ANTIBIOTIC POLICY IN THE TERTIARY CARE CENTRE

4. ANTIBIOTIC POLICY IN THE TERTIARY CARE CENTRE

The University Medical Centre Ljubljana (UMC) is the only tertiary care centre in Slovenia. In 2001 the UMC had 2,455 beds and admitted 82,594 patients, who stayed in hospital for a total of 582,745 bed-days, the average length of stay being 7.0 days. An open drug formulary is used for all drugs in the centre.

In the period from 1995 to 1997, the consumption of antibacterial drugs in the UMC (including psychiatric units which accounted for approximately 25% of bed-days) increased by 5.9%, attaining 43.68 DDD/100 bed-days in 1997 (Vipintin and #ipman, 1998). ␤-lactam agents were the most commonly used antimicrobials (53%), followed by macrolide and lincosamide antibiotics (13%), and quinolones (12%) (Vipintin and #ipman, 1998). In most units, a trend towards increasing use of macrolides, lincosamides, and quinolones was associated with a marked decline in the use of tetracyclines and amphenicols.

The utilization of some problem antibiotics in the UMC has been regulated since 1998. The original list of so-called restricted agents, drawn up by the antibi- otic committee, included 11 antibacterials and 1 antifungal drug (lipid associated forms of amphotericin B). Any drug from the list may be prescribed only on approval of ID or a few members of the antibiotic committee. A special order form, including data on the patient, type of infection or prophylaxis, and dosage is used for these drugs. Exceptionally, the use of an antibiotic from the list may be approved by telephone on the basis of previous consultation. The utilization of these antibiotics in individual hospital departments is monitored by a team of two ID doctors. Several departments may be covered by one team. Other common measures such as stop orders, systematic education of physicians, auditing, com- puter guided prescription, or rotation of antibiotics (Gould, 1999, 2002; Keuleyan and Gould, 2001; Struelens et al., 1999; van der Meer and Gyssens, 2001; Wilton et al., 2002) have not been used in the UMC. Unfortunately, the hospital manage- ment shows inadequate understanding of problems of antibiotic consumption and bacterial resistance and so most of the work in this field is done on a voluntary basis by a handful of enthusiasts. The consumption of antibacterials in the UMC from 1998 to 2002 is presented in Figure 1.

The data in Figure 1 show a 9% increase in the total consumption of antibacterials (from 58.91 to 64.31 DDD/100 bed-days) in the period from 1998 to 2002. The highest increase was observed in fluoroquinolones (64%),

258 Milan Cˇizˇman and Bojana Beovic´

70 AMPHENICOLS

3.04 2.27 60 3.82 3.87 4.01 2.5 3.73 3.51 4.25 5.13 TETRACYCLINES 3.82

4.19 4.53 5.31 50 4.28 7.09 8.2 SULFONAMIDES AND 7.02 7.42 TRIMETHOPRIM 6.7 11.66 AMINOGLYCOSIDE 40 7.73 8.79 9.46 ANTIBACTERIALS 7.11 OTHER ANTIBACTERIALS

30 10.13 11.49 DDD/100 bed-days 13.71 13.39 12.48 MACROLIDES, LINCOSAMIDES AND STREPTOGRAMINS

20 QUINOLONE ANTIBACTERIALS

22.98 OTHER BETA-LACTAM ANTIBACTERIALS

BETA-LACTAM 0 ANTIBACTERIALS,

Figure 1. Consumption of antibiotics in the UMC Ljubljana (DDD/100 bed-days)

followed by macrolides and lincosamides (9%), and other ␤-lactam antibacte- rials (33%). The consumption of penicillins was stable, whereas the consump- tion of other antibacterials, aminoglycosides, TMP/SMX, tetracyclines, and amphenicols decreased. The consumption of restricted antibiotics varied from

2.93 DDD/100 bed-days in 1998 to 2.77 DDD/100 bed-days in 1999, 3.76 DDD/100 bed-days in 2001, and 3.39 DDD/100 bed-days in 2002. In the same period, the average length of hospital stay declined from 7.9 days in 1998 to

7.3 days in 2002. Since restricted antibacterials accounted for only 5% of all antibiotic consumption in the centre, the institution of restrictive measures for this group of antibiotics could not influence significantly the total consump- tion of antibitiotics in the hospital. Consequently, a decrease in the total use of antibiotics was observed only in a few departments where ID specialists were responsible for the treatment of all bacterial infections (Beovic´ et al., 2003). On the other hand, restricted antimicrobials represent approximately a third of the total cost of antimicrobial agents in the centre. Therefore the restrictions may be expected to have a significant financial impact, besides helping to reduce the development of resistant organisms (White et al., 1997).