Audit of Prescribing Patterns for Restricted Antibiotics in an Inpatient Setting (APPRAIS): Appraisal Reveals Hospital Overuse and Underdosing of Carbapenems
This project evaluated the guideline concordance of inpatient use of restricted antimicrobials (daptomycin, imipenem, meropenem, ertapenem, linezolid and tigecycline) at the University of Alberta Hospital (UAH), examined the usability of the current formulary guidelines, and identified areas where action could be taken using stewardship to promote patient safety and appropriate antimicrobial use.
All inpatients at the UAH started on a restricted antibiotic from January 9th - February 6th, 2014 were prospectively enrolled and followed. Exclusion criteria included patients under the age of 18, and any patient treated with restricted antimicrobials as outpatients in the emergency department or medical outpatient unit. Patient charts and electronic health records were reviewed to collect relevant patient, microbiological and clinical data. Indication for use and guideline concordance was determined by the researcher, Drug Stewardship Pharmacist and Physician. Data was de-identified, entered into a secure database, and analyzed using Excel pivot tables and descriptive statistics.
Eighty-five patients were prescribed a total of 92 restricted antibiotics during the study period. The attending service ordered 77% of the restricted antibiotics; only 23% (n=21/92) of orders came from the Transplant Infectious Disease or Infectious Disease service. Orders were classified as "use outside of guidelines" 28% of the time (n=26/92). Twenty of these "use outside of guidelines" orders had appropriate non-restricted formulary options, which would have been considered equally safe and effective in the clinical situation. Fourteen percent (n=13/92) of the restricted antibiotics were incorrectly dosed by the attending services and 9 of the 13 incorrect orders (69%) under-dosed the patient.
This study demonstrated carbapenem overuse, a concern in the current era of evolving antimicrobial resistance, and a surprisingly high dosing error rate, which is a safety concern. An educational intervention has already been implemented to address the identified dosing issue. Going forward we hope to gain institutional support for an active, ongoing stewardship program, which is a current need in this facility.
M. Guirguis, None