Author(s)

Lanzone E. (1), Baldessarelli D. (2), Tinebra A. M. (1), Albini E. M. E. (1), Panarotto A. (1), Rossi C. (1) – (1) SC Farmacia Ospedaliera ASL Novara, (2) Scuola di Specializzazione Farmacia Ospedaliera Novara.

Why was it done?

A comprehensive analysis of systemic antibiotic use in hospitals during the first half of 2024 was conducted, revealing a significant increase in the consumption of WATCH class drugs, specifically carbapenems (ATC J01DH) and fluoroquinolones (J01MA). This prompted the implementation of rigorous monitoring for prescriptions of these drug classes.

What was done?

These antibiotics are key targets of the National Plan Against Antimicrobial Resistance (PNCAR 2022-2025), which mandates a reduction of at least 10% in consumption by 2025 compared to 2022. The initiative aimed to address the rising consumption and enhance antibiotic stewardship.

How was it done?

Data were extracted from the regional IT system, with consumption expressed in Defined Daily Doses (DDD) per 100 patient days. The project monitored the use of systemic antibiotics (ATC J01), focusing on carbapenems and fluoroquinolones. Motivated requests received by the Hospital Pharmacy (FO) were reviewed for therapeutic indications, dosage, treatment duration, and the availability of an antibiogram. All requests were recorded in an Excel sheet for effective data analysis and management.

What has been achieved?

In the first half of 2024, the Hospital Pharmacy received a total of 277 motivated requests for antibiotic prescriptions. Among these, 177 requests were aligned with the objectives of the PNCAR. Specifically, there were 54 requests for fluoroquinolones, including 35 for ciprofloxacin and 19 for levofloxacin. Within this subset, 16 requests included an antibiogram, while 27 were based on empirical data. Additionally, there were 6 requests for surgical prophylaxis, 1 for continuation of therapy, 1 accompanied by a positive urine culture, and 3 that were incorrectly filled out.
The analysis of requests also highlighted a significant number related to carbapenems, with a total of 123 submissions. Of these, 120 were for meropenem, 2 for imipenem in combination with cilastatin, and 1 for ertapenem. Notably, 80 of these requests included an antibiogram, with 74 deemed appropriate based on the established criteria.

What next?

Based on the collected data, modifications to the personalized motivated request form were proposed, introducing stricter criteria for empirical use of these antibiotics. This aims to limit their use to serious and well-defined cases, representing a significant step toward more effective antibiotic therapy and improved clinical outcomes while reducing the risk of resistance. The new form specifies that ciprofloxacin and levofloxacin requests can only be made under certain conditions, and carbapenems are restricted to cases of hemodynamic instability or severe respiratory failure.

Author(s)

Ignacio Javier Tamboleo Sánchez, Julia Fernández Vela, Fernando Lago Ballester, Mª CARMEN MIRA SIRVENT, Elena Conesa Nicolas

Why was it done?

The initiative started in October 2022, it was a response to the challenges associated with prolonged intravenous antibiotic use. The overarching goals were to enhance patient care, mitigate unnecessary intravenous antibiotic prescriptions, and foster a culture of responsible antimicrobial stewardship. Recognizing the need for a systematic and collaborative approach, the Antimicrobial Stewardship Program (ASP) pharmacist played a central role in implementing interventions across various medical specialties, with a clear focus on improving patient outcomes.

What was done?

The initiative promoted the adoption of sequential antibiotic therapy among hospitalised patients undergoing intravenous treatment for more than three days. Leveraging the Wise Antimicrobial Stewardship Support System® (WASPSS®) and detailed analysis of medical records, the programme identified eligible patients based on criteria such as clinical stability, oral bioavailability, infection specifics, and antibiotic suitability.

How was it done?

The ASP pharmacist’s central role proved instrumental, with 74% of alerts resulting in actionable recommendations. WASPSS® detects every patient with intravenous antibiotic more than 3 days and the ASP pharmacist decides which patients will benefit from sequential therapy. Choosing the recommendation criteria is essential to have a good response from medical specialties ensuring a more efficient and tailored approach to intervention implementation. The main obstacles to the introduction of this initiative were the establishment of refined communication routes and the targeted training to the different specialties which are not yet fully implemented.

What has been achieved?

Results revealed that 74% of alerts met the criteria for transitioning from intravenous to oral administration. Among the 573 alerts reviewed, 45.1% witnessed a successful switch to oral antibiotics, 21.2% showed no change, and 16.7% of patients were discharged. Notably, higher acceptance rates were observed in specific specialties, such as pneumology (61.3%) and general medicine (54.4%). Nevertheless, oncology (35,3%) general and digestive surgery (25,8%) had the lowest acceptance rate. In conclusion, the global acceptance rate was lowest than expected (43,8%) but there are many improvements measures that are being carried out.

What next?

This initiative serves as a beacon for responsible antibiotic management, making noteworthy contributions to patient safety, cost-effectiveness, and the overall quality of healthcare delivery. Recommending ongoing collaboration, continuous training, and regular analysis of recommendation criteria will enhance its impact.

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Author(s)

Sergio Portillo-Haro, Aída Rueda-Naharro, María Martínez-Pérez, Manuela Martínez-Camacho, David García-Marco

Why was it done?

Currently, multi-resistant microorganisms are a huge global problem of Public Health. In addition, this problem will be bigger in the next decades. The main strategy to face this threat is improve the use of antibiotics. DADA was born with this purpose. The app lets the Pharmacy Department manage a sizable number of inpatients using the time to analyse the results obtained by DADA. In other words, we have improved the efficiency in our use of time.
How was it done?
The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analysed carefully by a pharmacist and afterwards the conclusions are transmitted to an Infectious Diseases Medician, who decides if modify the treatment.

What was done?

In July 2022, Pharmacy Department designed an app easy to use and comfortable in order to detect active antibiotic treatments that might be de-escalated. This app, DADA (Automated Antibiotic De-escalation) is fed with data of antibiotic treatments and microbiological cultures. DADA reads and understands every gap of information, and finally search results between the active treatments comparing it with theorical de-escalation sequencies, designed by Infectious Diseases Commission in our hospital and based in local epidemiological guidelines. In this way, DADA works with automatic decision algorithms. In addition, DADA also provides alerts of active treatments for resistant microorganisms to that antibiotic.

How was it done?

The app was developed in July 2022, and since then it has been updated multiple times to adapt it to our needs and expectations and the changes in clinical guidelines. Every Monday and Thursday, the app is started up. The results are analyzed carefully by a pharmacist and afterwards the conclusions are transmited to an Infectious Diseases Medician, who decides if modify the treatment.

What has been achieved?

Since August 2022 to March 2023, using DADA, the Pharmacy Department has made 25 proposals of antibiotic de-escalation, and 11 proposals were accepted (44.0%) by Medicians. In addition, the Department made two proposals of change for resistance to that antibiotic, both accepted by Medicians. This app has improved efficiency of time in the clinical team.

What next?

The main outcome is to improve the confidence of Medicians in this tool, in order to increase the percentage of acceptance in the proposals. Furthermore, the app can be more complete and interprets data, such as analytics parameters. In the future, other hospitals might use this tool to analyse their patients or in outpatients treatments.

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Author(s)

Carlos Santos Rodríguez, Silvia Irene Corrales Vargas, Maria de los Ángeles Peña Peloche, Alfredo Julian Jover Sáenz, Miguel Ángel Ramos Gil, Arturo Morales Portillo, Marta Mir Cros, Francisco Ignacio Torres Bondia, Lluis Marqués Amat, Joan Antoni Schoenenberger Arnaiz

Why was it done?

Beta-lactam antibiotics are the most commonly used group of antimicrobial drugs but are also the ones with the most significant induction of allergic reactions. However, it is known that many of these patients do not present reactions upon rechallenge or have false allergy warnings in the medical records.

What was done?

To assess the impact of a pharmacist-driven programme for active beta-lactam allergy warning removal in adults in collaboration with the Allergology service.

How was it done?

We identified adults with active beta-lactam allergy warnings among outpatients aged 35 to 45 years over 26 months.
Both in the hospital and primary care setting the pharmacist assessed the current information of the cases in the electronic medical records (EMR) and through personal interviews or by telephone. The following data were retrieved: year of allergy registration, type of reaction described, tolerance of beta-lactam antibiotics, and the existence of Allergology reports.
The pharmacist, previously trained by the Allergology service, could proceed to remove or confirm the allergy label, if applicable, or refer the patient to the Allergology service for allergy tests.

What has been achieved?

We reviewed a total of 1178 cases with active beta-lactam allergy warnings. The most frequently implicated beta-lactam drug was amoxicillin, with 170/1178 (14.4%) cases.
111/1178 (9.4%) of cases had an allergic reaction in childhood, and in 714/1178 cases (60.6%) EMR did not describe the symptomatology or treatment that justifies the allergy.
The allergy warning was directly removed in 93/1178 (7.9%) of patients, as they had previous reports of Allergology, had tolerated antibiotics after the allergic reaction, or did not present symptoms compatible with an allergic reaction.
The review confirmed allergic warnings in 43/1178 (3.65%) cases, according to the symptomatology and the information recorded in the Allergology reports.
One thousand and forty-two cases were referred for beta-lactam allergy test performance in the allergology service, of which 47% yielded a negative result.

What next?

The pharmacist is qualified to remove the warning in cases with a doubtful allergy to beta-lactam antibiotics after a thorough medical record review and informed consent. Moreover, the pharmacist can provide valuable information that allows the classification of warnings according to the detected risk and facilitates subsequent decision-making by the allergist.

Author(s)

Sonja Guntschnig

Why was it done?

The aim of this good practice initiative (GPI) was to identify local resistance patterns, improve prescribing quality, reduce hospital costs, calculate antibiotic use data, track problem organisms, infection clusters and enable transfer chains tracing.

What was done?

With the introduction of a new antimicrobial stewardship (AMS) group into Tauernklinikum, Zell am See, a new informatics tool called HyBase® by epiNet AG was implemented to establish an interface linking microbiological results, consumption of antimicrobials, the hospital infections surveillance system “Krankenhaus-Infektions-Surveillance-System”(KISS) and the hospitals antimicrobial resistance data. AMS teams need suitable AMS surveillance systems to track intervention changes and measure results.

How was it done?

After purchasing release by the hospital management, HyBase needed an interface with several IT system providers, namely the internal microbiology laboratory (KISS software), System Application and Product in processing (SAP), and two external microbiology laboratories.

What has been achieved?

Antibiotic consumption figures were obtained retrospectively by calculating defined daily doses (DDD). This also gave insight into problematic use of certain antibiotics and indicated potential for antibiotic restriction.
Antimicrobial resistance patterns were displayed, which led to the introduction of infection control and AMS measures. Alert organism surveillance data was obtained and evaluated for different wards.

What next?

Learning from this implementation will enable changes in antimicrobial prescribing which will lead to improvements, both in healthcare quality and patient safety as well as a potential reduction in prescribing costs. Alert organism clusters will be detectable as will be transfer chains in the healthcare setting. It will also allow for the introduction of infection control agent stewardship for example by testing hand disinfection compliance or recording the spread of surface adherent organisms.
This GPI addresses the WHO antimicrobial resistance global action plan and local antimicrobial medicines concerns. It may prove useful for other healthcare settings and can be easily implemented to obtain data necessary for robust effective antimicrobial stewardship.

Author(s)

ANA CASTRO BALADO, MARÍA TERESA RODRÍGUEZ JATO, IRIA VARELA REY, MANUEL BUSTO IGLESIAS, FRANCISCO CAJADE PASCUAL, MARIA PUENTE IGLESIAS, IRENE ZARRA FERRO

Why was it done?

The prevalence of obesity has increased considerably in last decades. Pathophysiological changes in obese patients (body mass index >30kg/m2) produce pharmacokinetic and pharmacodynamic alterations that can condition the correct exposure to drugs if standard dosages are used. Incorrect dosing in obese patients can lead to toxicity or therapeutic failure. Usually, it is difficult to find information on drug dosing in this population, being sometimes contradictory.

What was done?

To develop an antimicrobial dosage infographic guide for obese patients to facilitate the correct prescription and validation in our hospital.

How was it done?

Initially, the pharmacy service established the antimicrobial groups to be included in the infographic guide, and within each of them, the most used in hospitalized patients were identified. A bibliographic search was carried out using the keywords “obese”, “dosing”, “antimicrobial” and “patient”. Technical data sheets, PubMed, Google Scholar, UpToDate, Micromedex and other hospital guidelines were consulted. A peer review was carried out and a table with antimicrobial groups and subgroups was designed, stablishing the body weight recommended for the adjustment if needed (total weight (TBW), ideal weight (IBW) and adjusted weight (ABW)), doses, and observations (monitoring of plasma levels, administration in extended/continuous infusion and/or special considerations). The table consisted of a total of 38 antibiotics, 10 antifungals, 6 antivirals and 4 antituberculous drugs. Of the total antimicrobials reviewed, 40% were dosed in obese patients by maximum dose, 38% were dosed based on weight (21% by ABW, 10% by IBW, and 7% by TBW) and 22% by standard doses. Equations for body weight descriptors were added in the infographic.

What has been achieved?

The protocol was validated by the hospital’s infectious diseases commission. Dosing information was then entered into the hospital’s electronic prescribing program facilitating the correct antimicrobial prescription and validation in obese patients. Training was provided in the intensive care unit, and the final document was disseminated through the hospital intranet and via email to all prescribing physicians in the center, being well embraced.

What next?

We will continue making formative sessions, as well as possible updates that may be beneficial for a better antimicrobial dosing in obese patients to avoid toxicities and/or therapeutic failure.

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Author(s)

Tania Truelshoej

Why was it done?

Department of infectious diseases at Aarhus Universitetshospital, Denmark, has succesfully implemented OPAT as a standard modality for certain patients requiring long-term intravenous antibiotic therapy e.g. patients with cystic fibrosis. This also include a guideline to OPAT self-administration at home.

To implement the OPAT guidelines throughout the hospital there was a need for an overview of available ready-to-use antibiotics for OPAT. The graphic guide is a help for the physicians in choosing the right drug-delivery-system suitable for OPAT self-administration.

What was done?

A graphic guide showing the ready-to-use antibiotics for outpatient parenteral antimicrobial therapy (OPAT) with special emphasis on drug-delivery-systems suitable for self-administration was developed.

How was it done?

Most information about the available ready-to-use antibiotics were obtained at the hospital pharmacy. In addition, the requirements for the different drug-delivery-system were obtained by interviewing nurses from different wards

What has been achieved?

Available ready-to-use antibiotics was listed in a graphic form with the following information: type of antibiotics, drug-delivery-system, available doses recommendations to time of administration and storage time and temperature. The drug-delivery-system were all illustrated with a photo.

The graphic guide is now part of the implemented guideline for OPAT at the hospital and is also available as a printed poster to place e.g. in the medicine room.
The guide is a help for the physicians in choosing the right drug-delivery-system suitable for OPAT self-administration and helps to raise overall awareness of the possibility of OPAT as self-administration at the hospital.

What next?

Implementation of the OPAT guideline and the included graphic guide has increased awareness of the need for the hospital pharmacy to deliver ready-to-use antibiotics that can match the needs for safe and efficient treatment at home. This is an important strategic focus for the hospital pharmacy in the coming years.

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Author(s)

Marie Keane

Why was it done?

In the ICU there was a lot of misunderstanding around the administration of vancomycin by intermittent dosing, particularly around the timing of pre-dose vancomycin levels and appropriate dose adjustment. It could take several days for a patient to reach the therapeutic range of vancomycin.

What was done?

A protocol for the administration of vancomycin by continuous infusion was developed for patients on ICU, replacing the previous method of giving vancomycin by intermittent dosing; this was developed in consultation with the Anaesthetics and Microbiology Departments.

How was it done?

To develop a vancomycin continuous infusion dosing schedule for patients admitted to ICU, through a review of the available literature and with reference to vancomcyin continuous infusion protocols already established on ICUs in other hospitals. A proposal for administration of vancomycin continuous infusion needs to be included on the electronic clinical information system currently in use in the ICU. An IV drug monograph for vancomcyin by continuous infusion will be included in the ‘ Intravenous Medication Infusion Guidelines’; this will provide information on compatibility with other infusions if required. To recommend vancomycin continuous infusion in patients as agreed with the Anaesthetics and Microbiology Consultants at the daily ward review, this would require the patient to have a dedicated IV line.

What has been achieved?

A finalised version of the Vancomycin Continuous Infusion protocol has been developed in consultation with Anaesthetic and Microbiology Consultants. We have included additional information for patients on CRRT (continuous renal replacement therapy) that has been used in some patients on continuous vancomycin infusion. A standardised prescription for infusion of vancomycin is available on the electronic prescribing system. Vancomycin continuous infusion is now recommended for any patients requiring vancomycin therapy on the ICU.

What next?

We would propose to audit the number of patients on Vancomycin Continuous Infusion in the ICU, including time taken to reach therapeutic range, frequency of sampling and any other cost-saving initiatives perceived.

Author(s)

Andreas von Ameln-Mayerhofer, Martin Breuling, Ina Geist

Why was it done?

In the context of antibiotic stewardship, rapid oralisation of a parenteral antibiotic is recommended in many antibiotic stewardship guidelines. Such a sequence therapy is easy to implement if both application pathways lead to comparable efficacy levels at the site of infection. However, this does not apply to all anti-infectives, in particular some beta-lactam antibiotics represent a challenge in therapy. Additionally, the information about this topic is very sparse in the literature.

What was done?

In order to achieve an improvement in antimicrobial prescriptions, we have addressed possible problems regarding oralisation of antibiotics. For this purpose, we graphically compared the simulated efficacy levels of parenteral and oral forms of beta-lactams.

How was it done?

We programmed a computer based procedure that allows a simulation of plasma levels of antibiotics upon intravenous versus oral administration. Based on the obtained data and EUCAST-based MIC-distributions for a set of bacteria, we assessed the respective putative clinical actions.

What has been achieved?

Our simulations show that some oral beta-lactams do not reach the PK/PD condition of a sufficient therapy (fT>MHK) in the approved dosage. The simulations have been used for education seminars with physicians and partly led to an improvement in oralisation procedures. Additionally, an oralisation standard has been established.

What next?

Our next step is to develop a special prescription form for oral antibiotics which will enable us to control prescription behaviour even more effectively. We plan to monitor the prescription habits for anti-infectives more closely before and after establishing the prescription form.