1. Application of Drug Use Evaluation & Feedback to Promote Rational Antibiotic Prophylaxis in C-Section in Kenya Dr. Nath W Opiyo Arwa, The Mater Hospital, Kenya 16 th November 2011, ICIUM Conference 2011

2. Presentation outline Introduction Methods Results Key lessons learned Implications of DUE Future studies/ reviews

3. 3 Introduction Antibiotic prophylaxis is useful in reducing incidences of surgical (operation) site infection. The use of antibiotic prophylaxis is however characterized by inappropriate practices such as use of broad-spectrum antibiotics; administering at wrong time; and continuing for too long Use of single dose has been found to be as effective as multiple doses and also cost effective to patients [1]. The recommended duration of prescribed antibiotics prophylaxis for c-section has reduced from 5 days to 3 days then to 24 hrs and finally to a single dose [2]. DUE serves as a structured criteria based method of identifying, monitoring and correcting challenges encountered in practice [1] Hopkins L, Smaill F, Antibiotic Prophylaxis Regimens and Drugs for C-section, Reprint for Cochrane Review in The Cochrane Library 2006, Issue [2] Liabsuetrakul T, Lumgiganon P and Chongsuvivatwong V, Prophylactic Antibiotic Prescription for Cesarean Section, International Journal for Quality in Health Care 2002: Vol.14NO. 6 pp. 503-508

4. Methodology DUE criteria developed and endorsed by Mater PTC Baseline retrospective review done in Jan- June 2006 Ongoing Subsequent DUEs were conducted periodically to date Random sampling of C-section cases from medical records Medical, Theatre and Nursing records, Treatment sheets were reviewed to identify antibiotic prescribed for each c- section delivery Antibiotics prescribed were compared with defined criteria 4

5. CRITERIA INDICATORDESCRIPTION ANTIBIOTIC ADMINISTEREDCo- Amoxiclav Cefuroxime Clindamycin Metronidazole –dirty surgery DOSE OF ABX ADMINISTEREDCo- Amoxiclav 1.2 gm IV STAT- TDS Cefuroxime 1.5 gm IV STAT Clindamycin 600 mg IV STAT Metronidazole 500 mg IV STAT TIMING OF FIRST ABX DOSEImmediately after cord- clamping DURATION OF ADMINISTRATIONCo- Amoxiclav up to 3 doses Cefuroxime 1.5 gm STAT REPEAT DOSES DURING SURGERYFor cases lasting longer than 4 hrs Loss of > 1.5 lts of blood

6. DUE findings June 2006 to Dec 2010

7. OVERALL ADHERENCE TO GUIDELINES

8. Feedback & Cost implications Feedback – Dissemination to MHPTC, Obs/ Gynae Div & Anaesthetists – Face to Face, CMEs, profiling individual performance, Use of opinion leaders – Regular feedback positive change in prescribing trends/ practice – Positive feedback reinforces good practice and reversed trends Cost savings: – Co-Amoxiclav US $ 22.14 per client – Cefuroxime US $ 15.83 per client – Annual extrapolation US $ 13,408

9. Key Lessons learned Fear of the unknown- Irrational prescribing Combination of strategies is critical for sustainable improvement Slight policy changes can result in significant cost savings Teamwork and mentorship is key in ensuring continuity of intervention despite staff turnover Dedication and motivated staff are key in sustaining Operational research should be integrated into regular schedule for maximum effectiveness

10. Implications of DUE Systematic, criteria-based program of drug use evaluations (DUE) with feedback on prescribing trends Use of single dose for antibiotic prophylaxis is beneficial even in poor resource setting prolonged antibiotic use does not confer value addition except in special cases Optimal medication use in ABX prophylaxis & Improved patient safety Adherence to guidelines is a challenge Wastage & variations in ABX choice that made care expensive reduced

11. Future studies Qualitative studies on underlying causes of lack of adherence to guidelines Expand scope of DUEs to additional forms of surgery DUEs involving reserve antibiotic use DUEs of prescribing OI medications in patients on HAART Scale up DUEs approach to other MTCs countrywide

12. Acknowledgements Mater Hospital administration and CEO, Mater PTC Members( Dr Agnes Chege, Dr M Dolan, Dr Mureithi, Dr Wanjala), Obstetrics and Gyn division, doctors and Nurses Former Colleagues: Ahmed Tawakal, Benjamin Maronda Management Sciences for Health: Mohan Joshi, Niranjan Konduri and Patrick Boruett

13. Thank you!