The effect of formulary restriction in the use of antibiotics in an Italian hospital

OBJECTIVE: To compare the expenditure and usage of antibiotics at the San Martino Teaching Hospital, a 2500-bed hospital in Genoa, Italy, before and after the implementation of an antibiotic control program that streamlined the hospital formulary and the creation of a restricted group of antibiotics requiring approval before use. METHODS: Usage and expenditure data for all antibiotics were collected from 1996 to 1998. Antibiotic usage was standardised by defined daily doses (DDDs) per 100/patient-days. Cost data were expressed in Euros. Changes in antibiotic usage was determined by comparing the mean usage during 1996 and 1997, the period before the implementation of the antibiotic control program, to 1998 when the streamlined formulary and restricted group of antibiotics, controlled by the Infectious Disease Team (IDT). were initiated. The Wilcoxon rank sign test was used to determine statistical significance of the changes in overall antibiotic use; a P value of less than 0.05 was considered significant. RESULTS: After the implementation of the antibiotic control program, overall antibiotic usage decreased by 8.5%, 28.00 DDD/100 patient-days during 1996-1997 to 25.62 DDD/100 patient-days during 1998. The control program resulted in overall savings of 342,927 Euros after the first year of implementation. The usage and expenditure in the restricted group of antibiotics decreased by 78.5% and 53.5%, respectively, (P=0.03). Restricting the use of ceftazidime and imipenem accounted for the majority of the decreased usage and savings. In the non-restricted group of antibiotics, usage increased only by 32.6% resulting in a net reduction of 46.3% in all antibiotic use. CONCLUSION: Although antibiotic control programs have been successful in other countries, this represents the first attempt at successful antibiotic control in a large Italian teaching hospital. Streamlining the formulary to control antibiotic choices and the creation of a restriction program using the expertise of infectious disease physicians resulted in significant reductions in the use of and expenditure for antibiotics.     

Antibiotic restriction policies in public hospitals.

We surveyed annual expenditure on antimicrobial agents and the use of antimicrobial restriction policies. Restriction policies were in use in 25 of 27 of the hospitals surveyed. Restrictions on the use of antimicrobials were extended into specialty intensive care or haematology units in only 13 of 20 hospitals which had such units. Antimicrobial restriction policies were, for the most part, similar amongst the hospitals surveyed. Use of restriction policies within specialist units was associated with reduced total hospital antibiotic expenditure per bed per year.     

某三甲医院抗菌药物专项整治活动前后使用情况对比调查

目的了解某三甲医院在实施抗菌药物专项整治活动前后抗菌药物使用情况。方法采用回顾性调查和对比分析的研究方法,对某三甲医院2010—04～2011—03（整治前）与2011—04～2011—12（整治后）抗菌药物总体使用情况进行对比分析。结果抗菌药物缩减为50个品种;整治前后门诊患者抗菌药物使用率分别为16．6％、17．1％,住院患者抗菌药物使用率分别为53．1％、55．2％;抗菌药物使用强度分别为61．2、47．7,Ⅱ类切口手术患者预防用药比例分别为27．8％,30．0％,均低于标准。结论抗菌药物专项整治活动后某院能较好的达到各项指标的要求,遏制了抗菌药物高起点滥用的局面,但是,在研究过程中也发现很多问题有待进一步解决。     

Evaluation of the introduction of an antimicrobial drugs formulary in a general hospital in Slovenia

Objective: To analyse the consumption of antimicrobials in a general hospital prior and after implementation of a drug formulary and the economic evaluation of the implementation.Method: Data were obtained from medical documentation collected over a one-month period for all in-patients in four major hospital departments prior to and after the implementation of a drug formulary. The ATC/DDD methodology was used to analyse consumption of antimicrobials. Patients were grouped in therapeutic groups according to their disease and the clinical and economic outcome of the implemented intervention was estimated. Retrospectively, pharmacoeconomical cost–effectiveness analysis was undertaken from the hospitals point of view.Results: The overall use of antimicrobials after implementation in DDD/100 bed-days increased by 16.8%. However, the drug formulary was successfully implemented in 1999, saving 33.7% DDD/100 bed-days of antimicrobials restricted by the formulary. At the same time, treatment time was shortened by 26.5%, with an overall saving of 35.1% per patient.Conclusions: The importance of a drug formulary for antimicrobials was demonstrated in terms of its clinical and economic outcome. A practical case of co-operation between physicians and clinical pharmacists in such a project was also revealed.     

Application of ATC/DDD methodology to evaluate perioperative antimicrobial prophylaxis

Objective To evaluate quality of perioperative antibiotic prophylaxis (PAP) and to calculate the cost per procedure in a Turkish university hospital. Setting A 352-bed teaching hospital in Denizli, Turkey. Method An prospective audit was performed between July and October 2010. All clean, clean-contaminated and contaminated elective surgical procedures in ten surgical wards were recorded. Antimicrobial use was calculated per procedure using the ATC-DDD system. The appropriateness of antibiotic use for each procedure was evaluated according to international guidelines on PAP. In addition, the cost per procedure was calculated. Results Overall, in 577 of the 625 (92.3%) of the studied procedures, PAP was used. PAP was indicated in 12.5% of the group where it was not used, and not indicated in 7.1% of the group where it was used. Unnecessarily prolonged antimicrobial prophylaxis was observed in 56.9% of the procedures, mean duration was 2.6?±?2.7?days. The most frequently used antimicrobials were cefazolin (117.9 DDD/100-operation) and sulbactam/ampicillin (102.2 DDD/100-operation). The timing of the starting dose was appropriate in 545 procedures (94.5%). In the group that received PAP, only 80 (13.7%) of the procedures were found to be fully appropriate and correct. The density of antimicrobial use per operation was 2.8 DDD. The mean cost of the use of prophylactic antimicrobials ?18.6 per procedure. Conclusion The density of antimicrobial use in PAP was found to be very high in our hospital. Antibiotic overuse extended into the postoperative period.     

The impact of clinical pharmacist and ID intervention in rationalization of antimicrobial use

What is known and objective

There is little research on the impact of implementing and monitoring antimicrobial policy in Saudi hospitals. The purpose of this study is to measure the impact of the clinical pharmacist (CP) and infectious disease consultant (ID) interventions on the use of three antimicrobials (caspofungin, imipenem, meropenem) in hospitalized patients in the King Abdullah Medical City hospital.

Methods

The study was carried out in the King Abdullah Medical City, in Mekkah, Saudi Arabia. The hospital is a tertiary center that provides CCU, CSICU, Cardiac, Hematology, ICU, Medical, Neuroscience, Oncology, and specialized surgery services. The use of three antimicrobials (caspofungin, imipenem, meropenem) was reviewed by the clinical pharmacist for four periods, pre and post implementation of policy. Relevant data were collected in four periods. In the first period, before policy implementation, data were collected retrospectively to be used as baseline status reference, and in the three remaining periods that followed data were collected prospectively, and compared to baseline data, to evaluate the role of clinical pharmacist and ID interventions in optimizing antimicrobial therapy.

Results and discussion

Caspofungin duration of therapy was not affected significantly by the intervention. Statistically significant reduction in antimicrobial therapy duration was observed in imipenem (37%) and meropenem (37%) from baseline, which indicate a better control on antimicrobial use and reduction in antimicrobial resistance.

What is new and conclusion

The impact of the clinical pharmacist and ID interventions, in reducing antimicrobial therapy duration using imipenem and meropenem, is clear from the result presented above. However, lack of restriction and follow up in the antimicrobial policy in case of negative culture makes antimicrobial use uncontrollable in these cases. Establishing good and accepted policy may help reduce consumption and total cost of therapy.     

临床药学信息管理系统对医院抗菌药管理的影响

目的：研究临床药学信息管理系统对医院抗菌药管理的影响。方法：介绍临床药学信息管理系统的主要功能、对医院抗菌药管理的影响、需改进的方面。结果：通过临床药学信息管理系统,能够统计原卫生部菌药专项整治涉及控制的抗菌药指标,包括门急诊和住院患者的抗菌药使用率、住院患者抗菌药使用强度、抗菌药处方点评、微生物送检率、围手术期抗菌药使用率。临床药学信息管理系统实施后,节省抗菌药管理工作人力,抗菌药统计数据全面客观,实行抗菌药管理动态实时监控,促进了抗菌药管理的依从性。该系统也存在不足和需改进的方面。结论：临床药学信息管理系统有效促进了医院抗菌药管理的实施。     

铜陵市医疗机构门诊用药处方合理性调查分析

目的 :了解铜陵市当前合理用药状况 ,促进合理用药水平的提高。方法 :随机抽查铜陵市 9家不同等级医疗机构 2 0 0 3年12月门诊处方 ,运用合理用药国际指标的核心指标进行分析。结果 :平均用药品种数为 1 98,抗菌药物使用率为 4 5 86 % ,注射剂使用率为 2 0 30 % ,基本药物使用率为 82 30 % ,平均处方金额为 6 0 92元 ,口服药和注射剂的平均DDDs为 8 6 3。结论 :采用国际指标评价门诊处方的合理用药具有可操作性和有效性 ,铜陵市合理用药水平较低 ,有待于干预和提高。     

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.     

Use of antimicrobial drugs in adults before and after removal of a restriction policy

The effects on the quantity and quality of antimicrobial drug use of removing an antimicrobial restriction policy are reported. Monthly totals for the number of courses of antimicrobial therapy and expenditures based on grams used were obtained from pharmacy records on adult inpatients for a portion (July-December 1987) of the restriction policy term and for the six months (July-December 1988) immediately after the policy ended. Data were obtained for nine restricted drugs and for three that were never restricted. Retrospective drug-use reviews were conducted for ceftazidime and imipenem-cilastatin. For the restricted agents, the total number of courses of therapy increased by 158% after the restriction policy was removed, and total expenditures increased by 103%. There were no significant changes in the number of courses of therapy or cost for the unrestricted antimicrobials. In the postrestriction period, ceftazidime and imipenem-cilastatin were used more often in patients who were less critically ill. Inappropriate use of imipenem-cilastatin occurred significantly more often after the restrictions were removed. Other factors potentially affecting the use of antimicrobials, such as patient age and the incidence of nosocomial infections, did not differ substantially between the two periods. The removal of an antimicrobial restriction policy resulted in increased use of and higher expenditures for previously restricted agents, as well as an increase in the inappropriate use of at least one agent.     

抗菌药物专项整治前后我院儿科抗菌药物使用情况探究

目的：探讨抗菌药物专项整治前后我院儿科抗菌药物使用情况。方法对我院儿科在2011年8月—2012年7月抗菌药物专项整治前和2012年8月—2013年7月抗菌药物专项整治后抗菌药物使用情况进行分析。结果抗菌药物专项整治后,我院儿科抗菌药物用量从整治前的916385限定日剂量（DDD）降至306952 DDD,销售金额低于抗菌药物专项整治前。结论抗菌药物专项整治后我院儿科抗菌药物应用渐趋合理,抗菌药物的临床应用得到了有效地规范。     

从处方分析探讨“全国抗菌药物临床应用专项整治活动”的必要性

目的:探讨开展"全国抗菌药物临床应用专项整治活动"的必要性。方法:收集上海市9家综合性三级医院2008-2010年含抗菌药物在内的原始电子处方,采用Excel对各项处方数据进行汇总,计算用药频度(DDDs)、年均增长率(CAGR)及抗菌药物使用强度(AUD)等,并进行分析。结果:3年来,9家样本医院抗菌药物处方数及处方金额呈逐年上升趋势,但其在总处方数和总处方金额中所占比例保持稳定。DDDs排序列前10位的药品类别中,第2代头孢菌素类药稳居首位,且DDDs上升的CAGR也最高。DDDs排序列前10位的药品中,属头孢菌素类的有4个,上升最快的是头孢呋辛(片剂),CAGR达17.3%。限制使用类药在抗菌药物中所占比例最高,超过50%;非限制使用类药所占比例次之,并呈逐年下降趋势;特殊使用类药虽然所占比例最小,但3年来呈极明显的逐年上升趋势。样本医院A的住院患者抗菌药物应用率3年来一直在65%以上,5个重点科室的抗菌药物AUD为40.37～198.43DDD/100人/天,与本次专项整治活动的标准均存在不小的差距。结论:虽然近年来临床抗菌药物的应用管理力度加强,但滥用现象仍较普遍,需要加强监控。     

综合干预管理对海盐县医疗机构合理使用抗菌药物的促进作用

目的:对县乡两级医疗机构门急诊使用抗菌药物进行综合干预,促进合理使用。方法:依照《抗菌药物临床应用指导原则》等法规,在各医疗机构实施综合干预措施。调研干预前1个时段、干预后2个时段各医疗机构抗菌药物使用、管理情况,进行对照研究。结果:综合干预管理后,各医疗机构完善了抗菌药物使用管理制度;3个时段门急诊处方抗菌药物不合理例次率,县级医院为14.13%、10.69%、7.25%,乡镇卫生院为23.65%、16.17%、14.38%,差异均有显著统计学意义(P<0.01)。结论:通过对县乡两级医疗机构抗菌药物使用管理的综合干预,降低了门急诊抗菌药物使用率,提高了合理使用率。     

PDCA干预模式在抗菌药物专项整治中的应用

目的探讨PDCA（计划、实行、检查、行动）干预模式在本院实施抗菌药物专项整治活动中的作用。方法将本院2012—07-12（干预前）及2013—01-06（干预后）抗菌药物的应用情况分为PDCA模式前后2种不同的管理方法进行回顾性对比分析。结果门诊患者抗菌药物处方比例由PDCA模式干预前的66．24％下降至干预后的19．20％;住院患者抗菌药物应用率由干预前的71．39％下降至干预后59．90％;治疗性应用抗菌药物的微生物标本送检率由干预前的10．00％上升至于预后31．70％：I类切口手术预防用药〈24h的比例由干预前的20．14％上升至干预后94．10％。结论通过PDCA模式对本院实施抗菌药物专项整治干预后,本院各项抗菌药物应用指标明显改善,说明该方法效果明显。     

Antimicrobial stewardship solutions with a smart innovative tool

BackgroundAntimicrobial consumption has been increasing lately. Hence, effective strategies are required to control antimicrobial use and decrease the development of antimicrobial resistance.ObjectiveTo evaluate the impact of the use of a mobile app on the implementation of antimicrobial stewardship program (ASP) interventions.MethodsThis was a longitudinal study conducted at El-Nile Badrawi Hospital in Cairo, Egypt, on inpatients receiving antimicrobials from January 2018 to December 2019. The study included 2 phases: the preimplementation phase, which included a paper-based ASP developed according to the Centers for Disease Control and Prevention Core Elements of Hospital Antibiotic Stewardship Programs 2014, and the mobile app phase where the MEDIcare Pro mobile app was developed and used in ASP intervention implementation. The study outcomes were antimicrobial consumption and cost, length of hospital and intensive care unit (ICU) stay, 30-day mortality rate and readmission rate, and detection of drug-related problems (DRPs).ResultsThe mobile app statistically significantly decreased antimicrobial consumption from 75.1 defined daily dose (DDD)/100 bed-days in the preimplementation phase to 64.65 DDD/100 bed-days in the mobile app phase, with a total cost savings of E£1,237,476. There was a significant reduction in the length of ICU stay, with a mean difference of 1.63 days between the 2 phases, but no significance was detected regarding length of hospital stay or readmission rate. There was a statistically significant decrease in mortality rate from 1.17% in the preimplementation phase to 0.83% in the mobile app phase (P = 0.02). The frequency of DRPs detected by pharmacists statistically significantly increased from 0.54/100 bed-days in the preimplementation phase to 3.23/100 bed-days in the mobile app phase.ConclusionThe use of a mobile app was found to be effective, applicable, and usable in guiding health professionals on rational antimicrobial use.