Improving antimicrobial duration of therapy with the implementation of antimicrobial lanyard cards and education in a regional hospital

Inappropriate antimicrobial prescribing is more prevalent in regional and rural hospitals when compared to urban and metropolitan hospitals. Barriers to delivery of antimicrobial stewardship (AMS) programs in this setting include lack of infectious diseases expertise, limited pharmacy resources and challenges in recruiting staff to regional and remote areas.^1,2 As a result, Toowoomba hospital, the main referral hospital in Darling Downs Hospital and Health Service (DDHHS), often encountered inappropriate durations of antimicrobials for common infections.

Inappropriate antimicrobial prescribing contributes to the emergence of resistance, which causes millions of deaths every year and is forecasted to increase in the future. A prolonged duration of treatment also increases the likelihood of side effects, drug interactions and higher healthcare costs.³

The pharmacists from DDHHS collaborated with the Queensland Statewide Antimicrobial Stewardship Program (QSAMSP) to address the inappropriate duration of antimicrobials for common infections. A retrospective audit tool developed by QSAMSP was utilised to collect baseline data on the duration of common respiratory, urinary and abdominal infections.

Data collected included:

• Type of infection
• Degree of source control (in the setting of abdominal infections)
• Date of initiation and cessation
• Expected duration of therapy 
• Number of excess days of treatment prescribed
• Compliance with the Therapeutic Guidelines: Antibiotic.

The retrospective audit reviewed four months of data. Only 55% of the patients were prescribed antimicrobials according to the Therapeutic Guidelines: Antibiotic recommendations for duration of therapy, compared to the national average of 68%.⁴ 

After discussing the findings, the team identified reasons for inappropriate duration of antimicrobial prescribing. These included:

• Lack of clinician awareness on the latest recommendations in the Therapeutic Guidelines: Antibiotic ­ 
• Lack of education on appropriate antimicrobial prescribing 
• Absence of AMS services resulting in a lack of feedback to clinicians. 

Several strategies were required to improve prescribing and optimise antimicrobial duration of therapy. In collaboration with the AMS physician, AMS pharmacist and resident pharmacist, the team developed: 

• Lanyard cards which included a colour coordinated scale indicating recommended treatment durations for common infections and guidance for intravenous to oral switch
• Education on the recommended duration of antimicrobial therapy, which was delivered to pharmacists, junior and senior medical officers.

A repeat audit following the implementation of the lanyard cards and delivery of education found an improvement in the duration of antimicrobial therapy for common indications, increasing to 72%. There was a reduction in the mean number of excess treatment days across all infections from 1.86 to 0.95 days, with the most significant decrease observed in respiratory infections from 1.64 to 0.11 days.  

Read about the project here:  https://doi.org/10.1002/jppr.1902