Electronic antibiotic stewardship in a tertiary cancer centre

Background:

The immunocompromised patient poses new issues when considering antimicrobial stewardship. We describe the introduction of an electronic stewardship system called Guidance DS into Peter MacCallum Cancer Centre (PMCC), Victoria, Australia. The system was developed and successfully implemented at the Royal Melbourne Hospital (RMH), however its transferability to a speciality setting had not been tested. The treating clinicians had previously been resistant to the introduction of antibiotic restriction, however a VRE outbreak in October 2006 prompted adoption of the system.

Objective:

To evaluate the impact of an electronic antibiotic stewardship tool, and to describe barriers and facilitators to effective implementation.

Methods:

PMCC is  tertiary referral centre that manages all cancers except for allogeneic stem-cell transplants. It has a busy ambulatory care service, and 100 inpatient beds. Junior medical staff rotate every 3 months from local general hospitals. Drug utilization was prospectively monitored using pharmacy data (as defined daily doses per 1000 bed-days) and analysed via time-series analysis with segmental linear regression. Data was collected from Jan 2005-July 2009. Antibiograms were generated using accepted methodology.

Results:

Guidance DS was launched in Feb 2007 and is supported by a multidisciplinary antimicrobial stewardship committee. The median number of approvals per month was 85 (40-226). Approximately 50% of approvals were for haematology patients. Piperacillin/tazobactam (PZ) was most commonly prescribed antimicrobial and for initial treatment of neutropenic fever (according to the institutional protocol). 16% of patients were escalated to meropenem for persistent fever or clinical deterioration. The gradients in the use of third generation cephalosporins (0.56, -0.55, P=0.42) and carbapenems (-1.8, -0.36,  P =0.006) fell after deployment, while extended-spectrum penicillin use increased (-0.05, 0.03, P=0.04). The gradient in the total grams restricted antibiotics/1000 bed-days has decreased after the intervention (9.1,-16.8, p=0.5). Annual whole-hospital antibiograms support the ongoing use of PZ monotherapy for neutropenic fever with >90% coverage of the common gram-negative pathogens.

The frequent rotations of medical staff has highlighted the need for regular intensive education. We have continued to improve our processes by changing the roles of ward pharmacists, performing weekly antimicrobial rounds and feeding back our findings to clinicians and surgeons.  The system has become accepted as part of routine care.

Conclusions:

Mandated electronic registration of restricted antibiotics results in early clinical review of patients. A similar pattern of change in antimicrobial use has been observed as that reported at the RMH. As an early adopter, we have identified several important factors that need to be considered in the imlementation of electronic systems.