Medicosnext
The more we use antibiotics, the more we lose antibiotics.
A young male patient with diagnosis of sepsis secondary to pneumonia was referred to us from another hospital. On reviewing his lab investigation reports, microbial culture reports of sputum, blood, and urine were missing. Chest X ray of the patient was suggestive of a pneumonic consolidation of left lower zone. The referral slip showed heaps of antibiotics covering similar spectrum, without renal dosage adjustments, dual anaerobic coverage, and interestingly, some antibiotics on the list were prescribed for duration longer than needed.
On receiving the patient in our emergency department at Karuna Hospital, he was immediately evaluated by a team comprising of an intensivist, a pulmonologist, a nephrologist, and a clinical pharmacist. Intervention was immediately called for and was done in a rational way by cancelling out antibiotics with similar spectrum, dosage adjustment according to creatinine clearance, and stopping antibiotics which were prescribed for duration longer than needed. Alongside, culture of sputum, blood, and urine were also sent for, including total blood count and differentials, procalcitonin, renal function test, and urine routine and microscopic examination. Procalcitonin reports was traced after four hours, which was suggestive of sepsis.
The team decided to upgrade the antibiotic in view of persistent sepsis marker and clinical deterioration of the patient. Interestingly, three days later, there was growth on sputum suggesting that a particular organism was sensitive only to colistin. Coincidently, the team has already put the patient on colistin while upgrading antibiotic. After five days, the patient’s condition improved gradually, his vitals were stable, and he was transferred to the medical ward. In our daily morning conference, this particular case was presented, which brought to light the importance of having an antimicrobial stewardship program (ASP) in the hospital. The hospital director, along with the hospital administration, agreed on this and decided to put this agenda in the Drug and Therapeutic Committee (DTC), which appointed internist and pulmonnologist as a director of ASP, clinical pharmacist as a member secretary, along with critical care physician, nephrologist, medical officer, and nursing-in-charge as team members. Thus, the Antimicrobial Stewardship Committee was formed at Karuna Hospital.
1. Dose Optimization Protocol
The first step taken by the ASP committee was development of a dose optimization protocol. This protocol enlisted dosage of antimicrobials, along with remarks highlighting safety warning of the particular drugs. The protocol was important because of variation in drug dosing according to individual practices. In my opinion, if one follows British text books for drug dosing, the dosing as per books written by Americans looks quite high, and vice versa.
For some physicians, the colistimethate sodium dosing with 9 miilion unit loading dose, followed by 4.5 miilion unit maintenance dose, seems inappropriate. Similarly, amoxicllin clavulnate twice dosing with 1.2 g, ceftriaxone 1 g once daily dosing, fluconazole loading dose of 800 mg, followed by maintenance dose of 400 mg, may look obnoxious, but in real world these are already being practiced and documented. In our context, for some new and not commonly used drug like teicoplanin, there is still a dosing variation within healthcare team members, because of which, patients are sometimes under-dosed or overdosed. Thus, this protocol also became somewhat of a consensus for appropriate dosing for physicians from different specialties. While developing the protocol, we considered available standard database and textbooks, and in some contexts, expert opinion and their practices, along with dosing recommended by journal articles. The ASP team is solely accountable for timely update of dose optimization protocol.
2. Segregation of Antimicrobials
The second step taken by the ASP team was segregation of antimicrobials. Antimicrobials were segregated as restricted antimicrobials and non-restricted antimicrobials. Restricted antimicrobials are second line antimicrobials, higher class antimicrobials, antimicrobials having high chances of dosing errors like fluconazole and teicoplanin, and those antimicrobials which were empirically used with off label indications. Antimicrobials with beta lactamase inhibitors were also included in the restricted antimicrobial list. To use restricted antimicrobials, permission has to be taken from the ASP team leader.
3. Antimicrobial Approval
Antimicrobial approval forms were designed to approve restricted antimicrobial use. The form contains indication for use of restricted antimicrobials (empiric, prophylactic, definitive, not responding to current antimicrobial, no alternative available, or allergic to current antibiotics), status of microbial culture and sensitivity report, creatinine clearance, and requested antimicrobial dose and dosing duration. If prescription of antimicrobials seems rationale, then approval for use of requested antimicrobial is given for 72 hours, and after that, based on culture report and patient status. The ASP team leader appointed to grant permission will decid whether or not to continue the antimicrobial. While making such a decision, physicians or surgeons involved in treatment of that particular patient will be informed, and their voice will also be heard.
In the context where a nurse ordered restricted antimicrobials without filling an antimicrobial approval form, the hospital pharmacy deserves the right to void that particular order. Hospital pharmacy also demands for carbon copy of antimicrobial approval form and keep it in their records.
The ASP team remains active from 9 am to 5 pm. If the prescription of a restricted antimicrobial is written outside this time frame, then automatic approval of restricted antimicrobial will be given for up to dose required to reach that time frame. After that, the ASP team will review and decide whether or not to grant permission for use.
4. Prescription monitoring
Prescription monitoring regarding appropriate use of antimicrobials for both categories, restricted and non-restricted, is done by a clinical pharmacist. The clinical pharmacist makes sure that the antimicrobial prescribed is rational, has been dosed appropriately for optimal duration, and administered and stored correctly. Also, that drug-drug interaction and drug-food interaction are minimized and adverse drug reactions of particular antimicrobials are watched by healthcare team members by notifying them earlier regarding possible adverse drug reactions.
5. Infusion protocol for antimicrobial administration
Recently, the ASP team has also designed a prolonged infusion protocol for certain antibiotics like meropenem, piperacillin-tazobcatum, and cefepimeetc. The reason behind this protocol is that several studies have concluded that prolonged infusion resulted in higher probability of pharmacokinetic–pharmacodynamic target achievement in ICU settings, along with higher clinical rate improvement and lower mortality. To implement infusion protocol, the major challenge was availability of extra infusion pumps. However, with support of hospital administration, extra infusion pumps were made available in the ICUs.
What next?
The future plan of the ASP team is to be more vigilant regarding antimicrobial use, and to implement antimicrobial approval more strictly. Besides that, the team is planning to gather antimicrobial sensitivity data of the hospital for a period of one year, in coordination with the microbiology department. Along with this, the team is currently working to bring out disease specific guidelines for antimicrobial use. The team has a plan to develop guidelines to switch intravenous antimicrobials to oral antibiotics.
