Impact of an antimicrobial formulary and restriction policy in the largest hospital in Italy
Introduction
The use of antimicrobial agents in developed countries is reported to be inappropriate in 20–60% of cases. This may result through incorrect pharmacological choice (e.g. use of broad-spectrum antibiotics when unnecessary, use of antibacterial drugs as antipyretics, etc.) but chiefly occurs because of inappropriate dosage and irrational treatment length. Antibiotics comprise a wide range of drugs with >200 substances approved and thus, available for clinical use.
Some antibiotics occur very frequently in medical prescriptions, particularly in the hospital environment, while other drugs with the same or greater efficacy and often lower cost, are ignored. New agents that have optimum microbiological and pharmacological features should be administered in only a few selected and targeted cases. It is difficult for physicians to keep up to date on new substances and the latest antimicrobial resistance patterns.
The extensive use of antibacterial agents is paralleled by the growing frequency of multidrug resistant strains (MDR) which is said to be related to the overuse of antibiotics, both in prophylaxis and in therapy [1], [2], [3], [4].
The last 15 years have seen the growth of MDR-bacteria such as Staphylococcus aureus met-R, vancomycin-resistant enterococci (VREF) and resistant Gram-negative bacteria (Pseudomonas spp., Escherichia coli, Klebsiella spp., Serratia spp., Enterobacter spp.) [5].
New classes of antibiotics may not be available in the future, therefore we should design, formulate and carry out a policy that establishes the best use of drugs which are now available [6], [7], [8], [9].
As a group of drugs, antibiotics have the greatest impact on the hospital budget, being ≈25% of the total drug expenditure. Such cost must be limited, however, this should be done not just considering economical aims, but after a proper analysis of each drug. In order to optimise the use of antimicrobial agents, we need to know the local management of antibiotic therapy and the microbiology of the local bacterial strains.
Both the use of these drugs and the incidence of bacterial resistance vary in different hospitals.
The hospital pharmacist — who is responsible for checking prescriptions — should therefore work together with the infectious disease specialist, who is the main consultant concerned with anti-infective therapy. Since the beginning of the 1980s, policies for the reduction of antibiotic use and related costs have been established in the US and northern Europe [10], [11], [12]. Nowadays almost all American hospitals have a committee that controls drug spending, especially for antimicrobial agents [13], [14].
In our hospital, after analysing prescriptions for 3 years, we have tried to rationalise the use of antibiotics through a policy of accurate information and if needed, restrictions of use modelled on data from other countries.
Section snippets
Background
S. Martino teaching hospital with 2500 beds is the largest hospital in Italy and one of the largest in Europe.
We analysed the use and the cost of antibiotics from 1995 to 1997 for each department in this hospital, after dividing the hospital into four large sections: surgery (S), internal medicine (IM), intensive care unit (ICU) and haemato/oncology (HO).
In S. Martino the cost of antimicrobials was 26% of total drug expenditure during the period examined. The cost per year of antibiotics was
Materials and methods
After a complete evaluation of all data, the Therapeutic Committee for Hospital Formulary (TCHF) of SMTH decided to create a formulary of antimicrobials agents which would contain all decisions taken by the Committee. As a result of the analysis, a committee composed of the head of the pharmacy department, infectious disease specialists, a pharmacologist expert and a medical executive of the hospital decided to exclude some drugs from the formulary and to allow the use of other drugs only on a
Results
From the cost analysis we found that with a similar number of days of hospitalisation (727 641 days in 1997 versus 707 280 days in 1998), the cost of antibiotic drugs decreased in 1998 after the introduction of the formulary by 10.5% with a saving of 345 000 Euros. The average cost of antibiotic per day of hospitalisation decreased from 4.53 Euros in 1997 to 4.18 Euros in 1998 with a saving of 8.5% in 1 year. The most dramatic reduction seen was for ceftazidime, available only on special named
Conclusions
About 500 of named patient requests were made after January 1, 1998, which were evaluated by an infectious disease consultant. There was an initial difficult period when physicians working in SMTH had to acclimatise to the new strategies and rules for antibiotic therapy, but these problems are now resolved.
This exercise reduced the use of some antibiotics which were not used properly [19]; the restriction policy has resulted in clear and immediate saving and we hope for an improvement in the
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