Review of antibiotic use in respiratory disorders at a regional hospital in Queensland

Abstract

Adherence to antibiotic guidelines has been shown to improve outcomes in several clinical situations. Respiratory conditions are a major cause of mortality and morbidity in Queensland. A recent study showed low levels of compliance with antibiotic guidelines in a Queensland metropolitan hospital. We undertook an audit of antibiotic use in a regional Queensland hospital against Therapeutic Guideline recommendations. Therapeutic Guideline recommendations were followed in 16% of cases with ceftriaxone the most commonly prescribed. Re-admission rate within 28 days was for 53%, 26%, 11% and 5% respectively for ceftriaxone, benzylpenicillin, amoxicillin/clavulanate and ceftriaxone combined doxycycline. Less than half of patients treated for pneumonia had concordant radiographic changes. Admission via the emergency department may be a factor in the preference for intravenous injection of ceftriaxone and presence of non-infective co-morbidities may also contribute to re-admissions. Considerable challenges exist in improving compliance with antibiotic guidelines which can improve patient outcomes and antibiotic stewardship.

Introduction

Antimicrobial resistance continues to be on the increase, while the development of new therapies has come to a standstill (Bauer et al., 2010). Reviewing recent rates of the spread of resistance, mankind’s ability to fight serious infections, including the use of prophylactic antimicrobial therapies, in regards to control of infection in surgery, will be very soon compromised (Liñares, Ardanuy, Pallares, & Fenoll, 2010). Antimicrobial stewardship programmes have been seen to be implemented worldwide with the aim of these programmes being guidelines assist in the optimisation of antibiotic therapy so that the risk of subsequent development of resistance is minimised (Bauer et al., 2010).

Adherence to antibiotic management guidelines has been shown to save lives and costs in diverse settings (Elemraid et al., 2014, Hecker et al., 2014; Wilke, Grube, & Bodmann, 2011). These allow better use of health resources and reduction of antibiotic drug resistance which are global challenges (Wilke et al., 2011). Selecting an appropriate antibiotic regimen for patients, especially those with bacterial infections, has an important role in overall patient management (Elemraid et al., 2014, Hecker et al., 2014, Wilke et al., 2011). A delay in the appropriateness of antimicrobial therapy has been identified as an important determinant of clinical outcome (Ibrahim, Sherman, Ward, Fraser, & Kollef, 2000).

Suboptimal use of antibiotic best practice guidelines in the management of patients with respiratory diseases continues to be of concern. In particular, the emergence of multi-resistance pseudomonas aeruginosa which can increase mortality, the risk of treatment complications and duration of admission and costs (Desai et al., 2010; Montero, Dominguez, Orozco-Levi, & Salvado, 2009). Aditionally, in Australia there has been a steady increase in the number of reports of Vancomycin Resistant Enterococcus (VRE) (Cosgrove, Carroll, & Perl, 2004; Elemraid et al., 2014). Vancomycin is the standard treatment for methicillin-resistant staphylococcus aureus (MRSA).

Up to 66% (51 out of 77) of Victorian hospitals are reportedly not meeting best practice prescribing guidelines when administering broad-spectrum cephalosporin (Robertson et al., 2002). This inertia surrounding the inappropriate use of antimicrobials contributes to the emergence of antimicrobial resistance.

In Queensland, respiratory conditions were the largest broad cause of mortality contributing to 13,067 hospitalisations in 2011–12 (Elemraid et al., 2014, Queensland Health, 2014). Furthermore, the mortality rate for chronic obstructive pulmonary disease (COPD) is 9% higher than the national rate and third highest of the states and territories (Queensland Health, 2014). Pneumonia and influenza deaths totalled 389 in 2010 with 15,684 hospitalisations in 2011–12b (Elemraid et al., 2014).

According to the Therapeutic Guidelines [TG] (2014b), mild community acquired pneumonia (CAP) is treated with oral amoxicillin or doxycycline, moderate CAP with benzylpenicillan and doxycycline, unless an allergy to penicillin is noted or are identified as being in a tropical region only then does the TG recommend ceftriaxone. Moxifloxacin is also an alternative in this case, especially if there is an immediate hypersensitivity to penicillin. Antibiotics are not recommended for influenza although antivirals can be prescribed such as oseltamivir and zanamivir. Reduced mortality has been demonstrated by McGeer et al. (2007) when antivirals are commenced in the hospitalised cohort providing they are commenced early.

Within the context of COPD adherence to best practice, prescribing guidelines were inadequate (Fanning, McKean, Seymour, Pillans, & Scott, 2014). The Australian Lung Foundation COPD-X Plan (2016), which endorses the TG (2014a), recommends the use of doxycycline or amoxicillin oral as first-line antibiotic therapy for exacerbation of COPD; however, some studies demonstrate differing regimes across Australian hospitals (Robertson et al., 2002).

The National Asthma Council Australia, does not recommend an antibiotic regimen for acute episodes of asthma, unless there are clinical symptoms and objective tests to confirm a bacterial infection. This is endorsed in the publication the Australian Asthma Handbook (2014), which underpins evidence in relation to the national guidelines for the management of asthma.

The TG (2014a, [Therapeutic Guidelines, 2014b]2014b), recommends using severity scoring systems such as: CORB Score (Table 1); CURB 65, (Table 2) and the SMART-COP (Table 3).

These scoring systems have been developed to predict mortality risk in community acquired pneumonia (CAP), and these have been applied to guide physicians in regards to patients’ admittance to the hospital or to the intensive care unit (ICU). These tools, however, were initially developed to predict mortality risk, and studies have demonstrated that the mortality risk does not always equate with the need for hospitalisation or ICU care (Niederman, 2009). When administering antibiotics to people with respiratory conditions, it is evident that adherence to best practice guidelines is variable. The aim of this study was to quantify the use of antibiotics in respiratory disease in a Regional Hospital and to access the adherence or non-adherence to TG best practice guidelines for antibiotics in this cohort of patients.