Transcript Application of drug use evaluation & feedback to promote

Application of Drug Use Evaluation & Feedback to
Promote Rational Antibiotic Prophylaxis in C-Section in
Kenya
Dr. Nath W Opiyo Arwa, The Mater Hospital, Kenya
16th November 2011, ICIUM Conference 2011
Presentation outline
• Introduction
• Methods
• Results
• Key lessons learned
• Implications of DUE
• Future studies/ reviews
Introduction
• Antibiotic prophylaxis is useful in reducing incidences of
surgical (operation) site infection.
• The use of antibiotic prophylaxis is however characterized
by inappropriate practices such as use of broad-spectrum
antibiotics; administering at wrong time; and continuing for
too long
• Use of single dose has been found to be as effective as
multiple doses and also cost effective to patients [1].
• The recommended duration of prescribed antibiotics
prophylaxis for c-section has reduced from ≥ 5 days to 3
days then to 24 hrs and finally to a single dose [2] .
• DUE serves as a structured criteria based method of
identifying, monitoring and correcting challenges
encountered in practice
[1] Hopkins L, Smaill F, Antibiotic Prophylaxis Regimens and Drugs for C-section, Reprint for Cochrane Review in The Cochrane Library 2006, Issue
[2] Liabsuetrakul T, Lumgiganon P and Chongsuvivatwong V, ‘Prophylactic Antibiotic Prescription for Cesarean Section’, International Journal for
Quality in Health Care 2002: Vol.14NO. 6 pp. 503-508
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Methodology
• DUE criteria developed and endorsed by Mater PTC
• Baseline retrospective review done in Jan- June 2006
• Ongoing Subsequent DUEs were conducted periodically to
date
• Random sampling of C-section cases from medical records
• Medical, Theatre and Nursing records, Treatment sheets
were reviewed to identify antibiotic prescribed for each csection delivery
• Antibiotics prescribed were compared with defined criteria
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CRITERIA
INDICATOR
DESCRIPTION
ANTIBIOTIC ADMINISTERED
•Co- Amoxiclav
•Cefuroxime
•Clindamycin
•Metronidazole –dirty surgery
DOSE OF ABX ADMINISTERED
•Co- Amoxiclav 1.2 gm IV STAT- TDS
•Cefuroxime 1.5 gm IV STAT
•Clindamycin 600 mg IV STAT
•Metronidazole 500 mg IV STAT
TIMING OF FIRST ABX DOSE
•Immediately after cord- clamping
DURATION OF ADMINISTRATION
•Co- Amoxiclav up to 3 doses
•Cefuroxime 1.5 gm STAT
REPEAT DOSES DURING SURGERY
•For cases lasting longer than 4 hrs
•Loss of > 1.5 lts of blood
DUE findings June 2006 to Dec 2010
ABX CHOICE
110%
90%
70%
50%
30%
10%
-10%
DOSE
TIMING OF 1ST DOSE
DURATION
OVERALL ADHERENCE TO GUIDELINES
100%
80%
68%
60%
46%
30% 31%
40%
20%
0%
5%
10%
24%
52%
42%
49%
Feedback & Cost implications
• Feedback
– Dissemination to MHPTC, Obs/ Gynae Div &
Anaesthetists
– Face to Face, CMEs, profiling individual performance,
Use of opinion leaders
– Regular feedback positive change in prescribing trends/
practice
– Positive feedback reinforces good practice and reversed
trends
• Cost savings:
– Co-Amoxiclav US $ 22.14 per client
– Cefuroxime US $ 15.83 per client
– Annual extrapolation US $ 13,408
Key Lessons learned
• Fear of the unknown- Irrational prescribing
• Combination of strategies is critical for sustainable
improvement
• Slight policy changes can result in significant cost
savings
• Teamwork and mentorship is key in ensuring
continuity of intervention despite staff turnover
• Dedication and motivated staff are key in sustaining
• Operational research should be integrated into
regular schedule for maximum effectiveness
Implications of DUE
• Systematic, criteria-based program of drug use
evaluations (DUE) with feedback on prescribing
trends
• Use of single dose for antibiotic prophylaxis is
beneficial even in poor resource setting
• prolonged antibiotic use does not confer value addition
except in special cases
• Optimal medication use in ABX prophylaxis &
Improved patient safety
• Adherence to guidelines is a challenge
• Wastage & variations in ABX choice that made care
expensive reduced
Future studies
• Qualitative studies on underlying causes of lack of
adherence to guidelines
• Expand scope of DUEs to additional forms of
surgery
• DUEs involving reserve antibiotic use
• DUEs of prescribing OI medications in patients on
HAART
• Scale up DUEs approach to other MTCs
countrywide
Acknowledgements
• Mater Hospital administration and CEO, Mater
PTC Members( Dr Agnes Chege, Dr M Dolan,
Dr Mureithi, Dr Wanjala), Obstetrics and Gyn
division, doctors and Nurses
• Former Colleagues: Ahmed Tawakal, Benjamin
Maronda
• Management Sciences for Health: Mohan
Joshi, Niranjan Konduri and Patrick Boruett
Thank you!