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Farm Hosp. 2009;33(1):48-52
Farmacia
HOSPITALARIA
Volumen 32. Número 6. Noviembre / Diciembre 2008
ÓRGANO OFICIAL DE EXPRESIÓN CIENTÍFICA DE LA SOCIEDAD ESPAÑOLA DE FARMACIA HOSPITALARIA
Farmacia
HOSPITALARIA
Editorial
Líneas estratégicas de formación en la Sociedad Española de Farmacia Hospitalaria (SEFH)
M.Á. Calleja Hernández
Originales
Morbilidad y costes asociados al síndrome depresivo en sujetos con ictus en un ámbito
poblacional
A. Sicras Mainar, R. Navarro Artieda, M. Blanca Tamayo, J. Rejas Gutiérrez
y J. Fernández de Bobadilla
Calidad de la farmacoterapia y seguridad de los pacientes en hemodiálisis tratados
con estimulantes eritropoyéticos
T. de Diego Santos, M. Climente Martí, E.V. Albert Balaguer y N.V. Jiménez Torres
CONSULTENOS: programa de información al alta hospitalaria. Desarrollo y resultados
del primer año de funcionamiento en 5 hospitales
M.Á. Pardo López, M.T. Aznar Saliente y E. Soler Company
Psicofármacos y gasto en la prisión de Madrid III (Valdemoro)
I. Algora-Donoso y O. Varela-González
Originales breves
Síndrome tóxico del segmento anterior: investigación de un brote
M. Sarobe Carricas, G. Segrelles Bellmunt, L. Jiménez Lasanta y A. Iruin Sanz
Estabilidad en suero fisiológico del busulfán intravenoso en un envase
de poliolefinas
J. Nebot Martínez, M. Alós Albiñana y O. Díez Sales
Artículo especial
Mejorar la adherencia al tratamiento antirretroviral.
Recomendaciones de la SPNS/SEFH/GESIDA
Cartas al Director
Lenalidomida: efectos adversos y comercialización
L. Ortega Valín, J.J. del Pozo Ruiz, C. Rodríguez Lage y F. Ramos Ortega
Revisión del tratamiento con gemtuzumab ozogamicin a propósito
de 3 casos clínicos
E. Fernández Cañabate, M. Longoni Merino, C. Estany Raluy
y R. Pla Poblador
Formulación de glicopirrolato tópico en hiperhidrosis
R. Albornoz López, R. Arias Rico, V. Torres Degayón y A. Gago Sánchez
•
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BRIEF REPORT
Work of a multidisciplinary team in the control of the prescription
of ertapenemq
M.V. Gil-Navarro, a, * R. Muñoz-Corte, a M. Herrero Romero, b M.D. Santos Rubio, a
E. Cordero Matía, b and J. Bautista Palomaa
a
Unidad de Gest ión Clínica de Farmacia, Hospit ales Universit arios Virgen del Rocío, Sevilla, Spain
Unidad de Gest ión Clínica de Enf ermedades Inf ecciosas, Hospit ales Universit arios Virgen del Rocío, Sevilla, Spain
b
Received March 11, 2008; accepted January 23, 2009
KEYWORDS
Ert apenem;
Ant ibiot ics;
Ant imicrobial
management t eam;
Ant ibiot ics policies;
Resist ance t o
ant ibiot ics
Abstract
Obj ect ive: To det ermine t he effect iveness of t he int ervent ion of a mult idiscipline ant imicrobial
cont rol group in t he correct prescript ion of Ert apenem.
Met hod: A 4-mont h long, prospect ive st udy int o prescript ions for ert apenem was carried out in
a t hird-level hospit al. Assessment int o t he degree of suit abilit y of each prescript ion according
t o t he inf ect ions commission usage crit eria. In t he sit uat ion where prescript ions were not
suit able, recommendat ions were given and accept ance of t his was recorded. The effect iveness
of t he ant imicrobial t reat ment used was assessed and t reat ment was considered effect ive when
t here was remission of t he signs and sympt oms of t he inf ect ion when t he t reat ment was
complet ed. The t reat ment was considered t o have f ailed when t he signs and sympt oms of
inf ect ion persist ed or progressed, requiring t he addit ion of anot her ant imicrobial agent ,
changing ant ibiot ics or t he prolongat ion of t he t reat ment for longer t han 2 weeks. Last ly, t he
differences in t he average lengt h of st ay and t he durat ion of t he ant ibiot ic t reat ment bet ween
groups were analysed.
Resul t s: Fort y-eight prescript ions were assessed. The usage crit erion was adequat e in 48%of
cases, wit h 78%effect iveness in t his group. In t he cases where t he prescript ion was not adequat e,
but a change in prescript ion was accept ed, t he effect iveness was 92%, wit h 55.5%of t hose cases
not accepting recommendation for change. The average stay was higher in this last group (P=.07).
The durat ion of t he ant ibiot ic t reat ment in t he pat ient s who accept ed t he change in prescript ion
was signiicantly less than in those who did not accept it (2 vs 7.4 days, P<.0001).
Concl usi ons: The cont r ol of er t apenem pr escr i pt i ons by a mul t i di sci pl i nar y gr oup was
effect ive.
© 2008 SEFH. Published by Elsevier España, S.L. All right s reserved.
qPartial results of this study were published as a scientiic communication in poster format at the 42nd ASHP Midyear Clinical Meeting.
Las Vegas, NV, December 2-6, 2007. RP930. [Accessed February 26, 2008.] Available from ht t p:/ / www.ashp.org/ meet ings/ midyear/
program/ Post ers-res.cfm
*Corresponding author.
E-mail address: [email protected] (M.V. Gil Navarro).
1130-6343/ $ - see front mat t er © 2008 SEFH. Published by Elsevier España, S.L. All right s reserved
Document downloaded from http://www.elsevier.es, day 17/06/2017. This copy is for personal use. Any transmission of this document by any media or format is strictly prohibited.
Work of a mult idisciplinary t eam in t he cont rol of t he prescript ion of ert apenem
PALABRAS CLAVE
Ert apenem;
Ant ibiót icos;
Equipo
mult idisciplinario
ant imicrobiano;
Polít ica ant ibiót ica;
Resist encia a
ant ibiót icos
49
Actuación de un equipo multidisplinario en el control de la prescripción de ertapenem
Resumen
Obj et ivo: Det erminar la efect ividad de la int ervención de un grupo mult idisciplinario de cont rol
ant imicrobiano en la correct a prescripción de ert apenem.
Mét odo: Est udio prospect ivo, durant e un período de 4 meses, de las prescripciones de ert apenem realizadas en un hospit al de t ercer nivel. Evaluación del grado de adecuación de cada
prescripción a los crit erios de ut ilización de la comisión de infecciones. En las sit uaciones en las
que no se adecuaban, se emit ió una recomendación y se regist ró la acept ación de ést as. Se
eval uó l a ef ect i vi dad del t rat ami ent o ant i mi crobi ano ut i l i zado; para el l o, se consi deró
tratamiento efectivo cuando hubo remisión de los signos y los síntomas de la infección al inalizar el t rat amient o. Se consideró fracaso del t rat amient o cuando los signos y los sínt omas de la
inf ección persist ieron o progresaron, requiriendo la adición de ot ro ant imicrobiano, la sust it ución por ot ro/ s ant ibiót ico/ s o la prolongación del t rat amient o más allá de 2 semanas. Finalment e, se analizaron las diferencias de est ancia media y duración de t rat amient o ant ibiót ico
ent re los grupos.
Result ados: Se evaluaron 48 prescripciones. Se adecuaron a los crit erios de uso un 48%de ést as,
con una efect ividad del 78%en est e grupo. En los casos en los que la prescripción no se adecuó,
pero se acept ó un cambio de t rat amient o, la ef ect ividad f ue del 92%, y f ue del 55, 5% en los
casos en los que no se acept ó est a recomendación. La t endencia de la est ancia media fue mayor
en este último grupo (p = 0,07). La duración del tratamiento antibiótico en los pacientes en los
que se aceptó el cambio fue signiicativamente menor que en los que no se aceptó (2 frente a
7,4 días; p < 0,0001).
Conclusiones: El cont rol de las prescripciones de ert apenem por un equipo mult idisciplinario fue
efect ivo.
© 2008 SEFH. Publicado por Elsevier España, S.L. Todos los derechos reservados.
Introduction
Resistance to antibiotics is considered to be a signiicant
public healt h problem. 1-3 Infect ions wit h mult i-resist ant
bact eria are associat ed wit h higher mort alit y and morbidit y
incidence rat es, longer hospit al st ays, and higher cost s, 4,5
all of which has t o do wit h t he fact t hat t here is less and
less market ing of ant imicrobial agent s wit h new act ion
mechanisms. 6,7
The main cause of increased resist ance is t he improper
use of ant imicrobial drugs, which occurs in 50% of cases in
some st udies, 8 and is caused by deicient ongoing training in
ant ibiot ic t reat ment , scant use of microbiology informat ion,
and t he false sense of securit y produced by administ ering
t hese drugs. 9,10
For these reasons, the leading scientiic organisations have
issued a general alert, and some, such as the Centres for
Disease Control and Prevention, have created an action plan
t o prevent t he incidence rat e of resist ant microorganisms
from cont inuing t o grow. 11 The Infect ious Diseases Societ y of
America12 has also recent ly published a guide on ant ibiot ics
policy which st resses t he need for carrying out ot her t ypes
of int ervent ions t hat are not exclusively rest rict ive, such
as forming mult idisciplinary groups cont aining at least 1
infect ious disease specialist and 1 pharmacist . This group
must perform a prospect ive follow-up on prescript ions,
measures rest rict ing access t o ant imicrobial agent s, t he
creat ion of empirical t reat ment guides, t herapeut ic deescalat ion and dosage adj ust ment . 13-15
Few st udies corroborat e t he use of mult idisciplinary
groups in daily clinical pract ice, and fewer st ill measure
t he effect iveness of ant imicrobial t reat ment recommended
by an mult idisciplinary group. Nickman et al 15 evaluat ed
t he effect iveness of a mult idisciplinary group t hat analysed
t he durat ion of post -operat ive ant ibiot ic t reat ment and
achieved bet t er use of ant ibiot ics; nevert heless, t hey
did not evaluat e clinical effect iveness, which is why t he
infect ion rat e in bot h groups may be of int erest . 16
Ert apenem is one of t he most int erest ing drugs for
analysing t he effect iveness of t hese groups, due t o it s
having appeared on t he market only recent ly, having a
microbiologic spect rum t hat is different from t hat of ot her
ant ibiot ics in it s class, and it s high cost . 17
The purpose of our st udy is t o det ermine t he effect iveness
of a mult idisciplinary ant imicrobial drug cont rol group
int ervening t o correct ly prescribe ert apenem in a general
t ert iary referral hospit al; t his hospit al has list ed ert apenem
in it s pharmacology guide since mid-2006 for t he usage
recommendat ions compiled in Table 1.
Method
Quasi-experimental study four months in length (JanuaryApril 2007) in a tertiary referral hospital with a restrictive
antibiotic policy approved by the infections committee (IC),
which manages ant ibiot ic use prior t o administ ering t he drugs
by means of a pharmacist ’s approval in depart ment s wit h a
unitary dose distribution system, and by means of a speciic
form in depart ment s where t here is no such syst em.
A mult idisciplinary group, made up of a hospit al pharmacy
specialist and a specialist in infect ious disease, prospect ively
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Gil-Navarro MV et al
50
Table 1 Indicat ions approved by t he infect ions commit t ee
for t reat ment wit h ert apenem
1. Community-acquired pneumonia with suspected
macroscopic aspirat ion
2. Community-acquired intra-abdominal infection,
cholecyst it is, or pyelonephrit is wit h a risk
of Escherichia coli ESBL
2.A. Severe sepsis or sept ic shock
2.B. Treat ment wit h quinolones, aminopenicillins,
or cephalosporins in t he last 2 mont hs
2.C. Three of the following criteria: >60 years, DM,
recurring UTI, urinary cat het er, hospit alisat ion
wit hin t he last yearaa
DM indicates diabetes mellitus; ESBL, extended spectrum
bet a-lact amases; UTI, urinary t ract infect ion.
a
Risk crit eria t aken from t he st udy by Rodríguez-Baño et al. 22
identiied all daily ertapenem prescriptions in admitted
pat ient s. In order t o verify compliance wit h t he hospit al’s
restricted usage recommendations (Table 1), each patient’s
clinical hist ory was consult ed, wit h t he collaborat ion of t he
microbiology depart ment , in order t o have early knowledge
of t he result s concerning isolat ion and sensit ivit y.
For t hose cases in which prescribing t he drug did not
follow the indications approved by the IC, the prescribing
clinic was offered a t reat ment alt ernat ive. In all cases, t he
pat ient was in follow-up unt il resolut ion of t he infect ion,
discharge from t he hospit al, or deat h, and re-admit t ed
pat ient s were in follow-up unt il a mont h aft er t heir
discharge.
Treat ment was considered t o be effect ive when t he
pat ient was clinically recovered, which implied t he t ot al
Table 2
remission of signs and sympt oms relat ed t o t he infect ion
at t he end of t he t reat ment . Treat ment was considered
unsuccessful when t he signs and sympt oms of t he infect ion
persist ed and progressed, and required t he addit ion of
anot her ant imicrobial agent , subst it ut ion of t he original
t reat ment wit h anot her ant ibiot ic or ant ibiot ics, or
prolonging t he t reat ment by more t han 2 weeks.
The following variables were recorded: age, sex,
healt h care depart ment , prescribing physician, indicat ion
request ed on t he prescript ion sheet , main diagnosis,
suit abilit y of t he indicat ion, int ervent ion performed
(alternative treatment), acceptance, effectiveness of the
ant ibiot ic t reat ment (ert apenem or accept ed alt ernat ive
treatment), duration of antibiotic treatment and hospital
st ay. The SPSS program, version 15.0, was used t o det ail
a st at ist ical descript ion of t he result s and an analysis of
t he c2 (categorical variables) or of the variance (continuous
variables) was used to detect differences between the
result s for different st rat a or subgroups. The t hreshold of
statistical signiicance was 95%.
The principal variables t hat were measured were
prescription suitability according to the IC’s indications,
t he degree of accept ance of recommendat ions made by
t he mult idisciplinary group and t he effect iveness of t he
ant imicrobial t reat ment in use.
Results
We evaluat ed 48 ert apenem prescript ions, which
corresponded t o 28 male and 20 female pat ient s. The mean
age was 58.7 years (16-84). Table 2 shows the health care
depart ment s in which pat ient s had been admit t ed and t he
indicat ions for which t hey request ed use of t he ant ibiot ic
t reat ment .
The healt h care depart ment s t hat issued t he most
prescriptions for ertapenem were the surgical ones (60%).
The indicat ions wit h t he most prescript ion request s were
communit y-acquired int ra-abdominal infect ion, cholecyst it is
Dist ribut ion of prescript ions by depart ment and indicat ion
Percent age of
prescriptions (n)
Percent age of indicat ed
prescriptions (n)a
Depart ment
Surgery
Emergency surgery
Int ensive care unit
Observat ion
Ot hers
33.3 (16)
27.0 (13)
10.4 (5)
6.3 (3)
23.0 (11)
43.7 (7)
38.4 (5)
80 (4)
33.3 (1)
54.5 (6)
Indicat ion f or t reat ment
Aspirat ion pneumonia
Risk of Escherichia coli ESBL due t o sepsis
Risk of Escherichia coli ESBL due t o previous ant ibiot ic t reat ment
Risk of Escherichia coli ESBL due t o all t hree risk fact ors
Isolat ion of Escherichia coli ESBL
Unknown
10.4 (5)
25.0 (12)
25.0 (12)
33.3 (16)
4.0 (2)
2.0 (1)
60 (3)
33.3 (4)
50 (6)
44 (7)
100 (2)
2.0 (1)
ESBL indicat es ext ended spect rum bet a-lact amases.
a
Prescript ions indicat ed following evaluat ion by t he mult idisciplinary group.
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Work of a mult idisciplinary t eam in t he cont rol of t he prescript ion of ert apenem
or pyelonephrit is wit h some risk fact or for Escherichia coli
extended-spectrum beta-lactamases (ESBL) (83%).
Forty-eight percent% (n=23) of the ertapenem
prescript ions met hospit al prot ocol. The most frequent
proiles for unsuitability were a lack of risk factors for E coli
ESBL; for t his sit uat ion, t he t reat ment recommended by
the IC was amoxicillin/clavulanic acid. In a lower number
of prescript ions, pat ient s present ed a risk of infect ion
by nosocomial microorganisms, in which case a broaderspect rum ant imicrobial t reat ment was recommended
(Table 2). The 3 most common E coli ESBL risk fact ors were
as follows: pat ient older t han 65, diabet ic, having been
hospit alised in t he past year.
Unsuit abilit y was relat ed t o t he healt h care depart ment
and t he prescribing doct or, alt hough result s were not
statistically signiicant.
In all cases in which prescript ion was not suit able, an
alt ernat ive ant ibiot ic t reat ment was recommended:
amoxicillin/clavulanic acid in 40% (n=10), piperacillin/
tazobactam in 16% (n=4), imipenem/vancomycin in 12%
(n=3), teicoplanin and ceftriaxone in 8% (n=2) and cloaxillin
and gentamycin in 4% (n=1). In 61% of cases in which an
alt ernat ive t reat ment was recommended, t hat t reat ment
was accepted (15 prescriptions). The most common reason
for not accept ing t he alt ernat ive was t hat t he prescribing
doct or suspect ed E coli ESBL, despit e t he pat ient not
having any risk fact ors. The accept ance rat e was 67%, 40%,
62.5%, and 75% during mont hs 1, 2, 3, and 4, respect ively,
indicat ing t hat t he highest percent age was reached in t he
last mont h.
There were no statistically signiicant differences in the
mean age for each group.
The effect iveness of t he ant imicrobial t reat ment used for
clinical resolut ion of t he illness was 78%in t he group wit h a
suit able indicat ion for ert apenem, 92%in pat ient s receiving
t reat ment wit h t he proposed alt ernat ive, and 69% in t hose
treated with ertapenem despite not meeting the IC’s
Table 3
51
indications. Differences were not statistically signiicant
(table 3).
We det ect ed a lower t endency of prolonged hospit al
st ays among t he group t hat accept ed t he alt ernat ive
t reat ment compared wit h t he group t hat did not , alt hough
the differences were not statistically signiicant (P=.07).
However, The mean durat ion of t reat ment was short er in
t he group t hat accept ed t he alt ernat ive compared t o t he
one t hat did not and used ert apenem (2 days vs 7.4 days;
P<.0001). We only found 25 patients who had undergone
a microbiologic cult ure, and of t hese pat ient s only 2
present ed isolat ed E coli ESBL (8%).
Discussion
In our st udy, half of t he prescript ions were not suit able;
t hese result s are similar t o t hose recorded in ant ibiot ic use
st udies8,18 and in t hose similar t o our own. 19
The suggest ed change in t reat ment was accept ed in
more t han half of all cases, which is a similar result t o
t hat recorded by ot her aut hors20; nevert heless, accept ance
could have been increased if t he mult idisciplinary group
had been formed before t he st udy began. We observe t hat
t he best accept ance rat e percent age was achieved in t he
last mont h of follow-up.
The fact that there were no statistically signiicant
differences in effect iveness result s among t he 3 groups
could be due t o t he small sample size, given t hat t here was
a t endency t owards increased effect iveness in t he group
t hat accept ed t he recommended alt ernat ive t reat ment ,
and t he percent age of re-admissions, t he mean lengt h of
t reat ment and t he mean hospit al st ay were higher in t he
group t hat did not accept t he alt ernat ives. This result is
consist ent wit h t he st udy carried out by Barenfanger et al, 21
in which t he mean hospit al st ay was reduced by 2.7 days in
t he int ervent ion group.
Effect iveness of t he ant imicrobial t reat ment act ually used
Group
Group 1
(n=23 patients)
Mean age, y
Percent male pat ient s, n
Mean length of antibiotic treatment, d
Mean hospital stay, d
Group 2
(n=12 patients)
Group 3
(n=13 patients)
57.08
39 (9)
8
37
53.38
75 (9)
2
20
67
77 (10)
7,
15.5
Result s
Effective treatment, % (n)
Not effective treatment, % (n)
78.2 (18)
21.8 (5)
91.6 (11)
8.4 (1)
69.2 (9)
30.8 (4)
Reasons f or t reat ment f ailure
Change in antibiotics % (n)
Re-admission, % (n)
Death, % (n)
80 (4)
0 (0)
20 (1)
100 (1)
0 (0)
0 (0)
25 (1)
50 (2)
25 (1)
Group 1 indicates patients whose initial indication was suitable for ertapenem according to the infection committee’s (IC) criteria;
group 2, patients for whom prescribing ertapenem did not meet IC recommendations and for whom the proposed alternative
treatment was accepted; group 3, patients treated with ertapenem despite not meeting IC recommendations.
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Gil-Navarro MV et al
52
Our st udy measures t he effect iveness of t he ant imicrobial
t reat ment , unlike most ant ibiot ic policy st udies t hat
evaluat e result s in reducing ant ibiot ic consumpt ion, cost s
or resist ance rat es aft er performing various int ervent ions
(restrictive and/or persuasive), but do not measure the
effect iveness of t he t reat ment t hat is act ually used. This
is the case in the study by García et al,13 which achieves a
reduct ion in t he t ot al consumpt ion of ant imicrobial drugs by
put t ing t oget her a mult idisciplinary group similar t o our own
which evaluat es all prescript ions of rest rict ed ant ibiot ics in
t he hospit al in one year, and which recommends anot her
treatment for cases in which the IC’s conditions are not
met .
The most important limitations of our study are, irstly,
t he prescribing healt h care depart ment s, since t he number
of prescript ions was much higher in one t han in t he rest of
t he hospit al depart ment s; t his could be a fact or masking
unsuit able use of t his ant ibiot ic, and t herefore, t he result s
cannot be ext ended t o ot her hospit al depart ment s. The
second limit at ion is not having included a measure of t he
severit y of pat ient s’ condit ions; however, t he number of
pat ient s admit t ed t o t he int ensive care unit was quit e low,
and logically, t his populat ion was in a more crit ical st at e
t han t he rest .
We can conclude t hat const it ut ing a mult idisciplinary
group t o follow up on ant ibiot ics is helpful in improving t he
use of ert apenem.
For fut ure st udies, it will be necessary t o include a larger
number of pat ient s and measure t he ecological impact of
having a mult idisciplinary group in a hospit al t o monit or
ant imicrobial t reat ment s.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Acknowledgments
16.
We would like t o acknowledge t he cont ribut ions of all who
assist ed in t he pharmacy depart ment , t he infect ious disease
depart ment and t he microbiology depart ment .
17.
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