Appropriate Antibiotic Use & Clinical Outcome in Acute Medical Wards

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Whitney Griffith
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1 Appropriate Antibiotic Use & Clinical Outcome in Acute Medical Wards Dr. Chan Kai Ming Associate Consultant Infectious Disease Management Tuen Mun Hospital

2 Introduction Antibiotics are powerful weapons against infection diseases Best use of antibiotics requires good knowledge of Pharmacokinetics and pharmacodynamics of antibiotics Characteristics of pathogens Characteristics of diseases Characteristics of patients

3 July 2004 Introduction First Audit in our Hospital Among 106 patients, 66% appropriateness in antibiotics use in acute medical wards. A series of case reviews Presentations and talks Distribution of guidelines

4 Objectives To audit the appropriateness in antibiotic usage and outcomes in acute medical wards of Department of Medicine & Geriatrics, Tuen Mun Hospital after one year of ongoing intervention measures.

5 Period Methods 25 th July 2005 to 7 th August 2005 Patients admitted to acute medical wards Concurrent daily assessment until discharge, transferred out or a maximum of two weeks

6 Assessment Methods Appropriateness in antibiotic use Management Clinical details Diagnosis Use of antibiotics Length of stay Mortality

7 Results

8 107 Admissions, 59 patients used antibiotics (55%) Appropriate Use, 35, 59% (95%CI 46.8% %) Inappropriate Initiation, 10, 17% Duration, Dosage & Route of Administration, 7, 12% Inappropriate Choice of Antibiotics, 7, 12%

9 Diagnosis UTI 11 19% Bone & Soft Tissue 2 3% Viral Infection 2 3% Sepsis 1 2% URTI 1 2% Biliary Sepsis 1 2% Chest Infection 29 49% Not Infection 12 20%

10 Biliary Sepsis 100% 80% 60% 40% 20% 0% Individual performance UTI Not Infection Chest infection Viral Infection Bone & Soft Tissue URTI Sepsis Appropriate Indication Choice Adminsitration

11 Biliary Sepsis 100% 80% 60% 40% 20% 0% Individual performance UTI Not Infection Chest infection Viral Infection Bone & Soft Tissue URTI Sepsis Appropriate Indication Choice Adminsitration

12 Biliary Sepsis 100% 80% 60% 40% 20% 0% Individual performance UTI Not Infection Chest infection Viral Infection Bone & Soft Tissue URTI Sepsis Appropriate Indication Choice Adminsitration

13 Biliary Sepsis 100% 80% 60% 40% 20% 0% Individual performance UTI Not Infection Chest infection Viral Infection Bone & Soft Tissue URTI Sepsis Appropriate Indication Choice Adminsitration

14 Antibiotics use Amp/Sulb 4% Cloxacillin 1% Cefuroxime 11% Acyclovir 1% Ceftriaxone 4% Cefoper/Sulb 3% Other 25% Levofloxacin 8% Amox/clav 59% Ciprofloxacin 4% Azithromycin 1% Clarithromycin 1% Imipenem/cila 3%

15 Outcomes Antibiotics not used Antibiotics appropriately used Antibiotics NOT appropriately used Median Length of Stay 2 days 3 days 4 days p = Mean Length of Stay 2.47 days 2.86 days 4.6 days p = Mortality 32.3 per per per 1000 p = 0.68

16 Discussion Education alone intervention did not result in higher rate of appropriate antibiotics use Other factors On going recruitment of junior doctors Unchanged antibiotics prescribing behaviours Insufficient information vs inappropriate behaviours

17 Other centres Discussion Hartford Hospital, USA 54.4% received recommendation. Arch Intern Med 1988 University of Vermont College of Medicine, USA 49% received suggestions in the intervention group. Arch Intern Med 1997 Teaching Hospital in Paris Two Third appropriate. Presse Med 2003

18 Other centres Discussion Christian Medical College & Hospital, Vellore, India. J Clin Epid % appropriate at the primary level 60% at the tertiary level Brazil Teaching Centres Therapeutic used was considered inadequate in 27%. Braz J Infect Dis 2004

19 22 65% of prescriptions are either inappropriate or incorrect.

20 66% (95% CI 54 78%) % (95% CI 47 72%) 2005

21 Clinical Outcomes Length of Stay Mortality Antimicrobial resistance Infection rates Antibiotics expenditures & utilization Hospital readmission rates

22 Clinical Outcomes Length of Stay Mortality Antimicrobial resistance Infection rates Antibiotics expenditures & utilization Hospital readmission rates

23 Outcomes Antibiotics not used Antibiotics appropriately used Antibiotics NOT appropriately used Median Length of Stay 2 days 3 days 4 days p = Mean Length of Stay 2.47 days 2.86 days 4.6 days p = Mortality 32.3 per per per 1000 p = 0.68

24 Antibiotics Stewardship Programme Antibiotics Stewardship Team Infectious Disease Specialist Microbiologist Pharmacist Infection Control Nurses

25 Mortality Rate Mortality (x 1/1000) Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Month of the year

26 Conclusion Appropriate antibiotic use is associated with shorter length of stay Overall prescribing behaviour of clinicians did not change over the past year Active expertise participation in patient management is recommended for achieving appropriate antibiotic use and better outcome

27 Acknowledgement Dr. Szeto Ming Leung Dr. Que Tak Lun

28 Thank you very much

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