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Quinolone Restriction - SharmaYang-Marlborough

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 Quinolone Restriction - SharmaYang-Marlborough Powered By Docstoc
					  QUINOLONE
RESTRICTION AT
MARLBOROUGH
   HOSPITAL
.
           Vibha Sharma, M.D.
    Infectious disease consultant and
    Medical director, infection control,
          Marlborough hospital

       Zsusun Timothy Yang, Rph
           Pharmacy director
         Marlborough hospital
 Why the concern with Quinolones

    From 2003 to 2006, C. difficile
 infections are observed to be more
     frequent, more severe, more
 refractory to standard therapy, and
more likely to relapse than previously
              described .
   Some cases have been attributed to a new strain
    designated BI, NAP1 or ribotype 027.
   Fluoroquinolone use has strongly correlated with the
    emergence of this strain.
   Antibiotic use is the most widely recognized and
    modifiable risk factor for C. difficile-associated diarrhea
    (CDAD)
   The use of broad-spectrum antimicrobials, use of
    multiple antibiotic agents, and increased duration of
    antibiotic therapy all contribute to the incidence of
    CDAD
       PREVIOUS USAGE OF
        QUINOLONES AT
     MARLBOROUGH HOSPITAL
   Moxifloxacin formulary quinolone (FQ).
    No renal dosing (400 mg po/iv daily).
    Does not cover UTI. Ciprofloxacin reserved for
    these patients.
    QUINOLONE RESTRICTIONS
   As of 12/1/10 FQ restriction to ID.
   24 hour supply allowed.
   Pharmacy contacts via communication
    sheet/paging MD.
   ID contacted via email.
   Further supply restricted to ID approval.
      COMMUNICATION SHEET
             USED
   Communication Sheet
From: Pharmacy To:
Flouroquinolone restriction
Dear doctor
A flouroquinolone has been ordered for this patient. Due to the
   increasing rate of resistant bacteria and C. diff colitis,
   flouroquinolones are now restricted (exception-CAP with PCN
   allergy). This antibiotic will be discontinued in 24 hours from the
   time of the order. Continuation of flouroquinolones requires
   ID approval. (Dr. Sharma) Restricted antibiotic ordered:
Pharmacist Signature:
Response:Message:                                   MD Signature:
SYSTEM   SENTRI 7                     MEDITECH DRUG
USED     REPORTING                    SEARCH REPORTING


PROS     Easy to run reports.         More types of data
         Data obtained quickly.       collected.
         Trends can be noted.         Tracks both scheduled
                                      and one time doses.


CONS     User dependent.              Time consuming.
         One dose not tracked.        Manual data and trend
         Data obtained superficial.   tracking.
         Cannot obtain                Duration of reported
         retrospective data.          prescription may not
                                      reflect actual length of
                                      therapy.
              SENTRI 7 DATA FOR
              QUINOLONE USAGE

Month     Sept 10   Oct 10   Nov 10   Dec 10   Jan 11   Feb 11


# rule    5         1        14       8        2        1
matches
    SENTRI 7 QUINOLONE DATA
   Only captures rule hits with Meditech profiling.
   Does not capture ED 1 dose removals (ie
    overides).
         MEDITECH DATA FOR
          QUINOLONE USAGE
                              Definitions
 # RX- # of orders entered in Meditech system (1 patient with 1
  renewal order and dosing/route changes can have 2 RX)
 # Pts- # patients listed in reporting
 # RX > 24 hours- RX with start and stop times > 24 hours
  entered
  From 12/10 on- checked individual patients with > 24 hours to
  validate if patient received > 1 day dosing. Assumption made
  that all patients prior to 12/10 had >24 hour therapy for #RX >
  24 hours.
 ** All Quinolone data aggregated.
        MEDITECH DATA FOR
      QUINOLONE USAGE CONT.
       8/10   9/10   10/10   11/10   12/10   1/11   2/11   3/1 to
                                                           3/16
                                                           2011

#rx    136    89     100     107     59      49     46     20


#pts 84       61     74      78      48      37     32     14


#RX 47        33     33      29      4       2      6      1

>24
hr
Pt > 47       33     33      29      2       2      3      1
24 h
Actual patients receiving > 24 hr
       Quinolone therapy
                     Actual patients receiving >24 hour therapy


      50

      45

      40

      35

      30
                                                                  Actual patients
      25                                                          receiving >24 hour
                                                                  therapy
      20

      15

      10

      5

      0
           Aug- Sep- Oct- Nov- Dec- 11-      Feb- Mar
            10   10   10   10   10 Jan        11 1-16
      QUINOLONE TRENDS
         AUG 09 TO 2/11
180
160
140
120
100                       #RX
 80                       #PTS
 60
 40
 20
  0
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 CHARACTERISTICS FOR PTS >
    24 HRS USAGE (12/10- )
1- 60 yo male with SIRS/Gastroenteritis
2- 39 yo female with PNA
3- 85 yo female with PNA (Documented PCN
  allergy)
4- 83 yo female with UTI (Documented PCN
  allergy)
5- 53 yo female with diverticulitis
6- 63 yo female with COPD- (PCN= hives)
7- 68 yo male with HA/SOB- dc home in 24 hours
8- 71 yo male COPD
SENTRI 7 DATA FOR ABX USAGE

Month 9/10    10/10 11/10 12/10 1/11   2/11




# RULE   77   19    48    44    88     23
MATCH
ES
     MEDITECH REPORTING
   Monthly analysis for August to March 1-16th for
    time frame of 8/09 to 3/16/11
   Antibiotics used for analysis: Ertapenum (E),
    Vancomycin (V), Ceftriaxone (CF),
    Levofloxacin, Ciprofloxacin, and Moxifloxacin
   Levofloxacin, Ciprofloxacin, and Moxifloxacin
    data aggregated (FQ)
   #RX and # PT collected.
                               #RX ABX SPREAD
250                                                       250
200                                            #RX (E)    200                       #RX(E)
150                                            #RX (V)    150                       #RX(V)
100                                            #RX (CF)   100                       #RX(CF)
50                                             #RX (FQ)                             #RX(FQ)
                                                          50
 0                                                         0
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     Quinolone most prescribed antibiotic in Feb 2010.
     Ceftriaxone most prescirbed antibiotic overall during
      winter months.
                                    #PTS ABX DATA
140
                                                            140
120                                                         120
                                               # PT(E)      100                       # PT(E)
100
                                               # PT (V)      80                       # PT(V)
 80
 60                                                          60                       # PT(CF)
                                               # PTS (CF)
 40                                                          40
                                               # PT (FQ)                              #PT(FQ)
 20                                                          20
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     Decline of patients on quinolones since December
      2010.
     Does not take account if patient switches antibiotic or
      has multiple drug therapy.
          % ABX orders comparing the four
                      drugs
60
50                                                                     50
                                                                %E     45
40                                                                     40
                                                                %V                                                                               %E
                                                                       35
30                                                                     30                                                                        %V
                                                                %CF    25
20                                                                     20                                                                        %CF
                                                                % FQ   15
10                                                                     10                                                                        %FQ
                                                                        5
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         Ertapenum usage initially high, now consistent.
         Ceftriaxone use increased with less usage of FQ and
          vice versa.
         ? Increase use of Vancomycin after winter months.
    CONCLUSION

   ONE TIME DOSES (OVERIDES, SDC
    PATIENTS)
   SIGNIFICANT DROP OF TREATMENT OF
    QUINOLONES IN HOSPITAL INPATIENT
    FLOORS.
   TIMELY COMMUNICATION ESSENTIAL
   INITIAL SELECTION FOR CAP REMAINS
    100%

				
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