Quality indicators of antibiotic

prescribing
Arjana Tambi Andraevi
University Hospital for Infectious Diseases Dr. F. Mihaljevi
Zagreb
Slika bacteria resistant to
antibiotics
 Antibiotic Resistance Control in Croatia

Croatian Committee for Antibiotic Resistance Surveillance, Craotian

Academy of Medical Sciences, 1996
Reference Center for Antibiotic Resistance Surveillance, University
Hospital for Infectious Diseases, 2003
Intersectorial Coordination Mechanism: Interdisciplinary Section for
Antibiotic Resistance Control (Interdisciplinarna sekcija za kontrolu
rezistencije na antibiotike, ISKRA), Ministry of health and Social
Welfare, 2006

European Antimicrobial Resistance Surveillance System, (EARSS)

2000
European Surveillance of Antibiotic Consumption, (ESAC), 2002
Alliance for prudent Use of Antibiotics (APUA) Croatia Chapter
 Total antibiotic use in hospital care in 2002, ESAC data

HC use in DDD/1000 inhabitants/day 4.0

3.5

3.0

2.5

2.0
Others*

1.5 Sulfonamides J01E

Quinolones J01M

1.0 Macrolides J01F

Tetracyclines J01A
0.5
Cephalosporins J01D

Penicillins J01C
0.0
FI FR HR LU PL BE GR EE SI MT DK SK HU SE NO
MRSA in 2007
 K. pneumoniae
3rd Generation Cephalosporin resistance, EARSS 2007
 P. aeruginosa
Carbapenem resistance, EARSS 2007
 Outpatient antibiotic use in 25 European countries in 2003*

Others

30 Sulfonamides (J01E)
Tetracyclines (J01A)

25 Quinolones (J01M)
DDD / 1000 inabitants / day

Macrolides (J01F)
Cephalosporins (J01D)
20
Penicillins (J01C)

15

10

0
Luxembourg

Finland
Portugal

Hungary

Norway
Poland
France

Croatia

Czech Rep.

Germany

Austria
Ireland

Sweden

Denmark
Spain

UK
Belgium

Netherlands
Estonia
Iceland
Slovakia

Slovenia
Italy

Israel
Greece

* For Iceland total data are use; for Poland 2002 data are used.
 Streptococcus pneumoniae
Penicillin non-susceptibility, EARSS 2007
 Escherichia coli
Fluoroquinolone resistance 2004

Escherichia coli
Fluoroquinolone resistance 2007
Can We Estimate Quality of Antimicrobial
Prescriptions from Consumption Data?

On a national level
Trends in consumption over the years
Success of interventions
Adherence to ISKRA national guidelines

In an individual hospital
Trends in consumption over the years
Success of interventions
Adherence to local guidelines
 Definitions
Quality: degree to which a set of inherent
characteristics (of a process) fulfills requirements (ISO
9000)

Quality indicator: a (retrospectivly) measurable aspect

of care provided for which there is evidence and / or
consensus that it represents quality (Campbell, BMJ 2003;
326:816)

Antibiotc prescribing quality indicator:

appropriateness of antimicrobial drug prescribing and
administration in hospital care, with reference to national
standards and international, national or local practice
guidelines
 Quality indicators
structure indicators (human and technical resources,
system organisation)
antibiotic management team
antibiotic guidelines
education programs
laboratory services
pharmacy services
IT support
process indicators
adherence to diagnostic and treatment guidelines in individual
patient care (drug choice, dosage, timing, duration)
outcome indicators
Clinical (cure rate, morbidity, mortality)
Microbiological (eradication rate)
Economic (drug consumption, treatment cost, length of stay)
Ecological outcomes (resistance rates)
 Performance audits

Audit:
analysis of appropriateness of individual
prescriptions Gould IM et al. JAC 1994;34:21-42
Simple audits
Point prevalence, baseline
Intervention audits
Before and after
 Performance audit criteria
Justification of the prescription
Are the criteria for infection met
Is there an indication for any antimicrobial drug
Choice of drug
More effective alternative
Less toxic alternative
Less expensive alternative
Narrower spectrum alternative
Dosing, route of administration
Switch from i.v. to oral
Duration of treatment, timing
Surgical prophylaxis
Empirical therapy

JWM van der Meer, I Gyssens CMI, 2001 // I Gyssens, Int J Antimicrob Agents, 2001
 Choice of drug
Empiric therapy
most likely causative microorganism
surveillance data on local sensitivity patterns
local guidelines for clinical syndromes
drug availability and prompt administration

Definitive therapy
Adjustment of the initial antimicrobial therapy, streamlining
Good communication with the microbiology laboratory from
request of the test to interpretation and application of the
results
 Who should perform audits

Clinical microbiologists
Infectious diseases clinicians
Clinical pharmacists / clinical
pharmacologists

Feedback of results: part of an intervention to

optimize the use of antibiotics
Educational tools for students and residents in
CM, ID, CF
I Gyssens, Int J Antimicrob Agents, 2001
 ABS International
www.abs-international.eu

Antibiotic prescribing quality indicators

Clinical relevance
Ecological relevance
Economic relevance
Validity
Generalisability
Assumed feasibility
 ABS International
www.abs-international.eu

Top 5 Structure indicators

Hospital multidisciplinary antibiotic management
team (AMT)
Antimicrobial drug formulary / annual updates
Annual update of local clinical guidelines for
empirical therapy based on review of local
resistance data
Local clinical guidelines for surgical prophylaxis
Guidelines for iv to oral switch available
 ABS International
www.abs-international.eu

Top 5 Outcome indicators

Total annual antibacterial consumption
Number of antibiotics to which resistance in major
pathogens increased >5% during the last year
Cumulative incidence of surgical interventions with
postoperative surgical site infection
Percentage of consumption iv vs iv+oral
Ratio between broadspectrum beta-lactam vs non-
broadspectrum beta-lactam
 ABS International
www.abs-international.eu

Top 4 Prophylaxis indicators

Prophylaxis indicated
Appropriate drug choice
Prophylactic antibiotic discontinued within 24
hours after surgery end time (except exceptions
Prophylaxis is started preoperatively within 30-
60 min before incision
 ABS International
www.abs-international.eu

Top Therapy indicators

Appropriate drug choice for indication vs local guideline
HAP / VAP
reassess and streamline AB therapy on day 3 based on culture results and
clinical response
discontinue appropriate AB therapy on day 7 if clinical response and non
Pseudomonas / MDR
AB therapy selected based on MDR risk factors and local microbial
epidemiology
quantitative culture of LRTI secretions performed prior to ATB therapy
Patients with S.aureus bacteremia
echocardiography performed
evaluated for foreign body
Iv catheter removal within 3 days
10 days appropriate treatment
Appropriate monitoring of blood level and dosing adjustment of
aminosides and glycopeptides
CAP
empiric therapy according to national guidelines
2 sets of blood cultures before first AB dose
Legionella urinary antigen
sputum sample for Gram stain and culture
ESAC II Hospital Care Subproject
Point Prevalence Study

20 hospitals participated

3 496 / 11 571 patients on antibiotics (30%)

3 655 treatments

52 DDD/100 admitted patients (33-88)

Indication for antibiotics
Pneumonia (19%)
Skin & soft tissue infections (13%)
 ESAC II Hospital Care Subproject
Point Prevalence Study

47% Comunity acquired

infections 7%
17%
47%
29% Hospital acquired
29%
infections
7% medical prophylaxis
17% peri-operative
prophylaxis
CAI HAI Med. Pr. Surg. Pr.
Total DDD per 100 admitted patients (adults)

ESAC II
Hospital Care
Subproject
2006
 Lenghth of pre-operative prophylaxis in surgical
specialities
ESAC II Hospital Care Subproject, 2006

100
90
80
70

60
50
40
30

20
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one dose 24h >24h

 University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

55% of patients on 3%
antibiotic therapy 55%
43% of patients without 43%
antibiotic therapy
3% medical prophylaxis

ATB No ATB Med. Pr.

 University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

84% Comunity acquired

8%
infections 8%
84%
8% Hospital acquired
infections
8% medical prophylaxis

CAI HAI Med. Pr.

Indication for antibiotic prescribing
University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

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Frequency of antibiotic prescribing
University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006
 Indication for specific antibiotic use
University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

Antibiotic Indications

Ceftriaxon Fev, Sep, Pneum, Ge, CNS, Boj,

Mot, Sst, Pye

Ciprofloxacin Pye, Sst, Ge, Boj, Fev, Sep

Co-amoxiclav Fev, Pneum, Pye, Urt, Sst, Mot

 Indication for specific antibiotic use
University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

Indication Antibiotics

Crystacillin (5), Gentamicin (3),

Skin & soft tissue Ciprofloksacin (3), Klindamicin (3),
Plivacillin (2), Klavocin (2), Orbenin (2),
Kefzol (1),Netilmicin (1), Extencillin (1),
Nolicin (1), Tazobaktam (1), Ceftriakson
(1)
Klavocin (11), Ciprofloksacin (5),
Pyelonephritis Gentamicin (2), Cefixim (2), Sinersul (2),),
Ninur (2), Cefipim (2), Ceftriakson (1),
Ampicilin (1), Ketocef (1 (Flukonazol)(1)
Sumamed (3), Klavocin (2), Doksiciklin (2),
Pneumonia Ceftriakson (2), Avelox (1)
 Appropriateness of antibiotic use
University Hospital for Infectious Diseases
Point Prevalence Study, 2006
ESAC II Hospital Care Subproject, 2006

35% adeqate antibiotic

1% 5%
therapy 35%
59% adeqate empiric 59%
antibiotic therapy
1% inappropriate choice
of antibiotics
5% other mistakes
adequate adequate empiric
inappropriate other
 Performance audits
Data accessibility
Routinly available administrative and clinical
records
Data collection workload
Number of indicators possible to validate with
time and human resources available
Indicator reliability
Inter-observer variations
Quality indicators.......
Questionnaires.......
Auditing..............