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Antimicrobial use measures

What to measure in antimicrobial use.
Hello, everybody. This a Aalaa Afdal with you. I am a clinical pharmacist and I’m happy to show you how to measure antimicrobial use and consumption within your antimicrobial stewardship programme. Today we will learn why we have to measure antimicrobial use within our institution and which parameters we shall measure. Also, we will learn how to measure and conduct a measurement plan for our interventions within the antimicrobial stewardship programme. Firstly, when we think about measurements and number, we may imagine this messy picture where numbers are everywhere and we are in a complete mess. But actually, measurement is a cornerstone in any successful organisation. It organises our work, guarantees sustainability for successful projects, and actually, it’s the first step for improvement.
To measure is to know our situation, baseline assessment, and identify our weak points to define actions for improvement. Lord Kelvin’s famous quote about measurements, “To measure is to know. If you cannot measure it, you cannot improve it.” That’s to say that antimicrobial measurement help us to monitor our progress and evaluate our interventions in order to decide whether to proceed, or we have to have another effective intervention, and so on. Antimicrobial misuse can be divided mainly into two major categories. The first one is the quality of antimicrobial use that reflects the prescribing pattern of an antimicrobial and the overall medication management process, while the second is the quantity of antimicrobial– how many grams we have dispensed.
Do we dispense too much antibiotics, higher doses, longer duration, unnecessarily added on combination, and so on. And finally, we cannot neglect to measure how much did we save when we used antimicrobials appropriately? Actually, cost savings is a very important parameter to show to our administration and gain their support for the sustainability of our projects. Administrations usually favour and support the projects that improve patients’ care with lower costs.
OK. We have to think about which measurements we will go for. We have to identify our sources of data. There is a collective data level where we look at the collective data in a specific period of time, such as pharmaceutical industry sales. And this is used at the country level, we cannot use at the hospital level. There is also pharmacy purchases for the whole hospital or pharmacy issuer, ward or whatever. There is also the patient data level where we have to look at each patient’s data separately and then collect all patients that are within an identified period, as well, such as antimicrobial prescriptions, chart reviews, or pharmacy information system or a computerised system. Let’s see how antibiotic chart look like.
It’s a follow-up sheet for antimicrobial prescriptions only for each patient when we track antimicrobials in a given ward. We can check the combination therapy, performance of antibiotic time-outs– that’s checking the stats of antimicrobial after 48 or 72 hours from implementation and decide if we have to stop it because culture result appeared and we have to de-escalates the antimicrobial therapy, or whether we have to shift to an older formulation, and so on. We can also check the correct selection with the correct dose, duration, frequency, and route of administration. The first problem we may face is that the number of patients admitted to a given ward may vary from time to time. For example, I may have 20 admission this month.
But next month, I may 100 admissions. Definitely the antimicrobial use will vary from these two months. So to overcome such problem, we have to represent our data in the form of a rate– x divided by y, a numerator divided by a denominator. There are a lot of different numerators that we will learn later in this topic, and also different denominators that we’ll go through, some of it now. But first I have to mention that there is no one identified metric is a superhero metric or the gold standard one, the best one that we have to use it every time. But actually, we can develop our metrics tailored on our goal or our target that we want to improve.
Now, let’s identify some targets, some different denominators that we may use. As I mentioned previously, the denominator may vary from one situation to another, and the good steward should know how to use each denominator. For instance, denominators used for quality measures are different from those for quantity measures. Let’s go some different denominators that we shall need to use within our work, or we may face while reading the literature. Denominators for quality measures can be in the form of a number of patients on antimicrobial therapy, or maybe number of prescriptions, or even total number of patients. And these items can be easily found from either collective or patient-level data.
On the other hand, denominators for quantity measures are in the form of inhabitant days, and this for antimicrobial consumption in primary care, and should not be used for consumption in hospitals or patient days, bed days, occupied bed days– actually, all terms are used interchangeably in literatures, and there is a very minute difference between them, which is neglected by all stewards. Or finally, number of admissions or discharges. So how we can calculate inhabitant day? It’s so simple. We multiply our numerator with 1,000 to get the quantity for each 1,000 inhabitant divided by the total population in that year, divided by 365 days of the year.
As I mentioned previously, the patient days and bed days or occupied bed days, OPD, are used interchangeably. Theoretically, day of admission plus day of discharge are considered one single day. But in practice, administered bed days are approximated to be calculated as follows– number of beds in a given ward multiplied by occupancy index of this ward in a given period of time– one month, for example– multiplied by the number of days in that period of time, which would be 30 days. Number of admissions in a given facility or ward is a more stable measure not impacted by a change in length of stay.
But it may be subject to change in admissions or transfer from ward to another in the same hospital. It’s a preferred, then, added-on metric for stewards.

In this video Aalaa Afdal, a pharmacist, explains how measurement is the cornerstone to antimicrobial stewardship programmes.

Audit was key to starting the antimicrobial stewardship programme described by Dr Fajolu and in Dr Brink’s low hanging fruit example from South Africa.

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Antimicrobial Stewardship for Africa

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