AN ELECTRONIC SOFTWARE TO AID RATIONALISED ANTIBIOTIC PRESCRIPTION AND IMPLEMENTATION OF THE LOCAL ANTIBIOTICS POLICIES Author: Michael Ogundele

ABSTRACT There is a worldwide consensus for promoting rationalised use of antibiotics to curb the imminent threat of rising antimicrobial resistance and treatment failures. One of the main weapons in managing antimicrobial resistance is the adoption of good prescribing practice. The UK recently launched the Hospital Pharmacy Initiative (HPI) with allocation of 12 million over 3 years to monitor and control more carefully the use of antibiotics. There is a developing role for non-medical prescribers worldwide and an increasing need for adaptive educational materials and innovative teaching methods. There is increasing evidence that computerized prescription systems can potentially reduce clinical errors. Use of printed educational materials or audit and feedback alone often result in no or only small changes in prescribing practices. AIMS: We aimed to design an easy-to-use, user-friendly desktop windows application for the General practitioners and hospital doctors as a quick reference for the rationalised prescription of antibiotics based on the locally agreed antibiotic policies and guidelines. METHODS: We have designed a software based on windows Microsoft Access and incorporates the recommendations of the local antimicrobial policies and guidelines. RESULTS: The software provides dosage recommendations for patients of different age groups and aids in calculating the correct antimicrobial dosage based on the given patients weight. It aids selection and correct dosage prescribing of appropriate antibiotic for selected disease conditions, based on locally agreed priority criteria. It provides a password protected Administrator area for editing the content of the database, including the list of diseases and list of empirical antibiotics and recommended dosage of antibiotics for different age groups. CONCLUSION: We have designed an easy-to-use software for hospital practitioners which requires no advanced computer skills and will help to implement the local antimicrobial prescription policies. This software application is available for free download on www.e-software-medical.com.

INTRODUCTION INCREASING PROBLEM OF ANTIMICROBIAL RESISTANCE Antimicrobial resistance has become a global public health problem. Although many factors contribute to this deteriorating situation, the use of antimicrobials is the single most important determinant of resistance. Overuse and misuse result from poor prescribing behaviour, uninformed patient demand and lack of adherence to the treatment regimen prescribed. Low-quality drug formulations, inadequate dosage regimens and insufficient duration of therapy are also important contributors to AMR. The development of drug-resistant strains of micro-organisms such as meticillinresistant Staphylococcus aureus ( MRSA) is an increasing problem worldwide, and has potentially disastrous consequences if not addressed. One of the main weapons in managing resistance is the adoption of good prescribing practice for antimicrobials. Research has shown that physicians in the community (in doctors' offices and clinics) can be partly to blame for resistant bacteria. Studies have shown that physicians inappropriately prescribe antibiotics for infections caused by viruses (such as the common cold). They also prescribe antibiotics that kill a wide variety of bacteria when an antibiotic that kills specific bacteria should be prescribed. Physicians may also prescribe the wrong dose for the wrong length of time. Inappropriate prescribing is due to many factors including patients who insist on antibiotics,

physicians who do not have enough time to explain why antibiotics are not necessary and therefore simply prescribe them to save time, physicians who do not know when to prescribe antibiotics or how to recognise a serious bacterial infection, or physicians who are overly cautious.(Arnold & Strauss 2005) In 2001, in response to this threat, WHO released the Global Strategy for Containment of Antimicrobial Resistance (13). The Global Strategy includes 14 priority interventions and 67 recommendations in the areas of advocacy, education, management and regulation of drug use. Certified prescribers have a clear responsibility for prescribing antimicrobial drugs appropriately. Because the treatment of acute infections often requires administration of medications on an empirical (syndromic) basis, implementation of standard treatment guidelines and essential drug lists are powerful mechanisms to improve prescription practices. (WHO 04) As a result of ongoing concern regarding rates of resistance to antimicrobials and inappropriate prescribing, the UK Department of Health (DH) allocated 12 million in 2003, to be spent over 3 years on developing the role of pharmacists to take a lead in the to monitor and control more carefully the use of antibiotics and promotion of rational antibiotic prescribing (Drumm 06). A meeting organized by the Specialist Advisory Committee on Antimicrobial Resistance in conjunction with the UK National Prescribing Centre and UK Department of Health held in London in 12 July 2005, focused on the developing role of the antibiotic pharmacist, especially in the development, maintenance and presentation of antibiotic guidelines (J Ant Chem Drummond). The tools at hand to combat the problem of resistant organisms are limited: apart from production of new drugs, vaccines, infection control in hospitals and in the community, and prudent prescribing are the other main viable options (Drumm 06). There have been several initiatives recently in the UK to improve optimal use of antibiotics including the establishment of antibiotic sub-committees to Drug and Therapeutics Committees (DTCs), audit of policies and practice, and appointment of ward-based pharmacists and specialist pharmacists (e.g. for HIV/ID, haematology/oncology and infection control). .(Drumm 06) Prudent antimicrobial prescribing is at the core of the Scottish Action Plan on Antimicrobial Resistance (Scottish Executive 2002), alongside surveillance of resistance and control of healthcare associated infection (HAI). A guidance document on prudent use of antibiotics and other antimicrobial drugs has been produced for NHSScotland by the Scottish Medicines Consortium (NHSScotland 2005). National and international regulatory authorities can play a vital role in the control of antibiotic resistance by providing post-licensure drug resistance information and recommendation for amendment of treatment guidelines.

The clinical significance of increasing antimicrobial resistance Several studies suggest that about adverse event related to medical therapy are common in of hospitalized patients (up to 3.7%). More than one third of adverse drug events (ADE) are associated with medication errors and are thus preventable (Kaushal et al 2001, Leape et 1993, Bates et al 1993, 1995) Patient mortality and morbidity are both increased in drug-resistant infections. Management of these infections is resource intensive in terms of treatment costs, bed occupancy and staff time.(NHS Scotland) A number of challenges related to antimicrobial prescribing identified in Scottish hospitals are representative of problems faced by healthcare professionals world wide. These include wide variation in antimicrobial prescribing policy and practice, inadequate supervision of prescribing and inappropriate choice, duration and records of administration by junior doctors and lack of hospital wide multidisciplinary approaches to antimicrobial prescribing (NHS Scotland 05) The role of antimicrobial guidelines in controlling the spread resistance

Antibiotic policies are general statements of hospital strategy whereas formularies specify available drugs and guidelines include reference to specific clinical conditions (Woodford et al 2004). Antibiotic policies should describe effective antibiotics in appropriate dosages, avoid unnecessary treatment, reduce the emergence of antibiotic resistance, promote good practice and contain costs.(Nathwani 1999) Antibiotic policies should provide guidance on dosage, length of treatment, choice of antibiotics, coverage of common infections and reasons for prophylaxis. It should also provide cautionary points (such as common side effects, contraindications or special dosages) about the recommended drugs. Recommended formats of antibiotic policies include the style of showing first choice drugs in a colour or font different from the alternatives, use English words instead of abbreviations of Latin terms for dosages and length of treatments. (Mayon-White & Wiffen 2005) Introduction of antibiotic policies has been shown to reduce the cost of therapy, total amounts of prescribing, preventing and controlling emergence of resistance, while maintaining the quality of care. A European-wide working group of the European Society for Clinical Microbiology and Infectious Diseases has been set up to address the role of antibiotic policies and other measures to control antibiotic misuse (Gould 1999) Adherence to guidelines has the potential to bring a number of desirable outcomes for patients, among these are: a better chance of effective treatment; less inequality (eliminating unnecessary variations in practice and so-called postcode prescribing); clarity as to how and why treatment decisions have been reached; and improved safety. From the healthcare provider viewpoint they can also facilitate audit and result in a decrease in costs.(Drumm 06) Between 1999 and 2002 various studies in the UK reported that in 1999, 90% to 93% of English hospitals had antimicrobial policies and antibiotic control documents. In the UK South East Region in 2004, 95% of the hospitals had antibiotic policies (92% response rate).6(Mayon White 05, 2004 Woodford et al.) [NAO study (100% response rate). In 2004, 53% responding hospitals] Other measures useful in controlling the spread resistance (Davey et al 2005) The role of ongoing education for prescribers has been emphasised. Action without education is at worst dangerous, or at best useless. The spectrum of prescribers is changing; today and tomorrows prescribers will include medical practitioners, dentists, optometrists, nurses, pharmacists and perhaps paramedics. It is essential that the necessary educational components be in place in the curricula for all of these roles in order to achieve the goals of rational prescribing. Rational use of antibiotics requires rational prescribing and evidence-based recommendations. There has recently been a public consultation and further policy work undertaken that may result in pharmacists joining the list of Independent prescribers by 2006..(Drumm 06) A Cochrane Review of Hospital Antibiotic Use (undertaken by the BSAC and Hospital Infection Society has) has systematically reviewed the literature in order to identify interventions that alone, or in combination, are effective in promoting prudent antibiotic prescribing to hospital inpatients. The results showed that several published interventions demonstrated improvement in antibiotic prescribing practices, and can reduce antimicrobial resistance or hospital acquired infections.(Davey et al 2005) Since there are many reasons why physicians in the community prescribe antibiotics inappropriately, No single intervention can be recommended for all behaviours in any setting. Multifaceted interventions including physician and public education, and patient-based interventions, particularly the use of delayed prescriptions for infections for which antibiotics were not immediately indicated, have been shown to be effective in reducing antibiotic prescribing for inappropriate indications (Arnold & Strauss 2005) Use of printed educational materials or audit and feedback alone resulted in no or only small changes in prescribing practices with the exception of a study documenting a sustained reduction in macrolide use in Finland.(Arnod &Straus 2005)
Studies have shown that about half of the time, physicians in hospital are not prescribing antibiotics properly.

THE ROLE OF COMPUTER-ASSISTED PRESCRIBING IN IMPROVING PATIENT SAFETY Information and communication technologies (ICTs) have the potential to address many of the challenges that health systems are currently confronting, but remain underused by healthcare professionals.(Gagnon et al 2009) A recent Cochrane review of the role of computerised advise on prescribing practices showed significant benefit for both health professionals and patients. It particularly reduced the risk of toxic drug levels and the length of time spent in the hospital. (Durieux et al 2008) Computerised prescribing systems can provide the users with clinical decision support such as warnings on allergies, drug-drug interactions and drug duplications. Specific improvements in reducing adverse drug events (ADE) can be obtained by computerised medication ordering and processing systems (Bates et 1998). Several studies have shown that computerized physician order entry could potentially have prevented up to 93% physician-generated and ward-based clinical pharmacists ADEs. (Kaushal 01) There is a paucity of electronic or computer-assisted prescribing tools available for physicians in many health organisations. From a survey of 465 hospitals in the UK in 2001/2002, 44% of formularies, 45% of policies and 35% of guidelines were available electronically. Increased access to electronic versions of antibiotic control documents by the professional staff of each hospital has been recommended. (Woodford et al 2004) Only 3 (13%)of the 23 UK hospitals surveyed in 2004 had antibiotic policies available to its staff on the intranet. (Mayon-White & Wiffen 2005). Design and Methods The aim of this project is to design an easy-to-use, user-friendly desktop windows application for the general practitioners and hospital doctors as a quick reference for the rationalised prescription of antibiotics based on the locally agreed antibiotic policies and guidelines. This software application is available for free download on www.e-software-medical.com.

Special features The software application is based on windows Microsoft office component (Access) which is widely available in most hospitals. It can incorporate the local logo of the institution and links to other local protocols and guidelines as references. It can provide dosage recommendations for patients of different age groups (Fig 1) It aids selection and correct dosage prescribing of appropriate antibiotic for selected disease conditions It aids in calculation f the correct antimicrobial dosage based on the given patients weight and the recommended weight-based dosage. It offers guidance on choice and priority of antibiotics to be prescribed in the empiric management of different disease conditions. It provides a password protected Administrator site for editing the content of the database, including the list of diseases and list of empirical antibiotics, recommended dosage of antibiotics for different age groups. It is intuitively easy to use and requires no advanced computer skills. Available for free download on www.e-software-medical.com Conclusion We have designed an easy-to use simple electronic assistant with intuitively easy to use interface which can be adapted to any current local hospital antibiotic prescription guidelines and protocols. This software has been found useful by general practitioners and hospital doctors. This software application is available for free download on www.e-software-medical.com.

Figures showing the switchboard and the welcoming page

Figure showing two examples of recommended list of antibiotics

Figure showing an example of recommended list of antibiotics

Figures showing details of each antibiotic and electronic aid to dose calculation

Figure showing the administrator page

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