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. Alert Antibiotics 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

9. IVOST

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. 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 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? Is the dose reasonable?
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  Initial drug kardex and add time of administration
AS PER CHART IV /08/12 
I Fixem
SEE GENTAMICIN PRESCRIBING CHART
Initial drug kardex and add time of administration LS
17:08 18

19. O Reminders to administer promptly and look out for toxicity signs 
This is NOT the prescription, just an initial prediction
Reminders to administer promptly and look out for toxicity signs 65
68 kg 68
5’ 7’’ O
320 mg
24 hourly
Alice Patient
05 / 06 / 1947 
Record gentamicin administration times accurately.
Doses are prescribed individually here, NOT normally >24 h in advance. 
No dose change IF
01/08 17: mg I Fixem I FIXEM FY1
01/ : LS AP 02/ :
02/08 18: mg I Fixem I FIXEM FY1

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