1. Antibiotic Prophylaxis for Dilation and Curettage Lindsey Carter, MD, Mentors: Christy Lee, MD and Lauren Demosthenes, MD Department of Obstetrics and Gynecology, Greenville Memorial Hospital Cost Scenarios A: Patient receives 100mg IV doxycycline prior to procedure and 200mg IV after procedure. B: Patient receives a single dose of 200mg oral doxycycline in pre-op prior to moving to OR. Clinical Scenario 32 y/o G3P2002 at 8wks by uncertain last menstrual period presents to the office for an ultrasound for dating. She reports having a positive pregnancy test at home 2 weeks prior. US shows a fetus with crown- rump length of 9mm without a heartbeat. You inform the patient that, unfortunately, this pregnancy is non viable. You counsel the patient on causes and frequency of early pregnancy loss and offer medical, expectant, and surgical management. The patient desires surgical management and you schedule her for a Dilation and Curettage (D&C) the next day. She receives doxycycline for antibiotic prophylaxis and the procedure is uncomplicated. She is discharged later that day in stable condition. Goal The aim of these cases is to outline two different ways a case could be managed, showcasing cost conscious interventions. Discussion Questions What is cost savings of using PO versus IV doxycycline? Is post-procedure dose of doxycycline indicated? What are barriers to universal administration of PO versus IV doxycycline? Charge Scenario A: 100mg IV dose doxycycline: $134 x 3 doses = $402 Scenario B: 100mg PO doxycycline: $23.50 x 2 doses = $47.00 Charges presented here are from hospital billing. They were obtained by looking at patient bills who received both IV and PO doxycycline during Suction D&C Teaching Moment In the two cases, for the exact same procedure, the charge difference is $355.00. Cost difference is approximately $15.00. The residency gynecology service has performed thirteen D&C’s since the start of 2016. One of those patients was allergic to doxycycline and received metronidazole. The remaining patients received a total of 27 doses of 100mg doxycycline, 13 were given IV, 11 PO, and 3 were of unknown route. Additionally, we are often giving 100mg prior and then 200mg after when ACOG recommends in Practice Bulletin #150,Early Pregnancy Loss, a single preoperative dose of doxycycline to prevent infection (Level C). According to the practice bulletin, some experts recommend a single dose of 200mg doxycycline one hour before surgery for infection prevention, although specific benefit for management of early pregnancy loss is unknown. One major barrier to universal administration of PO doxycycline is failure to recognize orders prior to moving the patient back to the operating room. Education to MDs, nurses and anesthesia would be beneficial in making the process of giving the doxycycline PO prior to anesthesia induction more seamless. Acknowledgments ACOG Practice Bulletins #104 and #150 were referenced. Special thanks to my mentors Dr. Christy Lee and Dr. Lauren Demosthenes Conclusion Oral doxycycline is a cost-conscious option for surgical prophylaxis during D&C. Full scope of possible savings at GMH is currently undetermined. New order sets in Epic along with physician and nurse education, will hopefully lead to the more widespread use of oral doxycycline. Intervention Plan Per GMH nursing supervisor, approximately ~20-30 D&C’s are performed each month by GMH physicians. Cost of doxycycline is considerably less when given PO versus IV route and could potentially amount to significant savings. I plan to look back through the last year of data on number of D&C’s performed at GHS to further determine impact of cost savings. I hope to implement a plan to educate staff, including nurses, Ob/Gyn physicians and anesthesia on cost- consciousness of PO doxycycline and reassess data after intervention. Above is a screenshot of D&E order set in Epic with PO doxycycline now selected as default order. PO was previously the default in Soarian as well. It is our hope that Epic will make it easier to see this order earlier in pre-op. Cost presented here is per Sam Carros, Pharmacy Manager at GHS. He reports hospital cost for 100mg PO doxycycline is $1.15 and between $14-$18 for IV depending on manufacturer availability