Electronic drug ordering system can be helpful to implement iv–oral switch guidelines

Jan M. Prinsa,*, Jeannine F. J. B. Nellena, Richard P. Koopmansb, Pim N. J. Langendijkc, Patrick M. M. Bossuytd and Peter Speelmana

a Department of Internal Medicine, Division of Infectious Diseases, Tropical Medicine and AIDS, b Department of Clinical Pharmacology, c Hospital Pharmacy, d Department of Clinical Epidemiology, Academic Medical Center, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands

Sir,

Last year we reported that 40% of patients starting on iv antibiotics are candidates for a switch to oral antibiotics after 2–3 days of therapy. An early switch is justified when the patient is improving, oral antibiotics would result in adequate drug levels at the site of infection and the patient is able to take oral medication.1 This strategy can result in substantial savings in costs and nursing time.

An important question is how to identify patients who are candidates for an early switch, and how to effect the iv–oral switch. It is well known that releasing iv–oral switch guidelines alone is not sufficient.2 Therefore, in phase II of our study,1 after switch guidelines had been introduced, a study physician identified the patients fulfilling the criteria by reviewing all patient charts on a daily basis. If applicable, she contacted the attending physicians to remind them of the guidelines.1 In other studies this was done by the hospital pharmacist or specialized audit nurses. However, this is a tedious job, as in our study 674 patients had to be audited to identify 182 patients on iv antibiotics.1 Electronic drug ordering systems might be a more convenient way to streamline antibiotic prescribing behaviour.3,4

In our hospital, an electronic drug ordering system has been introduced gradually during the past years. As a result, all medication, including antibiotics, is registered electronically at the central hospital pharmacy. We determined during a 2 month period (phase III), on wards for internal medicine (52 beds) or surgery (64 beds), whether the central registration of the antibiotic prescriptions could be helpful in the implementation of the switch guidelines. The central computer was programmed to provide, each day, a list of all patients who were on iv antibiotics for more than 48 h, and who were for that reason potential candidates for an iv–oral switch. The consulting infectious diseases physician reviewed these patient charts and contacted the attending physician to investigate whether the patient could indeed be switched to oral therapy. In the TableGo, the three study periods are compared: phase I of our first study, which was an inventorial phase before the introduction of switch guidelines, phase II of the first study, when a study doctor took care of the implementation of the guidelines,1 and the current study, phase III.


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Table. Characteristics of iv antibiotic courses during the first study (I, inventorial phase, II, implementation phase) and current computer-assisted study (III)
 
The mean number of antibiotic courses per patient, the indications for antibiotic therapy (data not shown) and the main reasons precluding iv–oral switch were comparable for the three study periods (TableGo). One exception was the larger number of patients suffering from severe leucopenia during phase III. This was explained by the fact that during phase III the ward for haematology–oncology was audited. An important difference between phases I/II and phase III was that during phase I/II all patients on antibiotics were audited, and during phase III only patients on iv antibiotics for >48 h. Therefore, patients switching from iv to oral antibiotics within 48 h were not identified during phase III. This, and the larger number of neutropenic patients, probably explains why, during phase III, fewer patients (29% as opposed to 42% and 44%, respectively) were candidates for an iv–oral switch.

The most important finding is that the percentage of patients eligible for an early iv–oral switch, who indeed switched to oral therapy, was 71% in phase II, as opposed to 54% before the introduction of guidelines, and 83% when a study doctor audited all patients on the ward. The time between the day the patient met the switch criteria, and the day the patient actually switched was c. 3 days during phase I and 1 day (median) in phases II and III.

Visiting the patients reported by the hospital pharmacy took approximately half an hour per day. An additional advantage was that in many instances other advice could be given on use and duration of antibiotics and selection of less toxic alternatives.

In conclusion, we found an electronic drug ordering system to be very helpful in streamlining the use of iv antibiotics. With relatively little effort, only a few patients receive antibiotics intravenously for longer than necessary.

Notes

J Antimicrob Chemother 2000; 46: 518–519

* Corresponding author. Tel: +31-5664380; Fax: +31-206972286; E-mail: j.m.prins{at}amc.uva.nl Back

References

1 . Sevinç, F., Prins, J. M., Koopmans, R. P., Langendijk, P. N., Bossuyt, P. M., Dankert, J. et al. (1999). Early switch from intravenous to oral antibiotics: guidelines and implementation in a large teaching hospital. Journal of Antimicrobial Chemotherapy 43, 601–6.[Abstract/Free Full Text]

2 . Feely, J., Chan, R., Cocoman, L., Mulpeter, K. & O'Connor, P. (1990). Hospital formularies: need for continuous intervention. British Medical Journal 300, 28–30.[ISI][Medline]

3 . Pestotnik, S. L., Classen, D. C., Evans, R. S. & Burke, J. P. (1996). Implementing antibiotic practice guidelines through computer-assisted decision support: clinical and financial outcomes. Annals of Internal Medicine 124, 884–90.[Abstract/Free Full Text]

4 . Evans, R. S., Pestotnik, S. L., Classen, D. C., Clemmer, T. P., Weaver, L. K., Orme, J. F. et al. (1998). A computer-assisted management program for antibiotics and other antiinfective agents. New England Journal of Medicine 338, 232–8.[Abstract/Free Full Text]