antibiotics use and concordance to

8/2/2019 Antibiotics Use and Concordance To

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SF Teoh 1, Samsinah Hussain1, CK Liam2

1

Departments of Pharmacy, Faculty of Medicine,University of Malaya, and 2General Medicine, University

Malaya Medical Centre (UMMC), Kuala Lumpur, Malaysia.

Antibiotics Use And Concordance ToGuidelines For Patients HospitalizedWith Community Acquired Pneumonia

(CAP)


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Outline Introduction

Objectives

Methodology

Results and discussion

Conclusion


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Introduction

Pneumonia: sixth mortality cause inMalaysia from 1991 to 20001,2.

Guideline-recommended antibiotic - more

cost saving without causing variation in

patients clinical outcome3,4,5,.


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Objectives

1. To describe the treatment pattern ofantibiotics use according to

American Thoracic Society (ATS) 2001guidelines3

Infectious Disease of America (IDSA) 2003

guidelines6

University Malaya Medical Centre (UMMC)2004 antibiotics guidelines7

for patients hospitalized with CAP inUMMC

2. To determine levels of guidelinesconcordance


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Methodology

Episodes fulfilling inclusion criteriawere included (n= 79)

Data analysis using SPSS (Statistical Package for SocialScience version 15.0)

Total patients (n= 202)

All patients hospitalized with CAP (between January2004 until November 2006) according to ICD 10th coding(J13, J14, J15, and Jl6)

Number of patients

excluded (n=123)

Guidelines adherence were determined according to

ATS, IDSA, UMMC recommendations


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Exclusion criteria

Less than 18 years old,pregnant or lactating

Hospital admissionwithin past 30 days

Aspiration or hospital-

acquired pneumonia Residence in nursing

home

Pneumonia as expectedoutcome of severechronic comorbidity

Tuberculosis

Others

discharge at patients

requestparticipation in

clinical trial

HIV positiveconcurrent

chemotherapy

immuno-suppression,cystic fibrosis

incomplete medicalrecords


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Comparison OfTreatment

Recommendations


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Not mentionedWithin 4 hoursWithin 8 hoursAntibioticinitiation

no co-morbid illness:

doxycycline OR

azithromycin

with co-morbid illness:

azithromycin +

amoxicillin/clavulanic

acid OR azithromycin +cefuroxime

severe:

ceftriaxone +

azithromycin OR

gatifloxacin

fluoroquinoloneOR advanced

macrolide

(azithromycin/

clarithromycin) +

beta-lactam

cardiopulmonarydisease :

fluoroquinolones

OR beta-lactam +

macrolides

nocardiopulmonary

disease:

azithromycin OR

fluoroquinolones

Empiricalantibioticformedical

wardedpatients

UMMC 2004 AntibioticGuidelines7

IDSA 2003Guidelines6

ATS 2001Guidelines3


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Results

andDiscussion


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Demographic Data

OfStudy Population


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84.8

15.2

67

12

At least 1 comorbidity

No comorbidity

34.227Malay

15.212Still smoking

30.424Had stopped54.443Non-smoker

6.85Others

27.822Chinese

31.625Indian

48.141Male

Percentage (%)n=79Demographic


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Types Of

Empirical AntibioticsTherapy


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40

23

10

23

1

50.6

29.1

12.7

2.53.8

1.3

0

10

20

30

40

50

60

iv beta lactam

+ macrolide(a)

iv amoxicillin/

clavulanic acidonly(b)

Other

antibiotics(c)

iv azithromycin

only(d)

Combination of

(a),(b),(c),(d)

No antibiotic

n = 79 Percentage


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Types Of Empirical

Antibiotics TherapyAccording

To GuidelinesRecommendations


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Concordance NoYesNoYesNoYes

UMMCIDSAATSGuidelines

202002IV azithromycin only

(b)

9310402812IV beta lactam andIV/PO macrolide (a)

101010No antibiotics

303030Combination ofabove

100100100Other antibiotics (d)

230230230IV amoxicillin/

clavulanic acid only

(c)

48(60.8)

31(39.2)

39(49.4)

40(50.6)

65(82.3)

14(17.7)

n(percentage)


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Reasons Of Low Concordance

More specific guidelines loweradherence

If criteria for use is not clearly specified

higher tendency to fall into adherence


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46.837Within 8 hours

53.242More than 8 hours

PercentageFrequencyTime to antibiotic

initiation

Early antibiotic delivery8,9,10:

Stepping down antibioticsEarly switch of parenteral to oral

antibiotics

Timing Of Antibiotics Initiation


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Comparison Of Length OfStay, Average Daily Antibiotic

Cost And Total TreatmentCost Between Guidelines


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0.002*49.7733.69Total treatment cost

0.046*46.4035.86Average daily antibiotic cost

0.005*48.9434.23LOS

UMMC Guidelines


0.06744.6635.22Average daily antibiotic cost0.029*45.5434.32LOS

IDSA Guidelines


0.013*53.8637.02Average daily antibiotic cost

0.002*57.2936.28LOS

ATS Guidelines

p-valueConcordantNon-Concordant

Guidelines


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Possible Reasons For Variation FromReported Findings

Differed from previous studies, earlier

antibiotics initiated patients incurred higher

average daily antibacterial costs (mean rank

RM47.32 vs. RM32.55, p-value=0.008).


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Guidelines concordance incurring higher costs

Majority of the non- adhered patients were

prescribed single beta-lactam

Limitation

None employment of severity levels measurement.

Assessment - by clinical judgement and vital sign

monitoring

Outcome measure merely consideration of

discharge status


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Conclusion

Concordance to available guidelines can

be further improved although higher

antibiotics costs were found in patients

treated in concordance to the guidelines.


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References

1. Malaysia Social Statistics Bulletin November 2005, Department ofStatistics, Putrajaya.

2. Vital Statistics Malaysia (Special edition) 2000, Department of

Statistics, Putrajaya.

3. American Thoracic Society Guidelines for the Management of Adultswith Community-Acquired Pneumonia Diagnosis, Assessment ofSeverity, Antimicrobial Therapy, and Prevention (2001). American

Journal of Respiratory Critical Care Medicine, vol. 163, pp. 17301754.

4. Dean, NC, Silver, MP, Bateman, KA, James, B, Hadlock, CJ & Hale,D (2001) Decreased mortality after implementation of a Treatment

Guideline for Community-Acquired Pneumonia, The AmericanJournal of Medicine, vol. 110, pp. 451-457. Retrieved September 16,2006 from Elsevier database.


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5. Mandell, LA, Barlett, JG, Dowell, SF, File, TMJr, Musher, DM &Whitney, C (2003) Update of Practice Guidelines for the Managementof Community-Acquired Pneumonia in Immunocompetent Adults,Clinical Infectious Diseases, vol. 37, pp. 1405-1433.

6. Marrie, TJ, Lau, CY, Wheeler, SL, Wong, CJ, Vanderwood, MK, Feagan,BG (2000) A Controlled Trial of a Critical Pathway for Treatment ofCommunity-Acquired Pneumonia, JAMA, vol. 283, no. 6, pp. 749-755.

7. University of Malaya Medical Centre Antibiotic Guidelines 2004,

Infection Control Team.8. Liam, CK (2005) Community Acquired PneumoniaA Malaysian

Perspective, The Medical Journal of Malaysia, vol 60, no 2, pp 249-265.

9. Thanimalai, S & Rajasuriar, R (2006) Timing of Antibiotic Administration

in Hospitalised Patients with Community Acquired Pneumonia inMalaysia (abstract), 6th Asian Conference of Clinical Pharmacy.

10. Barlett, JG, Breiman, RF, Mandell, LA & File, JrTM (1998) Community-Acquired Pneumonia in Adults: Guidelines for Management, Infectious

Disease Society of America. Clinical Infectious Diseases, vol. 26, pp.811-838.

References


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THANK YOU and

ACKNOWLEDGEMENT

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