Antibiotic prescribing and the emerging resistance to antimicrobial agents are important topics for people working in the field of infectious diseases (IDs). In hospitals especially, the pressure of antibiotic resistance is high, due to the presence of critically ill patients, the use of high dosages in intensive care units and because of the use of a great variety of anti-infectives.(1) On the other hand, according to a US study, up to 50% of antibiotic prescriptions in hospitals are inappropriate in terms of drug choice, route of administration, dose or length of treatment.(2) Finally, the financial aspect is also crucial, as an important amount of the drug budget is spent on anti-infective agents. At Salzburg Central Hospital (Austria), we spent about 14% of our drug budget on these agents in 2002.
How it all began …
In 1991, after two years in community pharmacies, I began to work as a hospital pharmacist at Salzburg Central Hospital. I soon started to specialise in antibiotics. Even now, I think antibiotics are a fascinating group of drugs, allowing you not only to treat an illness symptomatically, but also to cure a patient – assuming you choose the correct agent according to the pathogen and the site of infection.
When I became a member of the hospital hygiene conference in 1994, I learnt more about the many problems associated with IDs and antibiotic policies in our hospital, and began to realise that the situation required a multidisciplinary approach. Two years later, in 1996, an ID working group was founded, consisting of an ID doctor, a bacteriologist and myself as a pharmacist, with the head of the medical Intensive Care Unit (ICU) joining us one year later. We then set up a programme for improving antibiotic (AB) prescribing according to local resistance data (see Table 1).
Recently, I initiated a daily AB monitoring chart by email. This way, we automatically get data from the pharmacy about special anti-infectives, including restricted agents being ordered by wards. In Austrian hospitals, only orders for restricted ABs include data on the individual patients they are prescribed for. For the past few months, our group has been receiving a daily email with information about special anti-infectives being ordered by the different wards.
I start work at 7.30am. Since the birth of my daughter in December 2001, I work part-time (40%: eight hours at home, as there is a remote access to the hospital system on my computer, and eight hours at the hospital).
Accordingly, my days at the pharmacy hospital have to be planned carefully so I am as efficient as possible when I am at the hospital.
Mornings are not boring at all …
My working day kicks off with a pharmacology lecture to 24 midwife students, something that I have been doing for 10 years with great pleasure. At about 9.05am, I enter my office at the drug information department, which I helped establish in 1995 and was in charge of until the birth of my child. My successor gives me the latest news: interesting enquiries, new drugs, the timetable of the postgraduate lectures and what is going on in the hospital pharmacy.
I tread through my emails and, next, I have to find more literature for the comparison of gentamicin and netilmicin in paediatrics – really not an easy job. The only aminoglycoside currently used at our Children’s Hospital is netilmicin, and I am trying to convince the department to switch to the cheaper and clinically equivalent gentamicin. Unfortunately, studies on children are rare, and most of them have been published more than 20 years ago. In addition, they are not really comparable concerning dosage, as q24 dosage was only introduced with netilmicin. Finally, I make a few phone calls to “my” three doctors to check our timetable for the afternoon.
An interesting ID afternoon …
After a short lunch break, our working group meets a patient at the surgical ICU. At noon we meet at the ward to see a young girl after abdominal surgery. She had an ileus and is now suffering from a severe Candida nonalbicans and multiresistant Pseudomonas aeruginosa infection. The Candida infection was treated with liposomal amphotericin B in combination with caspofungin. We modified the treatment to caspofungin alone, as the benefit of a combination with amphotericin B is not clearly defined in the literature, and the ineffective meropenem was abandoned for combination ciprofloxacin–amikacin, both drugs being sensitive in vitro to the multiresistant Pseudomonas.
At 12.30am, we have our weekly ID meeting in the pharmacy’s 300-year-old conference room. Today, we have invited the AB specialist of the gynaecology department to update their AB guidelines. We first discuss when and how to use perioperative prophylaxis, then we go through the most common gynaecological infections and discuss their possible treatment. For example, the treatment of UTI in pregnant women who are allergic to beta-lactams is problematic, so we decide to carry out a literature search and discuss it further in three weeks’ time.
After the gynaecologist has left, we discuss our daily AB monitoring chart: today, there is no special news. Finally, we agree on the next meeting dates. A postgraduate symposium about the treatment of soft tissue infections will take place the next week on Friday. If my husband could manage to have a day off to take care of our daughter, I could attend. At about 3pm we leave and I return to my office, a bit tired. A cup of strong coffee gives me enough energy to do some work on my computer: correspondence, meeting summary, etc. As usual, my day is nearly finished but my work is not! I will have to spend at least one more hour at my “home office”. Finally, at about 4.45pm, I leave to pick up my daughter at the babysitter’s.
- Scott M. Strategies for better quality antibiotic prescribing. Hosp Pharm 2002;6:60-6.
- Knox K, Lawson W, Dean B, et al. Multidisciplinary antimicrobial management and the role of the infectious diseases pharmacist – a UK perspective. J Hosp Infect 2003;53:85-90.