Transcript The Assessment Of Sequential Antimicrobial Therapy In UMMC

The Assessment Of
Sequential Antibiotics
Therapy In University
Malaya Medical Centre
(UMMC)
Che Zuraini Sulaiman
Pharmacist
UMMC
INTRODUCTION
Sequential Antibiotics Therapy
 the conversion of intravenous to oral antibiotic treatment using
the same medication (Lelekis, et al. 2001)
 Pre-set criteria to direct sequential antibiotic therapy vs
physician-directed conversion
Advantages
 Cheaper treatment costs (Lelekis, et al. 2001)
 Shortens LOS (Lelekis et al., 2001, Hunter et al., 1995, van der Eerden et
al., 2004)

Reduce IV catheter-related complications ((Lelekis, et al. 2001, van
der Eerden et al., 2004, Vogel, F, 1995)

Convenient to patients and hospital personnel (Vogel, F, 1995)
AIM & OBJECTIVES
AIM
 To assess the need to establish a sequential
antibiotic therapy program in UMMC
OBJECTIVES
1. To identify the current practice of IV-tooral conversions in UMMC
2. To calculate the potential cost-savings of
sequential antibiotic therapy
METHODOLOGY
STUDY DESIGN
prospective observational study
DURATION OF STUDY
Dec 2006 - Feb 2007
STUDY POPULATION
all patients admitted to UMMC receiving targeted antibiotics
and fulfilling the inclusion criteria
CALCULATED SAMPLE SIZE
302 (confidence level 95%, confidence interval 5%, estimated
prevalence 0.50)
Targeted Antibiotics
Ampicillin
Benzypenicillin
Cloxacillin
Amoxicilin/clavulanic acid
Ampicillin/sulbactam
Azithromycin
Clindamycin
Cotrimoxazole
Ciprofloxacin
Cefuroxime
Inclusions
-soft tissue infection
-RTI
-UTI
-blood infection
-intra-abdominal
infection
Exclusions
Malignancy
Neutropenia or immunocompromised
Concomitant infections requiring
IV antibacterials for sustained
periods
Pregnant or moribund
Concomitant disease states that
contraindicate the use of oral
medications
CRITERIA FOR IV TO ORAL CONVERSION
(based on Dundee Infectious Disease Unit Criteria for Intravenous-Oral
Switch & Duke University Medical Centre Criteria for Switching to Oral
Antimicrobial Therapy)
-Signs and/or symptoms of infection are improved or have resolved according to
physician’s assessments
-Patient is afebrile (Temperature ≤37.9°C) or has had consistent improvement
in fever over a 24-hour period
-White blood cells are normalizing (if repeated measurements are available)
-GI absorption of drugs is normal (absence of vomiting or abnormal GI anatomy)
-The patient is able to receive enteral therapy (orally or through gastric feeding
tubes) as evidenced by concomitant enteral medications or nutrition
-No evidence of continuing sepsis with two or more of the following:
temperature >38˚C, pulse >90 beats/min, respiratory rate >20 breaths/min
or white cell count <4 or >12x109/L
1)Percentage receiving sequential antibiotic
therapy
2)Outcome of sequential antibiotic therapy
3)Potential cost savings of sequential
antibiotic therapy
potential cost
saving of
sequential
antibiotic therapy
=
antibiotic
acquisition
cost for IV
antibiotic
_
antibiotic
acquisition cost
for oral
antibiotic
SITES OF INFECTION, n (%), (N=212)
11
33
(5.2)
4
(1.9)
Soft tissue infections
(15.6)
Respiratory tract infections
111
(52.3)
Urinary tract infections
Blood infections
53
(25.0)
Intra-abdominal infections
385 patients’ case
notes reviewed
212 patients included
196 patients met criteria
for IV to oral conversion
(92.5%)
Converted to
oral antibiotics
(n=172)
16 patients did not meet
criteria for IV to oral
conversion (7.5%)
Not converted to
oral antibiotics
(n=24)
Potential cost
saving: RM1794.30
Converted before criteria were met
(n=35)
Converted when criteria were met
(n=38)
Clinical cured: n=35 (100%)
Clinical cured: n=38 (100%)
Converted after criteria were met
(delayed conversion) (n=99)
Clinical cured: n=99 (100%)
Potential cost saving: RM13948.70
MEAN (±SD) DURATION CRITERIA FOR IV TO ORAL CONVERSION WERE MET
(N=196)
Criteria for IV to oral conversion, N=196
Mean (±SD) duration to
meet criteria, day(s)
Criterion 1
Signs and/or symptoms of infection are improved or have resolved
according to physician’s assessments
3.9 (±2.3)
Criterion 2
Patient is afebrile (Temperature ≤37.9°C) or has had consistent
improvement in fever over a 24-hour period
2.3 (±1.9)
Criterion 3
White blood cells are normalizing (if repeated measurements are
available)
2.4 (±2.2)
Criterion 4
GI absorption of drugs is normal (absence of vomiting or abnormal
GI anatomy)
1.2 (±1.0)
Criterion 5
The patient is able to receive enteral therapy (orally or through
gastric feeding tubes) as evidenced by concomitant enteral
medications or nutrition
1.4 (±1.3)
Criterion 6
No evidence of continuing sepsis (with two or more of the following:
temperature 38˚C, pulse 90 beats/minute, respiratory rate 20
breaths/minute or white cell count 4 or 12x109/L)
1.1 (±0.6)
All criteria
4.3 (±3.3)
385 patients’ case
notes reviewed
212 patients included
196 patients met criteria for IV
to oral conversion
Converted to oral antibiotics
(n=172) (87.8%)
16 patients did not meet criteria
for IV to oral conversion
Not converted to oral antibiotics
(Group 4) (n=24) (12.2%)
Potential cost saving: RM1794.30
Delayed conversion (Group 3)
(n=99) (50.5%)
Converted before criteria
were met (Group 1) (n=35)
(17.9%)
Converted when criteria
were met (Group 2) (n=38)
(19.4%)
Clinical cured: n=99 (100%)
Clinical cured: n=35 (100%)
Clinical cured: n=38 (100%)
Potential cost saving:
RM13948.70
IV TO ORAL CONVERSION OF ANTIBIOTICS
ACCORDING TO SITES OF INFECTION (N=196)
385 patients’ case notes
reviewed
212 patients included
196 patients met criteria for IV
to oral conversion
Converted to oral antibiotics
(n=172)
16 patients did not meet criteria
for IV to oral conversion
Not converted to oral antibiotics
(Group 4) (n=24)
Potential cost saving: RM1794.30
Delayed conversion (Group 3)
(n=99)
Converted before criteria
were met (Group 1) (n=35)
Converted when criteria
were met (Group 2) (n=38)
Clinical cured: n=99 (100%)
Clinical cured: n=35 (100%)
Clinical cured: n=38 (100%)
Potential cost saving:
RM13948.70
OUTCOME OF TREATMENT (All patients
receiving sequential antibiotic therapy)
 Clinical cure (100%)
TOTAL POTENTIAL COST SAVING
(in 123 patients in 2 months)
 RM15743.00
Potential cost saving per
patient
Potential annual cost savings
: RM127.99
: RM94458.00
STUDY LIMITATIONS
exclusion of patients receiving
targeted antibiotics that were kept
as ward stock
inability to perform a detailed cost
analysis
 sequential antibiotic therapy is commonly
practised in UMMC
 the conversions from IV to oral antibiotics
are often delayed
 total potential cost savings was estimated
to be approximately RM100,000 annually
RECOMMENDATIONS
 Establishment of a safe and cost-
effective policy of sequential antibiotic
therapy in UMMC
 Development of a set of criteria for IV to
oral conversion with the help of ID team
 Implementation of sequential antibiotic
therapy program through team
approach
Acknowledgement
 Ms Ho See Wan1,
 Ms Reena Rajasuriar1,
 Prof Dr Adeeba A Kamarulzaman2

1
Department of Pharmacy, University Malaya
 2 Infectious Disease Unit, University Malaya Medical Centre
1. Lelekis, M & Gould, IM 2001, ‘Sequential antibiotic
therapy for cost containment in the hospital setting:
why not?’, Journal of Hospital Infection, vol. 48, no.
4, pp. 249-257. Retrieved July 25, 2006, from
Science Direct database.
2. Shah, PM 2000, ‘Sequential or switch treatment which criteria should be fulfilled?’, International
Journal of Antimicrobial Agents, vol. 16, no. 301,
pp. 301-302. Retrieved July 25, 2006, from Science
Direct database.
3. Hunter, KA & Dormaier, GK 1995, ‘Pharmacistmanaged intravenous to oral step-down program’,
Clinical Therapeutics, vol. 17, no. 3, pp. 534-540.
Retrieved July 16 2006, from Science Direct
database.
4. van der Eerden, MM, de Graaff, CS, Vlaspolder, C,
Bronsveld, V, Jansen, HM & Boersma, WG 2004,
‘Evaluation of an algorithm for switching from IV to
PO therapy in clinical practice in patients with
community-acquired pneumonia’, Clinical
Therapies, vol. 26, no.2,pp. 294-303.
5. Vogel, F 1995, ‘Sequential therapy in the hospital
management of lower respiratory infections’, The
American Journal of Medicine, vol. 99, no.
supplement 6B, pp. 14S-19S.
6. Barlow, GD & Nathwani, D 2000, ‘Sequential
antibiotic therapy’, Current Opinion in Infectious
Diseases, vol. 13, no. 6, pp. 599-607.
Thank You
Formula
 number of days of delayed conversion=number of
days with IV antibiotic−day all criteria of conversion
were met
 acquisition cost for IV antibiotic=number of days of
delayed conversionxbasic units of IV antibiotic given
per dayxbasic unit acquisition price of IV antibiotic
 acquisition cost for oral antibiotic=number of days of
delayed conversionxbasic units of oral antibiotic
given per dayxbasic unit acquisition price of oral
antibiotic
 the potential cost saving of antibiotic acquisition
cost=antibiotic acquisition cost for IV
antibiotic−antibiotic acquisition cost for oral antibiotic