David McDougall

Pilot of a National Inpatient Medication Chart in Australia: Improving prescribing safety and enabling prescribing training

WHAT IS ALREADY KNOWN ABOUT THIS SUBJECT Prescribing errors are common and are caused by multiple factors. Standard medication charts have been recommended by British and Australian Health services. A study of a standard medication chart in five hospitals in one state of Australia significantly reduced prescribing errors. WHAT THIS STUDY ADDS A standard medication chart developed in one area can be adopted through a collaborative process and successfully implemented across a diverse country resulting in similar reductions in prescribing errors. Three of the four stages of the prescribing process (information gathering, decision making and communication of instructions) can be improved by the use of an improved standard medication chart. The introduction of a standard medication chart has enabled development of standard prescribing education programmes. AIMS To establish whether a standard national inpatient medication chart (NIMC) could be implemented across a range of sites in Australia and reduce frequency of prescribing errors and improve the completion of adverse drug reaction (ADR) and warfarin documentation. METHODS A medication chart, which had previously been implemented in one state, was piloted in 22 public hospitals across Australia. Prospective before and after observational audits of prescribing errors were undertaken by trained nurse and pharmacist teams. The introduction of the chart was accompanied by local education of prescribers and presentation of baseline audit findings. RESULTS After the introduction of the NIMC, prescribing errors decreased by almost one-third, from 6383 errors in 15,557 orders, a median (range) of 3 (0-48) per patient to 4293 in 15,416 orders, 2 (0-45) per patient (Wilcoxon Rank Sum test, P < 0.001). The documentation of drugs causing previous ADRs increased significantly from 81.9% to 88.9% of drugs (χ(2) test, P < 0.001). The documentation of the indication for warfarin increased from 12.1 to 34.3% (χ(2) test, P= 0.001) and the documentation of target INR increased from 10.8 to 70.0% (χ(2) test, P < 0.001) after implementation of the chart. CONCLUSIONS National implementation of a standard medication chart is possible. Similar reduction in the rate of prescribing errors can be achieved in multiple sites across one country. The consequent benefits for patient care and training of staff could be significant.

Association of ertapenem and antipseudomonal carbapenem usage and carbapenem resistance in Pseudomonas aeruginosa among 12 hospitals in Queensland, Australia

OBJECTIVES The objective of this study was to determine the association between ertapenem and antipseudomonal carbapenem use and carbapenem resistance in Pseudomonas aeruginosa in 12 hospitals in Queensland, Australia. METHODS Data on usage of ertapenem and other antipseudomonal carbapenems, measured in defined daily doses per 1000 occupied bed-days, were collated using statewide pharmacy dispensing and distribution software from January 2007 until June 2011. The prevalence of unique carbapenem-resistant P. aeruginosa isolates derived from statewide laboratory information systems was collected for the same time period. Mixed-effects models were used to determine any relationship between ertapenem and antipseudomonal carbapenem usage and carbapenem resistance among P. aeruginosa isolates in the 12 hospitals analysed. RESULTS No relationship between ertapenem usage and P. aeruginosa carbapenem resistance was observed. The introduction of ertapenem did not replace antipseudomonal carbapenem prescribing to any significant extent. However, an association between greater usage of antipseudomonal carbapenems and greater P. aeruginosa carbapenem resistance was demonstrated. CONCLUSIONS It is likely that the only mechanism by which ertapenem can improve P. aeruginosa resistance patterns is by being used as a substitute for, rather than in addition to, antipseudomonal carbapenems.

Relapse of imported Plasmodium vivax malaria is related to primaquine dose: a retrospective study.

BackgroundRelapsing Plasmodium vivax infection results in significant morbidity for the individual and is a key factor in transmission. Primaquine remains the only licensed drug for prevention of relapse. To minimize relapse rates, treatment guidelines have recently been revised to recommend an increased primaquine dose, aiming to achieve a cumulative dose of ≥6 mg/kg, i.e. ≥420 mg in a 70 kg patient. The aims of this study were to characterize the epidemiology of P. vivax infection imported into Queensland Australia, to determine the rates of relapse, to investigate the use of primaquine therapy, and its efficacy in the prevention of relapse.MethodsA retrospective study was undertaken of laboratory confirmed P. vivax infection presenting to the two major tertiary hospitals in Queensland, Australia between January 1999 and January 2011.Primaquine dosing was classified as no dose, low dose (<420 mg), high dose (≥420 mg), or unknown. The dose of primaquine prescribed to patients who subsequently relapsed that prescribed to patients who did not relapse.ResultsTwenty relapses occurred following 151 primary episodes of P. vivax infection (13.2%). Relapses were confirmed among 3/21 (14.2%), 9/50 (18.0%), 1/54 (1.9%) and 7/18 (38.9%) of patients administered no dose, low dose, high dose and unknown primaquine dose respectively. High dose primaquine therapy was associated with a significantly lower rate of relapse compared to patients who were prescribed low dose therapy (OR 11.6, 95% CI 1.5-519, p = 0.005).ConclusionsRelapse of P. vivax infection is more likely in patients who received low dose primaquine therapy. This study supports the recommendations that high dose primaquine therapy is necessary to minimize relapse of P. vivax malaria.

Risk factors for urinary catheter associated bloodstream infection.

OBJECTIVES Urinary catheter associated bloodstream infection (UCABSI) causes significant morbidity, mortality and healthcare costs. We aimed to define the risk factors for UCABSI. METHODS A case-control study was conducted at two Australian tertiary hospitals. Patients with urinary source bloodstream infection associated with an indwelling urinary catheter (IDC) were compared to controls with an IDC who did not develop urinary source bloodstream infection. RESULTS There were 491 controls and 67 cases included in the analysis. Independent statistically significant risk factors for the development of UCABSI included insertion of the catheter in operating theatre, chronic kidney disease, age-adjusted Charlson comorbidity index, accurate urinary measurements as reason for IDC insertion and dementia. IDCs were inserted for valid reasons in nearly all patients, however an appropriate indication at 48 h post-insertion was found in only 44% of patients. Initial empiric antibiotics were deemed inappropriate in 23 patients (34%). CONCLUSION To our knowledge, this is the first study to look specifically at the risk factors for bloodstream infection in urinary catheterised patients. Several risk factors were identified. IDC management and empiric management of UCABSI could be improved and is likely to result in a decreased incidence of infection and its complications.

Problematic linkage of publicly disclosed hand hygiene compliance and health care-associated Staphylococcus aureus bacteraemia rates.

rates of health care-associated Staphylococcus aureus bacteraemia (HCA-SAB) not overlap, but the data period for HCA-SAB rates precedes the HH compliance data period. Second, the study design is potentially flawed since there are no published data to suggest that a single cross-sectional HH compliance rate (as reported by the authors) correlates with observed rates of HCA-SAB. Instead, previous studies have described stepwise improvements in HH compliance over periods of 12–24 months, with temporal changes in SAB rates (specifically methicillinresistant S. aureus [MRSA]) using statistical methods that assess trends over time rather than a single annual rate, such as that reported on the MyHospitals website.2-5 Thus, the authors’ analysis is not based on any previously validated approach. We agree that HCA-SAB rates are not related to HH compliance alone, but this has never been suggested by the National Hand Hygiene Initiative (www.hha.org.au). Issues such as invasive device insertion and maintenance, host factors and rates of staphylococcal infection in the community are all likely to have an impact.4 Studies that quantify the impact of such factors are difficult to undertake accurately, although Victorian data suggest that HH programs alone have the potential to reduce rates of MRSA bacteraemia by approximately 66%, albeit from a rather high pre-intervention rate.3 Hospital-acquired infections are a complex multifaceted issue that requires careful analysis and investigation.

Cryptococcal infections in solid organ transplant recipients over a 15-year period at a state transplant center

The aim of this research paper was to determine the incidence, risk factors, and clinical outcome of solid organ transplant (SOT) recipients diagnosed and treated for cryptococcosis at our institution.

Stability of Buffered Benzylpenicillin Solutions for Outpatient Parenteral Antimicrobial Therapy

The stability of benzylpenicillin infusions are temperature and pH dependent. Unbuffered benzylpenicillin solutions lack the stability required for continuous infusions in the outpatient setting.

Parenteral nutrition-associated bloodstream infection in an Australian teaching hospital—An 8-year retrospective study of over 11,000 PN-days

Abstract Background: Bloodstream infections (BSIs) are a well-recognized complication of parenteral nutrition (PN). However, their epidemiology and clinical consequences are incompletely described. Methods: A retrospective cohort study was performed, from 2002 to 2009, of all hospital inpatients who were administered PN, outside the intensive care setting, at a major tertiary hospital in Queensland, Australia. Results: In 780 episodes of PN administration, 120 BSIs occurred, giving an incidence of 10.0/1000 PN-days. The majority of PN-associated BSIs were classified as central line-associated (n = 98, 81.7%). Candida spp. were the most frequent pathogens. Observed BSI management revealed that over 8% of intravascular devices were inappropriately retained, over 30% of empirical antibiotic therapy was inappropriate, and 62% of antifungal therapy was delayed ≥ 48 h. All-cause hospital mortality was over 2-fold greater in patients with a PN-associated BSI compared to those without (17.9% vs 8.3%, crude odds ratio (OR) 2.4, 95% confidence interval (CI) 1.29–4.35, p = 0.002). BSI was identified as an independent risk factor for mortality (adjusted OR 3.54, 95% CI 1.76–7.12, p < 0.001). Low baseline albumin levels and a requirement for intravenous insulin infusion (a marker of sustained hyperglycaemia) were independent risk factors for the development of PN-associated BSIs. Conclusions: PN-associated BSI in hospital inpatients is common and is associated with mortality. The implementation of standardized evidence-based infection prevention strategies, particularly targeting IVD maintenance, is a priority. PN-associated BSI management pathways require optimization, with timely IVD removal and appropriate antimicrobial therapy. Depending on local epidemiology patterns, empirical antifungal therapy should be considered.