Improving IV antibiotic use; the role of the nurse

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Improving IV antibiotic use the role of the
nurse

• Lee Stewart
• Antimicrobials Pharmacist (South Glasgow)

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Overview

• Introduction the problems
• The solutions
• Empiric antibiotic policy
• Improving IV vancomycin and gentamicin use
• IVOST
• Alert antibiotics
• Summary and questions

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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
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Empiric antibiotic policy
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• Restricts the use of the 4c antibiotics
  (greatest C difficile risk)
• Co-amoxiclav
• Cephalosporins
• Ciprofloxacin ( other quinolones)
• Clindamycin

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Improving IV vancomycin and gentamicin use
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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
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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 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?

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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

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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

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IVOST
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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

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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 gt38C or
lt36C, heart rate gt90bpm, respiratory rate
gt20/minute, WCC lt4 or gt12) 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
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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 temp 36-38oC, 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 gt72 hours

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Alert Antibiotics
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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

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Alert Antibiotics
Pharmacy can only supply these alert antibiotics
when an Alert Antibiotic Form
has been completed fully
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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 patients name/unit number on
  the indent

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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

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Further information

• Posters on wards
• Therapeutics Handbook
• Intranet (? Clinical info ? antimicrobial
  guidelines)
• BNF
• IV monographs
• Nurse information sheets
• Local Antimicrobials Pharmacist

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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