Prescription Audit in Emergency Medicine in a teaching Institution.pptx

Prescription Audit and Responsible Antibiotic Use in a tertiary care Hospital

1. PRESCRIPTION AUDIT Responsible Antibiotic Use Dr. S.Balasubramanian MD, DCH,FIAP, FRCPCH (UK) Medical Director HOD PEDIATRICS Course Co- ordinator - IAP IDC PID Fellowship Kanchi Kamakoti CHILDS Trust Hospital, Honorary pediatrician, Southern Railway Headquarters Hospital CHENNAI

2. Focus in This Session Few Case Scenarios in Office & Hospital Practice Dilemmas in Antibiotic Therapy Audit of Prescriptions Commonly Given Perfect & Imperfect Actions Reasons for The Prevailing Situation The Way Forward

3. Case 1 – Child with “Throat Infection” 5 yr old – Fever, Throat Pain Cold,Cough & Red Tonsil & Throat 2 others in family have “Throat infection” Father on Azithromycin given by ENT Surgeon Young Pediatric Practitioner tells me “ How can I not give antibiotic ?” He prescribes Amoxyclav Is it Perfect or Imperfect? Let us Audit this Prescription

4. Child with “Throat Infection” Perfect Applying Modified Mcissac Score RADT Prescribing Amoxyciilin for 10 days on clinical/lab diagnosis Using Azithromycin only for Penicillin Allergy Imperfect Upfront Abx for all Throat Pains Giving Azithromycin – Since it is easy to give only OD/5 days Giving Routinely Amoxyclav Giving Cephalosporin or Quinolone particularly when there are some Loose Stools

5. Case 2 – Child with ? Sinusitis A 3 yr old Fever – 3 days – Afebrile from day 4 Mild Mucopurulent Rhinitis Xray - Bilateral Maxillary Sinusitis Advised Cefpodoxime for 5 days Let us Audit this prescription

6. Antibiotics for Rhinosinusitis Perfect Applying PWS Rule for Diagnosis Amoxycillin / Amoxyclav for at least 7 to 10 days Reserving CT Only for Complicated cases & not for diagnosis Ceftriaxone for Toxic, Ill, Hospitalised /Complicated Imperfect Choosing Azithromycin, Cefixime , Cefpodoxime , Clindamycin upfront Relying on Xray Diagnosis Giving Abx to All with Purulent/Mucopurulent Rhinitis 5 days course of Abx

7. Case 3 – Child with Pneumonia 2 yr old – Fever, Cough, Tachypnea TC 20000 Taking feeds well, Not toxic Xray Taken Inj Ceftriaxone IM prescribed for 7 days Let us Audit this

8. Child with Pneumonia Perfect Amoxycillin 40 mg/kg/day OP Treatment No repeat X ray if better Amoxyclav if recntly received Abx / Conjunctivitis + Avoiding Abx for Viral LRTI Imperfect Azithromycin + Amoxy / Amoxyclav routinely Azithromycin alone Oral Cephalsporin or Clindamycin Repeat X Ray after 1 week routinely Ceftriaxone for all CAP Routinely

9. Case 4 – Adolescent with Pneumonia 12 yr old boy Fever & cough (5 days) Temp 101 f , tachypnoeic ,SPO2 100% TC 4800 Hb 10 Mycoplasam IgM + ve Azithromycin Prescribed Let us Audit the prescription

10. Atypical Pneumonia Perfect Amoxycillin / Amoxyclav alone may be enough in older children. If Atypical Pneumonia is suspected on clinical Grounds, Azithromycin/ Doxycycline Levofloxacin as Montherapy Imperfect Only Azithromycin for CAP Reliance on IgM/PCR Azithromycin for Chronic Cough/All Wheeze + Fever

11. Case 5 – An Infant with CNS Infection 8/12 Infant- fever, vomiting for 2 days , followed by brief seizures . Looks sick, febrile, irritable AF full, tense Probable Acute Bacterial MENINGITIS TC-22,000 P68 L 31 M1 Hb 9 Platelet 4 Lakh CSF- WBC-2000-P80 L20 % Protein 450,Glucose 30/100 Gram stain-Nil organism Started on Ceftriaxone IV Let us Audit this

12. An Infant with CNS Infection Perfect Ceftriaxone + Vancomycin Upfront is justified De escalation based on sensitivity Loading Dose of Ceftriaxone Repeat LP if Resistant Bug Imperfect Only Ceftriaxone as Initial Empiric Therapy for Meningitis Pipto + Tazo for Older children with Meningitis Abx without CSF/ Blood Culture in such cases ( eg – Febrile Seizures)

13. Ceftriaxone + Vancomycin – Why?

14. Case 6 – Infant with Fever- No Focus 6 months old – Fever 2 day - No Focus Temp > 102* Anxious Family & Pediatrician TC 14200 DC P 78 L 22 CRP 24mg/dl Started on Cefixime He feels it could be Bacterial Infection Let us Audit this

15. Infant with Fever- No Focus Perfect To remember - UTI is the commonest Bacterial Infection No Abx without cultures CRP/PCT – Limited Value – Not as routine Extreme Leucocytosis – Pneumonia/UTI likely Imperfect Cefixime for All High Fever without focus Forgetting UTI as a Possiblity Parenteral Abx as OP Not doing Urinalysis as a starting point

16. Antibiotics for UTI Perfect Amoxyclav / Cefixime as OP after culturing Amikacin as Monotherapy after assessing RFT Ceftriaxone/ Piptaz depending on ESBL Prevalence Imperfect Nitofurantoin / Norfloxacin for Febrile UTI Abx for Asympomatic Bacteruria Bag Culture for diagnosis Not interpreting Colony Counts appropriately Prophylaxis for All First Episode UTI

17. Case 7 – Neonate with Fever 9 Days old Abd Distension, Poor Feeding 2 days Temp 38*C Hospitalised CBC, CRP, Blood Cultures,LP done Started on Ampi + Genta Let us Audit this

18. Antibiotics in Neonatal Sepsis Perfect Blood, Urine & CSF cultures before starting Abx Piptaz or Meropenem +or – Amikacin the choice today De escalation based on cultures Following duration rules Imperfect Treating CRP Values with Meropenem / Colistin Oral Abx Therapy Routine Prophylaxis

19. Case 8 – Infant with AWD 10/12 infant – diarrhea + some dehydration > 3 days,Temp 100* TC 13400, Urine R – N Stool R – 12 pus cells/HPF Day 1 – Cefixime Day 3 – Amikacin + Ofloxacin + Metronidazole Let us Audit this

20. Infant with AGE Perfect Zinc + ORS + Diet Advice + Counselling alone Abx for Dysentery Abx for SAM, Sepsis, Cholera Imperfect “GYL GYL” COMBOS Amikacin + or - Ceftriaxone for AWD Abx for Transitional Stools/Foremilk Diarrhea

21. Case 9 – Fever for 5 days 5 yr old – Fever 5 th day – increasing trend Spleen Tipped Young Pediatrician labels this as Enteric Fever Asks for CBC, Urine R & C&S, Widal Prescribes Ofloxacin + Azithromycin Let us Audit this

22. Fever for 5 days – Enteric Fever Perfect Doing Blood Culture before Abx Single drug Therapy Cefixime /Azithromycin/ Cotrimoxazole Stopping Abx if recovering fast & culture – ve Abx for at least 7-14 days Ceftriaxone only for Hospitalized, Toxic Imperfect Using Quinolones & Amikacin Dual Therapy Changing drug without proper reports Treating Widal /IgM report Missing Typhus & Not Considering Doxycycline Low dose Cefixime /Azithromycin

23. Question to the audience I s prescribing antibiotics unnecessary in majority of instances in private practice? Yes or No

24. Possible reasons Fever means bacterial – concept Parental pressure Fear of losing the client Fear of secondary infection Lack of time to think Saturday evenings Pressure from pharma industry Lack of confidence

25. Possible reasons Past bitter experience Genuinely convinced it is right. Past success Impractical to withhold antibiotics Parents are not convinced and happy Every visit should be followed by a new prescription with a new drug Sheer economics Peer pressure Playing safe and feeling secure Lack of Role Models Lacunae in Medical Curriculum Need for saving Antibiotics not felt Western concept not acceptable to our country ie . Rural practice

26. What should we do?

27. What have we done in our Hospital?

28. Thank You Please Email feedback to [email protected]