Can electronic chart systems help decrease antimicrobial costs? A Brazilian experience

Background: In our 150-bed general tertiary hospital, an antibiotic usage program has been on place for over 15 years. It consisted on formulary restriction, filling of  a mandatory handwritten antimicrobial form (AF) to justify the antibiotic use for each new antimicrobial course with a 7-day expiration date, infectious disease specialist consultation on demand , one-dose antimicrobial surgical prophylaxis and staff education. The adhesion rate of handwritten AF in the past was considered high, but pharmacy had difficulties with receiving AF before dispensing the antibiotic; problems with calligraphy made sometimes it hard to understand patterns of use. In 2009 we reached an adhesion rate of 100% to our electronic chart system (ECS) and we wondered if it could help to improve our antibiotic use.

Objective: to verify appropriateness of antibiotic use and to compare antimicrobial costs before and after implementation of electronic AF.

Methods:   Evidence-based antimicrobial protocols for the most common infectious diseases were rewritten and made available to all prescribing physicians through our ECS linked to the prescription site, starting at the end of December 2009.  At the same time the ECS turned it impossible to prescribe an antibiotic without filling an AF completely. The author (SF) daily consulted all AF , reviewed patient electronic charts and microbiological cultures and classified the new antimicrobial courses as “based on protocols”, “based on culture results” or “improper use”. Every time a deviation of protocols was noticed, SF contacted the physician at the same day or the following day to discuss the case. Also, SF daily consulted culture results and rapidly inform physicians about results.All AF corresponded to a new antibiotic course or to a continuation of a course after 7 days. Use over 14 days was strongly discouraged.  Costs were calculated by dividing the total cost of purchased antibiotics by patient-days. No major modification of antibiotic purchase policies was made during the study period. The study period went from January 2010 to September 2010 (ECS AF); antibiotic costs were compared from January 2009 to September 2010.

Results:  There were 3,691 antimicrobial courses with the correspondent number of AF; 601 (16%) were discussed with the prescribing physician. Two thousand nine hundred and forty-two (79%) AF were based on protocols, 636 (17%) based on cultures and 113 (3%) were improper use AF , mostly due to prolonged use of surgical prophylaxis (> 1 dose). The antibiotic cost /patient-days dropped from $10.84 to $8.56, with total savings of $31,000 so far. 

Conclusions:   Adhesion to protocols and use based upon cultures was considered to be good. The daily contact between SF and prescribing physicians was possible because patient information was readily available thanks to ECS. The ECS made it easier to follow antibiotic use and to correct its use timely. Savings from this program turn it maintainable.