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Quantity measures

Aalaa Afdal discusses quantity measures.
Quantity measures is the measures of the aggregate antimicrobial use. And it’s the most common metrics for the ASP. And they are often expressed as a rate, x divided by y, as we mentioned before. By using a standard approach to rate calculations, antimicrobial stewards are in a better position to make meaningful comparisons across locations where antibiotics are used– hospitals, wards, patients. There are many numerators that we can use, like defined daily dose, days of therapy, length of therapy, prescribed daily dose, and others. What’s the difference between days of therapy and length of therapy? Days of therapy are the number of days that a patient is on an antibiotic, regardless of the dose, and it’s applicable for paediatrics. That’s a good point.
For example, if we have a patient who is on two antimicrobials, he started his first antimicrobials on day one and day two, then stopped it. While, from day two to day five, he used another antimicrobial, which is antimicrobial two. So the days of therapy for the first antimicrobial for this patient are two days of therapy, while for the second are only four. So the total days of therapy of antimicrobials for this patient are six days of therapy. But what about length of stay? Length of stay are the duration when he started his first antimicrobial regimen till the end of the last antimicrobial drug used. Here, the length of therapy are five days.
Days of therapy can be used to target the consumption of certain antimicrobial, meropenem, or certain class, like carbapenems, or even certain formulation. And it depends on your goal. Defined daily dose can be used too. DOT. Days of therapy can be measures also to assess some ASP strategies implementation, such as unnecessary double coverage, such as redundant anaerobic coverage of ertapenem and metronidazole, or compliance to antimicrobial duration therapy. And this can be clear from days of therapy. So days of therapy are used to assess some prescribing habits for wards or institutions as well. It’s advisable to review resources attached for further details on antimicrobial use metrics. What’s a prescribed daily dose?
It’s the average prescribed dose in the main indication, defined locally at ward or hospital or even a group of hospital level, but it do not allow inter-hospital comparisons. What about the defined daily dose? The defined daily dose is the assumed average maintenance dose per day for a drug used for its main indication in adults. Which means that, for example, the paracetamol oral defined daily dose is 3 gram. That means that the average maintenance dose, not the loading one, used for an adult patient who weighs 70 kilogrammes of paracetamol used as an antipruritic is 3 grams daily. A defined daily dose will only be assigned for drugs that already have an ATC code. ATC code consists of many items.
A letter, the number, then another letter, then another letter, then another number. We will see in a few seconds. But it should be emphasised that the defined daily dose is a unit of measurement and does not necessarily reflect the recommended or prescribed daily dose. Doses for individual patients and patient groups will often differ from the defined daily dose and will necessarily have to be based on individual characteristics– age, weight, and so on. And also for pharmacokinetic considerations. Defined daily dose are not established for topical products, sera, vaccines, antineoplastic, allergens extracts, general and local anaesthesia, and also contrast media. So now I will show you briefly how to navigate and get the specific DDD for a given drug formulation.
When you first open the website for the WHO ATC/DDD, you will have a page like this. When you click DDD on your left, you will have more information about the defined daily dose. When you click the ATC/DDD Index, you will have this page where you can search for the DDD by the ATC code or the drug name. Obviously, searching by scientific name is much easier. So we’ll type, for example, ciprofloxacin. We will have all ciprofloxacin available. The code J is for systematic use of drugs. The number one is for antimicrobial class. The letter M is for quinolones. The letter A is for fluoroquinolones.
Finally, the number 2 is for the ciprofloxacin itself, that’s used as an anti-infective systemically without any combination. We will choose the first one. We will have the following. As we see, the defined daily dose for oral cipro is 1 gram. While that for parenteral use is 0.5, so we have to be very careful. Finally, don’t forget that the DDD is updated annually, and the last update is written below. How to calculate defined daily dose. First step is to determine the number of DDDs of each antibiotic, which will be by the total gram dispensed, number of packages multiplied by number of units per pack multiplied by concentration divided by the DDD defined by WHO Collaborating. And this is the numerator data.
Then you have to divide by a denominator data, as we mentioned before. Some examples you can see here, ciprofloxacin, 500 milligramme tab, 20 per tab, 100 packages. So the number of grams are 100 packages multiplied by 20 tablet per pack multiplied by 0.5 gramme per tab, which is equal 1000 gramme. Then the number of DDDs equal 1000 divided by 1, which is the DDD defined by WHO Collaborating Centre. So the total DDDs for ciprofloxacin to be taken orally are 1000 DDDs for this example. What are advantages? Advantages that they are independent from price and package size, easy, allow fair comparisons, and it can define that one day treatment receives approximately equal weight, whatever the drug is.
For example, 0.24 grams gentamicin is approximately equal to 4 grams cefotaxime, approximately equal to 14 grams piperacillin. But limitations. It does not suitable for paediatrics and patient with organ dysfunctions. It’s updated annually. We have to keep an eye on it. And the total DDDs is strongly influenced by formulary mix. Finally, we have to be aware of using the prescribed daily dose instead of defined daily dose and deal with it as a defined daily dose, but you didn’t use a defined daily dose defined by the WHO Collaborating Centre. This is an advice by the European Centre for Disease Prevention and Control. You can take a look. Thank you.

As Dr Adrian Brink explained in his low hanging fruit example they targeted duration of therapy and double cover.

In this video Aalaa Afdal explains how to use quantity measures to know your prescribing base-line and whether there has been an improvement.

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Antimicrobial Stewardship for Africa

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