Department of Microbiology, City Hospital NHS Trust, Dudley Road, Birmingham B18 7QH, UK
Received 17 August 2001; returned 12 November 2001; revised 14 January 2002; accepted 21 January 2002.
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Abstract |
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Introduction |
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Many different strategies have been employed in attempts to achieve this objective. An educational approach can produce marked reductions in antibiotic prescribing but the effect is generally short-lived owing to the rapid turnover of staff in health services.4 A more prolonged effect can be achieved by restricting the availability of selected antibiotics.57 The danger with this approach is that a lack of understanding can lead to conflict between those who designed the policy and those affected by it. Prescribing may also be moved to equally inappropriate, but unrestricted, agents. In one study, where restriction was introduced without any educational component, there was actually an increase in the use of the target antibiotic.8 We therefore de-cided to combine the two strategies in order to get a sustained reduction in antibiotic prescribing but also encourage clinicians to understand why a policy of restriction was being implemented.
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Methods |
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The hospital Drugs and Therapeutics Committee dis-cussed the use of antibiotics following a local survey that showed that 40% of antibiotic prescribing was inappropriate. It was decided that a combination of education and restriction of some agents would be used to improve prescribing.
The local survey indicated that, for a number of reasons, iv ciprofloxacin would be the best agent to pilot the technique. This agent was the only quinolone available for iv and oral use at City Hospital. There was a low level of knowledge about the spectrum of ciprofloxacin and the indications for its use. Expenditure on this drug was 20% of the total antibiotic spend, greater than any other antibiotic, and almost all iv use of ciprofloxacin outside ITU/HDU was inappropriate. Furthermore, the incidence of ciprofloxacin resistance within the hospital was small and we wanted to keep it that way.
In January 1999 a letter concerning antibiotic use was circulated to all clinical directors and then cascaded to all consultant medical staff. Appropriate use of iv and oral ciprofloxacin was outlined and comments invited. At the same time iv ciprofloxacin was withdrawn from ward stock and was only available from the pharmacy.
The full restriction policy was implemented in June 1999. A factsheet containing details of the spectrum, cost and recommended indications for both oral and iv ciprofloxacin was distributed to all doctors working in the hospital. Any clinician wishing to use iv ciprofloxacin was required to discuss the case with a senior microbiologist, at least one of whom was available 24 h a day. Use was never absolutely prohibited but more appropriate alternatives were often suggested.
Data on the total spent on antibacterial drugs for 1998, 1999 and 2000 were gathered from the pharmacy computer. Total usage of iv and oral ciprofloxacin and the number of occupied bed-days for the same period were recorded. Expenditure on ciprofloxacin, and the antibiotics most likely to be prescribed instead, ceftazidime and carbapenems (piperacillin/tazobactam was not on the formulary at City Hospital), was also noted. There was no change in the hospital purchase price for any of these agents during the study period. Data on the amount spent on all iv and oral quinolones were also obtained from the chief pharmacists at three neighbouring hospitals.
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Results |
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Table 1 shows that expenditure on ceftazidime and carbapenems remained essentially the same throughout the study period. More was spent on carbapenems on ITU/HDU during 1999, largely due to an outbreak of multi-resistant Acinetobacter baumanii, but the total fell to previous levels the following year. Use in other departments also dropped in 2000. The amount spent on ceftazidime fell slightly and then rose again but remained largely unchanged overall. The total spend on all antibacterial agents throughout the hospital was £33 159 (6.8%) lower in 2000 than in 1998.
Expenditure on all quinolones did not decrease in the same way in the three neighbouring hospitals contacted (Figure 1). There were large increases at Hospitals A and C, and at Hospital B expenditure remained relatively unchanged.
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Discussion |
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It is likely that both the educational and restrictive components were needed to produce sustained change. Use decreased most significantly following the first components of the programme and there was little extra improvement when restriction was introduced. However, as the effect of any education is often short-lived,4 restriction and justification were used to ensure that old prescribing practices did not recur once staff changed. In this programme the microbiologists were able to use the contact made for authorization as an opportunity to discuss a range of issues regarding antibiotic prescribing. The need for justification every time iv ciprofloxacin was requested served to continually reinforce the policy and its rationale. This is particularly important for junior medical staff who move frequently between hospitals with different antibiotic recommendations.
Although the use of iv ciprofloxacin was easily monitored following implementation of the programme, it was much more difficult to assess whether there were any harmful consequences. We could not study differences in patient outcome or length of treatment as there is no way to define which patients would have received iv ciprofloxacin had it not been for the change in policy. Furthermore, the time period was too short to monitor any effect on antimicrobial resistance.
The effect on expenditure on some uncontrolled antibiotics was recorded in order to assess whether prescribing had moved rather than decreased. The total cost for all antibacterial agents fell by £33 159 in the year following implementation, which was less than the saving made from reduced use of iv ciprofloxacin. It is likely that other antibiotics were used to replace ciprofloxacin to a certain extent but it is not possible to say whether there was an actual reduction in antibacterial use. Expenditure on the iv antibiotics most used as an alternative to ciprofloxacin, namely ceftazidime and carbapenems, increased slightly during the study period. There was a greater use of carbapenems on ITU/HDU in 1999 when there was a troublesome outbreak of multi-resistant A. baumanii. Use returned to below pre-outbreak levels once the outbreak was under control. It appears that ceftazidime may have been prescribed more to avoid the need for justification and microbiologists approval.
There were two noteworthy changes in the way in which ciprofloxacin was used. First, the increase in oral ciprofloxacin use was five times greater than the simultaneous fall in iv prescription. Therefore, although a financial saving was made, the overall quinolone antibiotic pressure was greater. Secondly, prescription of iv ciprofloxacin outside ITU/HDU virtually ceased. This was largely due to the promotion of the oral form for any patient who was not nil-by-mouth.
The expenditure on all quinolones was also obtained from three neighbouring Trusts in order to determine what was happening to quinolone use where different policies were in operation (Figure 1). At Hospital B unrestricted quinolone use was allowed over the study period and there was little variation in year-to-year use. Hospitals A and C both experienced problems with Clostridium difficile in 1999, which resulted in a greater use of ciprofloxacin and levofloxacin whilst cephalosporins were controlled. It is interesting to note that the incidence of C. difficile-associated diarrhoea did not change at City Hospital during the study period. The fall in quinolone expenditure, only seen at City Hospital, is likely to be due to the education and restriction programme put in place.
The direct costs of implementing the programme were minimal as both microbiology and pharmacy were already providing continuous cover, and factsheet production was the only other expense incurred. Our experience has shown that it is possible to obtain a sustained reduction in the iv use of one antimicrobial agent with a combination of education and restriction. This has been achieved whilst maintaining the support of the clinicians affected.
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Acknowledgements |
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Footnotes |
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References |
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2 . Standing Medical Advisory CommitteeSub-group on antimicrobial resistance. (1998). The Path of Least Resistance. Main Report. Department of Health, London.
3 . Castle, M., Wilfert, C. M., Cate, T. R. & Osterhout, S. (1977). Antibiotic use at Duke University Medical Centre. Journal of the American Medical Association 237, 281922.[Abstract]
4 . John, J. F. & Fishman, N. O. (1997). Pragmatic role of the infectious diseases physician in controlling antimicrobial costs in the hospital. Clinical Infectious Diseases 24, 47185.[ISI][Medline]
5 . Recco, R. A., Gladstone, J. L., Friedman, S. A. & Gerken, E. H. (1979). Antibiotic control in a municipal hospital. Journal of the American Medical Association 241, 22836.[Abstract]
6 . Bamberger, D. M. & Dahl, S. L. (1992). Impact of voluntary vs enforced compliance of third-generation cephalosporin use in a teaching hospital. Archives of Internal Medicine 152, 5547.[Abstract]
7 . McGowan, J. E. & Finland, M. (1974). Usage of antibiotics in a general hospital: effect of requiring justification. Journal of Infectious Diseases 130, 1658.[ISI][Medline]
8 . DeVito, J. M. & John, J. F. (1985). Effect of formulary restriction of cefotaxime usage. Archives of Internal Medicine 145, 10536.[Abstract]