Pragmatic-Approach-to-Rational-Antibiotic-Presrcibing-Hong-Kong-Experience課件講義整理

PragmaticApproachtoRationalAntibioticPresrcibing:HongKongExperienceProfessorCRKumanaChairofClinicalPharmacology&Therapeutics,DepartmentofMedicineTheUniversityofHongKongQueenMaryHospitalHongKongPragmaticApproachtoRational1AcknowledgementAntibioticStewardshipTeam,QueenMaryHospital ICU:DrsKYoung&JChan Microbiology&ID:DrsPLHo,WHSeto,RLee&CCCheng DeptofMedicine:ProfCRKumana,MsMKou DeptofSurgery:DrsKMChu&JHo DeptofOrthopaedics&Trauma:DrKYChiu DeptofPaediatrics:DrSChiu Pharmacy:MrWChui,MrRMak,MsEMa QualityImprovement&InfectionControlUnit:MsPChing,MsYKong, MsSLLeung,MsMKKwok,MsMMChan,MsMYuenOthers Doctors&NursesofQueenMaryHospital QueenMaryHospitalManagementCommittee MrAnthonyChan,ChiefPharmacist&colleagues,DeptofHealth MrPWLee&colleagues,HAHOChiefPharmacist’sOffice ProfJADickinson,Family&CommunityMedicine,TheChineseUniversity ofHongKongAcknowledgementAntibioticStew2OutlineofMaterialtobeCoveredBackground

Evolutionofourapproachto‘ImplementingRationalAntibioticPrescribing’5ExamplesofOurExperienceConclusionsOutlineofMaterialtobeCove3PrerequisitesforImplementingSuccessfulAntibioticPolicies(1)Determinethemainantibioticscurrentlybeingused/prescribedlocallyandtheirrespective‘indications’Understandwhatdrivesantibioticusage/prescribinginthepopulationofinterestPoliciesmustco-existwithsuitableInfectionControlMeasuresPrerequisitesforImplementing4PrerequisitesforImplementingSuccessfulAntibioticPolicies(2)Focusonsuspectedproblematicareas/aspectsofantibioticusage/prescribingObjectivelyverify/confirmwhetherthesuspectedproblemisrealandimportantDecidewhethertotacklesuchusage,andifsohowandtowhatextentPrerequisitesforImplementing5PrerequisitesforImplementingSuccessfulAntibioticPolicies(3)Beforedeveloping/executingthetargetedstrategy,considerthefollowing:

Isimplementationfeasibleinthelocal setting?(withavailableresources)

Willsuccessfulimplementation

genuine overallbenefit?(minimal/noballooneffect)PrerequisitesforImplementing6DefinedDailyDose(DDD)Assumedadultdosage/dayformainindication

e.g.DDDofampicillin=2G(500mgx4daily)

amoxycillin=1G(250mg

x4daily)Notarecommendeddosebutatechnicalunit(e.g.inGrams,millilitres,tabletsetc),butusedforcomparison,drawnupbyWHOOftenexpressedas: NoofDDDs/1000Inhabitants/DayDefinedDailyDose(DDD)Assume732101234ORALCEPHALO-SPORINSPARENTERALCEPHALO-SPORINSNon-hospitalHospitalUS$MillionBrazilCanadaEgyptFranceGermanyIndiaItalyJapanUK,USABrazilFranceGermanyItalyJapanKoreaMexicoSpainTurkeyUSACanada,FranceGermany,ItalyJapan,KoreaMexico,SpainTurkey,USA878889878889878889ExpenditureonCephalosporins&AminoglycosidesPARENTERALAMINOGLY’3ORALPARENTERALNon-hospital8ParenteralAminoglycosideSales/UtilisationHongKongSwedenKumanaetalJofAntimicrobChemother1989;24:1001-1010ParenteralAminoglycosideSale9HongKongSwedenSalesofParenteralCephalosporinsKumanaetalJofAntimicrobChemother1989;24:1001-1010HongKongSwedenSalesofParent10HONGKONGNEOMYCINNON-HOSPITAL HOSPITALNEOMYCINGENTAMICINTOBRAMYCINSWEDEN02040 010TOPICAL/LOCALAMINOGLYCOSIDESALESG/Millioninhabitants/Day848586848586848586848586848586848586AdaptedfromKumanaetal1989;JAntimicrobChemother241001-10GENTAMICINTOBRAMYCINHONGKONGNEOMYCINNON-HOSPITAL11TetracyclineStainingintheAdultDentitionofaDentalStudent

TetracyclineStainingintheA12NewZealand

3.8% Sucklingetal1976 (n=1000) NZDentalJ72201-10Norway

1.4% UlvestedHetal1978 (n=3157) ScandJDentRes86 147-52HongKong

14.9% KingNM&BrookAH1984 (n=230) NZDentalJ8047-9PERMANENTTEETHDISCOLOURATION:

PREVELANCESTUDIESOF‘TETRACYCLINESTAINING’NewZealand 3.8% Sucklinget13YEARLYSALESOFLIQUIDTETRACYCLINESHongKong

a(5.5million)UK

b(55million)Australia

c(15million)198218,000L13,000Lnil198318,0009,000“198411,0006,000“19856,000“19864,000“19873,000“Roundedtonearest1,000L(125or150mgofdrug/5ml).a)CourtesyMedical&HealthDept.,HK.b)Estimatedfromasurveyofprescriptions.

c)

Salesdisallowedafter1977.YEARLYSALESOFLIQUIDTETRACY14EstimatedAnnualUtilisationofLiquidTetracyclines(125or150mg/ml)per1000inhabitantsHKEnglandModifiedfromKumanaetal.1986.HKPractitioner8:1983-1940YearLitres/1000inhabitants/yearEstimatedAnnualUtilisationo15WhatDrivesAntibioticPrescribing?Pharmaceuticalpromotion,Fashion&NoveltyPeerpressure,Tradition&CulturalattitudesIgnoranceofharm,benefits&CostsAffordability&FinancingLegislationEducation&Policies

efficacy;safety;pharmacokinetics;cost-effectiveness!!WhatDrivesAntibioticPrescri16ProsecutionofAntibioticPoliciesinHongKongEvolutionofstrategy

hospitalprescribing,basedonImmediateConcurrentFeedback(ICF)toend-users

Inputfromallrelevantparties:End-users includingClinicians(especiallyopinionleaders), Microbiologists&Pharmacists

EndorsementbyDrugs&TherapeuticsCommitteeInitiativesdirectedatantibioticprescribinginthecommunity

ProsecutionofAntibioticPoli17SuitableEducation

followedbyAudit/monitoringtoidentify/confirmantibioticprescribingproblem

followedbyHOSPITALOngoingI.C.F.guidedbymonitoringgraduallyintroducedthroughoutthehospitalSuitableEducationAudit/moni18

Oneachworkingday,pharmacycomputer generateslistofinpatients(+corresponding ward&bedno)forwhomthespecifically targetedantibioticwasprescribed Respectivepatientrecordsareaudited thatmorningbyspeciallytrainednurses andclinicalpharmacists Likelyindications/reasonsareassessedICFSTRATEGY(1) Oneachworkingday,phar19ICFSTRATEGY(2)

Forpatientswhoseprescribingisdeemed nottoconform–ICFwasimplemented

Onthesameday–indicationforeach patientevaluatedbytheHospitalWorking GrouponRationalPrescribing:- ClinicalPharmacologistMicrobiologistsInfectionControlNursesClinicalPharmacistICFSTRATEGY(2)Forpati20I.C.F.=SamedaymemofromtheHospitalWorkingGrouponRationalPrescribingtotheprescribingdoctor(ccsupervisingMO)

Patientparticulars+relevantexplanations reappropriateRx/guidelines Explicitadvice:e.g.switchorceasedrug, ormodifyrouteofadministration Encouragediscussionofanyqueriesor problems(telnoprovided)I.C.F.=Samedaymemofromth21CostsofEquivalentDailyOral&IVDosing(March1996)375mgtds1.2gHK$1.5g375mgtdsCostsofEquivalentDailyOral22Tangible&IntangibleCostsofIVcomparedtoOralMedicationAcquisitionandstoragecostsusuallymuchhigherthanforequivalentoraldosesMorepatientdiscomfort,inconvenience&anxiety?Costofneedles,syringes,cannulae,infusionsets&fluidsGreatercommitmentofdoctor;s/nursestimeComplications(phlebitis/sepsis)Prolongedhospitalisation?Tangible&IntangibleCostsof23QMHInpatientsprescribedIVAmpicillin/sulbactam(Unasyn?)orCo-amoxiclav(Augmentin?)

Noof 7120 71657916797478486983Admissions 7473 7589790777787352ICFAdaptedfromSetoetal;BritJClinPharmacol1996;41:229-234(*&#;p<0.001)QMHInpatientsprescribedIVA24AdaptedfromSetoetalBJClinPharm1996;41:229-234ANTIBIOTICUSAGE:IV(dark)Oral(light)Ampicillin/sulbactam,Amoxicillin/clavulanateDDDs/1000admissionsJun94Dec92Feb93AprJunAugOct051015051015202530ICFCefuroximeAdaptedfromSetoetalBJCl25ImpactofICFonIVAmpicillin/sulbactam(Unasyn?)

&Amoxicillin/clavulanate(Augmentin?)PrescribingatQMHInpatientsforwhommemoswereissuedwereusuallyswitchedtooraldosingParenteral(specially‘inappropriate’)prescribingofbothdrugsbutnotcefuroxime-consistently

ˉOrally,AugmentinawasincreasinglyfavouredoverUnasynaEstimatednetmonthlysavings=HK$20,000–30,000

ImpactofICFonIVAmpicillin2610080

6040

20

0NoofprescriptionsAuditofvancomycin/teicoplaninprescriptionsforQMHinpatientsPreICF(Jul–Sep96)9weeksPrescriptionsdeemednottoconformtoCDCguidelines151/182(83%)100NoofprescriptionsAudit27QMHVancomycin/TeicoplaninUsage(exceptingICU&BMTC)9596

97

98

9596

97

98

ICFQMHVancomycin/TeicoplaninU28

Vancomycin/teicoplaninprescriptionsforinpatientsPre-ICF(9weeks)DuringICF(104months)Pvalue(2tailedc2)Empiricaltreatment94(516)157(145)<0.0001Prophylaxis25(137)26(24)<0.0001?-lactamsensitiveisolate*8(44)8(7)<0.0005CNSinasinglebloodcultureonly10(55)40(37)NSPrimarytreatmentofantibioticcolitis11(60)17(16)<0.0005TreatmentofMRSAcolonization3(16)65(60)<0.05Alloftheabove151(830)313(288)<0.0001

(No.notconforming/1000audited)No.notconformingNBBoneMarrowTransplantCentreandPaediatric&NeonatalICUwerenotaudited.*Inpatientswithout'penicillinallergy'Vancomycin/teicoplaninprescr29RETROSPECTIVEAUDITOFMEDICALRECORDSOFALLINPATIENTSWITHSAUREUSBACTERAEMIAS

30(50%)6021(49%)43MRSA16(19%)9125(24%)103MSSADeathsPtNosDeathsPtNosDuringICF1998PreICF1996Re:MRSAdeathsin1996(pre-ICF)&1998(duringICF)DemographicfeaturessimilarAllhadseriousunderlyingdiseasesDeathsensuedfrom<3to>100daysfromDxNotasinglecomplaintthatICFwasdetrimentalRETROSPECTIVEAUDITOFMEDICAL30Datasupplied&adaptedfromHAHOComputerizedPharmaceuticalSuppliesSystemDatasupplied&adaptedfromH31ConclusionsfromICFbasedStrategytargetedatVancomycin&TeicoplaninQMH’songoingICFbasedStrategytocurb‘inappropriate’Glycopeptideprescribingwasassociatedwithsubstantially

ˉ

usageDespitehighMRSArates,therewasnoapparenteffectonmortalityfromMRSAbacteraemiaNosimilar

ˉ

inGlycopeptideusagewasdiscernedinotherHKcomparitorhospitalsConclusionsfromICFbasedStr32

About"60%ofantibioticsaregivenforupper respiratoryinfections-ofwhich90%areviral”IndependentExpertAdvisoryCommitteefinally appointedbyUKGovernment(Chaired byProf RichardWise)tofocusonAntibioticResistance31yrsaftersuchagroupwasrecommended

BMJ2001;323:472,September1

CommunityAntibioticResistance:AGlobalProblem CommunityAntibioticResista33IndicationforAntibioticPrescriptionDerivedfrom1999&2000auditsofantibioticprescribingby143doctorsinthecommunity,*involving9321patientconsultations[*GPs,FMpractitioners,DH,ER,andotherclinicdoctors](CourtesyofProfJADickinson,DepartmentofCommunity&FamilyMedicine,CUHK,HK)IndicationforAntibioticPres34AntibioticPrescriptionsDerivedfrom1999&2000auditsofantibioticprescribingby143doctorsinthecommunity,*involving9321patientconsultations[*GPs,FMpractitioners,DH,ER,andotherclinicdoctors](CourtesyofProfJADickinson,DepartmentofCommunity&FamilyMedicine,CUHK,HK)AntibioticPrescriptionsDerive35OthersAmoxicillinAugmentin?CephalosporinsCloxacillinUnasyn?Prescriptionsfor?-LactamsAmpicillin(&Combinations)Derivedfrom1999&2000auditsofantibioticprescribingby143doctorsinthecommunity,*involving9321patientconsultations[*GPs,FMpractitioners,DH,ER,andotherclinicdoctors](CourtesyofProfJADickinson,DepartmentofCommunity&FamilyMedicine,CUHK,HK)OthersAmoxicillinAugmentin?Cep36%ofStrainsResistantto15?NA716861Strep.pneumoniaeNANANA1724H.InfluenzaeNA58681NAStaph.aureus0NA15NANAStrep.pyogenes

QMH

isolates#2000-2001

ResistanceofSomeRespiratoryTractBacterialPathogenstoVariousAntibiotics%ofStrainsResistantto10?NA8070NAStrep.pneumoniaeNANANA2020H.Influenzae9615250NAStaph.aureus0NA2221NAStrep.pyogenesPeni-cillinMethi-cillinErythro-mycinCo-trimo-xazoleAmpi-cillin

HKCommunityisolates2000**HKDepartmentofHealthSurveillanceData;

#

CourtesyDeptof

Microbiology,QMH;

?Referstohighgraderesistance(MIC

32)%ofStrainsResistantto15?37AdvisoryCommitteeonCommunicableDiseases(ChairedbyDrLoWingLok)LaunchedinitiativetostudyandenhanceAntibioticPrescribingintheCommunityInitialtarget-AntibioticTherapyofRespiratoryInfectionsIntenttomonitor-prescribingamongsamplesofFamilyPhysicians/GPs,coupledwithvarioustypesofeducationandauditsBottom-upstrategy,withinterestedGPsAdvisoryCommitteeonCommunic38TheDilemmaofAntibioticPoliciesTheeasiestser