Application of Drug Use Evaluation & Feedback to Promote Rational Antibiotic Prophylaxis in C-Section in

Kenya

Dr. Nath W Opiyo Arwa, The Mater Hospital, Kenya16th November 2011, ICIUM Conference 2011

Presentation outline

• Introduction• Methods• Results• Key lessons learned• Implications of DUE• Future studies/ reviews

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Introduction• Antibiotic prophylaxis is useful in reducing incidences of

surgical (operation) site infection.• The use of antibiotic prophylaxis is however characterized

by inappropriate practices such as use of broad-spectrum antibiotics; administering at wrong time; and continuing for too long

• Use of single dose has been found to be as effective as multiple doses and also cost effective to patients [1].

• The recommended duration of prescribed antibiotics prophylaxis for c-section has reduced from ≥ 5 days to 3 days then to 24 hrs and finally to a single dose [2] .

• DUE serves as a structured criteria based method of identifying, monitoring and correcting challenges encountered in practice

[1] Hopkins L, Smaill F, Antibiotic Prophylaxis Regimens and Drugs for C-section, Reprint for Cochrane Review in The Cochrane Library 2006, Issue [2] Liabsuetrakul T, Lumgiganon P and Chongsuvivatwong V, ‘Prophylactic Antibiotic Prescription for Cesarean Section’, International Journal for

Quality in Health Care 2002: Vol.14NO. 6 pp. 503-508

Methodology

• DUE criteria developed and endorsed by Mater PTC

• Baseline retrospective review done in Jan- June 2006

• Ongoing Subsequent DUEs were conducted periodically to

date

• Random sampling of C-section cases from medical records• Medical, Theatre and Nursing records, Treatment sheets

were reviewed to identify antibiotic prescribed for each c-section delivery

• Antibiotics prescribed were compared with defined criteria

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CRITERIAINDICATOR DESCRIPTION

ANTIBIOTIC ADMINISTERED •Co- Amoxiclav•Cefuroxime•Clindamycin•Metronidazole –dirty surgery

DOSE OF ABX ADMINISTERED •Co- Amoxiclav 1.2 gm IV STAT- TDS•Cefuroxime 1.5 gm IV STAT•Clindamycin 600 mg IV STAT•Metronidazole 500 mg IV STAT

TIMING OF FIRST ABX DOSE •Immediately after cord- clamping

DURATION OF ADMINISTRATION •Co- Amoxiclav up to 3 doses•Cefuroxime 1.5 gm STAT

REPEAT DOSES DURING SURGERY •For cases lasting longer than 4 hrs•Loss of > 1.5 lts of blood

DUE findings June 2006 to Dec 2010

OVERALL ADHERENCE TO GUIDELINES

0%

20%

40%

60%

80%

100%

5%10%

30% 31%24%

46%52%

42% 49%

68%

Feedback & Cost implications• Feedback

– Dissemination to MHPTC, Obs/ Gynae Div & Anaesthetists

– Face to Face, CMEs, profiling individual performance, Use of opinion leaders

– Regular feedback positive change in prescribing trends/ practice

– Positive feedback reinforces good practice and reversed trends

• Cost savings:– Co-Amoxiclav US $ 22.14 per client– Cefuroxime US $ 15.83 per client– Annual extrapolation US $ 13,408

Key Lessons learned• Fear of the unknown- Irrational prescribing • Combination of strategies is critical for sustainable

improvement• Slight policy changes can result in significant cost

savings• Teamwork and mentorship is key in ensuring

continuity of intervention despite staff turnover• Dedication and motivated staff are key in sustaining• Operational research should be integrated into

regular schedule for maximum effectiveness

Implications of DUE• Systematic, criteria-based program of drug use

evaluations (DUE) with feedback on prescribing trends

• Use of single dose for antibiotic prophylaxis is beneficial even in poor resource setting • prolonged antibiotic use does not confer value addition

except in special cases• Optimal medication use in ABX prophylaxis &

Improved patient safety• Adherence to guidelines is a challenge• Wastage & variations in ABX choice that made care

expensive reduced

Future studies• Qualitative studies on underlying causes of lack of

adherence to guidelines • Expand scope of DUEs to additional forms of

surgery• DUEs involving reserve antibiotic use• DUEs of prescribing OI medications in patients on

HAART• Scale up DUEs approach to other MTCs

countrywide

Acknowledgements• Mater Hospital administration and CEO, Mater

PTC Members( Dr Agnes Chege, Dr M Dolan, Dr Mureithi, Dr Wanjala), Obstetrics and Gyn division, doctors and Nurses

• Former Colleagues: Ahmed Tawakal, Benjamin Maronda

• Management Sciences for Health: Mohan Joshi, Niranjan Konduri and Patrick Boruett

Thank you!