Improving IV antibiotic use; the role of the nurse

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 • Improving IV vancomycin and gentamicin use • IVOST • Alert antibiotics • Summary and questions

3. Morbidity,mortality & stay Increased costs Healthcare associated infection Threatens medical advances Development & spread of resistance 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%ofantibiotic therapy isinappropriate

4. Empiric antibiotic policy

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

6. Improving IV vancomycin and gentamicin use

7. 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

8. 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 • Vancomycin usually500-1500mg 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?

9. Getting it right 2 • Use the Administration Recording Charts • 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

10. 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

11. IVOST

12. 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

13. 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

14. 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 temp36-38oC, 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

15. Alert Antibiotics

16. 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

17. Alert Antibiotics Pharmacy can only supply these alert antibiotics when an Alert Antibiotic Form has been completed fully

18. 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

19. 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

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

21. 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