Improving IV antibiotic use; the role of the nurse Lee Stewart Antimicrobials Pharmacist (South Glasgow)

Improving IV antibiotic use; the role of the nurse

Lee StewartAntimicrobials Pharmacist (South Glasgow)

Overview

• Introduction; the problems

• The solutions– Empiric antibiotic policy– Alert antibiotics– IVOST– Improving IV vancomycin and gentamicin use

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

Alert Antibiotics

Alert Antibiotics

• Examples (see form for full list)• Tazocin, ceftriaxone, IV ciprofloxacin, IV clindamycin,

meropenem

• Alert Antibiotics are– Broad spectrum – Toxic– ExpensiveValuable agents reserved for

specified permitted indications other indications only on the advice of a

microbiologist/ID physician

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

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

IVOST GuidelineReview the need for IV therapy DAILY

Oral route compromised (e.g. vomiting, nil by mouth, severe diarrhoea, swallowing disorder, unconscious)

orDeteriorating 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

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

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

Kardex examples

Getting it right 1

• Is the prescription clear?– Dose & frequency (especially if 48 hourly/stat dose)

• Is the dose reasonable?– Shared responsibility (& liability)– Gentamicin usually 180-400mg dose (up to 600mg)– 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? – Signs of toxicity or prolonged gentamicin course?

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

GENTAMICIN

AS PER CHART IV 01/08/12

I Fixem

SEE GENTAMICIN PRESCRIBING CHART

LS

17:08

Initial drug kardex and add time of administration

Gentamicin Prescription Record Administration Record Monitoring Record Pre-prescribing checks Complete each time a dose is given (ensuring gentamicin

is prescribed ‘as per chart’ on the kardex) Complete each time gentamicin is administered (in addition to the kardex)

Record ALL sample dates/times accurately below. See overleaf for monitoring advice.

*Infuse over 30 mins* Toxicity assessments

Date to be

given

Time to be given 24 h clock

Gentamicin Dose (mg)

Prescriber’s signature and PRINTED name Date given Time started

24 h clock

Given by Date of sample

Time of sample

24 h clock

Gent level

(mg/L)

Action/ Comments (please initial action to be taken)

|

24 hourly 48 hourly Withhold Stop

Details/other : Before prescribing:

Check renal and oto/vestibular

function |

24 hourly 48 hourly Withhold Stop

Details/other :

*Discuss with an infection specialist and document in the notes if treatment continues beyond 3 to 4 days * Risks of prolonged treatment must be considered and treatment options discussed with microbiology or infection specialist

|

24 hourly 48 hourly Withhold Stop

Details/other : Before prescribing:

Check renal and oto/vestibular

function |

24 hourly 48 hourly Withhold Stop

Details/other :

*Discuss with an infection specialist before continuing onto a second sheet*

Step 1: Calculate and prescribe the first dose of gentamicin (see overleaf for more details) If creatinine is known - use the online gentamicin dose calculator. If creatinine is not known - give 5 mg/kg gentamicin (maximum 400 mg) or, if CKD 5, give 2.5 mg/kg (maximum 180 mg) on advice of

senior medical staff Prescribe gentamicin ‘as per chart’ on the medication chart (kardex). AVOID specifying dose or administration time on the kardex. Prescribe individual doses in the prescription record section below, specifying the date and time the dose should be given.

Step 2: Monitor creatinine and gentamicin concentration and reassess the dosage regimen Check gentamicin concentration after the first dose and then at least every 2 days (see overleaf for more details). Monitor creatinine daily. Seek advice if renal function is unstable (e.g. a change in creatinine of >15-20%).

Step 3: Assess daily: the ongoing need for gentamicin; signs of toxicity Consider an alternative agent if creatinine is increasing or the patient becomes oliguric. If gentamicin continues for >7 days, suggest referral to audiology for assessment. Refer to guidelines or clinical pharmacist for further advice on prescribing, monitoring and administration.

ADULT PARENTERAL GENTAMICIN (GGC): PRESCRIBING, ADMINISTRATION & MONITORING CHART

Patient name: …………………………………………………. Date of birth: ……………………………………………………… CHI no.: ………………………………………………………….....

Affix patient label

Age: …………………………....... Sex: M / F

Weight: ………………………..... Height: ………………..……….

Creatinine: ………………………. on: ........ /………. /….…..

Use for all patients prescribed intravenous gentamicin unless prophylactic indication or synergistic doses (usually in endocarditis) are being used

Initial Gentamicin Dose*: Predicted Frequency*:

Online calculator (preferred method) Manual calculation Weight based, creatinine not known

PROMPT ADMINISTRATION within 1 hour of recognition of sepsis reduces mortality

SIGNS OF GENTAMICIN TOXICITY

RENAL: ↓ urine output/oliguria or ↑ creatinine

OTO: NEW tinnitus, dizziness, poor balance, VESTIBULAR hearing loss, oscillating vision Toxicities may occur irrespective of gentamicin concentration

Source of first dose:

*this is not a prescription and may change. Doses must be prescribed individually below.

01/08 17:00 320 mg I Fixem I FIXEM FY1 01/08 17:08 LS AP 02/08 07:34 1.6 No dose change IF

65

68 kg

68

5’ 7’’

01 08 12

O 320 mg

24 hourly

Alice Patient

05 / 06 / 1947

0506471234

02/08 18:00 320 mg I Fixem I FIXEM FY1

This is NOT the prescription, just an

initial prediction

Doses are prescribed individually here, NOT normally >24 h in advance.

Record gentamicin

administration times accurately.

Reminders to administer promptly and look out for toxicity signs

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 12-48 hours then at

least every 2-3 days– See information sheet for further details

Further information• Posters on wards

• Therapeutics Handbook

• Intranet ( ‘Clinical info’ ‘antimicrobial guidelines’)

• BNF

• IV monographs

• Nurse information sheets

• Local Antimicrobials Pharmacist; for SGH/VI– [email protected]– Page 6055– Ext 62716 (SGH) or 65533 (VI)

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