DRUG USE EVALUATION:ANTIBIOTIC PROPHYLAXIS IN C-SECTION AT THE MATER HOSPITALAuthors: Boruett P., Opiyo N.A., Maronda B.O. For the Mater Hospital Pharmacy and Therapeutics Committee (MHPTC) The MHPTC acknowledges the collaboration of key stakeholders especially the division of Obstetrics and Gynecology and the technical assistance provided by Management Sciences for Health-RPM Plus Program

IntroductionAntibiotic prophylaxis is useful in reducing incidences of surgical (operation) site infection.The use of antibiotic prophylaxis is however characterized by inappropriate practices such as use of broad-spectrum antibiotics; administering at wrong time; and continuing for too longUse of single dose has been found to be as effective as multiple doses and also cost effective to patients [1].The recommended duration of prescribed antibiotics prophylaxis for c-section has reduced from 5 days to 3 days then to 24 hrs and finally to a single dose [2] .DUE serves as a structured criteria based method of identifying, monitoring and correcting challenges encountered in practice [1] Hopkins L, Smaill F. Antibiotic prophylaxis regimens and drugs for cesarean section. Cochrane Database of Systematic Reviews 1999, Issue 2[2] Liabsuetrakul T, Lumgiganon P and Chongsuvivatwong V, Prophylactic Antibiotic Prescription for Cesarean Section, International Journal for Quality in Health Care 2002: Vol.14(6) pp. 503-508

Objective of DUEThe objective of the DUE was to establish appropriate antibiotic prophylaxis for caesarean sections at The Mater Hospital between January 2006 and June 2006.The Mater Hospital Pharmacy and Therapeutic Committee (MHPTC) in conjunction with division of Obstetrics and Gynaecology undertook the baseline retrospective DUE*

* Boruett was trained on DUEs in the Regional DTC-TOT course organized by the Ministry of Health/ Uganda, Makerere University/Uganda and RPM Plus/MSH in collaboration with WHO & INRUD in Uganda (2004)

Stepwise Approach to DUE:

Step 2

Establish criteria and thresholds

Step 1

Develop scope of activities

Step 6

DUE follow-up

Step 3

Data collection and data entry

Step 5

Develop recommendations and a workplan

Step 4

Data analysis

MethodsThe criteria for the DUE were developed prior to commencing, using a literature review and discussions with Ob/Gyn consultants, registrars, pharmacists, and hospital anaesthetists. Comparison was also made with practices at a private hospital in Nairobi.The Mater Hospital P&T Committee endorsed the criteria.A retrospective review of 110 medical records of C- sections done between January and June 2006Medical, Theatre and Nursing records, Treatment sheets were reviewed to identify antibiotic prescribed for each c-section deliveryPrescribing trends were compared with the set criteria Antibiotic choice, dose, duration, timing of first dose formed the basis of comparison

DUE Criteria for Antibiotic Use inC-sections A compliance threshold of 90% was set

Overall Results :-Observations:Adherence to defined antibiotic dose (86.8%) and duration of antibiotic prophylaxis (5%) was below the 90% threshold.Use of antibiotics for 2-7 days was the main reason for failure to meet defined criteria

Indicator

Meets criteria

Results

Antimicrobial choice

Antimicrobial agent is as per criteria.

97%

Dose Prescribed

Dose as per criteria.

86.8 %

Duration

Duration as per criteria.

5%

Overall Adherence

Complied with all above criteria

5%

Cost Implications of Overuse of Antibiotics

Illustration using Co-amoxiclav Inj. 1.2g -Extrapolated to 600 C-Sections Annually

Chart5

412200

1236600

824400

Co-Amoxiclav

template 1 injectables

Cost of Surgical Propylaxis for C-Sections

Data source - Jan to June 2006

COST OF A SINGLE DOSECo-AmoxiclavCefuroximeComments

1.2 gm Inj.1.5 gm Inj.

ADrug Cost582492Acquisition cost (i.e. cost of drug to the pharmacy)

BPharmacy time cost2525If applicable, calculate time in minutes to prepare a single dose multiplied by average cost of employee

CNursing time cost1515time in minutes to prepare/administer a single dose multiplied by average cost of employee

DSyringe/Needle5050

EIV Set

FIV Fluids

Gloves1515

GTotal Cost to administer a single dose of antimicrobial687597Add data from items A to F (automatically calculated)

Number of C-sections9999This is the actual number of C-sections cases analyzed for the study

HTotal Cost for C-sections68,01359,103This is the actual cost of 99 C-sections analyzed for the study (automatically calculated)

INumber of yearly C-Sections600600300 C-sections were performed in Jan-June 2006 - Assumption is that 600 C-sections are performed in one year

JYearly Cost for 1 dose412,200358,200Number of yearly C-sections multiplied by total cost of a single dose of antimicrobial (automatically calculated)

KYearly Cost for 3 doses1,236,600n/aNumber of C-sections multiplied by total cost of a single dose of antimicrobial times 3 (automatically Calculated)

LCost Savings per year for using a single dose824,400878,400Difference in yearly cost for 3 doses versus 1 dose (automaticially calculated)

Note: All costs in Kenya Shillings

template 2 oral ABX

Cost of Surgical Propylaxis for C-Sections-Additional Oral Doses

Data source - Jan to June 2006

COST OF ORAL ANTIBIOTICSOral Co-amoxiclav 625mg TabletOral Cefuroxime 500mg TabletComments

ADrug Cost99169.9Acquisition cost (i.e. cost of drug to the pharmacy)

BPharmacy time cost2525If applicable, calculate time in minutes to prepare a single dose multiplied by average cost of employee

CNursing time cost77time in minutes to prepare/administer a single dose multiplied by average cost of employee, for doses given as inpatient

DSyringe/Needle

EIV Set

FIV Fluids

Gloves

GTotal Cost to administer a single dose of oral antimicrobial131201.9Add data from items A to F (automatically calculated)

Number of C-sections9999

Number of C-sections receiving oral antibiotic7878This is the actual number of C-sections cases receiving oral antibiotics for the study

HTotal Cost for C-sections receiving oral antibiotics1021815748.2This is the actual cost per single dose of oral antibiotic of C-sections analyzed for the study (automatically calculated)

Number of yearly C-Sections600600

INumber of yearly C-Sections receiving oral antibiotic473473300 C-sections were performed in Jan-June 2006 - Assumption is that a similar proportion of patients will get oral antibiotics in 600 C-sections are performed in one year

JYearly Cost for 1 dose of oral antibiotics61,92795,444Number of yearly C-sections multiplied by total cost of a single dose of antimicrobial (automatically calculated)

KYearly Cost for oral antibiotic 10 doses619,273954,436yearly cost for one dose of oral antimicrobial (automatically calculated) times 12 (automatically Calculated)

Average cost saving per patient receiving oral antibiotics1,3102,019

Overall cost saving per year on use of oral antibiotics1,573,709

LOverall Cost Savings per year for using a single dose2,452,109Comprises Difference in yearly cost for 3 doses versus 1 dose (automaticially calculated) plus cost saving on oral antibiotic

Note: All costs in Kenya Shillings

Sheet1

Sheet1

412200

1236600

824400

Co-Amoxiclav

Summary

ComponentCo-AmoxiclavCefuroxime

Yearly Cost for 1 dose$412,200358,200.00

Yearly Cost for 3 doses$1,236,600-

Extrapolated Cost Savings per year for using a single dose$824,400878,400.00

Yearly Cost for additional oral antibiotic 10 doses$619,273954,436.36

Average cost saving per patient on eliminating oral antibiotics$1,3102,019.00

Overall cost saving per year on eliminating use of oral antibiotics$1,573,709

Overall Cost Savings per year for using a single dose$2,452,109

ComponentCefuroxime

Yearly Cost for 1 dose358,200.00

Yearly Cost for 3 doses-

Extrapolated Cost Savings per year for using a single dose878,400.00

Yearly Cost for additional oral antibiotic 10 doses954,436.36

Average cost saving per patient on eliminating oral antibiotics2,019.00

Overall cost saving per year on eliminating use of oral antibiotics

Overall Cost Savings per year for using a single dose

ComponentCo-Amoxiclav Inj. 1.2gCefuroxime 1.5g Inj.

Single dose$412,200358,200.00

3-doses$1,236,600-

Savings for Single Dose$824,400878,400.00

Cost of Oral Doses$619,273954,436.36

Overall Cost Savings for Using Single Dose Injection Only$1,573,709

Overall Cost Savings per year for using a single dose$2,452,109

Summary

0

0

0

Co-Amoxiclav

Sheet3

Average Cost of an EmployeeNursePharmacy

Average Monthly Salary25,000.0050,000.00

Total Hours worked per month162.00162.00

Cost per hour154.32308.64

Cost per minute2.575.14

Time to prepare/dispense dose5.005.00

Time cost12.8625.72

Summary of Cost Implications* of Antibiotic Overuse*Note: Costs extrapolated to 600 C-sections annually

template 1 injectables

Cost of Surgical Propylaxis for C-Sections

Data source - Jan to June 2006

COST OF A SINGLE DOSECo-AmoxiclavCefuroximeComments

1.2 gm Inj.1.5 gm Inj.

ADrug Cost582492Acquisition cost (i.e. cost of drug to the pharmacy)

BPharmacy time cost2525If applicable, calculate time in minutes to prepare a single dose multiplied by average cost of employee

CNursing time cost1515time in minutes to prepare/administer a single dose multiplied by average cost of employee

DSyringe/Needle5050

EIV Set

FIV Fluids

Gloves1515

GTotal Cost to administer a single dose of antimicrobial687597Add data from items A to F (automatically calculated)

Number of C-sections9999This is the actual number of C-sections cases analyzed for the study

HTotal Cost for C-sections68,01359,103This is the actual cost of 99 C-sections analyzed for the study (automatically calculated)

INumber of yearly C-Sections600600300 C-sections were performed in Jan-June 2006 - Assumption is that 600 C-sections are performed in one year

JYearly Cost for 1 dose412,200358,200Number of yearly C-sections multiplied by total cost of a single dose of antimicrobial (automatically calculated)

KYearly Cost for 3 doses1,236,600n/aNumber of C-sections multiplied by total cost of a single dose of antimicrobial times 3 (automatically Calculated)

LCost Savings per year for using a single dose824,400878,400Difference in yearly cost for 3 doses versus 1 dose (automaticially calculated)

Note: All costs in Kenya Shillings

template 2 oral ABX

Cost of Surgical Propylaxis for C-Sections-Additional Oral Doses

Data source - Jan to June 2006

COST OF ORAL ANTIBIOTICSOral Co-amoxiclav 625mg TabletOral Cefuroxime 500mg TabletComments

ADrug Cost99169.9Acquisition cost (i.e. cost of drug to the pharmacy)

BPharmacy time cost2525If applicable, calculate time in minutes to prepare a single dose multiplied by average cost of employee

CNursing time cost77time in minutes to prepare/administer a single dose multiplied by average cost of employee, for doses given as inpatient

DSyringe/Needle

EIV Set

FIV Fluids

Gloves

GTotal Cost to administer a single dose of oral antimicrobial131201.9Add data from items A to F (automatically calculated)

Number of C-sections9999

Number of C-sections receiving oral antibiotic7878This is the actual number of C-sections cases receiving oral antibiotics for the study

HTotal Cost for C-sections receiving oral antibiotics1021815748.2This is the actual cost per single dose of oral antibiotic of C-sections analyzed for the study (automatically calculated)

Number of yearly C-Sections600600

INumber of yearly C-Sections receiving oral antibiotic473473300 C-sections were performed in Jan-June 2006 - Assumption is that a similar proportion of patients will get oral antibiotics in 600 C-sections are performed in one year

JYearly Cost for 1 dose of oral antibiotics61,92795,444Number of yearly C-sections multiplied by total cost of a single dose of antimicrobial (automatically calculated)

KYearly Cost for oral antibiotic 10 doses619,273954,436yearly cost for one dose of oral antimicrobial (automatically calculated) times 12 (automatically Calculated)

Average cost saving per patient receiving oral antibiotics1,3102,019

Overall cost saving per year on use of oral antibiotics1,573,709

LOverall Cost Savings per year for using a single dose2,452,109Comprises Difference in yearly cost for 3 doses versus 1 dose (automaticially calculated) plus cost saving on oral antibiotic

Note: All costs in Kenya Shillings

Sheet1

Sheet1

412200

1236600

824400

Co-Amoxiclav

Summary

ComponentCo-AmoxiclavCefuroxime

Yearly Cost for 1 dose$412,200358,200.00

Yearly Cost for 3 doses$1,236,600-

Extrapolated Cost Savings per year for using a single dose$824,400878,400.00

Yearly Cost for additional oral antibiotic [10 doses]$619,273954,436.36

Average cost saving per patient on eliminating oral antibiotics$1,3102,019.00

Estimated cost saving per year on eliminating use of oral antibiotics$786,855

Estimated Cost Savings per year for using a single dose of Cefuroxime Inj$1,665,255

ComponentCefuroxime

Yearly Cost for 1 dose358,200.00

Yearly Cost for 3 doses-

Extrapolated Cost Savings per year for using a single dose878,400.00

Yearly Cost for additional oral antibiotic 10 doses954,436.36

Average cost saving per patient on eliminating oral antibiotics2,019.00

Overall cost saving per year on eliminating use of oral antibiotics

Overall Cost Savings per year for using a single dose

Summary

412200

1236600

824400

Co-Amoxiclav

Sheet3

Average Cost of an EmployeeNursePharmacy

Average Monthly Salary25,000.0050,000.00

Total Hours worked per month162.00162.00

Cost per hour154.32308.64

Cost per minute2.575.14

Time to prepare/dispense dose5.005.00

Time cost12.8625.72

Strategies to Improve Antibiotic UseManagerial StrategiesDrug Use EvaluationGuideline on Antibiotic Prophylaxis in C-section.Clinical pharmacy programs.Use of automatic stop ordersEducational StrategiesFace-to-face communicationEducation outreachGroup sessions Influencing Opinion leadersPrinted Educational Materials

SummaryAdministration of single dose is relatively rare at the HospitalUse of 3 doses, instead of a single dose of Co-amoxiclav carries huge cost implications as illustrated above. To increase the quality of antimicrobial prophylaxis in Caesarean section surgery, efforts should be put into developing guidelines acceptable to all disciplines.Other consequences of overuse of antibiotics include:Increase in antibiotic resistance and adverse drug reactionsIncrease in costs of healthcare including costs of drugs, pharmacy time, nursing care and time, and cost of consumables e.g. syringes, needlesDUE will be an ongoing program at Mater Hospital

DUE Performance Matrix

Sheet1

Ongoing DUE at the Mater Hospital Performance Matrix

ActivityTimeline

J-06 to N-06D-06J-07F-07M-07A-07M-07J-07J-07A-07S-07

Managerial Strategies

Activity 1:Drug use Evaluation

a) Baseline evaluation

b) Follow-up after intervention (Quarterly)

Sheet2

Ongoing DUE at the Mater Hospital Performance Matrix

ActivityTimelines

D-06J-07F-07M-07A-07M-07J-07J-07A-07S-07

Activity 2: Development of Guideline

a) Drafting of guideline

b) Circulation of draft to stakeholders

c) Approval by MHPTC , Medical advisory Committee and Hospital administration

d) Official launch of guideline

e) Implementation of Guideline

Sheet4

Ongoing DUE at the Mater Hospital Performance Matrix

ActivityTimelines

D-06J-07F-07M-07A-07M-07J-07J-07A-07S-07

Activity 3: Clinical Pharmacy Program

Two pharmacists to take part in ward rounds at maternity ward

Educational Strategies

Activity 4: Educational activities

a) One to one detailing by pharmacists

b) Group training session: CME, Clinical meetingCMECMECME

c) Newsletter article on antibiotic prophylaxis

d) Bulletin featuring protocol on antibiotic prophylaxis in c-section

Sheet3

ActivityTimeline

Jun to Nov 06D-06J-07F-07M-07A-07M-07J-07J-07A-07S-07

Managerial Strategies

Activity 1:Drug use Evaluation

a) Baseline evaluation

b) Follow-up after intervention (Quarterly)

Activity 2: Development of Guideline

a) Drafting of guideline

b) Circulation of draft to stakeholders

c) Approval by MHPTC , Medical advisory Committee and Hospital administration

d) Official launch of guideline :

e) Implementation of Guideline

Activity 3: Clinical Pharmacy Program

Two pharmacists to take part in ward rounds at maternity ward

Educational Strategies

Activity 4: Educational activities

a) One to one detailing by pharmacists

b) Group training session: CME, Clinical meetingCMECMECME

c) Newsletter article on antibiotic prophylaxis

d) Bulletin featuring protocol on antibiotic prophylaxis in c-section