Pharmacist-led antimicrobial program produces major savings

A multidisciplinary antimicrobial management program led by pharmacists at the 473-bed University of Kentucky Chandler Medical Center in Lexington reduced antimicrobial agent expenditures by nearly $500,000 over five years. That cost reduction of 25% led to a 2004 Best Practices Award of $2,000 from ASHP.

"Physicians make antibiotic selection based on their clinical expertise or past experience, including information received from the marketing of certain drugs," said John Armitstead, R.Ph., the university's director of pharmacy services. "We instituted protocols that ensured the pharmacist feedback necessary to make certain the appropriate and most cost-effective drugs were chosen."

The savings resulted through implementation of policies developed by a subcommittee of the hospital's pharmacy and therapeutics committee. It included representatives from the surgery, pediatrics, internal medicine, transplant, critical care, infectious diseases, pharmacy, and nursing departments. "Our pharmacists led in developing the program, but it was effective because of the active total cooperation of our medical staff," said Robert Rapp, Pharm.D., manager of clinical services.

"We were especially cost effective by reducing variation regarding empiric treatments, when we don't know the origin of an infection, because empiric treatment reflects 70% of antibiotic use," said Armitstead.

The subcommittee's goals were to develop and implement initiatives to ensure the appropriate use of antimicrobials by physicians and to review the existing formulary. Key pharmaceutical interventions included removal of ceftazidime and cefotaxime from the formulary, introduction of cefepime (Maxipime, Bristol-Myers Squibb) and a combination product containing piperacillin sodium and tazobactam sodium (Zosyn, Wyeth) to the formulary, restriction of vancomycin and carbapenem use, and selection of a single fluoroquinolone agent. As a result, the hospital was able to justify hiring an additional full-time pharmacist and to employ a physician part-time to lead the antimicrobial program.

Based on a regression analysis, the hospital had anticipated a rate of antibiotic resistance of 47% in 2005 and 56% in 2010, Armitstead said. "Now it appears the combination of formulary interventions, education, and infection control practices has put us in the unusual position of potentially decreasing MRSA rates," he told Drug Topics.

Nosocomial infection reduction education is a very significant part of the antimicrobial program, noted Rapp. An increased institutional awareness of the need for vigilance resulted from the subcommittee's multidisciplinary composition, he said. "Pharmaceutical control of antimicrobial agents is very important," he said. "But never, never as important as infection control."

Physician involvement in the development of the program was crucial to reducing institutional resistance to pharmacist recommendations for changes in physician antibiotic prescribing patterns, said Armitstead. "That was the real key to our success," he observed. "This kind of pharmacist review of physician [prescribing] patterns could be controversial. But we involved physicians and nurses from the beginning, which meant that when a decision was made, everyone knew there had been medical input."

The ASHP Best Practices Award in Health-System Pharmacy is an annual recognition program conducted in cooperation with Pfizer Inc., said Douglas Scheckelhoff, R.Ph., director of ASHP's pharmacy practice sections. "We recognize outstanding practitioners who have successfully implemented innovative systems, improving the quality of patient care," he explained. Award decisions are made based on originality and innovation, significance of the program to the health system, demonstration of improvements in quality of patient care, the significance of the program to pharmacy practice, and the quality of the descriptive report submitted to ASHP and Pfizer, he said. "The awards committee was impressed that the program demonstrated how pharmacist involvement can make a significant difference hospitalwide, and by the considerable amount of data they had collected in support of the program's effectiveness," he added.