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Finding low-hanging fruit in antimicrobial stewardship
Many IV fluoroquinolones unnecessary
Researchers are finding a systemic problem involving the unnecessary use of IV fluoroquinolones in the acute care wards of hospitals. While the data came from 128 Veterans Administration (VA) hospitals, the research suggests this is a trend that all health care systems should address through antimicrobial stewardship programs.1
"For antibiotic stewardship, we wanted to pick a topic where we could get a sense of how things were going in the VA and probably elsewhere, as well," says Makoto Jones, MD, research investigator and staff physician at the VA Salt Lake City Health Care System in Salt Lake City, UT.
Parenteral to oral conversion of fluoroquinolones is a relatively easy stewardship step to take, he notes.
"It may be a marker of how well an antibiotic stewardship program is doing," Jones adds.
The 152-bed VA hospital system uses a barcode medication administration to make sure that the right patient gets the right medication. The VA electronic health record collects these and other data, including admission/discharge/transfer data, which tells where a patient is at any given time in the hospital.
"We were able to look at whether an antibiotic was given intravenously or by mouth," Jones says. "We set up the rules so if somebody was given IV antibiotics for two days in a row, we took that as their intention to give IV antibiotics."
Barcode medication administration data were used because medication orders often can change within the first day — sometimes even before a single dose is administered, he explains.
Researchers focused on fluoroquinolones because the drug's bioavailability is the same whether it's given intravenously or orally. So if the patient's gastrointestinal tract could handle the oral medication then many patients could be switched from IV to oral antibiotics, he adds.
"It's an easy switch, and we have randomized control trials saying it appears to get people out the door faster and in a safe manner," Jones says. "If we continue to give patients IV antibiotics they probably stay in the hospital longer than they need to."
Providers sometimes have a mental block about the IV to PO conversion if patients are not transitioned early in their hospital stay.
"Providers think they have to go through a certain process to get the patient out the door," Jones explains. "Most of these patients are pneumonia patients, and the difference in length of stay is on the order of five days. A previous VA study in the 1990's demonstrated a six-day length of stay for those experiencing early IV to PO conversion versus an 11-day length of stay for those that continued to receive IV therapy."
Almost half of IV use avoidable
The research question was framed this way: What is the proportion of IV fluoroquinolone days out of all fluoroquinolone days that is unnecessary and potentially avoidable, and what is the proportion of IV fluoroquinolone days out of all IV fluoroquinolone days that is potentially avoidable IV fluoroquinolone use?
Investigators found that avoidable IV fluoroquinolone use overall was 46.8% of all fluoroquinolone days. The percentage of IV fluoroquinolone days that was avoidable was 90.9%.1
"The idea here is that of all the fluoroquinolones you are using, close to half are IV when they could have been PO," Jones says.
"This is the low-hanging fruit aspect," he adds. "We felt this switch was one of the more simple things to implement for antibiotic stewardship programs."
Infectious disease physicians already know that the IV to PO conversion in antibiotics can save in drug costs and administrative costs, as well as preventing unnecessary patient hospitalization, Jones says.
"We focused on this because in all the rural, small hospitals, the question is where do you start in antibiotic stewardship, and we're presenting evidence that you start with the basics and then continuously monitor it," he says. "When you begin with the basics, the more difficult things like quantifying and measuring de-escalation can be the next step."
The research also addresses the limitations of the study by providing alternative measures without counting patients' first two days of IV fluoroquinolone administration or any IV fluoroquinolone use in the ICU. Taking out these components resulted in the statistics being cut in half: 20.9% of IV fluoroquinolone days out of all fluoroquinolone days were avoidable, and 45.9% of IV fluoroquinolone days out of all IV fluoroquinolone days were avoidable.1
"This study doesn't really add to the science of IV to PO conversion, but as far as systematic measurement and comparisons go, it shows the magnitude of what can be done," Jones says.
"People have been harping on this for 10 to 15 years, and the study indicates there is room for quality improvement," he adds. "And we did find some correlation between avoidable fluoroquinolone use and all antibiotic use, indicating there may be underlying, hidden influences of overall hospital antibiotic stewardship quality."
Reference
- Jones M, Huttner B, Madaras-Kelly K, et al. Parenteral to oral conversion of fluoroquinolones: low-hanging fruit for antimicrobial stewardship programs? Infect Cont Hosp Epi. 2012;33(4):362-367.
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