The findings of a study analysing intravenous (IV) antibiotic usage in a private mining hospital in North West Province have emphasised the need for antibiotic stewardship to optimise treatment duration and promote IV-to-oral switch, when appropriate, to reduce risks linked to prolonged IV antibiotic use.
In their study, published in the SA Medical Journal, D Seimela, J M du Plessis, M Vorster, and A F van Niekerk from North West University wrote that amoxicillin-clavulanic acid – the most frequently used IV antibiotic – accounted for 48.2% of all IV antibiotic initiations.
The most common dose was 1200 mg (48.2%), with a three times a day (tds) frequency being the most prevalent.
A high proportion of IV antibiotic initiations (91.1%) was reviewed, with IV-to-oral switch (49.0%) being the most common action, followed by discontinuation (41.3%). The average length of hospital stay was 5.8 days, with patients receiving IV antibiotics for an average of 3.4 days.
Multi-drug resistance
The misuse and overuse of intravenous (IV) antibiotics contributes to the spread of multi-drug resistance, consequently increasing mortality, they wrote, but these effects can be minimised through treatment reviews which optimise antibiotic therapy without compromising patient clinical outcomes.
This cross-sectional study design was followed using retrospective data from patient files and the hospital electronic healthcare software (TriMed) between 1 January and 31 December 2022.
Demographic data were recorded for 677 patient profiles, with males representing 53.8% (n=364). A total of 731 admissions occurred during the study period.
The most prevalent indication for IV antibiotic use was upper and lower respiratory tract disorders, representing 25.2% of the total admissions. Staphylococcus aureus was the most commonly treated micro-organism, representing 22.8% (n=23) of the total isolated micro-organisms.
IV antibiotics were initiated 885 times, and amoxicillin-clavulanic acid was the most used antibiotic (51.2%). Most antibiotics (48.2%) were used at a dose of 1 200 mg, with a dosing frequency of three times a day (72.3%).
A total of 806 review actions, out of 885 intravenous antibiotic initiations, were conducted (91.1%). The prevalence of IV-to-oral switch was 49.0%, while 41.3% of IV antibiotics were stopped after review. IV antibiotic de-escalation represented 7.2% of the total reviews, while an oral antibiotic was added to 1.7% of the IV antibiotics after review.
At review, the prevalence of adding IV antibiotics to another IV antibiotic was 0.7%. The average length of hospital stay was 5.8 days, while patients continuously received IV antibiotics for 3.4 days on average.
The researchers wrote that there is a need to monitor IV antibiotic use and encourage IV antibiotic de-escalation to limit the rampant use of broad-spectrum antibiotics and manage the most prevalent infections effectively in the shortest possible time, reducing the average hospital stay.
IV antibiotic treatment review is pivotal to optimise antibiotic therapy, the transition of IV to oral antibiotics, and discontinuation of IV antibiotics when they are no longer necessary.
South African context
IV antibiotic use, common in both low- and high-income countries, plays a crucial role in saving lives, especially for treating and managing life-threatening bacterial infections, and is generally believed to be superior to oral formulations, especially for severe infections.
In South African hospitals, the overuse and misuse of IV antibiotics, when oral formulations with equivalent efficacy are available, is a form of irrational antibiotic use that can compromise patient outcomes and strain healthcare systems financially.
This also enables antibiotic resistance (ABR) that causes antibiotics to lose their effectiveness against various pathogens. ABR is a global public health crisis and by 2050, predict experts, it is estimated that ABR will have caused more than 10 m deaths.
Key findings
The study authors found that respiratory and musculoskeletal disorders were the most commonly recorded provisional diagnoses at admission, while S. aureus was the most commonly identified micro-organism after microbiological testing.
Amoxicillin-clavulanic acid was the IV antibiotic agent most commonly used in the study setting, with the majority of IV antibiotics prescribed falling into the Access group. The most commonly prescribed dose was 1 200 mg for amoxicillin-clavulanic acid, representing >48% of the prescribed doses, while 72.3% of the IV antibiotics were prescribed at a dosing frequency of tds, which could indicate compliance with SA dosing guidelines for the use of amoxicillin-clavulanic acid and ceftriaxone – the most commonly used IV antibiotics in the study.
In some cases, the IV antibiotics were continuously administered for longer than recommended, and during the treatment review, were mainly switched to oral formulations or stopped, based on the clinical presentation of the patient, microbiology results, and whether or not the patient could tolerate oral formulations.
Exceeding the normal recommended duration was noted in a patient provisionally diagnosed with cellulitis and given IV antibiotics for more than two months, with E. coli being the identified micro-organism.
A study on E. colicellulitis in immunocompromised patients indicated that they clinically improve after 11 days of IV antibiotic therapy, and thereafter the treatment regime should be downgraded to oral antibiotic formulations.
However, the prevalence of IV antibiotic de-escalation was low, indicating that antibiotic de-escalation was rarely done in the study setting – where most admitted patients to the hospital were males between 25 and 59.
The female ward had the highest admission rate, as it uniquely accommodated both female and paediatric patients, unlike the other three wards, which exclusively admitted male patients.
Upper and lower respiratory tract disorders, followed by pain and musculoskeletal disorders, represented the highest percentages of admissions. This finding could be because the working environment of the private company is characterised by strenuous working activities and air pollution.
The study authors suggested that guidelines specifically targeting IV antibiotic use in respiratory and musculoskeletal disorders must be strengthened to optimise the clinical outcomes of patients presenting with these disorders.
Amoxicillin-clavulanic acid in the Access group was the IV antibiotic used the most, representing just more than 50% of all IV antibiotics used. Regarding overall usage of antibioticcs, 72.4% were in the Access group, followed by 25.7% in the Watch group.
The WHO has recommended that by 2023, Access antibiotics should represent at least 60% of all antibiotics used; the research findings therefore show that the hospital was adherent to the WHO guidelines.
An Austrian study indicated that an IV-to-oral switch 48-72 hours after initiation reduces the readmission rate, minimises the reoccurrence of infections, and has been proven to avoid >6 000 doses of IV antibiotics.
An IV-to-oral switch can therefore be practised in clinically stable patients to reduce LOS, which was recorded as 5.8 days in the present study. Antibiotic de-escalation occurred 58 times, representing 7.2% of the total reviews.
Antibiotic de-escalation is essential to reduce the spread of ABR by using narrow-spectrum antibiotics that specifically target the cultured pathogen and limit the use of broad-spectrum antibiotics, which are associated with spread of ABR when misused or overused.
The present study showed that most patients were discharged after IV treatment was reviewed and switched to an oral formulation.
This finding could indicate that the IV-to-oral switch was conducted because the patient had to be discharged, and was not necessarily an in-hospital intervention. The study also revealed 14 instances where oral antibiotics were added to IV antibiotics during treatment review. This addition could have been because the API of the specified antibiotic agent was procured only in oral formulation in the study setting.
Adding an oral formulation to the IV antibiotic indicates that the patients qualified to take oral formulations, yet were put on IV antibiotics.
Ward rounds with the involvement of a pharmacist are recommended to assist in addressing pharmacokinetic concerns and ensuring that the appropriate IV-to-oral switch is performed to treat patients optimally.
Limitations
The study was conducted in a single setting in North West Province, so the findings cannot be generalised to all hospitals in SA or even that province. The study population is a mining community, so the findings cannot be generalised to the ordinary population outside the mining community or patients in private hospitals in that region.
The study did not assess whether the dose and frequency of the prescribed antibiotics were appropriate for the identified diagnosis, so conclusions on the appropriateness of antibiotic prescribing cannot be drawn
The authors said the results highlight the need to monitor IV antibiotic use in hospital settings. Appropriate monitoring will help minimise unnecessary use of IV antibiotics when patients can be managed effectively with oral formulations, and limit the use of broad-spectrum antibiotics through de-escalation.
IV antibiotic use in hospitals can also be improved by encouraging the selection of antibiotic agents in the WHO Access group and reducing the use of Watch and Reserve antibiotics at the point of initial admission, thus assisting in minimising the spread of ABR.
The study also identified a gap in the practice of IV antibiotic de-escalation. They propose future research studies focusing on factors that hinder the practice of antibiotic de-escalation when conducting IV treatment reviews.
D Seimela, BPharm; J M du Plessis, MB ChB, MPharm; M Vorster, BPharm, MBA; A F van Niekerk, BPharm, MScPharm
Faculty of Health Sciences, North-West University, Potchefstroom, SA.
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