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Required indication for antimicrobials
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The world may be dangerously close to a post-antibiotic era, in which resistant organisms cause infections that cannot be treated with existing antibiotics. Antimicrobial stewardship programs and appropriate prescribing are widely recognized in delaying, but not solving, this predicament. Additionally, requiring indications for antimicrobials can be beneficial in several ways.
First, when pharmacists can see the indication for the antimicrobial at the time of order verification, they can better assess appropriateness of the drug, dose, route and frequency in a prospective fashion. Second, requiring antimicrobial indications enables stewardship programs to easily retrieve the reason behind antibiotic use in the hospital, allowing programs to make interventions or provide education where needed. Third, CMS has recently added, “Antibiotic orders include an indication for use” as a clinical standard on draft surveyor worksheets as a tool to assess infection prevention measures. There are several steps involved in implementation of required indications for antimicrobials, as well as barriers.
Kati Shihadeh
Required indications
Required indications for antimicrobials would help the pharmacist during order verification assess appropriateness of the drug, dose, route and frequency. There are numerous examples of antimicrobials that have different recommended doses depending on the indication. For example, the dose of meropenem (Merrem, AstraZeneca) for meningitis is 2 g IV every 8 hours, whereas the dosing regimen utilized for most other indications is 500 mg IV every 6 hours or 1 g IV every 8 hours, depending on the standard dosing per institution. Another example is with daptomycin (Cubicin, Cubist). For skin and soft tissue infections, the recommended dose is 4 mg/kg IV once daily, whereas for endocarditis, the recommended dose is at least 6 mg/kg IV once daily. There are many more examples of how dosing differs based on indication. Ensuring that the first dose of an antibiotic in a critically ill patient is optimal is likely equally important to the timing of administration. To ensure that the first dose is optimal, it is imperative to know what is being treated.
Stewardship programs are always looking for new ways to capture data around antimicrobial use. If each required indication built into the antimicrobial order had a specific code, the indication could be pulled into a report. Stewardship pharmacists or physicians could generate a report using the indications to see which antimicrobials are being prescribed for that indication. The stewardship team may discover, for example, that micafungin (Mycamine, Astellas Pharma) is being prescribed for esophageal candidiasis in patients who have no resistant Candida spp. colonization or no risk factors for resistant Candida spp., so fluconazole (Diflucan, Pfizer) would be the preferred agent. Different electronic medical records and computerized physician order entry (CPOE) programs would have different functionalities and capabilities.
The Department of Health and Human Services is placing a high priority on improving patient safety and quality of care within the health care systems. CMS is taking steps to support HHS and promote high-quality patient care. CMS has developed draft worksheets for hospital surveyors to use during their assessment of hospital compliance. These draft worksheets include a section titled “Systems to prevent transmission of MDROs and promote antibiotic stewardship.” Within this section, there is a line to assess whether antibiotic orders include an indication for use. At this point, this survey is a draft; however, it likely will not be long before it is required to clearly document the reason for a patient being on an antimicrobial.
Key steps to take
There are several key steps to take when initiating required indications for antimicrobials. First, someone will need to formulate a proposal for required indications. In creating the proposal, infectious disease physicians and an infectious disease-trained pharmacist should be involved in developing the list of required indications for antibacterials, antifungals and antivirals. The proposal should be presented to and approved by the committee that would oversee this project, whether it is an antibiotic subcommittee of a larger formulary committee or a pharmacy and therapeutics committee. Second, discussions should take place with information technology personnel who will be creating the electronic build in the CPOE. Lastly, education will need to take place for all who will be affected by this change. Physicians should also inform on how to select the indication for which they are prescribing the antimicrobial.
There may be initial push back from physicians because they may see this as one more obstacle to ordering medication. With proper education, physicians will realize that they should know why they are prescribing the antimicrobial, so it just involves checking a box on their part. Physicians may be concerned that the indication they are prescribing for is not listed as an option. It is important when creating the list of indications to include an “other” option so the physician can free text the indication. Pharmacists also will need education because they will now be seeing the indication attached to the order.
Knowing why antimicrobials are prescribed at the time of order entry is valuable for assessment of order appropriateness, as well as for driving activities of a stewardship program. Indications documented within the antibiotic orders may soon become a requirement of federal regulatory agencies.
References:
McKenzie C. J Antimicrob Chemother. 2011;66:ii25-ii31.
Meropenem [package insert]. Wilmington, DE: AstraZeneca; Revised 2010.
For more information:
Kati Shihadeh, PharmD, is a PGY2 infectious diseases resident at the University of Minnesota Medical Center. She can be reached at the University of Minnesota Medical Center, Fairview, Pharmacy Services, C-365 MMC 611, 420 Delaware St. SE; Minneapolis, MN 55455; email: kshihad1@fairview.org.
Disclosure: Boeser and Shihadeh report no relevant financial disclosures.