Impact of an antimicrobial formulary and restriction policy in the largest hospital in Italy

Abstract

We have analysed the expenditure on antimicrobial drugs in the largest hospital in Italy; over this period, a committee prepared an antibiotic policy document. This formulary lists all antimicrobial drugs available in the hospital. Some drugs were removed from the list and others are only available on special request for a named patient. In the hope of optimising drug utilisation, we included all the reasons for the choice of agent in the document. The introduction of this formulary resulted in an immediate saving and perhaps in the future we shall also observe an improvement in bacterial resistance patterns.

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.