Improving IV antibiotic use; the role of the nurse

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

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

Empiric antibiotic policy

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

Improving IV vancomycin and gentamicin use

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

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 180-400mg dose Vancomycin usually 500-1500mg 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?

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 30-60 minutes Check the level after the initial dose then at least every 2-3 days See information sheet for further details

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 12-48 hours then at least every 2-3 days See information sheet for further details

IVOST

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

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

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

Alert Antibiotics

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

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

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

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

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

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