K Chan Specialist Registrar in General Surgery. R Ward Consultant in General Surgery. P Lal Consultant in Clinical Microbiology. Aintree University Hospital ...
Research
A collaborative antimicrobial ward round can promote prudent antimicrobial practices in an emergency general surgical unit How to minimise the risk of healthcare-acquired infections.
MG Parry Core Surgical Trainee K Chan Specialist Registrar in General Surgery R Ward Consultant in General Surgery P Lal Consultant in Clinical Microbiology Aintree University Hospital NHS Foundation Trust DOI: 10.1308/147363515X14134529300346
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T
he Surviving Sepsis Campaign by the Society of Critical Care Medicine has highlighted the importance of antibiotic use within one hour of hospital admission.1 Infection features frequently in the differential diagnosis for patients presenting to the emergency general surgical unit (EGSU). Accordingly, empirical antibiotics (often broad-spectrum) are used in initial management of these patients. Extensive use of broad-spectrum antibiotics has led to huge problems with resistance (eg methicillin-resistant Staphylococcus aureus, multidrug-resistant extended-spectrum β-lactamase-producing Enterobacteriaceae), and is implicated in many healthcare-acquired infections (HCAIs), including those caused by Clostridium difficile.2 Antimicrobial stewardship is vital to reduce HCAIs and slow the progression of antimicrobial resistance. The ‘Start Smart – Then Focus’ approach has been recommended for all antibiotic prescriptions. ‘Start Smart’ involves appropriate initiation of antibiotic regimens using local guidelines. ‘Then Focus’ emphasises the need for review by 48 hours and adoption of a clear action plan, which is termed the ‘Antimicrobial Prescribing Decision’.3 The EGSU is unique to Aintree University Hospital (AUH) in Liverpool. It encompasses a surgical admissions unit coupled with a general surgical ward. The EGSU has a high turnover of patients (>600 surgical admissions per month) and acts as a ‘nodal unit’ for management of most of the general surgical admissions to AUH. Antibiotic prescription here, therefore, dominates antibiotic prescription throughout the surgical unit. Prudent antimicrobial prescribing is a priority for the Aintree University Hospital NHS Foundation Trust (AUHNHSFT). A weekly, collaborative antimicrobial ward round (AWR) was initiated in the EGSU in January 2011 to promote prudent prescribing of antibiotics. METHODS A collaborative ward round (consultant microbiologist, antibiotic pharmacist, junior doctors, consultant general surgeon) for
the EGSU takes place every week. Presently hospitalised patients prescribed antibiotics were identified using the electronic prescribing system of AUHNHSFT. Hence, a sample of the antibiotic prescriptions on the unit was provided. During the AWR, antibiotic prescriptions were reviewed for indication, duration of the antibiotic course, and compliance with the formulary of AUH. An incorrect ‘stop date’ was defined as when the stop date did not adhere to the prescribing guidelines of the hospital. Clinical records and microbiology results were reviewed and antibiotic treatment adjusted accordingly. A prescription was deemed to be ‘appropriate’ by the consultant microbiologist and consultant general surgeon with regard to adherence to the antibiotic protocol of AUHNHSFT. Data were collected prospectively for 10 months (February to December 2011) using a standardised proforma (Tables 1–3). Daily defined doses per 1,000 occupied bed days (DDDs/1,000OBDs) were calculated for this period, and also from February to December 2010. DDD was calculated according to criteria set by the World Health Organization.4 RESULTS Between February and December 2011, data were collected on 18 non-consecutive, collaborative ward rounds. A total of 117 patients who had been prescribed antibiotics were the study cohort. All patients had drug-allergy status documented on the electronic prescribing system. An indication for starting antibiotics was documented in 85 patients (72.6%). Eightyone patients (69.2%) had an absent or incorrect stop/review date. Of these patients: 59 (50.4%) had no stop/review date; 19 (16.2%) had a stop date prescribed but a review date was deemed more appropriate; 3 patients (2.6%) had incorrect durations of an antibiotic course. The latter three patients were considered to be an ‘inappropriate prescription’ owing to the failure to adhere to the hospital formulary and were, therefore, used in the further analysis shown below. Thirty
Table 1 Proforma headings used for data collection on the weekly antimicrobial ward round in the emergency general surgical unit at Aintree University Hospital in Liverpool Proforma heading Patient Name/Identifier Consultant Antibiotic Prescription Indication Documented (Y/N) If Yes, List Indication Stop/Review Date Documented (Y/N) Appropriate Therapy (Y/N) If No, List Reason Ward Round Intervention/Comments/Follow-Up
Table 2 Reasons for inappropriate microbiology therapy, present on the proforma, used on the weekly antimicrobial ward round in the emergency general surgical unit at Aintree University Hospital in Liverpool Reason for inappropriate therapy No appropriate indication for starting antibiotic(s) Indication but no antibiotic prescribed Incorrect antibiotic(s) Incorrect route Incorrect dose/frequency Incorrect stop date Prolonged duration of antibiotic course Not acted on available microbiology data Penicillin allergy Result of antibiotic assay out of desired range
Table 3 Possible interventions, present on the proforma, adopted on the weekly antimicrobial ward round in the emergency general surgical unit at Aintree University Hospital in Liverpool Intervention Antibiotic stopped Antibiotic changed Dose/frequency changed Route changed Antibiotic started Stop date changed to shorter course Stop date recorded Stop date changed to longer course Microbiology data acted upon Results of antibiotic assay acted upon Advice ignored Oral-to-intravenous switch e10
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Table 4 Observed bed days (OBD) and daily defined doses (DDD) in the emergency general surgical unit at Aintree University Hospital in Liverpool for February to December 2010 and from February to December 2011 Time period
OBD
DDD
DDD/1,000 OBD
February–December 2010
8,984
12,820
1,427
February–December 2011
9,288
9,259
997
patients (25.6%) were found to be on inappropriate antibiotic therapy (two of which had multiple incorrect prescriptions). Figure 1 highlights the reasons for the inappropriate antibiotic prescriptions. In total, 32 antibiotic prescriptions were amended during the study period. Of the patients who were on inappropriate antibiotic therapy, 12 patients (40%) had no appropriate indication for starting antibiotics. Two-thirds of these patients were found to have had an incorrect diagnosis of a urinary tract infection (UTI) or pyelonephritis (patients with absent urinary symptoms and either a negative urine test or urine culture on the ward). Other cases included incorrect prophylactic use of antibiotics in trauma and in undiagnosed abdominal pain. Another 12 patients (40%) were prescribed incorrect antibiotics. Half of these cases were because of a failure to adhere to the antibiotic policy of the AUHNHSFT, including prescription of metronidazole alongside tazocin and inappropriate antibiotics for specific dental/submandibular abscesses. The remaining half of cases was because of failure to amend the antibiotic prescription after revision of the diagnosis following further investigation or procedural intervention. This may have come after negative results for CT, endoscopic retrograde cholangiopancreatography or a laparotomy. In one patient, antibiotics were not stopped after appropriate surgical intervention for a perforated duodenal ulcer even though there was no evidence of purulent peritonitis. Four patients (13.3%) had available results for microbiology cultures that had not been acted upon. These were cases of an abdominal collection, liver abscess, and two cases of pyelonephritis. Three patients (10%) had incorrect stop dates, and another patient had e11
an incorrect frequency of administration of benzyl penicillin, which showed that antibiotic policy for course length and/or frequency had not been followed. Since introduction of the weekly AWR on the EGSU, a reduction in the DDDs/1,000 OBDs of 30% has been observed based on data from February to December 2011 compared with the same timeframe in the previous year (see Table 4). DISCUSSION The AWR takes place once a week, so it is only a ‘snapshot’ of antibiotic activity in the EGSU. The AWR can highlight the reasons why inappropriate antibiotics have been prescribed so that this crucial information can be fed back to the physicians who carried out the prescribing. The AWR was employed to amend antibiotic prescriptions, and resulted in a reduction of DDDs/1,000 OBDs of 30%. This approach reduces the prevalence of HCAIs by reducing unnecessary exposure to antibiotics. The AWR should not act as a failsafe mechanism for antibiotic prescription but instead highlight areas for change surrounding antibiotic use among surgical trainees. In the present study, we highlighted three key issues with regard to antibiotic prescribing: (i) accurate documentation; (ii) awareness of the antibiotic formulary; (iii) antibiotic review after 24/48 hours. Documentation plays a vital part in antibiotic prescription. With introduction of electronic prescribing to hospital trusts throughout the UK, documentation of allergy status has improved substantially. This phenomenon may be because ‘alert boxes’ prevent further prescription without its completion, and keeps drug allergy a top priority for physicians in charge of hospital admission.
Documentation of allergy status was good, but documentation of an appropriate stop date was unacceptably poor. This result emphasises the need for the prescribing clinician to always add a stop date to each antibiotic prescription. If the diagnosis is in doubt during the initial stages of hospital admission, or if clinical response requires modification of course length, highlighting the need for a review of the course length is an acceptable alternative. Our results highlight the need for increased awareness of the antibiotic formulary. Many inappropriate prescriptions were attributable to not following hospital guidelines. Many options are available and vary nationwide with regard to use of electronic/paper formularies. Antibiotic cards attached to the lanyards of junior doctors are now commonplace at AUH, and distributed at induction. Development of an application for mobile phones detailing the antibiotic formulary would also be a welcome addition to the busy schedule of the admitting physician, and could maximise correct use of antibiotics. Clinicians must be reminded of the appropriate indication for antibiotics, especially with diagnoses of pyelonephritis or a UTI. Awareness of the need for a positive urine test or positive urine culture on the ward and urinary symptoms is important, and can be achieved with interactive educational sessions for clinicians.5 Highlighting this requirement as part of the induction for junior doctors may help reduce inappropriate use of antibiotics. Another deficiency highlighted in the present study was the need for prescribing amendments. Patients started on empirical antibiotics initially were continued on these antibiotics despite available microbiology data or further investigation suggesting otherwise. The need for antibiotics must be reassessed by adjusting the regimen, or even stopping it completely. If a diagnosis is in doubt and empirical antibiotics have been started, the need for review at 24/48 hours is required and antibiotics continued, changed or stopped based on the clinical picture.
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Reason for not being on the appropriate antibiotics Figure 1 Reasons for inappropriate antibiotic prescriptions for patients admitted to the the emergency general surgical unit at Aintree University Hospital in Liverpool for February to December 2011
CONCLUSION The AWR at AUH was used to correct the antibiotic prescriptions deemed inappropriate a quarter of the time, and reduce the DDDs/1,000 OBDs of antibiotics. It is an excellent tool for highlighting areas for improvement in antibiotic prescribing and could improve standards of patient care. Emphasis must be placed on the importance of appropriate prescribing according to the antibiotic formulary with accurate documentation, and to amend these prescriptions pending further investigation, microbiology data, or period of observation.
Improving the quality of antibiotic prescribing in the NHS by developing a new Antimicrobial Stewardship Programme: Start Smart – Then Focus. J Antimicrob Chemother 2012; 67(S1) :i51–i63. 4. WHO Collaborating Centre for Drug Statistics Methodology. Definition and general considerations, (updated 17 December 2003) (available at: www.whocc. no/ddd/definition_and_general_considera/) [accessed 17 November 2014]. 5. Trautner BW. Asymptomatic bacteriuria: when the treatment is worse than the disease. Nat Rev Urol 2011; 9: 85–93.
REFERENCES 1. Dellinger RP, Levy MM, Rhodes A et al. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and shock, 2012. Crit Care Med 2013; 39: 165–228. 2. Gould IM. Controversies in infection: infection control or antibiotic stewardship to control healthcare-acquired infection? J Hosp Infect 2009; 73: 386–391. 3. Ashiru-Oredope D, Sharland M, Charani E et al.
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