- Email: [email protected]
P2101 Do antibiotic ward rounds improve antibiotic prescribing?
Quality of antibiotic prescribing colonised with an isolate with high level resistance to Tobramycin, most will remain colonised (7/10). The isolation of HLR P aeruginosa didn’t cease once TSI therapy was stopped. Reference(s) [1] Longitudinal development of tobramycin resistance in Pseudomonas aeruginosa isolates from children with cystic fibrosis on nebulised tobramycin – effects on clinical outcomes. Doyle M, McNally P, Leen G, Dier J, Greally P, Murphy P. ECCMID, 2006.
P2099 Strong association between ciprofloxacin use and ciprofloxacin resistance within a hospital I. Willemsen, A. Heijneman, D. Bogaers-Hofman, J. Kluytmans (Breda, NL) Objectives: In the last years the use of ciprofloxacin in our hospital has increased significantly. The objective of this study was to determine the increase of resistance over time and to determine if the density of antibiotic use correlates with the resistance in E. coli within individual hospital units. Method: The density of the use of ciprofloxacin (cip), amoxicillin + clavulanic acid (amcl), 1st- and 2nd-generation cephalosporins (cef) and trimethoprim/Sulfamethoxazole (sxt) was measured in 6 consecutive one-day prevalence-surveys between 2001 and 2004. The susceptibility patterns from E. coli were obtained from the Laboratory Information System between 2003 and 2006. The percentage of resistance to cip, amcl, cef and sxt in E. coli isolates was calculated per unit and over time. Results: A total of 4105 patients were included in the prevalencesurveys. 23% (938) of the patients were on antibiotics, of whom 12.8% (120) were treated with cip, 39.1% (367) with amcl, 13.2% (124) with cef and 5.7% (53) with sxt. 4790 E. coli susceptibility patterns were obtained from hospitalised patients. There was a significant increase of resistance over time for all antibiotics, except for SXT, and a significant correlation between the prevalence of use and the percentage of resistance for cip (R = 0.795, p = 0.006), amcl (R = 0.860, p = 0.001) and cef (R = 0.828, p = 0.003). For cip the urology unit rose above the other units with a use of 9.9% and a resistance rate of 19.8%. Also cip resistance showed the strongest increase over time.
Conclusion: This study shows that cip resistance is associated with the density of its use even on the micro-level of a hospital unit, and its
S607 use has the strongest association with resistance of all frequently used groups of antimicrobial-agents in the hospital.
Quality of antibiotic prescribing P2100 Appropriateness of antibiotic therapy on weekends vs weekdays J. Bishara, D. Hershkovitz, S. Pitlik (Petah-Tiqwa, IL) Background: Several recent reports have raised concerns about the adequacy of medical care provided by hospitals on weekends. Antibiotic resistance is an emerging and universal problem and one of its major contributors is the inappropriate prescription of antibiotics. Objective: To compare the appropriateness of antibiotic treatment prescribed in an emergency department (ED) of a tertiary medical centre on weekdays and weekends. Methods: During a one month period medical charts of 1029 ED visits, who were discharged from ED were reviewed. Data of patients that were discharged with antibiotics was blindly evaluated by two infectious diseases specialists, and an “appropriateness score” was given to the antibiotic prescription. Results: Antibiotics were prescribed at discharge for182 (17.7%) patients. The appropriateness score was significantly better at the beginning of the week and declined progressively toward the weekend (p = 0.025). Appropriateness scores were higher for the surgical and urological wings (p = 0.011), and for diagnoses of pneumonia and urinary tract infection (p = 0.005). Time of the day, patients age and sex did not have a significant effect on the appropriateness score. Conclusions: During the week, there is a progressive decay in the appropriateness of antibiotic prescriptions in the ED. More studies are needed to clarify measures improving appropriate antibiotic therapy in weekends. P2101 Do antibiotic ward rounds improve antibiotic prescribing? J. Hinton, M.S. Kyi, S. Barnass (Isleworth, Middlesex, UK) Objectives: – To review all prescription charts for patients receiving restricted antibiotics to ensure they are in line with the Trust Antibiotic Guidelines or have been approved by one of the medical microbiologists – To ensure antibiotics are stopped appropriately. – To optimise timing and choice of switch from intravenous to oral antibiotics. – To provide ongoing education of staff during the review. – To ensure ward staff are aware that the prescriptions are reviewed. – To inform guidelines on review of antibiotics for pharmacists new to the Trust. Methods: Ward antibiotic charts were reviewed weekly (on different days of the week and at different times) between May 2005 and October 2006 by the Senior Antibiotic Pharmacist and one of the Consultant Microbiologists. All patients’ charts for whom restricted antibiotics had been prescribed were reviewed, and patients were often reviewed on several occasions. Changes were made or antibiotics stopped, as appropriate, after consultation with the doctors looking after the patient and explanation of the rationale. If the medical staff could not be contacted, a note was left in the medical notes or on the prescription chart to request review. Results: A total of 403 patients’ charts were reviewed (mean 22 per month, range 5−50). Of these, 212 (52.6%) had been approved by the medical microbiologist or were in line with the Trust Antibiotic Guidelines. 224/403 (55.5%) antibiotics were continued and 180/403 (44.5%) were changed or stopped. The mean number changed or stopped per month was 10 (45.5%), with a range of 1−24 (11−69%). The percentage of restricted antibiotics approved by the medical microbiologists or in line with the Trust Antibiotic Guidelines, and the percentage of antibiotics changed or stopped, did not change over the course of the study or with the experience of the cohort of junior doctors,
S608 the majority of whom change posts at the beginning of August each year. Junior ward staff know who we are and we deal with medical and pharmacy enquiries on our round. Unused restricted antibiotics are taken back to pharmacy, decreasing the likelihood of their use. Other prescribing problems which are found are addressed. Conclusion: We have not seen an improvement in prescribing of restricted antibiotics, but we expect a continuing need to review charts and educate staff. We plan to improve the prescription charts with a box for the indication and duration of treatment. Guidelines to assist new pharmacists have been compiled. P2102 Pre-admission penicillin in patients with meningitis or meningococcal disease J.M. Darville, A.M. Lovering, A.P. MacGowan (Bristol, UK) Objectives: UK government guidelines recommend that patients with suspected meningitis or meningococcal disease receive intra-muscular penicillin before admission to hospital. This study assesses adherence to these guidelines by determining the frequency of such antibiotic use in the area served by North Bristol Trust hospitals in a 6 year period. Methods: Laboratory computer records were searched for patients from whom Neisseria meningitidis was isolated from any sample, and for those from whom Streptococcus pneumoniae or Haemophilus influenzae were isolated from CSF samples. Hospital computer records were searched for patients for whom the final diagnosis was infectious meningitis. Personal, demographic, clinical and therapeutic data were extracted from patients’ hospital notes. To estimate the extent of preadmission illness, 10 presenting symptoms consistent with meningitis or meningococcal disease were each allocated one point. The data were transferred to a data-base for analysis. Results: Mean severity scores are in brackets. 57 patients (2.9) did not see a doctor (medical practitioner) pre-admission. 7 of these had meningococcal septicaemia, 46 had meningitis (15 meningococcal) and 2 had meningococcal infection. 149 patients (3.36) did see a doctor. 40 (3.75) of these had antibiotic and 109 (3.21) did not. Of the 40, 4 had septicaemia (all meningococcal) and 35 had meningitis (11 meningococcal). Of the 109, 13 had septicaemia (all meningococcal) and 90 had meningitis (29 meningococcal). 72 patients (3.15) had meningococcal disease. 48 (3.15) of these saw a doctor, 24 (3.17) did not. Of the 48, 15 (3.67) had antibiotic, 33 (2.91) did not. 46 (3.44) patients with rash saw a doctor.18 (3.72) of these had antibiotic, 28 (3.25) did not. Of 32 (3.28) patients with meningococcal disease and rash seeing a doctor, 13 (3.69) had antibiotic, 19 (3.0) did not. 175 patients (3.3) had meningitis. 125 (3.47) of these saw a doctor, and of these 35 (3.77) had antibiotic, 90 (3.36) did not. Conclusions: Patients may be more likely to receive pre-admission antibiotic the more symptoms they present with, when a rash is present or when Neisseria meningitidis is subsequently isolated. However, the majority of patients with meningitis or meningococcal disease seeing a doctor before admission did not receive antibiotic. Our study suggests that the guidelines have not been adequately observed and that it may necessary to revise them. P2103 Value of early serum assay for dosage adjustment of vancomycin in continuous infusion A. Forgeot, A. Carricajo, J. Morel, C. Venet, P. Mahul, S. Guyomarc’h, N. Fonsale, C. Auboyer, F. Zeni, G. Aubert (Saint-Etienne, FR) Objective: It is difficult to obtain rapid bactericidal effects with vancomycin (V) due to the increased MIC for staphylococcal strains (in particular hetero-glycopeptide intermediate Staphylococcus aureus). The aim of this study was to obtain a serum concentration for V (SCV) of between 25 and 30 mg/L and a serum concentration/MIC ratio of >8 within first 24 hours in patients receiving V in a continuous infusion. Methods: In 2005 and 2006, all patients requiring treatment with V in the two study ICUs were given a loading dose of V of 30 mg/kg in a
17th ECCMID / 25th ICC, Posters 1-hour infusion followed by V at a dosage of 30 mg/kg/24 h. Creatinine clearance (CLc) was required to be >50 mL/min. Dosage was adjusted daily using a predetermined algorithm according to results of SCV: SCV < 25 mg/L, dosage increased by 4 to 8 mg/kg/24 h; SCV > 30 mg/L, dosage reduced by 4 to 8 mg/kg/24 h. V concentrations were measured by FPIA kit (Abbott, USA) and the MIC for V was determined using the E-Test method (AB Biodisk, Sweden). Results: 21 patients were included in the study, 11 of whom presented documented infection (coagulase-negative Staphylococcus sp and Staphylococcus aureus with MIC between 0.5 and 3 mg/L). Mean CLc was 105 mL/min (range 50 to 178), mean body weight was 83 kg (range 60 to 115), and SAPS II was 42.4 (range 22 to 64). A serum concentration of V 26.5 mg/L within 6 hours of the start of treatment (best cut-off) was predictive of a concentration of V in excess of 25 mg/L at 24 h. The positive predictive value was 100% for the 14 patients with CLc < 120 mL/min and 90% for all 21 patients. Conclusion: The target concentration for V of between 25 and 30 mg/L was achieved within 24 hours using our protocol in patients with CLc < 120 mL/min. Concentrations of V below the target level were seen in patients with CLc > 120 mL/min. Assay of V 6 hours after the start of treatment allowed early dosage adjustment. The serum concentration target must be reassessed on achievement of the MIC for V with regard to the offending staphylococcal strain. P2104 Surgical antibiotic prophylaxis in a Turkish university hospital S. Serin Senger, T. Togan, O. Kurt Azap, F. Timurkaynak, H. Arslan (Ankara, TR) Objective: Since surgical site infections are important causes of morbidity, mortality, and healthcare costs, we aimed to assess the appropriateness of use of surgical antimicrobial prophylaxis at our institution. Methods: A retrospective evaluation of the use of antimicrobial prophylaxis in patients undergoing major surgery at Ba¸skent University Hospital from July to September 2006 was carried out. The surgical operations included were liver and kidney transplantations, cardiovascular surgery, urological operations, neurosurgical operations, head and neck surgeries, orthopaedic surgery, breast surgery, general abdominal colorectal surgery, and abdominal and vaginal hysterectomy. Patients having infectious diseases prior to the surgery were excluded. The guidelines to assess choice of antimicrobial agent and duration of prophylaxis, were ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery (1999), IDSA (Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project) (2004), and Sanford Guide (2005). Results: A total of 148 patients with a mean age of 41.9 years (ranged 1−89 with SD = 24.5) were included in the study. General Surgery was the leading department where 50 (33.8%) of the operations were performed. Cefazolin was the most commonly used antibiotic (constituting 48.0% of all the antimicrobial agents) during the study period. In 77 (52.0%) of the cases the prophylaxis decisions were appropriate, with proper choices of antibiotics in 51 cases and omissions in 26, in accordance with the guidelines. Unnecessary prolongation of prophylaxis in the patients of appropriately chosen antibiotics was found to be 41.0%. Conclusion: The results showed a significantly high level of inappropriate use of antimicrobial prophylaxis in our institution. To improve the proper use of prophylactic antimicrobials, the infection control committee planned to prepare a local guideline and to organise educational sessions for the surgeons.
P2099 Strong association between ciprofloxacin use and ciprofloxacin resistance within a hospital I. Willemsen, A. Heijneman, D. Bogaers-Hofman, J. Kluytmans (Breda, NL) Objectives: In the last years the use of ciprofloxacin in our hospital has increased significantly. The objective of this study was to determine the increase of resistance over time and to determine if the density of antibiotic use correlates with the resistance in E. coli within individual hospital units. Method: The density of the use of ciprofloxacin (cip), amoxicillin + clavulanic acid (amcl), 1st- and 2nd-generation cephalosporins (cef) and trimethoprim/Sulfamethoxazole (sxt) was measured in 6 consecutive one-day prevalence-surveys between 2001 and 2004. The susceptibility patterns from E. coli were obtained from the Laboratory Information System between 2003 and 2006. The percentage of resistance to cip, amcl, cef and sxt in E. coli isolates was calculated per unit and over time. Results: A total of 4105 patients were included in the prevalencesurveys. 23% (938) of the patients were on antibiotics, of whom 12.8% (120) were treated with cip, 39.1% (367) with amcl, 13.2% (124) with cef and 5.7% (53) with sxt. 4790 E. coli susceptibility patterns were obtained from hospitalised patients. There was a significant increase of resistance over time for all antibiotics, except for SXT, and a significant correlation between the prevalence of use and the percentage of resistance for cip (R = 0.795, p = 0.006), amcl (R = 0.860, p = 0.001) and cef (R = 0.828, p = 0.003). For cip the urology unit rose above the other units with a use of 9.9% and a resistance rate of 19.8%. Also cip resistance showed the strongest increase over time.
Conclusion: This study shows that cip resistance is associated with the density of its use even on the micro-level of a hospital unit, and its
S607 use has the strongest association with resistance of all frequently used groups of antimicrobial-agents in the hospital.
Quality of antibiotic prescribing P2100 Appropriateness of antibiotic therapy on weekends vs weekdays J. Bishara, D. Hershkovitz, S. Pitlik (Petah-Tiqwa, IL) Background: Several recent reports have raised concerns about the adequacy of medical care provided by hospitals on weekends. Antibiotic resistance is an emerging and universal problem and one of its major contributors is the inappropriate prescription of antibiotics. Objective: To compare the appropriateness of antibiotic treatment prescribed in an emergency department (ED) of a tertiary medical centre on weekdays and weekends. Methods: During a one month period medical charts of 1029 ED visits, who were discharged from ED were reviewed. Data of patients that were discharged with antibiotics was blindly evaluated by two infectious diseases specialists, and an “appropriateness score” was given to the antibiotic prescription. Results: Antibiotics were prescribed at discharge for182 (17.7%) patients. The appropriateness score was significantly better at the beginning of the week and declined progressively toward the weekend (p = 0.025). Appropriateness scores were higher for the surgical and urological wings (p = 0.011), and for diagnoses of pneumonia and urinary tract infection (p = 0.005). Time of the day, patients age and sex did not have a significant effect on the appropriateness score. Conclusions: During the week, there is a progressive decay in the appropriateness of antibiotic prescriptions in the ED. More studies are needed to clarify measures improving appropriate antibiotic therapy in weekends. P2101 Do antibiotic ward rounds improve antibiotic prescribing? J. Hinton, M.S. Kyi, S. Barnass (Isleworth, Middlesex, UK) Objectives: – To review all prescription charts for patients receiving restricted antibiotics to ensure they are in line with the Trust Antibiotic Guidelines or have been approved by one of the medical microbiologists – To ensure antibiotics are stopped appropriately. – To optimise timing and choice of switch from intravenous to oral antibiotics. – To provide ongoing education of staff during the review. – To ensure ward staff are aware that the prescriptions are reviewed. – To inform guidelines on review of antibiotics for pharmacists new to the Trust. Methods: Ward antibiotic charts were reviewed weekly (on different days of the week and at different times) between May 2005 and October 2006 by the Senior Antibiotic Pharmacist and one of the Consultant Microbiologists. All patients’ charts for whom restricted antibiotics had been prescribed were reviewed, and patients were often reviewed on several occasions. Changes were made or antibiotics stopped, as appropriate, after consultation with the doctors looking after the patient and explanation of the rationale. If the medical staff could not be contacted, a note was left in the medical notes or on the prescription chart to request review. Results: A total of 403 patients’ charts were reviewed (mean 22 per month, range 5−50). Of these, 212 (52.6%) had been approved by the medical microbiologist or were in line with the Trust Antibiotic Guidelines. 224/403 (55.5%) antibiotics were continued and 180/403 (44.5%) were changed or stopped. The mean number changed or stopped per month was 10 (45.5%), with a range of 1−24 (11−69%). The percentage of restricted antibiotics approved by the medical microbiologists or in line with the Trust Antibiotic Guidelines, and the percentage of antibiotics changed or stopped, did not change over the course of the study or with the experience of the cohort of junior doctors,
S608 the majority of whom change posts at the beginning of August each year. Junior ward staff know who we are and we deal with medical and pharmacy enquiries on our round. Unused restricted antibiotics are taken back to pharmacy, decreasing the likelihood of their use. Other prescribing problems which are found are addressed. Conclusion: We have not seen an improvement in prescribing of restricted antibiotics, but we expect a continuing need to review charts and educate staff. We plan to improve the prescription charts with a box for the indication and duration of treatment. Guidelines to assist new pharmacists have been compiled. P2102 Pre-admission penicillin in patients with meningitis or meningococcal disease J.M. Darville, A.M. Lovering, A.P. MacGowan (Bristol, UK) Objectives: UK government guidelines recommend that patients with suspected meningitis or meningococcal disease receive intra-muscular penicillin before admission to hospital. This study assesses adherence to these guidelines by determining the frequency of such antibiotic use in the area served by North Bristol Trust hospitals in a 6 year period. Methods: Laboratory computer records were searched for patients from whom Neisseria meningitidis was isolated from any sample, and for those from whom Streptococcus pneumoniae or Haemophilus influenzae were isolated from CSF samples. Hospital computer records were searched for patients for whom the final diagnosis was infectious meningitis. Personal, demographic, clinical and therapeutic data were extracted from patients’ hospital notes. To estimate the extent of preadmission illness, 10 presenting symptoms consistent with meningitis or meningococcal disease were each allocated one point. The data were transferred to a data-base for analysis. Results: Mean severity scores are in brackets. 57 patients (2.9) did not see a doctor (medical practitioner) pre-admission. 7 of these had meningococcal septicaemia, 46 had meningitis (15 meningococcal) and 2 had meningococcal infection. 149 patients (3.36) did see a doctor. 40 (3.75) of these had antibiotic and 109 (3.21) did not. Of the 40, 4 had septicaemia (all meningococcal) and 35 had meningitis (11 meningococcal). Of the 109, 13 had septicaemia (all meningococcal) and 90 had meningitis (29 meningococcal). 72 patients (3.15) had meningococcal disease. 48 (3.15) of these saw a doctor, 24 (3.17) did not. Of the 48, 15 (3.67) had antibiotic, 33 (2.91) did not. 46 (3.44) patients with rash saw a doctor.18 (3.72) of these had antibiotic, 28 (3.25) did not. Of 32 (3.28) patients with meningococcal disease and rash seeing a doctor, 13 (3.69) had antibiotic, 19 (3.0) did not. 175 patients (3.3) had meningitis. 125 (3.47) of these saw a doctor, and of these 35 (3.77) had antibiotic, 90 (3.36) did not. Conclusions: Patients may be more likely to receive pre-admission antibiotic the more symptoms they present with, when a rash is present or when Neisseria meningitidis is subsequently isolated. However, the majority of patients with meningitis or meningococcal disease seeing a doctor before admission did not receive antibiotic. Our study suggests that the guidelines have not been adequately observed and that it may necessary to revise them. P2103 Value of early serum assay for dosage adjustment of vancomycin in continuous infusion A. Forgeot, A. Carricajo, J. Morel, C. Venet, P. Mahul, S. Guyomarc’h, N. Fonsale, C. Auboyer, F. Zeni, G. Aubert (Saint-Etienne, FR) Objective: It is difficult to obtain rapid bactericidal effects with vancomycin (V) due to the increased MIC for staphylococcal strains (in particular hetero-glycopeptide intermediate Staphylococcus aureus). The aim of this study was to obtain a serum concentration for V (SCV) of between 25 and 30 mg/L and a serum concentration/MIC ratio of >8 within first 24 hours in patients receiving V in a continuous infusion. Methods: In 2005 and 2006, all patients requiring treatment with V in the two study ICUs were given a loading dose of V of 30 mg/kg in a
17th ECCMID / 25th ICC, Posters 1-hour infusion followed by V at a dosage of 30 mg/kg/24 h. Creatinine clearance (CLc) was required to be >50 mL/min. Dosage was adjusted daily using a predetermined algorithm according to results of SCV: SCV < 25 mg/L, dosage increased by 4 to 8 mg/kg/24 h; SCV > 30 mg/L, dosage reduced by 4 to 8 mg/kg/24 h. V concentrations were measured by FPIA kit (Abbott, USA) and the MIC for V was determined using the E-Test method (AB Biodisk, Sweden). Results: 21 patients were included in the study, 11 of whom presented documented infection (coagulase-negative Staphylococcus sp and Staphylococcus aureus with MIC between 0.5 and 3 mg/L). Mean CLc was 105 mL/min (range 50 to 178), mean body weight was 83 kg (range 60 to 115), and SAPS II was 42.4 (range 22 to 64). A serum concentration of V 26.5 mg/L within 6 hours of the start of treatment (best cut-off) was predictive of a concentration of V in excess of 25 mg/L at 24 h. The positive predictive value was 100% for the 14 patients with CLc < 120 mL/min and 90% for all 21 patients. Conclusion: The target concentration for V of between 25 and 30 mg/L was achieved within 24 hours using our protocol in patients with CLc < 120 mL/min. Concentrations of V below the target level were seen in patients with CLc > 120 mL/min. Assay of V 6 hours after the start of treatment allowed early dosage adjustment. The serum concentration target must be reassessed on achievement of the MIC for V with regard to the offending staphylococcal strain. P2104 Surgical antibiotic prophylaxis in a Turkish university hospital S. Serin Senger, T. Togan, O. Kurt Azap, F. Timurkaynak, H. Arslan (Ankara, TR) Objective: Since surgical site infections are important causes of morbidity, mortality, and healthcare costs, we aimed to assess the appropriateness of use of surgical antimicrobial prophylaxis at our institution. Methods: A retrospective evaluation of the use of antimicrobial prophylaxis in patients undergoing major surgery at Ba¸skent University Hospital from July to September 2006 was carried out. The surgical operations included were liver and kidney transplantations, cardiovascular surgery, urological operations, neurosurgical operations, head and neck surgeries, orthopaedic surgery, breast surgery, general abdominal colorectal surgery, and abdominal and vaginal hysterectomy. Patients having infectious diseases prior to the surgery were excluded. The guidelines to assess choice of antimicrobial agent and duration of prophylaxis, were ASHP Therapeutic Guidelines on Antimicrobial Prophylaxis in Surgery (1999), IDSA (Antimicrobial Prophylaxis for Surgery: An Advisory Statement from the National Surgical Infection Prevention Project) (2004), and Sanford Guide (2005). Results: A total of 148 patients with a mean age of 41.9 years (ranged 1−89 with SD = 24.5) were included in the study. General Surgery was the leading department where 50 (33.8%) of the operations were performed. Cefazolin was the most commonly used antibiotic (constituting 48.0% of all the antimicrobial agents) during the study period. In 77 (52.0%) of the cases the prophylaxis decisions were appropriate, with proper choices of antibiotics in 51 cases and omissions in 26, in accordance with the guidelines. Unnecessary prolongation of prophylaxis in the patients of appropriately chosen antibiotics was found to be 41.0%. Conclusion: The results showed a significantly high level of inappropriate use of antimicrobial prophylaxis in our institution. To improve the proper use of prophylactic antimicrobials, the infection control committee planned to prepare a local guideline and to organise educational sessions for the surgeons.