Antimicrobial Stewardship

Isn’t That Doctor Business?

Janine Carrucan

Nursing Director Infection Prevention & Control

Standard 3: Preventing and controlling

healthcare associated infections

Antimicrobial stewardship

Safe and appropriate antimicrobial prescribing is a

strategic goal of the clinical governance system.

Townsville, North Queensland

Townsville Hospital and Health Service

2013

• Funded AMS program comprising

–1.0 FTE specialist AMS pharmacist

–0.8 FTE clinical nurse

–ID/clinical micro physician from existing

resources

Trial of activities

• 30 bed neurosurgical ward

Antimicrobial IV administration

• Push

• Hang

• Flush

Top 10 antimicrobials

METHODS OF ADMINISTRATION OF COMMONLY USED INTRAVENOUS ANTIBIOTICS

The following are recommended ways of administering intravenous medications. The advice given is meant to be a brief guide only and for more information see the Australian Injectable Drugs Handbook or consult a Clinical Pharmacist.

Legend: WFI – water for injection, NS – 0.9% Sodium Chloride, GS – Dextrose & Sodium Chloride solns, G5W – Glucose 5%

KCL compatibility: Y = compatible N = Incompatible, do not mix U = unknown, do not mix

References: Australian Injectable Drugs Handbook, 5th Edition, The Society of Hospital Pharmacists 2011 & Pharmacy Department Princess Alexandra Hospital & Health Services

DRUG ADMINISTRATION

& RATE

DILUENT COMPATIBLE

INFUSION

FLUID

RECOMMENDED

CONCENTRATIONS/DILUTION

PRECAUTIONS/SPECIAL NOTES KCL COMPATIBILITY

Via as an

Y SITE ADDITIVE

Ampicillin Bolus over 3 – 5 mins

Infusion over 30 mins

WFI 10ml NS (See notes) 30mg/ml i.e. 1g in 40ml

Dose in 50-100ml for infusion

Glucose containing solutions cause rapid degradation;

however, ampicillin can be given via Y-site with glucose

containing solutions if the contact time is very short e.g. <15

mins

Y U

Benzylpenicillin (BenPen) Bolus 3 – 5 min

Infusion over 60 mins

WFI 20mls NS,GS,G5W Dose in 20mls (bolus)

Dose in 50 – 100ml (infusion)

Maximum rate of 300mg/min for doses over 1.2g Y Y

Cefotaxime Infusion over 30mins* WFI 10ml NS, GS, G5W,

Hartmann’s

Dose in 50 – 100ml (infusion) *Rapid IV injection has led to life threatening cardiac

arrhythmias

U U

Ceftazidime Bolus 3 – 5 min

Infusion over 15 – 30 mins

WFI 10ml NS, G5W,

Hartmann’s

Dose in 10ml (bolus)

Dose in 50 – 100ml (infusion)

Can be an irritant – dilute further if needed Y Y

Ceftriaxone Up to 1g: over 2-4 mins*

>1g: infusion over 15 – 30

mins

WFI 10ml NS, GS, G5W 1g in 10mls (bolus)

2g in 50 – 100ml (infusion)

*Ceftriaxone cannot be administered simultaneously with

calcium containing fluids (e.g. Hartmann’s) even via different

infusion lines

U U

Cephazolin Bolus 3-5 mins

Infusion over 30 mins

WFI 10ml G5W, NS, GS,

Hartmann’s

Dose in 10ml (bolus)

Dose in 50 – 100ml (infusion)

Y U

Flucloxicillin Infusion over 30 min WFI 10ml NS, GS, G5W,

Hartmann’s

Dose in 50 – 100ml (infusion) Irritant – may need to dilute further Y Y

Meropenem Infusion over 30 min WFI 10ml/500mg

WFI 20ml/1g

NS, GS, G5W Dilute in 50 – 100ml for infusion Y U

Piperacillin/Tazobactam

Infuse over 30 mins WFI 20ml G5W, NS Dose in 50 – 100ml Usually takes a few minutes to reconstitute after WFI is

added to the vial

Y U

Teicoplanin Bolus over 5 mins

Infusion over 30 min

3.14 ml of diluent

provided

NS, GS, G5W,

Hartmann’s

Dose in 50 – 100ml for infusion DO NOT SHAKE - if foam present; allow to settle for 15 mins

before giving.

U U

Penicillin allergy

mismatch

PENICILLIN ALLERGY

In serious penicillin allergy (e.g. anaphylaxis, bronchospasm, urticaria, angioedema), avoid ALL penicillins, cephalosporins and other beta-lactam antibiotics. In non-severe penicillin allergy (e.g. mild rash) use cephalosporins & carbapenems with caution. Some reactions (e.g. nausea) are not considered allergies and do not warrant prohibiting penicillin use.

Record allergies on the medication chart in the ‘Allergy section’, the yellow alert sheet in the front of the patient notes

(include details of drug and reaction, and the name of the person completing the record). Place an alert sticker on the

front cover of the patient notes.

Contact your ward pharmacist or AMS Pharmacist (31874) for any concerns/queries.

Created by – THHS AMS Team - December 2013. Endorsed: THHS AMS Committee

Acknowledgements: Pharmacy Department, Women’s and Children’s Hospital, Adelaide SA & Counties Manukau District Health Board, Auckland, New Zealand

Ampicillin

Amoxycillin

Amoxycillin/clavulanic acid (Augmentin®)

Benzathine penicillin

Benzylpenicillin (Penicillin G)

Phenoxymethylpenicillin (Penicillin V)

Dicloxacillin

Flucloxacillin

Piperacillin/tazobactam (Tazocin®)

Ticarcillin/clavulanic acid (Timentin®)

Cefaclor

Cefepime

Cefotaxime

Cefoxitin

Ceftazidime

Ceftriaxone

Cefuroxime

Cephalexin

Cephazolin

Doripenem, Ertapenem, Imipenem, Meropenem

Aztreonam

Azithromycin, Erythromycin, Roxithromycin,

Clarithromycin Ciprofloxacin, Norfloxacin, Moxifloxacin

Clindamycin, Lincomycin

Doxycycline, Minocycline, Tigecycline

Gentamicin, Tobramycin, Amikacin

Linezolid

Metronidazole

Trimethoprim/Sulfamethoxazole

Vancomycin

Therapeutic drug monitoring

vancomycin/gentamicin

The next “R” of rights of drug administration

• Restriction/approval

Cat C Restricted

All anti-HIV drugs Ganciclovir

Adefovir Itraconazole

Amikacin Ketoconazole

Amphotericin B Lincomycin

Artemether+

Lumefantrine(Riamet

)

Linezolid

Artesunate Mefloquine

Atovaquone Meropenem

Azithromycin

(oral 600mg tablets)Paromomycin

Aztreonam Pentamidine

Caspofungin Praziquantel

Cefoxitin Primaquine

Ceftaroline Pyrimethamine

Chloramphenicol (IV) Quinine

Ciprofloxacin Ribavirin

Colistin Rifampicin (IV)

Dapsone Teicoplanin

Daptomycin Tigecycline

Ertapenem Tobramycin

Fusidic acidTrimethoprim/

Sulfamethoxazole IV

Fluconazole (IV) Valganciclovir

Flucytosine Vancomycin (PO)

Foscarnet Voriconazole

Cat B Restricted except listed indication

Azithromycin (IV) Imiquimod

Cefaclor Isoniazid

Cefepime Metronidazole (IV)

Ceftazidime Moxifloxacin

CefotaximeNeomycin/ Polymyxin/

Gramicidin

Cefuroxime Oseltamivir

CeftriaxonePiperacillin/ Tazobactam

(Tazocin)

Ciprofloxacin

ear/eye dropsPosaconazole

ClarithromycinRibavirin with

peg-interferon alfa

Clindamycin Rifabutin

Ethambutol Rifampicin (PO)

Entecavir Terbinafine

FamciclovirTicarcillin-Clavulanic Acid

(Timentin)

Fluconazole PO Tobramycin Eye drops

Gentamicin (IV) Valaciclovir

Gentamicin eye

dropsVancomycin (IV)

Specimen collection

• Urine

• Faeces

• Respiratory

• Other body fluids

IV to oral switch?

Auditing/educationAuditing

– Sepsis audit

– NAPs audit

– acNAPs audit

– Surgical antibiotic prophylaxis/SSS

Education

– Nursing Grand Rounds

– Nurses education

– Patient focused education

– Shadowing at IV administration times to assess compliance

Evaluation

• Too much for one dedicated FTE

• Included in the ICP role description

• Targeted AMS topics each month

• Ensure goals are achievable within the resources

• All achievements will have positive outcomes for patients

NO!

AMS is NOT just Doctor Business!