Improving IV antibiotic use; the role of the nurse Lee Stewart Antimicrobials Pharmacist (South Glasgow)

Overview Introduction; the problems The solutions Empiric antibiotic policy Alert antibiotics IVOST Improving IV vancomycin and gentamicin use

Introduction: the problems ~1/3 of inpatients will receive an antibiotic ~1/3 of antibiotics given via the IV route ~40% of the drug budget spent on antibiotics up to 50% of antibiotic therapy is inappropriate Morbidity,mortality & stay Increased costs Development & spread of resistance Healthcare associated infection Threatens medical advances

Empiric antibiotic policy

Restricts the use of the ‘4c’ antibiotics (greatest C difficile risk) Co-amoxiclav Cephalosporins Ciprofloxacin (& other quinolones) Clindamycin

Alert Antibiotics

Alert Antibiotics Examples (see form for full list) Tazocin, ceftriaxone, IV ciprofloxacin, IV clindamycin, meropenem Alert Antibiotics are Broad spectrum Toxic Expensive Valuable agents reserved for specified permitted indications other indications only on the advice of a microbiologist/ID physician

Alert Antibiotic Form Pharmacy can only supply when an Alert Antibiotic Form has been completed fully From pharmacy distribution or StaffNet ( ‘Clinical info’  ‘antimicrobial guidelines’) Completed by medical staff and/or pharmacists Nurses Send the completed form to pharmacy with the first indent requesting the alert antibiotic Re-order the same antibiotic for the same patient by including the patient’s name/unit number on the indent Don’t miss/delay doses; pharmacy will give an ‘emergency supply’ if you can’t get form completed

IVOST

IVOST Guideline IVOST = IV to oral switch therapy IV antibiotic therapy often prolonged unnecessarily in hospital Increased risk of line infection & bacteraemia Increased length of stay Increased expenditure Increased demands on nursing time IVOST guideline developed to enable a switch to oral therapy to be made early and appropriately

Review the need for IV therapy DAILY IVOST Guideline Review the need for IV therapy DAILY Oral route compromised (e.g. vomiting, nil by mouth, severe diarrhoea, swallowing disorder, unconscious) or Deteriorating clinical condition/Continuing sepsis* (*i.e. 2 or more of: temp >38°C or <36°C, heart rate >90bpm, respiratory rate >20/minute, WCC <4 or >12) or Special indication (e.g. meningitis/CNS infection, endocarditis, immunosuppression, bone/joint infection, deep abscess, cystic fibrosis, moderate to severe cellulitis, severe pneumonia) or No oral formulation of the drug available NO? Switch to oral therapy

Nurse involvement with IVOST Prompt for daily review of IV route & alert medical staff to changes in availability of oral route Prompt medical staff to consult microbiology when IV gentamicin is required for >3-4 days

Improving IV vancomycin and gentamicin use

Vancomycin and gentamicin use Narrow therapeutic index agents Nephrotoxic and ototoxic When given IV, monitoring and interpretation of blood levels essential for safe and effective use Consistently in top 10 drugs associated with reported medication incidents

Kardex examples

Getting it right 1 Is the prescription clear? Is the dose reasonable? Dose & frequency (especially if 48 hourly/stat dose) Is the dose reasonable? Shared responsibility (& liability) Gentamicin usually 180-400mg dose (up to 600mg) Vancomycin usually 500-1500mg dose Do you need to speak to the doctor? Levels not being checked Significantly delayed dose (e.g. lost IV access) Prescribed in ‘once only’ section & unsure if ongoing Is it OK to dose after level taken? Signs of toxicity or prolonged gentamicin course?

Getting it right 2 Use the correct recording chart for site and drug See examples given out Record accurate infusion start and stop times Space to record accurate sample times for levels Gentamicin Prescribed as charted on kardex, doses on separate prescribing/administration/monitoring chart Normally infused over 30 minutes Check the level after the initial dose then at least every 2-3 days See information sheet for further details

GENTAMICIN  Initial drug kardex and add time of administration AS PER CHART IV 01/08/12  I Fixem SEE GENTAMICIN PRESCRIBING CHART Initial drug kardex and add time of administration LS 17:08 18

O Reminders to administer promptly and look out for toxicity signs  This is NOT the prescription, just an initial prediction Reminders to administer promptly and look out for toxicity signs 65 68 kg 68 5’ 7’’ 01 08 12 O 320 mg 24 hourly Alice Patient 05 / 06 / 1947 0506471234  Record gentamicin administration times accurately. Doses are prescribed individually here, NOT normally >24 h in advance.  No dose change IF 01/08 17:00 320 mg I Fixem I FIXEM FY1 01/08 17:08 LS AP 02/08 07:34 1.6 02/08 18:00 320 mg I Fixem I FIXEM FY1

Getting it right 3 Vancomycin Some sites have a prescribing chart, others don’t Beware of loading doses prescribed in the ‘once only’ section Intermittent infusion; maximum 500mg/hour Vancomycin continuous infusion; 24 hour dose split into 2 equal 12 hour continuous infusions Levels are required if given IV (not for PO) Check the level within the first 12-48 hours then at least every 2-3 days See information sheet for further details

Further information Posters on wards Therapeutics Handbook Intranet ( ‘Clinical info’  ‘antimicrobial guidelines’) BNF IV monographs Nurse information sheets Local Antimicrobials Pharmacist; for SGH/VI lee.stewart@ggc.scot.nhs.uk Page 6055 Ext 62716 (SGH) or 65533 (VI)

Summary You will see many antibiotic prescriptions Up to 50% of these will be inappropriate Inappropriate use has adverse patient and public health consequences NHSGGC has policies to promote and support prudent antimicrobial use YOU have a key role to play in ensuring that patients receive appropriate, safe and effective antimicrobial therapy