Antibiotic cost controls used to fight resistance

Survey finds most hospitals control antibiotic use

Originally implemented in many hospitals as cost-saving measures, antibiotic control policies are now being revisited as weapons against the growing problem of drug-resistant pathogens, says Timothy S. Lesar, PharmD, pharmacy director at Albany (NY) Medical Center.

For example, an antibiotic order sheet (AOS) originally designed principally to ensure the most appropriate and cost-effective drugs were being ordered, now doubles as a method to ensure compliance with antibiotic resistance strategies at the hospital. A variety of such policies — including automatic stop orders for specific indications and other formulary restrictions — also are in place at many other hospitals, according to a recently published survey by Lesar.1

The national survey of 48 university hospitals revealed most (81%) use either restrictions or official recommendations to manage antibiotic use. Antibiotics were restricted most commonly by service or unit, indication, or by the infectious disease service. Antibiotic order sheets were used in 21 (44%) of the hospitals, of which 14 required completion by the prescriber. Automatic stop orders were used in 34 (71%) of institutions and were listed on the AOS in 84% of the institutions that used order sheets.

’A lot of those [measures] were originally done to reduce costs,” Lesar tells Hospital Infection Control. ’We have had quite a problem here with resistance, and really what we have done is simply utilize some of the same tools.”

Controls can mean big savings

Typically accounting for a large slice of the total pharmacy drug budget, antibiotics have been targeted for cost control efforts due to reports that they may be routinely prescribed inappropriately.2-3 Though the survey did not attempt to directly assess the efficacy of controls against either resistance or cost, responding hospitals reported average annual antibiotic budgets of $2.1 million for inpatients and another $1.8 million for outpatients. In addition, efforts to both lower costs and resistance may sometimes conflict because more expensive drugs may be needed to provide alternatives for resistant pathogens. Conversely, over-reliance on a single inexpensive agent could inspire resistance through selective pressure in the hospital environment. Still, Lesar estimates hospitals ’starting from scratch” could use antibiotic control measures to cut costs in the 25% range while still keeping a lid on resistance problems.

The AOS used at Albany requires clinicians to order drugs from an approved formulary list for both prophylaxis and therapeutic situations, citing both antibiotic substitutions and automatic stop orders that will take effect unless they specify otherwise.

Working with the same set of tools

’We try to find alternatives that people will want to use, but also will help us achieve our ends,” he says. ’The way to do that is to use the same tools we used to use to reduce costs, which are antibiotic order forms, calling physicians, and stop orders. All of those things can also be helpful in controlling resistance.”

Recent changes in the hospital formulary — as outlined in an in-house pharmacy newsletter distributed to staff — include those designed to fight problems with vancomycin-resistant enterococci. As part of the strategy, plans call for limiting the use of vancomycin to the following situations and infections:

• oral use in Clostridium difficile colitis patients failing metronidazole therapy;

• methicillin-resistant staphylococci;

• ampicillin-resistant enterococci;

• endocarditis prophylaxis;

• serious gram-positive infections in patients with life-threatening penicillin allergy.

Pharmacists take active role

’If you order a drug that we are trying to restrict like vancomycin — and you don’t have an indication that fits criteria — the clinical pharmacist goes and looks at that patient and makes alternative suggestions,” Lesar explains. ’So it is a way of efficiently identifying patients that need to be evaluated for action.”

Monitoring for compliance with established restrictions was primarily the responsibility of the pharmacist processing the order in hospitals responding to the survey. When an order did not comply with restrictions, or compliance could not be determined, the prescriber was contacted prior to dispensing in 77% and 83% of the cases, respectively, the survey found. In cases of noncompliance in which the prescriber refused to alter an order to meet restrictions, 40% of surveyed hospitals refused to dispense the drug, and 35% dispensed the drug but referred the case to another authority such as the infectious disease service.

’I think the best way to look at this is — what are the tools you can use to control antibiotics?” Lesar says. ’Controlling antibiotics can mean controlling costs, it also can control what is being used so you don’t worsen the chances of resistance — meaning we’re going to change the environment in the hospital by directing the use of medications.”

References

1. Lesar TS, Briceland L, et al. Survey of antibiotic control policies in university-affiliated teaching institutions. Ann Pharmacother 1996; 30:31-34.

2. Berman Jr, Zaran FK, Rybak MJ. Pharmacy-based antimicrobial monitoring services. Am J Hosp Pharm 1992; 49:1,701-1,706.

3. Dunagan WC, Woodward RS, Medoff G, et al. Antimicrobial misuse in patients with positive blood cultures. Am J Med 1989; 87:253-259.