The role of the clinical microbiology laboratory and the clinical pharmacy in the management of infectious disease (ASM, 1992). Introduction.
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Drug Costs↗
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Results for “Formularies, Hospital as Topic”
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Selection of antimicrobial agents for routine testing in a clinical microbiology laboratory.
Each clinical microbiology laboratory must establish its own standard battery of antimicrobial agents to be tested routinely on clinical isolates of various organism groups. Some choices are based upon the intrinsic activities of antimicrobial agents for a particular group of organisms, for example, agents primarily active against either Gram-positive or Gram-negative bacteria. For final selection of limited batteries of agents for routine testing, however, it is necessary to use additional criteria based upon physician prescribing patterns and the availability of antimicrobial agents in a particular institution. A fundamental principle in the selection process should be routine testing and reporting of those antimicrobial agents that physicians actually use, that is, the institution's formulary agents. Testing of the most appropriate drugs for an institution may be complicated by lack of availability of some antimicrobial agents among the standard panels offered by automated instrument or commercial test system manufacturers. The laboratory should develop its final test batteries in consultation with the infectious disease and pharmacy services and the pharmacy and therapeutics and infection-control committees of the medical staff. These choices should not be made based upon the most convenient selection of drugs from the laboratory's perspective or based upon pharmaceutical industry promotional efforts.
Anti-Bacterial Agents↗
Formulary control of antimicrobial usage. What price freedom?
Formulary controls are the most common and probably the most effective method for controlling abuse of antimicrobial agents in hospitalized patients. Such programs may include restriction of both the number of agents available and the way these agents may be used. These programs have been demonstrated to control pharmacy expenditures. Other potential advantages include reductions in the incidence of adverse drug reactions and the antimicrobial resistance among the hospital flora, and improvements in the overall quality of prescribing of antimicrobials. There are few data to document such benefits, however. Potential disadvantages are also poorly documented but include inconvenience for prescribing physicians, increased administrative costs, prescribing errors, and increased antimicrobial resistance. Antimicrobial control programs will likely remain common, but the availability of new information technologies should enable a transition to systems based on concurrent assessment of antimicrobial appropriateness with immediate feedback to the prescribing physician.
Anti-Bacterial Agents↗
A team approach to hospital formulary replacement.
A multidisciplinary antibiotic review team (MART) was implemented to improve patient care and reduce antimicrobial expenditures. MART consists of pharmacists and infectious disease (ID) physicians reviewing patients three times weekly. Antibiotic expenditures were reduced by recommending conversions to therapeutically equivalent antibiotics, conversion to an oral agent, and completion of treatment with home infusion therapy. In addition, MART proposed therapeutic interchanges from ceftriaxone to cefotaxime to the P and T committee. ID physician or pharmacist offered recommendations and initiated order changes if the attending physician agreed. Annualized savings was $74,371, with 40% of the recommendations resulting in an improved antimicrobial therapy.
Anti-Bacterial Agents↗
Econotherapeutics.
A program that represents the efforts of a hospital pharmacy management company to control drug costs is described. The program, Econotherapeutics, was developed in response to a changed health care reimbursement system that focused on the costs of products rather than the revenue generated by these products. For antimicrobial agents, a hospital-specific antibiogram is used to encourage cost-effective prescribing. A pharmacist intervention program, medical staff presentations, drug usage evaluation, management systems, and educational programs for pharmacists are all essential parts of the program. Centralized data gathering has allowed cost comparison of specific antimicrobial agents so that differences between variable cost estimates and costs based on actual use can be evaluated. Actual dose and dosage interval were used to calculate average cost per treatment day in a 121-hospital sample. Our cost data support the choice of cefotaxime over ceftriaxone.
Anti-Bacterial Agents↗
Selection of cephalosporins for hospital formularies.
Because of the large number of cephalosporins available for use, and for economic reasons, most hospitals have restricted the number of cephalosporins for inclusion on hospital formularies. No more than one first-generation oral and parenteral cephalosporin is necessary. The second- and third-generation oral cephalosporins are more active in vitro against Haemophilus influenzae and Enterobacteriaceae, and the selection of one of these drugs should be based primarily on acquisition cost. There is usually minimal, if any, need for a second-generation parenteral cephalosporin on hospital formularies. The choice of a single third-generation parenteral cephalosporin should be made primarily on the cost of equivalent daily dosages. A single antipseudomonal cephalosporin should be included in the hospital formulary, and the selection should be based on cost and availability.
Administration, Oral↗
Clinical outcome of a mandatory formulary switch for dihydropyridine calcium channel blocker therapy at a Veteran's Administration Medical Center.
Recently, changes in antihypertensive therapies with similar properties have been made based primarily on cost savings for hospital formularies. To assess blood pressure (BP) control and adverse side effects associated with a switch of patients on nifedipine GITS to felodipine at our Veteran's Administration Medical Center (VAMC), we prospectively studied physician records and patient-reported side effects (both from the medical record and patient questionnaires) in 127 hypertensive patients (70 +/- 10 years, 95% men, 88% nonblack, 44% with coronary disease) who underwent the forced switch in therapy. During the period of patient visits/chart review, physicians were unaware that the study was being conducted. A minimum of 2 months and two visits on each therapy was required for patient inclusion. The mean doses of nifedipine GITS and felodipine used were 55 +/- 24 mg/day and 8 +/- 2.6 mg/day, respectively. The use of supplemental antihypertensive agents was similar in both calcium channel blocker groups. Systolic BPs and heart rates were similar in patients taking the two drugs, and the diastolic BP was modestly lower in patients taking felodipine (78 +/- 10 mm Hg for felodipine and 80 +/- 10 mm Hg for nifedipine, P < .05). There were no differences in the incidence of side effects (both patient-reported and provider-reported) for the two antihypertensive therapies. These data demonstrate that in an hypertensive population followed in a VAMC, mandatory switching of stable dihydropyridine calcium channel blocker therapy did not result in any significant changes in short-term (2 to 3 months) BP control nor were adverse side effects different based on both physician- and patient- reported sources of information.
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Experience with a drug formulary in a large Italian city hospital.
The preparation and distribution of a drug formulary, providing some 377 pharmacological entities together with significant general information, in a large city hospital, enabled the collection of data on the pattern of drug use in this setting. Out of the 377 selected drugs, 27 were never used in the course of one year: most notable among these were the cephalosporin cephalothin, the antifungal griseofulvin, piperazine and the leading anti-H1-blocker terfenadine. Thirteen pharmaceutical preparations were used in over 50,000 doses; among these were the amiloride + hydrochlorothiazide combination, co-trimoxazole and lorazepam. Examination of specific drug series, e.g. of cephalosporins, showed a clear preference for the longer acting ceftriaxone versus a minor use for oral agents, e.g. cefadroxil. There was a wide choice of cardiovascular agents and a relative stability in the preference for major and minor antipsychotics. Outside of the formulary list, only a small number of preparations were requested, among these some traditional analgesic combinations and some extractive products. The provision of a hospital formulary may, in some way, modify drug choice in the hospital, although some established patterns of use are difficult to change. On the other hand, some interesting information was provided on the criteria of choice of hospital physicians.
Formularies, Hospital as Topic↗
Emergency department procedural sedation formularies.
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Procedural Sedation↗
Prescribing to older ED patients.
The purpose of this article is to assist emergency physicians in selecting safe and effective drug therapy for seniors. Because safer alternatives exist, medications on the Beers list of potentially inappropriate medications should generally be avoided. We also review risks associated with several classes of medications: nonsteroidal anti-inflammatory drugs, benzodiazepines, and anticholinergic medications. They are associated with adverse outcomes when taken by older adults and should be used with caution. We also address the use of opioid medications in seniors. Although they are not without risk, opioids are generally safe with slow titration, precautions, and a bowel regimen to prevent constipation. Prescribers should also consider the need for estimating creatinine clearance when prescribing medications that require dosage adjustment in the setting of renal insufficiency. Two areas in need of research are identifying the proper dosing and safety of medications in seniors and prescribing with electronic decision support to assist in prescribing decisions.
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Impact of a formulary switch from ticarcillin-clavulanate to piperacillin-tazobactam on colonization with vancomycin-resistant enterococci.
BACKGROUND: The prevalence of vancomycin-resistant enterococci (VRE) is increasing, despite infection control measures. Limited data link ticarcillin-clavulanate to higher VRE prevalence. METHODS: Active surveillance for VRE was conducted before and after a formulary switch from ticarcillin-clavulanate to piperacillin-tazobactam. Rectal swabs were obtained serially in 863 adult patients admitted to intensive care units (ICUs) between November 1, 2000 and September 30, 2004. RESULTS: In the postswitch period, 38 of 497 (7.6%) patients acquired VRE versus 42 of 366 (11.5%) patients in the preswitch period. Survival analysis showed an overall hazard ratio (HR) of .68 postswitch versus preswitch ( P = .07), with the greatest change in the surgical ICU (HR = .17, P = .006). Multivariate analysis showed an overall HR = .51 ( P = .004). Hospital-wide, nonstool VRE clinical cultures fell from 39 (.58/1000 patient days) in the 10-month preswitch period to 27 (.33/1000 patient days) in the 12-month postswitch period. Infection control practices and use of other antibiotics remained stable. CONCLUSIONS: VRE acquisition appeared to decrease in association with a formulary change from ticarcillin-clavulanate to piperacillin-tazobactam.
Anti-Bacterial Agents↗
Eliminating analgesic meperidine use with a supported formulary restriction.
PURPOSE: Meperidine is a commonly used analgesic despite unique disadvantages compared with other opioid analgesics. The objective of this study was to measure the effects of a meperidine formulary restriction on the prescribing of parenteral opioid analgesics. MATERIALS AND METHODS: The study was performed at a single 750-bed tertiary care teaching hospital in Rochester, NY. The formulary restriction limited meperidine to use exclusively for rigors or procedural sedation and was supported by an educational initiative and a computerized order entry system. Independent computerized pharmacy records were used to capture all doses of parenteral morphine, meperidine, and hydromorphone administered to patients in the emergency department or on a medical or surgical inpatient floor during data-collection periods. Baseline data were collected during two 3-day periods before the formulary restriction; then comparison data were collected during three 3-day periods over 15 months after the formulary restriction. RESULTS: The number of administered doses of meperidine per day decreased from 37.5 (20.8% of parenteral opioid doses before the restriction) to 0.22 (0.1% of parenteral opioid doses, P = .001). The total number of opioid doses and morphine doses given did not change, whereas the number of hydromorphone doses increased significantly postrestriction, from 16.0 doses per day (8.9% of total) to 59.7 doses per day (29.5%) (P = .009). CONCLUSION: Meperidine formulary restriction, supported by an educational program and computerized order entry, effectively eliminated analgesic meperidine use. Hydromorphone use increased proportionately to offset the decreased use of meperidine.
Analgesics, Opioid↗
Antimicrobial stewardship.
Antimicrobial stewardship is a key component of a multifaceted approach to preventing emergence of antimicrobial resistance. Good antimicrobial stewardship involves selecting an appropriate drug and optimizing its dose and duration to cure an infection while minimizing toxicity and conditions for selection of resistant bacterial strains. Studies conducted over the years indicate that antibiotic use is unnecessary or inappropriate in as many as 50% of cases in the United States, and this creates unnecessary pressure for the selection of resistant species. Because the pharmaceutical industry pipeline for new antibiotics has been curtailed in recent years, and it may be >/=10 years before important new antibiotics to treat certain resistant bacteria find their way to market, a premium has been set on maintaining the effectiveness of currently available agents. Several strategies, including prescriber education, formulary restriction, prior approval, streamlining, antibiotic cycling, and computer-assisted programs have been proposed to improve antibiotic use. Although rigorous clinical data in support of these strategies are lacking, the most effective means of improving antimicrobial stewardship will most likely involve a comprehensive program that incorporates multiple strategies and collaboration among various specialties within a given healthcare institution. Computer-assisted software programs may be especially useful in implementing these comprehensive programs. The antimicrobial stewardship program at the Hospital of the University of Pennsylvania, which has been shown to improve appropriateness of antibiotic use and cure rates, decrease failure rates, and reduce healthcare-related costs, is used as an example in support of this multifaceted, multidisciplinary approach. At this time, data from well-controlled studies examining the effect of antibacterial stewardship on emergence of resistance are limited, but available data suggest that good antibiotic stewardship reduces rates of Clostridium difficile-associated diarrhea, resistant gram-negative bacilli, and vancomycin-resistant enterococci.
Anti-Bacterial Agents↗
The driving force in hospital formularies: economics versus efficacy.
The rising cost of pharmaceuticals has created a focus on hospital cost containment. From 1990 to 2000, spending on prescription drugs increased 200%. Through a variety of mechanisms and contracting, hospital formularies have become increasingly more restrictive. Physician choice with regard to antibiotics specifically is becoming more limited. The field of pharmacoeconomics looks at the cost effectiveness of the drugs we use. The pressures on the pharmaceutical industry and hospitals are reviewed here with a discussion of antibiotic prophylaxis, new expensive therapies, and physician responsibility. The driving force behind hospital formulary design is often economic, whereas the physician desires variety and efficacy. This review discusses some of the key issues related to drug costs and expenditures.
Drug Costs↗
Professionals' awareness of operational antibiotic prescribing controls in UK NHS hospitals.
In recent years, there have been increasing recommendations for multidisciplinary collaboration between clinical pharmacists and medical microbiologists in an attempt to control the quality (and quantity) of antibiotic prescribing. A questionnaire addressing the utilization of antibiotic prescribing controls was sent to the chief pharmacist and medical microbiologist in UK NHS hospitals. Responses were received from both the chief pharmacist and the medical microbiologist employed in the same hospital from 83 hospitals (a 30% response rate from two independent studies). A high level of disagreement and poor awareness was identified between the interprofessional staff groups regarding the existence of antibiotic formulary (with disagreement between the two groups, or not known by one or both respondents, in 46% of the paired hospitals, N = 38) and guideline documents (13%, N = 11), performance of antibiotic prescribing audits (40%, N = 33), and whether pharmacists (52%, N = 43) and medical microbiologists (77%, N = 64) monitored physician compliance with antibiotic prescribing control documents. This study has identified poor knowledge of the existence of basic antibiotic prescribing control mechanisms and the role of professional colleagues. It is suggested that there is some way to go before 'Agenda for Change' principles of flexible and collaborative roles are met.
Anti-Infective Agents↗
The conversion of cefoxitin usage to cefotetan: an interdisciplinary approach.
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Cefotetan↗
Future depends on public recognition ... health planning in Delaware.
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Community Pharmacy Services↗
Antibiotic formulary selection.
Physicians worldwide are being forced to consider economics in the care of patients. In most hospitals, antibiotics are a steadily increasing segment of the pharmacy budget. This article discusses how the authors used drug pharmacokinetics, restriction policies, and cost benefit analysis to design a cost-effective antibiotic formulary.
Anti-Bacterial Agents↗