Vancomycin and teicoplanin use in Victorian hospitals. The Victorian Drug Usage Evaluation Group.

OBJECTIVE: To determine patterns of prescribing of glycopeptide antibiotics (vancomycin and teicoplanin) in Victorian hospitals and identify areas for targeted intervention. DESIGN: A concurrent, observational, multisite evaluation of drug use. SETTING: Thirty-five Victorian hospitals, 1-14 September 1997. STUDY POPULATION: Patients commencing a glycopeptide antibiotic course. MAIN OUTCOME MEASURES: Rate of glycopeptide antibiotic use; indications; duration of use; main hospitals using glycopeptide antibiotics. RESULTS: 293 patients (269 adults and 24 neonates) commenced on 302 glycopeptide antibiotic courses: 296 intravenous (i.v.) vancomycin courses and three each of oral vancomycin and parenteral teicoplanin. The overall rate of use was 10.3 courses per 1000 inpatient separations. Of 271 i.v. vancomycin courses for adults, 176 (65%) were for treatment--120 empirically. The median duration of treatment courses was 4.7 days (interquartile range, 2.0-8.2 days). A flucloxacillin-resistant organism was confirmed for 44% of treatment courses. Ninety-five i.v. vancomycin courses were for prophylaxis, including for cardiac (54%) and vascular surgery (21%); 82% of prophylactic courses were administered for less than 24 hours. Of all the glycopeptide antibiotic courses, 69% were administered at five major metropolitan hospitals. CONCLUSIONS: Glycopeptide antibiotic use in Victoria is concentrated in the major metropolitan hospitals. Prolonged durations of vancomycin therapy, including for surgical prophylaxis and empirical therapy not subsequently confirmed by microbiology findings, would be suitable targets for interventional strategies.

Hospitalisation for adverse events related to drug therapy: incidence, avoidability and costs.

OBJECTIVES: To determine the incidence of hospital admissions for adverse events related to drug therapy, and to assess whether these drug-related admissions (DRAs) could have been reasonably prevented. SETTING: A tertiary teaching hospital. DESIGN AND PATIENTS: Prospective assessment of all admissions through the emergency department and resulting in a stay of more than 24 hours during 30 consecutive days in November and December 1994 to determine if the admission was related to drug therapy. Cases of intentional overdose were excluded. MAIN OUTCOME MEASURES: The number, type, causality and avoidability of drug-related admissions. RESULTS: Of 965 admissions, 55 (5.7%) were assessed as being drug-related. Drug-related admissions (DRAs) were designated possibly (38%), probably (46%) or definitely (16%) drug-related; caused by prescribing factors (26%), patient noncompliance (27%) and adverse drug reactions (47%); and classified as definitely (5.5%), possibly (60.0%) and not (34.5%) avoidable. The estimated annual cost to the hospital for all DRAs was $3,496,956 and for unavoidable DRAs was $1,629,494. CONCLUSION: The DRA rate we found lies around the middle of the range of other published rates. Few DRAs were judged definitely avoidable and over one-third were unavoidable. Nevertheless, the largest proportion were judged possibly avoidable. As the drugs identified in this study are clearly needed in the community, efforts to reduce DRAs must concentrate on education, counselling and monitoring of drug therapy.

Prescriber guidelines improve initiation of anticoagulation.

OBJECTIVES: To improve the initiation of anticoagulation in patients with thrombotic disorders. DESIGN AND SETTING: We carried out a preliminary audit in 1991, developed and implemented strategies to address identified problems, and followed up with another audit in 1993. Medical records of inpatients at The Royal Melbourne Hospital whose anticoagulation therapy was initiated with heparin (intravenous) in therapeutic doses and subsequently converted to warfarin were prospectively assessed over 19-day periods. INTERVENTION: Pocket-sized laminated prescriber guidelines for initiating anticoagulation were disseminated after publishing the results of the first audit, together with a single prominent display of two posters in series advocating the use of the guidelines. RESULTS: The audits identified 25 eligible patients in 1991 and 27 in 1993. The mean duration of intravenous heparin therapy was reduced from 150 hours in 1991 to 97 hours in 1993 (P < 0.002). The mean delay before initiating warfarin therapy after starting heparin therapy was reduced from 69 hours in 1991 to 21 hours in 1993 (P < 0.002). The mean percentage of time the activated partial thromboplastin time was within the therapeutic range increased from 30% in 1991 to 44% in 1993 (P < 0.05) and was above the therapeutic range increased from 13% in 1991 to 24% in 1993 (P < 0.01). Although the number of adverse events was too small to draw definitive conclusions, no difference in adverse haemorrhagic effects was noted between the 1991 and 1993 groups. CONCLUSION: There was an improvement in the initiation of anticoagulation and we hypothesise that this was most likely due to a broad acceptance of the guidelines into clinical practice.