Transcript Quinolone Restriction

QUINOLONE
RESTRICTION AT
MARLBOROUGH
HOSPITAL
.
Vibha Sharma, M.D.
Infectious disease consultant and
Medical director, infection control,
Marlborough hospital
Zsusun Timothy Yang, Rph
Pharmacy director
Marlborough hospital
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 .
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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.
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
PREVIOUS USAGE OF
QUINOLONES AT
MARLBOROUGH HOSPITAL
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Moxifloxacin formulary quinolone (FQ).
No renal dosing (400 mg po/iv daily).
Does not cover UTI. Ciprofloxacin reserved for
these patients.
QUINOLONE RESTRICTIONS
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As of 12/1/10 FQ restriction to ID.
24 hour supply allowed.
Pharmacy contacts via communication
sheet/paging MD.
ID contacted via email.
Further supply restricted to ID approval.
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:
SYSTEM
USED
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.
SENTRI 7 DATA FOR
QUINOLONE USAGE
Month
Sept 10
Oct 10
Nov 10
Dec 10
Jan 11
Feb 11
# rule
matches
5
1
14
8
2
1
SENTRI 7 QUINOLONE DATA
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Only captures rule hits with Meditech profiling.
Does not capture ED 1 dose removals (ie
overides).
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)
 # Pts- # patients listed in reporting
 # 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.
MEDITECH DATA FOR
QUINOLONE USAGE CONT.
8/10
9/10
10/10
11/10
12/10
1/11
2/11
3/1 to
3/16
2011
136
89
100
107
59
49
46
20
#pts 84
61
74
78
48
37
32
14
#RX 47
>24
hr
Pt > 47
24 h
33
33
29
4
2
6
1
33
33
29
2
2
3
1
#rx
Actual patients receiving > 24 hr
Quinolone therapy
Actual patients receiving >24 hour therapy
50
45
40
35
30
Actual patients
receiving >24 hour
therapy
25
20
15
10
5
0
Aug- Sep- Oct- Nov- Dec- 1110
10
10
10
10 Jan
Feb- Mar
11 1-16
QUINOLONE TRENDS
AUG 09 TO 2/11
180
160
140
120
100
80
60
40
20
0
#RX
#PTS
b
b
c
c
g
pr Ju n
ct
ct
e
e
e
e
u
A
O
D
-F
-O
-A
-D 1 -F
0
0
90
0
90
0
1
1
1
1
1
1
1
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
SENTRI 7 DATA FOR ABX USAGE
Month 9/10
10/10 11/10 12/10 1/11
2/11
# RULE
MATCH
ES
19
23
77
48
44
88
MEDITECH REPORTING
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Monthly analysis for August to March 1-16th for
time frame of 8/09 to 3/16/11
Antibiotics used for analysis: Ertapenum (E),
Vancomycin (V), Ceftriaxone (CF),
Levofloxacin, Ciprofloxacin, and Moxifloxacin
Levofloxacin, Ciprofloxacin, and Moxifloxacin
data aggregated (FQ)
#RX and # PT collected.
#RX ABX SPREAD
250
250
200
#RX (E)
200
#RX(E)
150
#RX (V)
150
#RX(V)
100
#RX (CF)
100
#RX(CF)
50
#RX (FQ)
50
#RX(FQ)
0
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10
-A
ug
10
-S
ep
10
-O
ct
10
-N
ov
10
-D
ec
11
-J
an
03
/0
11
1
to
-F
eb
03
/1
6/
20
11
9O
ct
9No
v
9De
c
10
-J
an
03
/0
1
1to
Fe
03
b
/1
6/
20
10
9Se
p
9Au
g
0
Quinolone most prescribed antibiotic in Feb 2010.
Ceftriaxone most prescirbed antibiotic overall during
winter months.
#PTS ABX DATA
# PT(E)
# PT (V)
# PTS (CF)
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9O
ct
9No
v
9De
c
10
-J
03
an
/0
1
1to
Fe
03
b
/1
6/
20
10
9Se
p
9Au
g
# PT (FQ)
140
120
100
80
60
40
20
0
# PT(E)
# PT(V)
# PT(CF)
#PT(FQ)
10
-A
ug
10
-S
ep
10
-O
ct
10
-N
ov
10
-D
ec
11
-J
an
03
/0
11
1
to
-F
eb
03
/1
6/
20
11
140
120
100
80
60
40
20
0
Decline of patients on quinolones since December
2010.
Does not take account if patient switches antibiotic or
has multiple drug therapy.
% ABX orders comparing the four
drugs
60
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11
-F
eb
03
/1
6/
20
11
03
/0
1
to
11
-J
an
10
-D
ec
%FQ
10
-N
ov
1Fe
03
b
/1
6/
20
10
03
/0
1
to
10
-J
an
9No
v
9De
c
9O
ct
9Se
p
9Au
g
0
%CF
10
-O
ct
% FQ
%V
ep
%CF
20
10
%E
10
-S
%V
30
50
45
40
35
30
25
20
15
10
5
0
ug
%E
10
-A
50
40
Ertapenum usage initially high, now consistent.
Ceftriaxone use increased with less usage of FQ and
vice versa.
? Increase use of Vancomycin after winter months.
CONCLUSION
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ONE TIME DOSES (OVERIDES, SDC
PATIENTS)
SIGNIFICANT DROP OF TREATMENT OF
QUINOLONES IN HOSPITAL INPATIENT
FLOORS.
TIMELY COMMUNICATION ESSENTIAL
INITIAL SELECTION FOR CAP REMAINS
100%