1. Improving IV antibiotic use; the role of the nurse

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

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. Improving IV vancomycin and gentamicin use

7. 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

8. Getting it right 1 Is the prescription clear? Is the dose reasonable?
Dose & frequency (especially if 48 hourly/stat dose)
Is the dose reasonable?
Shared responsibility (& liability)
Gentamicin usually mg dose
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?

9. Getting it right 2 Use the Administration Recording Charts Gentamicin
Essential for safe and effective treatment
Record accurate infusion start and stop times
Space to record accurate sample times for levels
Gentamicin
Infuse over minutes
Check the level after the initial dose then at least every 2-3 days
See information sheet for further details

10. Getting it right 3 Vancomycin
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

11. IVOST

12. 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

13. Review the need for IV therapy DAILY
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 <36°C, heart rate >90bpm, respiratory rate >20/minute, WCC <4 or >12) or
Special indication (e.g. meningitis/CNS infeciton, endocarditis, immunosuppression, bone/joint infection, deep abscess, cystic fibrosis, moderate to severe cellulitis, severe penumonia) or
No oral formulation of the drug available
NO?
Switch to oral therapy

14. Nurse involvement with IVOST
Prompt for daily review of IV route & alert medical staff to changes in availability of oral route
Alert medical staff when sepsis is resolving
Nurses obtain and document ¾ of the criteria
if temp 36-38oC, pulse ≤90bpm and RR ≤20 then the patient will not meet the definition of sepsis, regardless of the WCC
Prompt medical staff to consult microbiology when IV gentamicin is required for >72 hours

15. Alert Antibiotics

16. Alert Antibiotics 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

17. Alert Antibiotics
Ceftazidime
Imipenem
Ceftriaxone
Linezolid
Ciprofloxacin (IV only)
Meropenem
Clindamycin (IV only)
Piperacillin/tazobactam (Tazocin®)
Daptomycin
Quinupristin/dalfopristin (Synercid®)
Doripenem
Teicoplanin
Ertapenem
Tigecycline
Pharmacy can only supply these alert antibiotics when an Alert Antibiotic Form has been completed fully

18. Alert Antibiotic Form Available from
Pharmacy distribution
Intranet ( ‘Clinical info’  ‘antimicrobial guidelines’)
Completed by medical staff and/or pharmacists
Nurses
Ordering without a form can lead to delays in supply
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

19. Alert supply of at weekends/OOH
Doses must not be omitted due to inability to have a form completed
If necessary, pharmacy will supply limited amounts at weekends without an alert form
Alert antibiotics will continue to be held in emergency cupboards and be available via the on-site co-ordinator/on-call pharmacist
A completed Alert Antibiotic Form should be sent to pharmacy as soon as possible on the next working day

20. Further information Posters on wards Therapeutics Handbook
Intranet ( ‘Clinical info’  ‘antimicrobial guidelines’)
BNF
IV monographs
Nurse information sheets
Local Antimicrobials Pharmacist

21. 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