Prescribing practice predisposed patients to C difficile
Antibiotic prescribing practices at Maidstone and Tunbridge Wells NHS
Trust unnecessarily predisposed vulnerable patients to developing Clostridium
difficile infection, a Healthcare Commission investigation (PDF 1.7Mb)has
concluded.
Patients were given broad-spectrum antibiotics where other antibiotics
would have sufficed and would have been less likely to allow C difficile infection to develop. Excessive numbers
of antibiotics were used for simple infections, often in an additive
way, and antibiotics were often used for excessive periods. Broad-spectrum
antibiotics were also used when there was little evidence of a significant
infection.
“Despite recent dissemination of information about the potential
risks from broad-spectrum antibiotics, some of the prescribing in the
trust
was worrying,” the report of the investigation says. “Patients
who might have been expected to make a full recovery from their condition
at the time of admission received broad-spectrum antibiotics, contracted
C difficile and some died.”
Antibiotics need to be seen as potentially dangerous drugs and prescribed
only if there is a clear clinical indication, it says. “Supervision
of junior doctors in this respect is particularly important. Antibiotics
should be targeted, of the narrowest spectrum possible, and used for
the shortest time possible. The continuing need for antibiotics should
be reviewed daily.”
The commisson reviewed the case notes of 50 patients who had died having
been infected with C difficile. In 80 per cent there was at least one
unsatisfactory element of the clinical management and monitoring of C
difficile infection. And in at least 32 per cent the reviewers had concerns
about the antibiotic therapy prescribed to treat the C difficile
infection itself. Most often, this was because vancomycin was not used
when there was evidence that metronidazole had failed to control C
difficile infection.
However, the report points out that the antibiotic policy in place before
the outbreak was a reasonably standard one and comparable to those in
similar hospitals. The policy did not restrict the use of broad-spectrum
antibiotics, but this was also the case in 38 per cent of trusts, the
report says.
The report draws attention to the fact that pharmacists were not informed
of proposed changes to antibiotic guidance and not involved in their
development and to problems caused by low staffing levels and the use
of “escalation” areas. Pharmacists interviewed by the commission
said nurses often did not have time to provide them with information
they needed about patients. Escalation areas were used as wards when
no suitable beds were available and it took time to organise a full pharmacy
service.
Anti-infective
pharmacist’s
view
Kieran Hand, consultant pharmacist (anti-infectives) at Southampton
University Hospitals NHS Trust, said: “A quarter of cases of
mild diarrhoea due to C difficile will resolve themselves
without treatment provided the precipitating antibiotics are stopped,
but
nurses need to be aware that patients with diarrhoea may have C
difficile infection and that they need to isolate
the patients promptly and send a stool sample to be tested.
"If patients
have a fever, leucocytosis
or clinical signs of colitis, then they should be started on metronidazole
and oral rehydration salts — some patients at Maidstone and
Tunbridge Wells suffered dehydration and went on to develop renal
impairment.”
There is a lot to learn about controlling infection outbreaks, he
added, partly because many antibiotics are off-patent, so research
is publicly funded and tends to happen more slowly than industry-sponsored
trials. “We are reasonably confident that we know which antibiotics
pose low, medium and high risks for developing C difficile and
so we can draw up guidelines accordingly,” Dr
Hand said.
“ One of the most important roles pharmacists can
play is to make junior doctors aware the guidelines exist and to
alert clinician colleagues when they are not adhering to the recommendations.”
He
added: “A couple of recent studies have suggested that for
patients with severe diarrhoea associated with C difficile,
oral vancomycin may have the edge over metronidazole and should be
used
initially for treatment. The potential benefits of vancomycin must
also be balanced against the risk of selecting for vancomycin-resistant
enterococci, which can present a significant clinical challenge in
the hospital environment.”
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The
Pharmaceutical Journal
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