in the clinical use of albumin were asked to abide by the guidelines; also, pharmacists conducted inservice educational programs on the use of hetastarch. Patterns of albumin and hetastarch use changed significantly (p less than 0.05) after the educational program was implemented. From August 1984 to March 1985, the mean number of units of albumin and hetastarch purchased monthly were 325.5 and 0.4, respectively. These numbers changed to 195.3 and 163.1 units, respectively, from April to November 1985. The monthly cost avoidance associated with this change was $5127, which extrapolates to $61,526 annually. An educational program can be effective in controlling hospital expenditures for plasma volume expanders. However, clinicians should be aware of the potential adverse effects of hetastarch and should avoid using it in excessive amounts or in patients with underlying coagulopathies.     

1 780例出院病人抗菌药物应用现状调查

目的:了解某医院抗菌药物使用现状和存在问题。方法:对某院2006年1月份的1780份出院病例进行回顾性调查。对抗菌药物使用率、用药密度,用药种类及构成比,用药时间及联用情况、细菌培养及药敏试验等进行分析。结果:1780例出院患者中,有1379例使用了抗菌药物,抗菌药物使用率为77.47%,其中预防用药占47.50%;只用一种抗菌药物的有234例,占16.97%;使用较多的抗菌药物依次为第3代头孢菌素类(包括抑酶剂联合制剂),氟喹诺酮类,青霉素类(包括抑酶剂联合制剂),硝基咪唑类和大环内酯类;52.57%的患者用药时间<7d;27.41%的患者用药时间>14d;进行药敏试验者仅占全部用药人数的7.11%。结论:住院病人抗菌药物使用中存在使用率高、用药起点高、用药时间长、联用品种多及预防用药比例偏高,细菌培养和药敏试验率低等不合理用药现象。     

住院患者抗菌药物临床使用情况监测调查分析

目的了解2010年第一季度我院住院患者抗菌药物临床使用情况,为临床合理用药提供参考。方法调查监测当日在院全部患者的抗菌药物使用率;按25%比例随机抽取各科室住院患者的医嘱信息及电子病历,对抗菌药物使用的各项数据进行综合分析;针对抽样科室监测结果分析住院患者抗菌药物的使用情况。结果我院抗菌药物总使用率为60.88%;抗菌药物使用以单一用药为主,占47.57%;联合用药主要集中在二联,占32.04%;全院进行病原菌检查及药敏试验比率较低,仅为27.18%。抽样科室使用的抗菌药物以β-内酰胺类为主,其中头孢菌素使用频次最高;限制使用品种使用过多,使用频次过高,以移植科使用抗菌药物所占比率最高,为19.50%;病原菌检查及药敏试验率低。结论我院抗菌药物总体使用率偏高,存在不合理使用现象,须加强抗菌药物的使用管理与监测。     

Development of Antimicrobial Competencies and Training for Staff Hospital Pharmacists

Antimicrobial stewardship is an important component in health care outcomes of all patients. Many institutions are seeking the best methods to incorporate antimicrobial stewardship strategies into their hospitals including pharmacy services. Multiple factors should be considered when beginning or expanding an antimicrobial stewardship program. The purpose of this article is to discuss the development of basic antibiotic competencies and training for staff pharmacists in a community hospital. The article includes an assessment of pharmacists’ knowledge pre education and post education, perception of benefits from an antibiotic education program, and learning needs and preferences.     

Integration of clinical and administrative strategies to reduce expenditures for antimicrobial agents

A comprehensive program of clinical and administrative strategies to reduce expenditures for antimicrobial agents is described. Clinical intervention strategies include the use of antimicrobial order sheets, standardized dosage regimens, restriction policies for certain antimicrobial agents, and position statements on the use of restricted agents. A cornerstone of the program is the support for cost-reduction interventions offered by the pharmacy and therapeutics committee and its subcommittee on therapeutics; that support is demonstrated through endorsement and enforcement of pharmacy programs. Physicians are reminded of the cost-reduction programs through periodic articles in the pharmacy newsletter and an "antibiogram" card supplied by the division of epidemiology. The effectiveness of these interventions has been demonstrated by progressive decreases in expenditures for antimicrobial agents during 1987 and 1988. Antimicrobial agents also account for increasingly smaller percentages of the total drug budget. This combination of clinical and administrative strategies reduced expenditures for antimicrobial agents by more than $700,000 over two years without the use of clinical specialists or any apparent sacrifice in the quality of patient care.     

2008-2011年息烽县人民医院抗菌药物应用分析

目的：了解我院抗菌药物临床应用情况,为临床合理选用抗茵药物提供参考和用药信息。方法：采用回顾性分析方法,提取医院药品信息管理系统中2008年1月-2011年12月门诊药房和住院药房抗菌药物原始处方数据、用量与销售金额,并从医院病案室提取各年住院患者数和平均住院天数。利用Excel2003对我院2008-2011年抗茵药物的用量、销售金额、用药频度（DDDs）、限定日费用（DDC）、抗菌药物使用强度（AUD）、药物利用指数（DUI）等进行统计、分析。结果：我院门诊抗茵药物销售金额占药品总销售金额比例维持在6％以下,较住院药房抗茵药物销售金额占药品总销售金额比例低,且抗菌药物处方量占门诊总处方量比例呈逐年下降趋势。门诊患者注射用头孢菌素类药销售金额呈现较高的增长趋势,其中注射用头孢唑肟增幅最大,年均增长率（CAGR）达728．33％;口服制剂以硝基咪唑类药奥硝唑片增幅最大,CAGR达257．67％;罗红霉素胶囊与阿莫西林胶囊的DDDs排序居前列。DDC排序居前3位的抗菌药物则为注射用关洛西袜／舒巴坦钠、注射用阿洛西林和注射用头孢硫脒。而住院药房抗菌药物销售金额占药品总销售金额比例由2008年的30．30％降至2011年的13．89％,下降近2倍,且抗茵药物处方量占总处方量比例呈逐年下降,抗菌药物使用强度（AUD）由2008年的75．11DDD降至2011年的54．42DDD。住院药房注射用头孢菌素类销售金额占主导,其中注射用头孢硫脒增幅最大,CAGR达317．76％;第3代头孢菌素类注射用头孢噻肟和注射用头孢曲松DDDs排序居前列;第2代头孢菌素注射用头孢孟多DDC排序居首位。结论：我院抗菌药物应用须进一步规范,严格执行抗菌药物分级管理制度,确保患者得到有效治疗。     

我院呼吸内科抗菌药物使用调查分析

目的：了解医院呼吸内科抗菌药物使用情况。方法：抽取2011年6月～11月出院患者病历100份,统计分析抗菌药物使用情况。结果：抗菌药物使用率92.00%,其中单用36.95%,联合用药63.05%,更换使用29.35%,共涉及8类16种,使用频率最高的是头孢菌素类,使用疗程3～29d。结论：我院呼吸内科的抗菌药物使用存在一些问题,需进一步提高合理用药水平。     

Comprehensive therapeutic interchange program in a community hospital

The implementation of a comprehensive therapeutic interchange program is described. The need to reduce the number of telephone calls to physicians about nonformulary drug orders, reduce drug costs, and maximize the effectiveness of drug therapy prompted the development of an automatic therapeutic interchange program at a 273-bed nonteaching community hospital. Pharmacists and physicians agreed that a telephone call to discuss every nonformulary drug order was unnecessary. The pharmacy department presented the automatic interchange program to the pharmacy and therapeutics committee. The program was reviewed by the committee, the hospital attorney, and medical staff members and was instituted in 1986 for drug products, such as vitamins and antacids, for which interchanges are noncontroversial. A newsletter describing the program was distributed, and inservice education sessions were held. A reminder was placed on order forms that an interchange for nonformulary drugs would be made unless the nonformulary agent was deemed "medically necessary" by the physician. In such cases, the physician is contacted to discuss the therapeutic alternative. As acceptance of the program and cost efficiencies were demonstrated, more controversial agents were phased in during subsequent years. It was difficult to obtain approval to add some agents, such as third-generation cephalosporins, to the program, but noncompliance and confusion have been minimal. An automatic therapeutic interchange program has worked well at this institution since 1986.