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3h. AMR: Improving Rational Use of Antibiotics in Health Care Facilities
Improving the Rational Medicine Use through the MTP Approach in Cambodia
1INRUD Cambodia, Cambodia; 2Ministry of Health, Deapartment of Drugs and Food; 3World Health Organization
Problem statement: The monitoring, training, and planning (MTP) approach for improving the rational use of medicines in public health facilities in Cambodia was introduced and implemented since 2001 with the support of WHO. The approach sought to address a host of irrational drug use problems such as poly-pharmacy, inappropriate use of antimicrobials, over-use of injections, non-adherence to clinical guidelines, and inappropriate dosing regimens, among others. With over 9 years of accumulated data and experience on the approach, this paper provides some evidence on the effectiveness of this approach in improving the rational use of medicines in the country.
Objectives: To use the MTP approach to improve, on sustainable basis, prescribers’ skills in identifying and resolving irrational medicines use problems at provincial referral hospitals through hospital Medicines Therapeutic Committees (MTC). Evidence on the effectiveness of the approach in reducing irrational use of medicines with indicators and targets defined by MTC at provincial referral hospitals is provided.
Design: Interventional, time-series with baseline data for comparison
Setting: Public sector: provincial referral hospitals
Study population: Prescribers and members of MTC at 55 public provincial referral hospitals
Intervention and method: A problem-solving approach as provided by the MTP method was systematically implemented from 2001 to 2010 to prescribers to improve rational use of medicines. Members of participating hospital MTCs identified medicines use problems, quantified those using suitable indicators, identified their possible causes, and agreed on appropriate solutions to resolve them. Outcome of their effort were reviewed at MTC monthly meetings.
Outcome measure(s): Proportion of patients (in %) receiving antibiotics, IV fluid, and injection formulations compared, on quarterly basis, to baseline data, including an assessment of the duration of treatment, correctness of diagnoses, and medication prescribed.
Results: Among other favorable outcomes, in 2001, for example, the use of IV in normal delivery in one province declined by 100% (from 70 to 0%) and in other three provinces the unnecessary use of antibiotics during delivery and various trauma cases declined by an average of 63% (range: 37–85%). Between 2005 and 2008, the average reduction in injudicious use of antibiotics (in medicine, pediatric, surgery, and maternity wards) was 48% (range: 3–82%).
Conclusions: Given the opportunity and training, hospital members of the MTC using the MTP approach can reduce the magnitude of irrational medicines use in a hospital setting.
Funding source(s): Ministry of Health of the Royal Government of Cambodia, GFATM, and WHO
Promoting Rational Antibiotic Prophylaxis in Clean Surgeries in China
1Dept.of Epidemiology and Biostatistics, School of Public Health, Peking University, China.; 2China National Health Development Research Center, MoH；INRUD China Core Group Member; 3National Institute of Hospital Management, MoH, China; INRUD China Core Group Member
Problem statement: An official report shows that 80–90% of the clean surgeries were with irrational antibiotic prophylaxis in Chinese tertiary hospitals in 2007.
Objectives: To promote rational antibiotic prophylaxis in clean surgeries in China
Design: A controlled intervention study. The effect of the intervention was measured and compared before and after intervention, and compared with the control group.
Setting: Public general tertiary hospitals
Study population: The sampling frame is within the National Monitoring Network of Clinical Antibiotics Use (Network) which consists of 164 tertiary hospitals distributed in 31 provinces. All provinces were divided into 3 groups based on their gross domestic product per capita in 2007. Three hospitals were randomly selected from each group, 9 hospitals were selected as intervention group (IG). Three other hospitals voluntarily joined IG, a total of 12 tertiary general hospitals were finally included in IG. Each hospital in IG was required to collect all the medical records of the 3 targeted clean surgeries (i.e., thyroidectomy, mastectomy, and hernia) discharged in the months of March and September 2008, March and June 2009, respectively. All the network hospitals were assigned to control group (CG). Each hospital in CG was required to randomly select 15 surgery cases from all the discharged cases in the 2nd week of the 1st month of each quarter (January, March, June, and September), and report to the Network every half year in June and December. There were 164 hospitals providing data to the Network in March 2008, and 171 hospitals in March and June 2009 (additional hospitals joined the Network). All targeted clean surgery cases were indentified from the Network as control sample. 212 cases were identified from Network database in March 2008, which were extracted from the 2008 first half year of reporting; 445 cases were identified from the 2009 first half year of reporting, including the data for March and June 2009. In total, 3,961 and 657cases identified in IG and CG, respectively, for the study.
Interventions: Circulating and implementing MOH regulations in both IG and CG; launching DTC training course plus circulating related materials and literature of rational antibiotic prophylaxis in clean surgery to physicians in IG. Other interventions in IG include formulating guidelines at hospital level and using the monitoring, training, and planning (MTP) method to comply with the guidelines.
Outcome measure(s): Proportion of antibiotic medication with or without indication was judged. The cases using antibiotics with indication were evaluated with a synthetic score to measure the rationality of antibiotic prophylaxis.
Results: Following three waves of interventions, the proportion of cases not using antibiotics rose from 3.5% to 11.9%, and the average duration of antibiotic medication of IG declined from 4.9 to 4.1 days (Kruskal-Wallis H Test, p<0.05). The proportion of antibiotics use without indication of IG decreased from 61.9% to 60.9%, and the rationality scores of IG increased from 55.4 to 77.0. Comparing the changes of IG with CG during March 2008 and June 2009 following the third intervention, the proportion of antibiotics use without indication decreased from 61.9% (IG) and 84.4% (CG) (χ2 test, p<0.01) to 60.9% (IG) and 59.1% (CG) (χ2 test, p>0.05); the rationality scores increased from 55.4 (IG) and 57.6 (CG) (t test, p>0.05) to 77.0 (IG) and 64.3 (CG) (t test, p<0.01), respectively. The key irrational antibiotic prophylaxis problems were antibiotic selection, medication given at the wrong time, and the long duration of medication, which held 28.1%, 34%, and 69.6% of the total indicated cases, respectively.
Conclusions: The interventions made limited improvement in not using antibiotics without indication, but significant improvement in using antibiotics with indication toward rationality. There are complicated factors affecting the antibiotics use decision-making beyond the capacity of technical interventions.
Funding source(s): WHO
Application of Drug Use Evaluation and Feedback to Promote Rational Antibiotic Prophylaxis in C-Sections in Kenya
1The Mater Hospital ,Kenya, Kenya; 2Management Sciences for Health/Strengthening Health Systems
Problem Statement: Antibiotic prophylaxis is beneficial to both elective and non-elective cesarean section surgery patients. However, the use of surgical antibiotic prophylaxis is characterized by inappropriate practices including inappropriate selection of antibiotic, wrong dosage and time of administration, and long duration of use.
Objectives: To evaluate the impact of the systematic, criteria-based program of drug use evaluations (DUE) with feedback on prescribing trends in antimicrobial prophylaxis for cesarean section at the Mater Hospital, a leading private hospital in Nairobi, Kenya.
Design: This is a retrospective review of medical records of C-sections done between January 2006 and June 2009. It consists of a baseline DUE and subsequent DUEs with feedback conducted every six months. Prescribing trends were compared with the set criteria based on antibiotic choice, dose, duration, and timing of first dose.
Setting: The study was conducted by the Mater Hospital Pharmacy and Therapeutic Committee (MHPTC) in conjunction with the obstetrics and gynecology division at the hospital.
Study Population: The hospital performs an average of 600 C-sections annually. The records reviewed were randomly sampled from the medical records. HIV sero-positive patients were automatically excluded because their immunological status merited longer-term antibiotic therapy.
Intervention: This was an ongoing, systematic, criteria-based program of drug use evaluations with feedback through MHPTC to registrars, consultants, pharmacists, nursing staff and Hospital anesthetists to improve rational use of antibiotics. Managerial and educational strategies were used to improve antibiotic prophylaxis in C-section at the hospital. Regular dissemination of findings at division meetings sensitized members on DUE results and hospital guidelines.
Outcome measures: Percentage of antibiotic prophylaxis prescribed as per guideline
Results: Overall adherence to all aspects of criteria of DUE is only achieved when all criteria are met including that on duration of prophylaxis. The proportion of prescription adhering to all criteria was 5% at baseline. Subsequent DUEs show an increase in cases that fully adhered to the criteria from 5% at baseline, 10.3% (DUE-1), 23.5 (DUE-4), 46.1% (DUE-5, and 52.3% (DUE-9).Overconsumption of antibiotics, especially the use of additional oral antibiotics post-operatively, was the main challenge according to our findings.
Conclusions: Application of structured DUE is a useful strategy to identify, monitor, and help correct challenges encountered during antibiotic prophylaxis in C-section surgeries at health facilities. This should be augmented by other strategies implemented through multidisciplinary hospital teams such as pharmaceutical therapy committees.
Funding source: No funding source
Randomized Controlled Study of Antibiotic Approval Program on Patients’ Clinical Outcomes and Antibiotic Expenditures
Faculty of Medicine Siriraj Hospital, Thailand
Problem statement: Piperacillin/tazobactam, imipenem, and meropenem were inappropriately used in 50% of hospitalized patients at Siriraj Hospital. Antibiotic approval is a recommended measure for controlling inappropriate antibiotic use. A concern of this measure is it could have a negative effect on clinical outcomes for the patients whose antibiotics are changed or discontinued.
Objective: To determine effectiveness of antibiotic approval program on patients’ clinical outcomes and antibiotic expenditures
Methods: Adult hospitalized patients who were prescribed the target antibiotics (i.e., piperacillin/tazobactam, imipenem, or meropenem) from August to November 2007 were randomized to antibiotic approval group (A) or control group (C). An infectious disease specialist was responsible for antibiotic approval in A group. All participating patients were followed for clinical outcomes and antibiotic expenditures.
Results: The target antibiotics were prescribed to 486 patients (516 episodes) in C group and 462 patients (512 episodes) in A group. The patients allocated to A group had more favorable clinical outcome (68.9% vs. 60.5%, p<0.01), shorter duration of target antibiotics (7.5 d. vs. 9.3 d., p<0.01), shorter duration of all antibiotics (12.7 d. vs. 16.4 d., p<0.01), and lower mortality due to infections (29.4% vs. 35.4%, p<0.05) than those in C group. Multivariate analysis revealed that unfavorable clinical outcome was significantly associated with the C group and having respiratory tract infections. The costs of the target antibiotics and all antibiotics in A group were much less than those in C group. The actual difference in the cost of antibiotic consumption between A group and C group, cost saving, was 143,793 US dollars.
Conclusions: An antibiotic approval program is an effective measure for reducing antibiotic consumption without compromising the clinical outcomes.
Funding source(s): Faculty of Medicine Siriraj Hospital, Thailand