1. QUINOLONE RESTRICTION AT MARLBOROUGH HOSPITAL

2. Vibha Sharma, M.D. Infectious disease consultant and Medical director, infection control, Marlborough hospital Zsusun Timothy Yang, Rph Pharmacy director Marlborough hospital.

3. Why the concern with Quinolones From 2003 to 2006, C. difficile infections are observed to be more frequent, more severe, more refractory to standard therapy, and more likely to relapse than previously described.

4. Some cases have been attributed to a new strain designated BI, NAP1 or ribotype 027. Some cases have been attributed to a new strain designated BI, NAP1 or ribotype 027. Fluoroquinolone use has strongly correlated with the emergence of this strain. Fluoroquinolone use has strongly correlated with the emergence of this strain. Antibiotic use is the most widely recognized and modifiable risk factor for C. difficile-associated diarrhea (CDAD) Antibiotic use is the most widely recognized and modifiable risk factor for C. difficile-associated diarrhea (CDAD) The use of broad-spectrum antimicrobials, use of multiple antibiotic agents, and increased duration of antibiotic therapy all contribute to the incidence of CDAD The use of broad-spectrum antimicrobials, use of multiple antibiotic agents, and increased duration of antibiotic therapy all contribute to the incidence of CDAD

5. PREVIOUS USAGE OF QUINOLONES AT MARLBOROUGH HOSPITAL Moxifloxacin formulary quinolone (FQ). Moxifloxacin formulary quinolone (FQ). No renal dosing (400 mg po/iv daily). Does not cover UTI. Ciprofloxacin reserved for these patients.

6. QUINOLONE RESTRICTIONS As of 12/1/10 FQ restriction to ID. As of 12/1/10 FQ restriction to ID. 24 hour supply allowed. 24 hour supply allowed. Pharmacy contacts via communication sheet/paging MD. Pharmacy contacts via communication sheet/paging MD. ID contacted via email. ID contacted via email. Further supply restricted to ID approval. Further supply restricted to ID approval.

7. COMMUNICATION SHEET USED Communication Sheet From: Pharmacy To: Flouroquinolone restriction Dear doctor A flouroquinolone has been ordered for this patient. Due to the increasing rate of resistant bacteria and C. diff colitis, flouroquinolones are now restricted (exception-CAP with PCN allergy). This antibiotic will be discontinued in 24 hours from the time of the order. Continuation of flouroquinolones requires ID approval. (Dr. Sharma) Restricted antibiotic ordered: Pharmacist Signature: Response:Message: MD Signature:

8. SYSTEMUSED SENTRI 7 REPORTING MEDITECH DRUG SEARCH REPORTING PROS Easy to run reports. Data obtained quickly. Trends can be noted. More types of data collected. Tracks both scheduled and one time doses. CONS User dependent. One dose not tracked. Data obtained superficial. Cannot obtain retrospective data. Time consuming. Manual data and trend tracking. Duration of reported prescription may not reflect actual length of therapy.

9. SENTRI 7 DATA FOR QUINOLONE USAGE Month Sept 10 Oct 10 Nov 10 Dec 10 Jan 11 Feb 11 # rule matches 5114821

10. SENTRI 7 QUINOLONE DATA Only captures rule hits with Meditech profiling. Only captures rule hits with Meditech profiling. Does not capture ED 1 dose removals (ie overides). Does not capture ED 1 dose removals (ie overides).

11. MEDITECH DATA FOR QUINOLONE USAGE Definitions # RX- # of orders entered in Meditech system (1 patient with 1 renewal order and dosing/route changes can have 2 RX) # RX- # of orders entered in Meditech system (1 patient with 1 renewal order and dosing/route changes can have 2 RX) # Pts- # patients listed in reporting # Pts- # patients listed in reporting # RX > 24 hours- RX with start and stop times > 24 hours entered # RX > 24 hours- RX with start and stop times > 24 hours entered From 12/10 on- checked individual patients with > 24 hours to validate if patient received > 1 day dosing. Assumption made that all patients prior to 12/10 had >24 hour therapy for #RX > 24 hours. ** All Quinolone data aggregated. ** All Quinolone data aggregated.

12. MEDITECH DATA FOR QUINOLONE USAGE CONT. 8/109/1010/1011/1012/101/112/11 3/1 to 3/16 2011 #rx1368910010759494620 #pts8461747848373214 #RX >24 hr 473333294261 Pt > 24 h 473333292231

13. Actual patients receiving > 24 hr Quinolone therapy

14. QUINOLONE TRENDS AUG 09 TO 2/11

15. CHARACTERISTICS FOR PTS > 24 HRS USAGE (12/10- ) 1- 60 yo male with SIRS/Gastroenteritis 2- 39 yo female with PNA 3- 85 yo female with PNA (Documented PCN allergy) 4- 83 yo female with UTI (Documented PCN allergy) 5- 53 yo female with diverticulitis 6- 63 yo female with COPD- (PCN= hives) 7- 68 yo male with HA/SOB- dc home in 24 hours 8- 71 yo male COPD

16. SENTRI 7 DATA FOR ABX USAGE Month9/1010/1011/1012/101/112/11 # RULE MATCH ES 771948448823

17. MEDITECH REPORTING Monthly analysis for August to March 1-16 th for time frame of 8/09 to 3/16/11 Monthly analysis for August to March 1-16 th for time frame of 8/09 to 3/16/11 Antibiotics used for analysis: Ertapenum (E), Vancomycin (V), Ceftriaxone (CF), Levofloxacin, Ciprofloxacin, and Moxifloxacin Antibiotics used for analysis: Ertapenum (E), Vancomycin (V), Ceftriaxone (CF), Levofloxacin, Ciprofloxacin, and Moxifloxacin Levofloxacin, Ciprofloxacin, and Moxifloxacin data aggregated (FQ) Levofloxacin, Ciprofloxacin, and Moxifloxacin data aggregated (FQ) #RX and # PT collected. #RX and # PT collected.

18. #RX ABX SPREAD Quinolone most prescribed antibiotic in Feb 2010. Ceftriaxone most prescirbed antibiotic overall during winter months.

19. #PTS ABX DATA Decline of patients on quinolones since December 2010. Does not take account if patient switches antibiotic or has multiple drug therapy.

20. % ABX orders comparing the four drugs Ertapenum usage initially high, now consistent. Ceftriaxone use increased with less usage of FQ and vice versa. ? Increase use of Vancomycin after winter months.

22. CONCLUSION ONE TIME DOSES (OVERIDES, SDC PATIENTS) ONE TIME DOSES (OVERIDES, SDC PATIENTS) SIGNIFICANT DROP OF TREATMENT OF QUINOLONES IN HOSPITAL INPATIENT FLOORS. SIGNIFICANT DROP OF TREATMENT OF QUINOLONES IN HOSPITAL INPATIENT FLOORS. TIMELY COMMUNICATION ESSENTIAL TIMELY COMMUNICATION ESSENTIAL INITIAL SELECTION FOR CAP REMAINS 100% INITIAL SELECTION FOR CAP REMAINS 100%