The appropriateness of antimicrobial use in the outpatient clinics of three hospitals in the Netherlands

Annemieke K Van Den Broek,Reinier M Van Hest,Fanny N Lauw,Caroline E Visser,Kamilla D Lettinga,Jan M Prins,Afra Jimmink

doi:10.1186/s13756-020-0689-x

Abstract

ObjectivesAntimicrobial Stewardship Programs commonly have an in-hospital focus. Little is known about the quality of antimicrobial use in hospital outpatient clinics. We investigated the extent and appropriateness of antimicrobial prescriptions in the outpatient clinics of three hospitals.MethodsFrom June 2018 to January 2019, we performed ten point prevalence surveys in outpatient clinics of one university hospital and two large teaching hospitals. All prophylactic and therapeutic prescriptions were retrieved from the electronic medical records. Appropriateness was defined as being in accordance with guidelines. Furthermore, we investigated the extent to which the dose was adjusted to renal function and documentation of an antibiotic plan in the case notes.ResultsWe retrieved 720 prescriptions for antimicrobial drugs, of which 173 prescriptions (24%) were prophylactic. A guideline was present for 95% of prescriptions, of which the guideline non-adherence rate was 25.6% (n = 42/164) for prophylaxis and 43.1% (n = 224/520) for therapy. Of all inappropriate prescriptions (n = 266), inappropriate prescriptions for skin and soft tissue infections (n = 60/226) and amoxicillin-clavulanic acid (n = 67/266) made up the largest proportion. In only 13 of 138 patients with impaired or unknown renal function the dosage regimen was adjusted. Amoxicillin-clavulanic acid was the drug for which most often renal function was not taken into account. In 94.6% of prescriptions the antibiotic plan was documented.ConclusionsIn hospital outpatient clinics, a substantial part of therapeutics were inappropriately prescribed. Amoxicillin-clavulanic acid was the most inappropriately prescribed drug, due to non-adherence to the guidelines and because dose adjustment to renal function was often not considered.

Highlights

Antimicrobial resistance leads to increased morbidity, mortality and healthcare costs worldwide [1]
Prior to the point prevalence surveys (PPS), we developed an algorithm for the electronic medical records (EMR) of the hospitals that generated all prescriptions of the Anatomical Therapeutic Chemical (ATC) groups A02B, A07A, J01, J02, J04, J05, P01 and P02, per day and per outpatient clinic
The EMR reports were verified on completeness by comparing the electronically generated data with data retrieved by manually checking all patient files of the outpatient departments, during 3 days for Academic Medical Center (AMC) and MC Slotervaart (SLZ), and during 1 day for the OLVG W, because the EMR report of that hospital had already been used and validated for other purposes

Summary

Introduction

Antimicrobial resistance leads to increased morbidity, mortality and healthcare costs worldwide [1]. In order to contain antimicrobial resistance, Antibiotic Stewardship Programs (ASP) have been developed to measure and improve the appropriateness of antimicrobial use [2]. A common way to measure the appropriateness of antimicrobial use is by evaluating whether antimicrobials are ASPs are commonly focused on in-hospital therapeutic and perioperative prophylactic antimicrobial use [4]. Up to 90% of antimicrobial use occurs in the outpatient setting, of which, next to family practice, internal medicine and paediatrics are the largest contributors [5, 6]. Available studies evaluating outpatient antibiotic use addressed therapeutic antimicrobial use in the ambulatory setting in general, of which 30–50% was inappropriately prescribed [7,8,9]. Due to the variety of clinical practice locations that are considered ambulatory care settings, there is little in-depth

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