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Improving IV antibiotic use; the role of the nurse Lee Stewart Antimicrobials Pharmacist (South Glasgow)

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Presentation on theme: "Improving IV antibiotic use; the role of the nurse Lee Stewart Antimicrobials Pharmacist (South Glasgow)"— Presentation transcript:

1 Improving IV antibiotic use; the role of the nurse Lee Stewart Antimicrobials Pharmacist (South Glasgow)

2 Overview Introduction; the problems The solutions –Empiric antibiotic policy –Alert antibiotics –IVOST –Improving IV vancomycin and gentamicin use

3 Introduction: the problems ~1/3 of inpatients will receive an antibiotic ~1/3 of antibiotics given via the IV route ~40% of the drug budget spent on antibiotics up to 50% of antibiotic therapy is inappropriate  Morbidity, mortality & stay Increased costs Development & spread of resistance Healthcare associated infection Threatens medical advances

4 Empiric antibiotic policy

5 Restricts the use of the ‘4c’ antibiotics (greatest C difficile risk) Co-amoxiclav Cephalosporins Ciprofloxacin (& other quinolones) Clindamycin

6 Alert Antibiotics

7 Examples (see form for full list) Tazocin, ceftriaxone, IV ciprofloxacin, IV clindamycin, meropenem Alert Antibiotics are –Broad spectrum –Toxic –Expensive  Valuable agents reserved for  specified permitted indications  other indications only on the advice of a microbiologist/ID physician

8 Alert Antibiotic Form Pharmacy can only supply when an Alert Antibiotic Form has been completed fully –From pharmacy distribution or StaffNet (  ‘Clinical info’  ‘antimicrobial guidelines’) –Completed by medical staff and/or pharmacists Nurses –Send the completed form to pharmacy with the first indent requesting the alert antibiotic –Re-order the same antibiotic for the same patient by including the patient’s name/unit number on the indent –Don’t miss/delay doses; pharmacy will give an ‘emergency supply’ if you can’t get form completed


10 IVOST Guideline IVOST = IV to oral switch therapy IV antibiotic therapy often prolonged unnecessarily in hospital –Increased risk of line infection & bacteraemia –Increased length of stay –Increased expenditure –Increased demands on nursing time IVOST guideline developed to enable a switch to oral therapy to be made early and appropriately

11 IVOST Guideline Review the need for IV therapy DAILY Oral route compromised (e.g. vomiting, nil by mouth, severe diarrhoea, swallowing disorder, unconscious) or Deteriorating clinical condition/Continuing sepsis* (*i.e. 2 or more of: temp >38°C or 90bpm, respiratory rate >20/minute, WCC 12) or Special indication (e.g. meningitis/CNS infection, endocarditis, immunosuppression, bone/joint infection, deep abscess, cystic fibrosis, moderate to severe cellulitis, severe pneumonia) or No oral formulation of the drug available NO?Switch to oral therapy

12 Nurse involvement with IVOST Prompt for daily review of IV route & alert medical staff to changes in availability of oral route Prompt medical staff to consult microbiology when IV gentamicin is required for >3-4 days

13 Improving IV vancomycin and gentamicin use

14 Vancomycin and gentamicin use Narrow therapeutic index agents –Nephrotoxic and ototoxic –When given IV, monitoring and interpretation of blood levels essential for safe and effective use Consistently in top 10 drugs associated with reported medication incidents

15 Kardex examples

16 Getting it right 1 Is the prescription clear? –Dose & frequency (especially if 48 hourly/stat dose) Is the dose reasonable? –Shared responsibility (& liability) –Gentamicin usually mg dose (up to 600mg) –Vancomycin usually mg dose Do you need to speak to the doctor? –Levels not being checked –Significantly delayed dose (e.g. lost IV access) –Prescribed in ‘once only’ section & unsure if ongoing –Is it OK to dose after level taken? –Signs of toxicity or prolonged gentamicin course?

17 Getting it right 2 Use the correct recording chart for site and drug –See examples given out –Record accurate infusion start and stop times –Space to record accurate sample times for levels Gentamicin –Prescribed as charted on kardex, doses on separate prescribing/administration/monitoring chart –Normally infused over 30 minutes –Check the level after the initial dose then at least every 2-3 days –See information sheet for further details

18 GENTAMICIN AS PER CHART IV 01/08/12 I Fixem SEE GENTAMICIN PRESCRIBING CHART LS 17:08 Initial drug kardex and add time of administration

19 01/08 17: mg I Fixem I FIXEM FY1 01/08 17:08 LS AP 02/08 07: No dose change IF kg 68 5’ 7’’ O 320 mg 24 hourly Alice Patient 05 / 06 / /08 18: mg I Fixem I FIXEM FY1 This is NOT the prescription, just an initial prediction Doses are prescribed individually here, NOT normally >24 h in advance. Record gentamicin administration times accurately. Reminders to administer promptly and look out for toxicity signs

20 Getting it right 3 Vancomycin –Some sites have a prescribing chart, others don’t –Beware of loading doses prescribed in the ‘once only’ section –Intermittent infusion; maximum 500mg/hour –Vancomycin continuous infusion; 24 hour dose split into 2 equal 12 hour continuous infusions –Levels are required if given IV (not for PO) –Check the level within the first hours then at least every 2-3 days –See information sheet for further details

21 Further information Posters on wards Therapeutics Handbook Intranet (  ‘Clinical info’  ‘antimicrobial guidelines’) BNF IV monographs Nurse information sheets Local Antimicrobials Pharmacist; for SGH/VI –Page 6055 –Ext (SGH) or (VI)

22 Summary You will see many antibiotic prescriptions Up to 50% of these will be inappropriate Inappropriate use has adverse patient and public health consequences NHSGGC has policies to promote and support prudent antimicrobial use YOU have a key role to play in ensuring that patients receive appropriate, safe and effective antimicrobial therapy

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