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DUE of PIPERACILLIN and Tazobactum
DUE of PIPERACILLIN and Tazobactum
A Dissertation submitted to
BY
S. VENKATESH (15Z91R0041)
P.SHIVANI (15Z91R0031)
M.SHAILAJA (15Z91R0028)
K.SWAPNA (15Z91R0038)
RANGAREDDY (DIST)
APRIL-2019
CERTIFICATE
This is to certify that this dissertation work titled ‘‘Drug utilization evaluation of
PIPARACILLIN AND TAZOBACTUM Technological University, Hyderabad in partial
fulfillment of the requirement for the award of Bachelor of Pharmacy is a record of research
performed by S.VENKATESH (15Z91R0041),P.SHIVANI (15Z91R0031),M.SHAILAJA
(15Z91R0028), K.SWAPNA (15Z91R0038) during the academic year 2018 – 2019 under my
guidance and supervision.
RANGAREDDY (Dist).
DATE:
PLACE:
CERTIFICATE
This is to certify that this dissertation work titled ‘‘Drug utilization evaluation of
PIPERACILLIN AND TAZOBACTUM at a tertiary care in Hyderabad’’ was carried out by
S.VENKATESH (15Z91R0041),P.SHIVANI (15Z91R0031), M.SHAILAJA (15Z91R0028),
K.SWAPNA (15Z91R0038) during the academic year 2018-2019 under the guidance Dr.Anup
Jagarlamudi, M.Pharm, Ph.D. Head of department (HOD) department of pharmacy practice, in
partial fulfillment of the requirement for the award of Bachelor of Pharmacy, Jawaharlal Nehru
Technological University, Hyderabad.
Principal,
DATE:
PLACE:
DECLARATION
This to certify that the project work entitled “DRUG UTILIZATION EVALUATION OF
PIPERACILLIN AND TAZOBACTUM AT A TERTIARY CARE IN HYDERABAD” has been
carried out under the supervision of Dr. Anup Jagarlamudi M.Pharm, Ph.D., (HOD), Department
of Pharmacy Practice, KVK college of pharmacy, and that we have not submitted these results in
any form previously for the award of any degree.
By
S.VENKATESH (15Z91R0041)
P.SHIVANI (15Z91R0031)
M.SHAILAJA (15Z91R0028)
K.SWAPNA (15Z91R0038)
DATE:
PLACE:
DEDICATION
DATE:
PLACE:
ACKNOWLEDGEMENTS
gastroenterology, Dr.sravan sir Gandhi hospital, Dr.Anup jagarlamudi sir (HOD) of Kvk College
This project bears an imprint of many people’s work. We sincerely thank to our project guide
Mr. J. ANUP (HOD) sir, M.pharm, PhD department of pharmacy Practice, KVK College
of pharmacy, Hyderabad for guidance an encouragement in carrying out this project work. I
sincerely and wholeheartedly thank to, staff of hospital, for supporting us in carrying out our
project. Without their constant encouragement and support, this wouldn’t have materialized. We
also wish to express our gratitude to the officials and other staff members, who rendered their
help during the period of our project work. Our special thanks to all staff members, of Kvk
College of pharmacy for rendering their kind co-operation for completion of our project work.
Last but not least we wish to express our sincere gratitude and love to all our friends
for their manual support, strength, and help and for everything.
My sincere”THANKS TO ALL”
Sincerely,
ABBREVATIONS:
1 INTRODUCTION 1-8
4 RESULTS 37-44
5 DISCUSSION 45-54
6 STATASTICS 55
7 CONCLUSION 56
8 ANNEXURE 57-59
9 REFERENCE 60-65
INTRODUCTION:
Certain events (indicators) serve as “flags” of potential opportunities to improve drug use. Some
are
• Adverse drug events, including medication errors, preventable adverse drug reactions, and
toxicity.
• Signs of treatment failures, such as unexpected readmissions and bacterial resistance to anti-
infective therapy.
1
Classification:
Prospective DUE
Concurrent DUE
Retrospective DUE
Types of DUE:
Quantitative
Quantify current state of drug use
Study trends of drug use
Study time course of drug usage at national, regional, local or institutional levels
Qualitative (DUR)
Study appropriateness of drug utilization
Links prescription data with drug indications
Uses of Quantitative Drug Utilization Studies:
To estimate drug utilization in populations by
Demographic characteristics
Used as denominators to calculate rates of ADRs
To monitor
_ Specific therapeutic categories
_ Effects of regulatory activities
Markers for crude estimates of disease prevalence
To plan importation, production & distribution
To estimate drug expenditures
Uses of Qualitative Studies:
To study appropriateness of drug uses
_ Indications
_ Daily dose
_ Length of therapy
To asses clinical efficacy (high intrinsic value) of most common sold drugs
2
Steps involved in DUE:
The following eight steps outline the basic information necessary to start and maintain a DUE
Program.
Step1. Establish Responsibility
Responsibility falls to the DTC or a subcommittee of the DTC that functions only to monitor
DUEs In the hospital or clinic. The DTC should undertake this responsibility with considerable
Interest, because this process can solve many medicine use problems, as has proven to be the
Case in many countries where this quality assurance function has been fully utilized. The DTC or
a subcommittee must establish procedures that will govern the committee in its activities
concerning medicine use review and evaluation. As part of the responsibility of the DUE
function, the DTC must establish a plan, outlining which medicines will be a part of the DUE
process. This plan needs to be updated and evaluated each year.
Step2. Develop Scope of Activities
The DTC should assess and identify medicine use problems and using this information to
develop a scope of activity for the DUE program. The scope can be extensive or it can focus on a
single aspect of pharmaceutical therapy. Methods to identify medicine use problems include and
ABC or vital, essential, nonessential (VEN) analysis, defined daily dose analysis, ADR reports,
medication error reports, antibiotic sensitivity results, procurement studies, hospital and primary
care clinic indicator studies, patient complaints or feedback, and staff feedback. These screening
mechanisms serve to provide the DTC with information concerning medicine use that would
need further evaluation in a DUE. Because of the large number of medicines available at a
hospital or clinic, the DTC must concentrate on the most important medicines, those with the
highest potential for problems, to get the most return on the work involved. These high priority
areas would include—
• High-volume medicine use
• Medicines with a low therapeutic index
• Medicines with a high incidence of ADRs
• Expensive medicines
• Medicines that are critically important, including those in the following categories:
Cardiovascular, emergency, toxicology, oncology, intravenous medicines, and narcotic
Analgesics
3
• Antimicrobial medicines, both prophylactic and therapeutic
• Injections
• Medicines undergoing evaluation for addition to the formulary
• Medicines used for off-label indications
• Medicines used for high-risk patients
Steps 3and 4. Establish Criteria, Define and Establish Thresholds
Criteria are statements that define correct medicine use. Establishing criteria is the single most
Important procedure in a DUE. Criteria for the use of any medicine should be established by the
DTC using relevant evidence-based literature sources and recognized international and local
experts. The criteria for any DUE should reflect what is in the country’s STGs (assuming that
they have been developed correctly) and any medicine-use protocols that exist. Credibility of the
DUE relies on criteria that are based on evidence-based medicine. Criteria must be developed
with and accepted by the medical staff for the process to be credible. Criteria should be
developed for three to five of the most important indicators for each aspect of medicine use.
Reviewing larger numbers of indicators will make for a more difficult DUE process and may
significantly impair the outcomes of the review. This is not to say that more extensive use of
indicators should not be reviewed, only that results are more easily obtained and possibly more
meaningful when the scope is narrowed to include only the most important aspects of care. After
developing criteria, the DTC must establish a threshold or standard (benchmark) against which
the criteria will be judged. A threshold refers to the percentage of charts or records that will meet
or exceed the established criteria for the medicine. Ideally, this threshold will be 100 percent, but
realistically, a smaller percentage will be more appropriate to account for exceptions to routine
medicine prescribing. Therefore, a threshold of 90 to 95 percent is typically used for many
criteria, but each instance must be carefully analyzed before reaching a conclusion. A
comprehensive list of indicators for appropriate medicine use includes the following
components-
• Process indicators
Indications—specific uses for the medicine in question
Dose—specific doses for any approved indication for appropriate duration
Quantity dispensed—correct number of doses administered
Preparation—steps involved with preparing a medication for administration
4
Monitoring—laboratory test necessary and intervals of testing during the use of the
Medicine
Contraindications—known contraindications
Drug interactions—significant medicine interactions, including medicine-medicine,
Medicine-food and medicine-laboratory
Administration—specific steps necessary to administer a medicine, especially for
Injectables
Patient education—instructions and education that a patient should receive with the
medicine
Outcome indicators—specific outcomes to be realized from medicine use
Lowered blood pressure, stabilized blood glucose, and fewer migraine and asthma
attacks
Decreased visits to the emergency room, decreased hospitalizations
improved patient quality of life (obtained from questionnaires)
5
areas and distractions. Typically, medicine-related criteria that are reviewed in these types of
evaluations are as follows—
• Prospective studies (obtained from prescription records)
Indication
Dose
Duration of therapy
Dosage form and route of administration
Potential medicine interactions
Appropriate therapy and medicine selection (corresponds to STGs)
Therapeutic duplication
Contraindications
Quantity dispensed
• Retrospective studies (obtained from prescription, medical records, laboratory records)
Laboratory monitoring
Monitoring therapeutic use of high-cost medicines
ADRs to medications
Correct use of generic or therapeutic equivalents
Patient outcomes from pharmaceutical therapy
Collection of the data is performed by reviewing a suitable sample of charts or prescription
records from the health care facility, usually by selected pharmacy personnel. At a minimum, 50
to 75 records should be reviewed at each health care facility. The larger the facility and the more
practitioners who are available, the larger the percentage of records that would need to be
reviewed and analyzed.
Step 6. Analyze Data
Data are collected, tabulated, and analyzed to see if criteria and thresholds are met.The following
important steps should be completed when analyzing data—
Tabulate results for each indicator
Analyze results to see if the criteria are met and the thresholds are not exceeded
Determine why thresholds are not met
Analyze data quarterly or more frequently if a threshold is not met, it may indicate a
medicine use problem that requires the attention of the DTC.
6
Step 7. Develop Recommendations and Action Plan
After completing the data analysis, information is presented to the DTC and a decision is made
as to the appropriateness of the information in the DUE. The DTC also must decide on whether
to continue, discontinue, or expand the functions of the DUE in question. All medicines that do
not meet the thresholds must be evaluated carefully and plans must be made to improve the use
of the medicine relative to the criteria.
Recommendations should be prepared for the DTC to address the following—
Inappropriate medicine use
Unacceptable patient outcomes
Methods to resolve any medicine use problem
Recommendations should include specific steps to correct any medicine use problem that is
evident from performing the DUE. For example, if a specific medicine is being prescribed at a
high dose, then the recommendations need to reflect this and how the DTC might improve the
dosing of this medicine. Interventions to improve medicine use might include—
Education, including letters to practitioners, in-service education, workshops, newsletters,
and face-to-face discussions
Implementation of medicine order forms
Prescribing restrictions
Formulary manual changes
Change (or better enforcement) of the STGs
Step 8. Conduct DUE Follow-up
Follow-up in every DUE is critical to ensure resolution of any unresolved medicine use
problems. The DUE may have identified new problems that need to be resolved within the health
care system. If the problems are not resolved, then the DUE will have little usefulness to the
health care system. As a part of a follow-up plan, the DTC must assess the need to continue,
modify, or stop the DUE activity depending on the results of each specific medicine review. A
DUE should be an ongoing process in which medicine-related problems are regularly addressed.
Medicine review should be considered a long-term program, one that is continuously updated
and revised to reflect current situations and needs within the health care institution. All programs
within the DTC should be evaluated yearly. This complete evaluation is necessary to look
comprehensively at the entire program and analyze its merits and its utility in improving
7
medicine use. Programs that do not have a significant impact on medicine use should be
redesigned so that they can provide measurable improvements. Without improvements in
medicine use and patient outcomes, the time spent on DUE will be of no value. It must be
stressed that indicators and criteria for a DUE can be highly individualized depending on the
specific needs of the health care facility. (1)(2)
8
LITERATURE REVIEW:
1. Young-Mo Yang
2. Perry CM (4)
3. Min E, et al
Evaluation of 140 surgical ICU patients over the course of a year who received vancomycin +/-
pip-tazo for at least 48 hours. AKI was defined as an increase in serum creatinine more than 1.5
times baseline during antibiotic therapy. The authors controlled for severity of illness and
concomitant use of other nephrotoxic antibiotics. The incidence of AKI was higher in the
vancomycin + pip-tazo group (40.5%) compared to the vancomycin alone group (9.0%, p &
lt; 0.001).
9
4. Maria F (5)
PIP/TAZO may safely be used in pediatric patients as an empiric treatment for serious infections
in hospital environments where resistance to common first-line antimicrobials has emerged. The
most common indications in pediatric patients are nosocomial infections owing to resistant
Gram-negatives, exacerbation of pulmonary colonization with Pseudomonas aeruginosa in
patients with cystic fibrosis, intra-abdominal infections, fever and neutropenia in pediatric cancer
patients. The influence of PIP/TAZO routine use on the selection of extended-spectrum beta
lactamase producing Gram-negatives and on the prevalence of vancomycin-resistant enterococci
is still a matter of debate. In particular the use of PIP/TAZO in neonates and PIP/TAZO
monotherapy in pediatric cancer patients with fever and neutropenia should be investigated in
prospective randomized studies including a sufficient number of patients.
5. Young M (6)
This retrospective study was designed to involve all patients admitted to Hamad General
Hospital and prescribed piperacillin/tazobactam as an empiric therapy from January 1 to March
31, 2008. The medical records of such patients were retrospectively reviewed and studied. Our
study showed that there was an injudicious use of piperacillin/tazobactam at our hospital,
evidenced by the significant number of inappropriate empiric prescriptions and inappropriate
drug modifications, based on the results of microbial cultures and antibiograms.
10
7. Gin A (7)
8. Fedullo P
To determine the frequency and cause of inadequate initial antibiotic therapy with vancomycin
and piperacillin-tazobactam in patients with severe sepsis and septic shock in the emergency
department (ED), characterize its impact on patient outcomes, and identify patients who would
benefit from an alternative initial empiric regimen. Vancomycin and piperacillin-tazobactam
were an inappropriate antibiotic combination for approximately 24% of patients with either
severe sepsis or septic shock in the ED. Patients with known COPD, residence at a skilled
nursing facility, a history concerning for Clostridium difficult, and immunosuppression would
benefit from an alternative regimen. Future prospective studies are needed to validate these
findings.
9. Nowé P (8)
11
clinical response at endpoint. The bacteriological response rate was 73% (82/112) at endpoint.
Overall, 82% of all pathogens were eradicated. Therapy was associated with a low incidence of
side effects, and adverse experience were mild and of short duration.
To discuss the antimicrobial activity, pharmacokinetics, clinical efficacy, and adverse effect
profile of piperacillin/tazobactam, a new beta-lactam/beta-lactamase inhibitor combination. The
combination of tazobactam with piperacillin results in an antimicrobial agent with enhanced
activity against most beta-lactamase-producing organisms. Preliminary data indicate that
piperacillin/tazobactam has proven clinical efficacy in the treatment of a variety of infections,
especially polymicrobic infections.
12. Hellwig T, et al
Retrospective evaluation of all adult patients admitted to Sanford USD Medical Center over a 6
month period who received vancomycin +/- pip-tazo for more than 48 hours. AKI was defined as
an increase of serum creatinine > 0.5 mg/dL or a 50% increase from baseline. Of the 735
patients evaluated, the incidence of AKI for vancomycin alone, pip-tazo alone, and combination
of vancomycin + pip-tazo were 4.9%, 11.1%, and 18.6%, respectively (vancomycin vs. pip-tazo,
p = 0.014; vancomycin vs. combination, p = 0.005). When looking at just the ICU patients, a
similar result was seen. Incidence of AKI was 6.0%, 12.2%, and 21.2%, respectively
(vancomycin vs. pip-tazo, p = 0.279; vancomycin vs. combination, p = 0.005).
12
13. Moenster RP, et al
A retrospective cohort study was conducted of all diabetic patients with osteomyelitis treated
with vancomycin plus either pip-tazo or cefepime for at least 72 hours at a VA Medical Center
between January 2006 and December 2011. The primary outcome was development of AKI,
defined as an increase in SCr of 0.5 mg/dL or 50% of baseline. 139 patients met inclusion
criteria; 109 in the pip-tazo group and 30 in the cefepime group. In patients receiving
vancomycin + pip-tazo, 29.3% (32/109) developed AKI compared to 13.3% (4/30) treated with
vancomycin + cefepime (p=0.099). A multiple logistic regression analysis identified weight and
average vancomycin trough as the only significant predictors of AKI. The authors were unable to
detect a statistically significant difference in AKI between groups; however, power was not met.
Conducted a prospective observational study in a tertiary care teaching hospital for six months
in general medicine and screened 555 antibiotic prescriptions. The study concluded that the
clinical pharmacists and Clinicians need to play vital role in minimizing the antibiotic problems
by conducting continual awareness programs regarding up-to-date prescribing guidelines in the
hospital and also minimizing the antibiotic resistance. The active participation of clinical
Pharmacists in the clinical ward rounds and documentation of Pharmacist observation on
prescription in patient folder is highly recommended for safety and drug monitoring.
13
16. M. Shamna et al (2014)
Carried out a prospective study in all departments for a period of one year to detect and analyse
adverse drug reaction of antibiotics in inpatients of a tertiary care hospital. The study concluded
that adverse drug reaction to antibiotics is getting common and it resulted in increased health
care cost and length of hospital stay. Therefore study suggest that health system should promote
the spontaneous reporting of adverse drug reaction to antibiotics , proper Literature Review
Department of Pharmacy Practice 22 documentation and periodic reporting to regional
pharmacovigilance centers to ensure drug safety.
This study was conducted to estimate the rationality of Piperacillin /Tazobactam utilization in
our hospital. The data came out with 76 prescriptions which were ordered for 73 patients. Main
indications for utilization of Piperacillin/ Tazobactam were febrile neutropenia (34/76; 44.73%).
Overall percentage of rational and irrational use of empiric therapy was (49/76; 64.47%) and
(27/76; 35.52%) respectively (P- value 0.001). Cases of wound/surgery/skin/soft tissue infections
(WSSSTI), abdominal infections and pneumonia and unit of palliative care, showed higher
trends of irrational prescribing. Microbiology data was positive for (40/76; 52.63%)
prescriptions. This study showed that there was an unwise use of Piperacillin/Tazobactam at our
hospital, as supported by significant proportion of irrationality in the view of empiric
prescriptions and drug modifications even in the presence of microbial culture results.
14
polymicrobial infections, including intra-abdominal, skin and soft-tissue and lower respiratory
tract infections.
The antibiotic piperacillin/tazobactam has recently been licensed for use in Denmark.
Piperacillin/tazobactam combines a well known beta-lactam antibiotitic, piperacillin, and an
inhibitor of bacterial beta-lactamase, tazobactam. The combination of piperacillin and
tazobactam compared to piperacillin alone has an expanded antimicrobial spectrum, which
includes Klebsiellae, Escherichia coli, and Proteus vulgaris resistant to ampicillin, as well as
beta-lactamase-producing Staphylococcus aureus. As piperacillin in itself possesses
antimicrobial activity against streptococci, enterococci, and Pseudomonas aeruginosa, the
antimicrobial activity of piperacillin/tazobactam indicates that the combination may constitute an
alternative to third generation cephalosporins and carbapenems in the treatment of complicated
intra-abdominal infections infections in critically ill patients and for the empirical treatment of
acute neutropenic febrile patients, as indicated by clinical studies.
21. File TM Jr
Piperacillin/tazobactam has excellent in vitro activity against the most pathogens involved in
skin infections. Two large multicentre studies recently evaluated the efficacy and safety of
piperacillin/tazobactam in the treatment of skin and soft tissue infections in patients in hospital.
15
The efficacy and safety of piperacillin/tazobactam (4 g/500 mg every 8 hours) have been
assessed in an open study in Europe. Among 120 evaluable patients, 93% were clinically cured
or improved. Only six patients were withdrawn from the study because of side effects.
Piperacillin/tazobactam seems to be both effective and safe in the treatment of skin and soft
tissue infections in patients confined to hospital.
22. Alzahrani M
16
24. A. Simon (16)
17
minimum of 5 days. There was a favorable response rate of 97% and eradication of the causative
pathogen was documented or presumed in 93% of patients. Seventy-one intensive care patients
with severe lung disease received 4 g piperacillin/500 mg tazobactam intravenously every 6 h;
afterward they were given amikacin 7.5 mg/kg every 12 h. Minimum duration of treatment was 5
days. Therapy with piperacillin/tazobactam plus amikacin was well- tolerated, produced a 74%
favorable clinical response rate, and eradicated the responsible pathogen in 70% of patients.
Conducted a study to assess rational use of antimicrobials in the medicine outpatient department
of a teaching hospital. A total of 650 prescriptions were collected from the medicine OPD.
Prescriptions containing antimicrobial were grouped using the anatomical therapeutic chemical
(ATC) codes. They concluded that higher frequency of irrational antimicrobial prescriptions
suggests that antimicrobial restriction policies and a multidisciplinary effort to reduce usage are
urgently required.
Conducted a study to evaluate the pattern of drug utilization in inpatients of general medicine
department. The data for study was obtained from 80 inpatients prescriptions and the DDD/100
bed days were calculated. The study indicates that there improvement in prescribing pattern of
antibiotics is possible by adhering to standard guidelines of treatment and restriction policies to
promote rational drug use.
18
30. Admane PD et al (2015) (21)
Carried out a study to assess the use of antimicrobials in tertiary care hospital. A prospective
cross sectional study was conducted in outpatient department over a period of 8 months and total
1942 prescriptions were collected. The study results analysed that the rational use of
antimicrobial agents is needed to control antibacterial resistance, side effects and reduced cost of
the treatment.
Carried out a prospective observational study over a period of months and screened 1139
prescription to assess the patterns of drug utilization evaluation by WHO prescribing indicators
among special population in a tertiary care government teaching hospital retrospectively and
prospectively. The study concluded that it is necessary to avoid over prescription, follow
guidelines while prescribing drugs generic name, reduce the use of antibiotics after susceptibility
testing , to minimize the use of injections and to confine to the National essential drug list are
necessary to further improve rational use of drugs.
Studied on the patient’s awareness on the rational use of antibiotics and its resistance by
developing a questionnaire. The study revealed that there was a very high consumption of
antibiotics mainly cephalosporin’s. Dispensing of antibiotics is very high in community
pharmacy despite of federal regulations. They proposed health education programmes should be
given to the patients regarding antibiotics.
Conducted a prospective observational study in a tertiary care teaching hospital for six months in
general medicine and screened 555 antibiotic prescriptions. The study concluded that the clinical
pharmacists and Clinicians need to play vital role in minimizing the antibiotic problems by
conducting continual awareness programs regarding up-to-date prescribing guidelines in the
hospital and also minimizing the antibiotic resistance. The active participation of clinical
Pharmacists in the clinical ward rounds and documentation of Pharmacist observation on
prescription in patient folder is highly recommended for safety and drug monitoring.
19
34. M. Shamna et al (2014) (25)
Carried out a prospective study in all departments for a period of one year to detect and analyse
adverse drug reaction of antibiotics in inpatients of a tertiary care hospital. The study concluded
that adverse drug reaction to antibiotics is getting common and it resulted in increased health
care cost and length of hospital stay. Therefore study suggest that health system should promote
the spontaneous reporting of adverse drug reaction to antibiotics , proper documentation and
periodic reporting to regional pharmacovigilance centers to ensure drug safety.
Studied on antibiotic sensitivity pattern in urinary tract infection at a hospital. The most
common samples isolated were Escherichia coli, Klebsiella, Pseudomonas, and Staphylococcus
aureus.E.coli showed high sensitivity to Amikacin and Nitrofurantoin. E.coli isolates were also
sensitive to Minocycline, showing a good utility of this drug for the treatment for patients with
urinary tract infections.
20
38. Mayadah Shehadeh et al (2011) (29)
Studied on the knowledge, attitudes and behavior regarding antibiotics use and misuse among
adults in the community of Jordan. The study showed that knowledge of when antibiotics should
be used, the efficacy of antibiotics as well as the risk of antibiotic resistance is inadequate in
study population. To prevent the inappropriate antibiotics consumption the health authorities had
to implement their regulations to prohibit the selling of Prescription Only Medicine (POM)
without prescription.
Studied on adverse events to antibiotics in inpatients of a university hospital. The aim of the
study was to evaluate the occurrence of adverse events to antibiotics in inpatients of a hospital.
The study results indicate that an inadequate knowledge on antibiotics or lack of information
about the patient at the time of prescription were the major factors involved in the occurrence of
adverse event
Conducted a study including 556 in patients to assess prescription on the basis of type of use,
specialty, site of infection, route of administration and the antimicrobial agent used. The study
showed that 56% of in-patients were prescribed antimicrobial agents and 44% of them received a
combination of antimicrobials and concluded that there is need of review of antimicrobial
prescribing practices.
21
42. Ravi Pathiyil Shankar et al (2003) (33)
Carried out a over a period of 3 month including 203 patients study to collect demographic
information, antibiotic prescribing patterns, and common organism isolated including antibiotic
sensitivity patterns. The study concluded that antibiotic resistance is getting common, therefore
formulation of policy for hospital antibiotic use and should organize educational programs
especially for junior doctors.
Conducted a review on moxifloxacin usage which has increased at Vancouver General Hospital.
It is unclear, however, whether the use of the drug is optimal according to its indication. They
22
hypothesized that moxifloxacin was over utilized and that opportunities existed to optimize its
use and study was designed to characterize moxifloxacin use in concordance with evidence-
based assessment criteria. An observational DUE was conducted over a 4-week period (from
February 17 to March 16, 2007) at Vancouver General Hospital, a 955-bed tertiary care hospital.
In patients who received at least one dose of moxifloxacin were enrolled. Evidence-based
assessment criteria were developed to evaluate the appropriateness of moxifloxacin use, and
PDA database was developed for data collection. The primary endpoint was the proportion of
moxifloxacin use for approved first-line indications. Results showed that Results: A total of 132
patients were included. Eighty-nine patients (67%) received moxifloxacin for first-line
indications, including community-acquired pneumonia (57%) and acute exacerbation of chronic
bronchitis (10%). Forty-three patients (33%) had alternative indications, primarily hospital-
acquired
23
46. Juno J. Joel et al (37)
Carried out Drug Use Evaluation on Ofloxacinn for the purpose of presenting the more
reasonable drug therapy. Fifty eight cases of patients, who had been treated with ofloxacin in
Korea University Kuro Hospital from September 1. 1994 to April 30. 1995 were reviewed
retrospectively. The applicated criteria for ofloxacin was " Criteria for Drug Use
Evaluation" established by ASHP report 1993. The results of the analysis show that 34
cases (59%) were met with the criteria for the justification of use, while 24 cases (41%) were
not. In critical indicators, several criteria including culture & sensitivity test, vital sign,
WBC monitoring and urinalysis were relatively well performed showing the accepted level
above 70%, while serum creatinine monitoring and administration time were infrequently
performed with low accepted level. Accepted level of ofloxacin was relatively high, while notice
about drug interaction and complications were low, which indicate that medication were being
performed under the insufficient information about each drug in clinic. The cased met with all
criteria were 13 cases (22%), all included of which were in internal medicine. From the results, it
could be concluded that medical staff should get the more information on general area of
antimicrobial agents include complication, duration of therapy and characteristics of each drugs.
24
48. Rattanaumpawan P et al (39)
25
to 68% of prescribers the therapy was cost-effective. Redman’s syndrome was reported in 44%
of the cases. This study concludes that vancomycin is being used appropriately in right doses and
for right indications and is cost effective to the majority of patients. Yet the special precautions
must be followed such as prolonged infusion time and measuring the plasma drug concentration
after administration. ADRs and the possibility of any untoward medical occurrence or the risks
of drug related morbidity and mortality can be avoided under the supervision of a pharmacist.
26
rational use of ceftriaxone in Medical ward of Dessie referral Hospital, Dessie-Ethiopia.
Retrospective systematic study was used to assess rational use of ceftriaxone. The study was
conducted by reviewing medication records of 316 patients, who received ceftriaxone during
hospitalization at Medical ward of Dessie referral Hospital from December 30, 2011 to January,
2013. A systematic sampling method was used to select inpatient prescriptions in this ward with
ceftriaxone and patient cards were located based on the medical record number on the
prescription papers. Data was collected by using structured format and evaluated against WHO
criteria for drug use evaluation as per standard treatment guideline of Ethiopia. Most patients
were dosed as 2 g/day (79.4%). The duration of therapy was found to be high in the range 2-7
days (51.69%). Ceftriaxone was mainly used as pneumonia treatment (38.8%). Maintenance
fluids were the most commonly co- administered medications with a frequency of 62.16%. The
use of ceftriaxone was appropriate only in 170 cases (55.8%) for the justification of use. Most of
inappropriate uses were seen in terms of duration during treatment of pneumonia followed by
frequency for the treatment of meningitis. Consistency of prescriber to the national standard
treatment guideline was found to be low. To improve rational use and prevent the development
of resistance; prescribers should adhere to the national standard treatment guideline.
Intensification of short term trainings and antibiotic control systems are some of the possible
solutions the hospital has to do. ceftriaxone therapy does not meet the current STG of Ethiopia.
27
2010) for general hospitals. Results: The proportion of patients who received ceftriaxone was
59.3 % and 49 % in the public & the private hospital, respectively. Pneumonia, meningitis
and sepsis were the common diagnoses in which ceftriaxone was prescribed in both hospitals.
Maintenance fluids were the top ranked co prescribed drugs in either hospital. Only 48.9 % in the
public hospital and 44.6 % of records in the private hospital showed overall ceftriaxone use
compliance to the guideline. Days of hospital stay was associated with appropriateness of
ceftriaxone therapy. Conclusions: Even though ceftriaxone is one of the most commonly
prescribed drugs in both hospitals, appropriateness of its use, according to the Ethiopian standard
treatment guideline, was less than expected. This was so mainly from its indication and duration
of therapy. Increasing the duration of hospital stay, however, showed to improve the
appropriateness of ceftriaxone utilization.
28
54. Alemayehu Sileshi et al (45)
29
tertiary care hospitals in four provinces. Statistics describing linezolid utilization were calculated
and the appropriateness of use was assessed according to a treatment algorithm based on
recommendations of the Infectious Diseases Pharmacy Specialty Network in 2001.Results
revealed that Ninety-nine linezolid courses were prescribed for 103 infections in 95 patients
(mean age 57.8 years, 52.6% male) with an average length of hospital stay of 40.6 days. Fifty-
three per cent of patients had an allergy to at least one antibiotic other than linezolid. The major
use of linezolid was for treatment of skin and soft tissue infections (32.0%), followed by
bacteremia (15.5%). The most prevalent pathogen was methicillin-resistant S aureus, identified
in 44.7% of infections. Linezolid was primarily prescribed as the oral form following other
intravenous anti-infectives (55.6% of courses) for an average duration of 14.4 days. The rate of
appropriate utilization was 53% (range 25% to 75% by site). In 93.5% of courses deemed
inappropriate, recommended first-line therapies were not attempted before linezolid.Conclusions
Linezolid was prescribed appropriately in approximately one-half of cases reviewed. The rate of
appropriate utilization is similar to those rates reported in other Canadian antibiotic reviews.
Conducted review on Meropenem at a tertiary care university hospital: A report from Northern
Iran The inappropriate use of antibiotics remains the primary factor in antimicrobial drug
resistance. In this study, we evaluate the use of meropenem in surgical/medical wards of Imam
Khomeini Tertiary Referral Hospital, Sari, Iran. This retrospective observational study was used
to assess rational use of meropenem. The study was conducted by reviewing medical records of
100 admitted patients who received meropenem during March 2013 to January 2014.Meropenem
was prescribed most frequently in Intensive Care Unit (22%), and pneumonia was the most
common diagnosis (35%). The third-generation cephalosporins were the most frequently
prescribed antimicrobials after meropenem (53%). In 21% of the patients, imipenem was
changed to meropenem. Most of the inappropriate uses were seen in terms of frequency of
meropenem use (34%), followed by duration of meropenem therapy (28%).Comparing our study
results has shown higher inappropriate use. It is necessary to take action to improve prescribing
habit in order to reduce the unnecessary usage of antibiotic thus enhance rational antibiotic use.
30
METHODOLOGY:
Aim:
To assess the usage of piperacillin and tazobactum at a tertiary care center in Hyderabad
compared to the indications for piperacillin and tazobactum use and standard treatment
guidelines and provide recommendations to improve rational use of piperacillin and tazobactum
at these hospitals and reduce the development of further antibiotic resistance, prevent ADRs
associated with the drug, and to reduce the economic burden on the patient with inappropriate
use.
Objective:
To analyse the pattern of piperacillin and tazobactum use among patient categories
identified by age.
To identify the illnesses most frequently treated with piperacillin and tazobactum.
To determine whether piperacillin and tazobactum was appropriately prescribed in
respect of dose, dose frequency, and dose duration.
To identify areas in which further information and education was needed by health care
provider.
To evaluate reason for stopping (discontinue) the drug is based on guide line or not.
To assess whether the indication of piperacillin and tazobactum is on par with standard
guidelines or not.
To assess the frequency of ADRs associated with the drug use.
To assess the potential and actual Drug-Drug interactions associated with piperacillin
and tazobactum.
WORK PLAN:
Piperacillin/tazobactam, sold under the brand names piptaz among others, is a combination
medication containing the antibiotic piperacillin and the β-lactamase inhibitor tazobactam. The
combination has activity against many Gram-positive and Gram-negative bacteria including
Pseudomonas aeruginosa. It is used to treat pelvic inflammatory disease, intra-abdominal
infection, pneumonia, cellulitis, and sepsis. It is given by injection into a vein. Now a days
31
piperacillin and tazobactum is irrationally prescribed globally particularly in India. Hence it
facilitates the development of resistant strains to piperacillin and tazobactum. It is more prone to
cause complications (ADR’s) like fever, neuropenia and it is usually contraindicated in patients
with a history of allergic reactions to any of the penicillins, cephalosporins, or βlactamase
inhibitors.
Study Design:
A retrospective evaluation of piperacillin and tazobactum usage patterns was carried out at a
tertiary care hospital for the period of 3 months corresponding to the dates 1-1-2018 to 31-3-
2018 for conducting the evaluation process we had followed the standard guide lines formulated
by WHO.
Step 1 : Responsibility
The hospital where the study was conducted don't have DTCs and moreover the
study is for academic purposes and hence the responsibility lied entirely with the
students and guide.
Step 2. Scope of Activities
During the process of evaluation, the prescriptions were analyzed for correct
indication, correct dose, frequency, ADRs, Drug-Drug interactions, and contra-
indications.
Step 3.Criteria
Standard prescribing guidelines for piperacillin/tazobactam as formulated by
FDA.
Step 4. Establishing Threshold
Taking into consideration, the prescribing habits (KAP) of the doctors at these
centers, the indicators are assigned with a threshold of 90-100 %.( 3)
32
members of this group were studied in less than 10 cases.
Uncomplicated and complicated skin and skin structure
infections, including cellulitis, cutaneous abscesses and
ischemic/diabetic foot infections caused by
piperacillin-resistant, βlactamase producing strains of
Staphylococcus aureus. Postpartum endometritis or pelvic
inflammatory disease caused by piperacillin-resistant,
βlactamase producing strains of Escherichia coli.
Community acquired pneumonia (moderate severity only)
caused by piperacillinresistant, βlactamase producing
strains of Haemophilus influenza. Nosocomial pneumonia
(moderate to severe) caused by piperacillin-resistant,
βlactamase producing strains of Staphylococcus aureus
and by piperacillin/tazobactam-susceptible Acinetobacter
baumanii, Haemophilus influenza, Klebsiella pneumonia,
and Pseudomonas aeruginosa (Nosocomial pneumonia
caused by P. aeruginosa should be treated in combination
with an aminoglycoside
Dose and Piperacillin and Tazobactam for Injection should be
frequency and administered by intravenous infusion over 30 minutes. The
duration usual total daily dose of Piperacillin and Tazobactam for
Injection for adults is 3.375 g every six hours totaling 13.5 g
(12 g piperacillin/1.5 g tazobactam).
Nosocomial Pneumonia: Initial presumptive treatment of 95
patients with nosocomial pneumonia should start with
Piperacillin and Tazobactam for Injection at a dosage of 4.5
g every six hours plus an aminoglycoside, totaling 18 g (16 g
piperacillin/ 2 g tazobactam)
Renal impairment patients:
For patients on hemodialysis, the maximum dose is 2.25 g
every twelve hours for all indications other than nosocomial
33
pneumonia and 2.25 g every eight hours for nosocomial
Pneumonia. Since hem dialysis removes 30% to 40% of the
administered dose, an additional dose of 0.75 g Piperacillin
and Tazobactam for injection (0.67 g piperacillin/0.08 g
tazobactam) should be administered following each dialysis
Period on hemodialysis days. No additional dosage of
Piperacillin and Tazobactam for injection is necessary for
CAPD patients.
Pediatric patients:
For children with appendicitis and/or peritonitis 9 months of
age or older, weighing up to 40 kg, and with normal renal
function, the recommended Piperacillin and Tazobactam for
injection dosage is 100 mg piperacillin/12.5 mg tazobactam
per kilogram of body weight, every 8 hours. For pediatric
patients between 2 months and 9 months of age, the
recommended Piperacillin and Tazobactam for injection
dosage based on pharmacokinetic modeling, is 80 mg
piperacillin/10 mg tazobactam per kilogram of body weight,
every 8 hours
34
The inactivation of aminoglycosides in the presence of
penicillin-class drugs has been recognized. It has been
postulated that penicillin-aminoglycoside complexes form;
these complexes are microbiologically inactive and of
unknown toxicity. Sequential administration of piperacillin
and tazobactam with tobramycin to patients with normal
renal function and mild to moderate renal impairment has
been shown to modestly decrease serum concentrations of
tobramycin but does not significantly affect tobramycin
pharmacokinetics. When aminoglycosides are administered
in combination with piperacillin to patients with end stage
renal disease requiring hemodialysis, the concentrations of
the aminoglycosides (especially tobramycin) may be
significantly altered and should be monitored. Since
aminoglycosides are not equally susceptible to inactivation
by piperacillin, consideration should be given to the choice
of the aminoglycoside when administered in combination
with piperacillin to these patients. Probenecid administered
concomitantly with Piperacillin and Tazobactam for
Injection prolongs the half-life of piperacillin by 21% and
that of tazobactam by 71%.Vancomycin No pharmacokinetic
interactions have been noted between Piperacillin and
Tazobactam for Injection and vancomycin. Heparin
Coagulation parameters should be tested more frequently and
monitored regularly during simultaneous administration of
high doses of heparin, oral anticoagulants, or other drugs that
may affect the blood coagulation system or the thrombocyte
function. Vecuronium Piperacillin when used concomitantly
with vecuronium has been implicated in the prolongation of
the neuromuscular blockade of vecuronium. Piperacillin and
Tazobactam for Injection could produce the same
35
phenomenon if given along with vecuronium. Due to their
similar mechanism of action, it is expected that the
neuromuscular blockade produced by any of the
non-depolarizing muscle relaxants could be prolonged in the
presence of piperacillin. (See package insert for vecuronium
bromide.) Methotrexate Limited data suggests that
co-administration of methotrexate and piperacillin may
reduce the clearance of methotrexate due to competition for
renal secretion. The impact of tazobactam on the elimination
of methotrexate has not been evaluated. If concurrent therapy
is necessary, serum concentrations of methotrexate as well as
the signs and symptoms of methotrexate toxicity should be
frequently monitored.
Outcome Negative culture/Improved symptomatology
No treatment failure 90
36
Results
A total of 65 case sheets were obtained that contained piperacillin and tazobactum as one
of the drug in the treatment plan during the course of their stay at hospital. The 65
number of cases were obtained from the following dates 1-1-18 to 30-3-18. Month wise the
number of case sheets that contains piperacillin and tazobactum are as follows
jan 24 2 3 3 1 33
Feb 13 2 2 1 2 21
March 8 1 2 1 0 12
3%
9%
9%
6%
73%
37
DEPARTMENTS:
nephrology 45
pediatrics 7
gynecology 5
gastroenterology 5
pulmonology 3
50
45
40
35
30
25
20
15
10
5
0
38
Age wise the number of case sheets that contain piperacillin and tazobactum are as follows
0-10 4
11-20 4
21-30 7
31-40 14
41-50 8
51-60 21
61-70 5
71-80 0
81-90 2
91-100 0
39
Piperacillin and tazobactum usage according to age:
druguse
25
20
15
10 druguse
Sex wise the number of case sheets that contain piperacillin and tazobactum are as follows
Males = 42
Female = 23
Indication wise number of case sheets that contain piperacillin and tazobactum areas
follows:
Nephrology indications:
Hemodialysis – 12
Peritoneal dialysis – 7
Septic shock – 11
IJV -12
Pcnl + djs – 1
PCN -1
Obstructive uropathy – 3
40
Ckd – acute deterioration – 19
AKI – 10
LRIT-1
UTI – 1
Cellulitis – 1
Renal biopsy -1
Diabetic foot infection – 1
Pediatrics:
Blunt injury with pneunomediastinum – 1
Endotracheal tube – 1
Preoperative prophylaxis, of biliary tree surgery – 1
Central venous catheter with fever – recent abdominal surgery -1
Tracheitis -1
Nasocomial pneumonia -1
Post operative purulent wounds -1
Gynecology:
Pelvic peritonitis -1
Bartollins abscess -1
Abdominal hysterectomy -1
UTI -1
Acute salpingitis -1
Gastroenterology:
Foleys catheter -1
EVL -1
BILIARY STENT REMOVED, HILAR STRICTURE -1
Post adjunct chemotherapy -1
Acute cholangitis -1
Pulmonology:
41
Rt – synpneumonic effusion, CAP, kochs -2
Pulmonary hypertension -1
0-10 1 7
11-20 1 19
21-30 3 14
31-40 1 19
41-50 3 19
51-60 1 15
61-70 3 18
71-80 0 0
81-90 4 5
91-100 0 0
42
Duration:
20
18
16
14
12
10
8
6
4
2
0
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100
11-20 2.25g 3g
21-30 2.25g 5g
31-40 2.25g 5g
61-70 2.25g 5g
71-80 0 0
91-100 0 0
43
Dose:
0
0-10 11-20 21-30 31-40 41-50 51-60 61-70 71-80 81-90 91-100
44
DISCUSSION:
Piperacillin/tazobactam, sold under the brand names piptaz among others, is a combination
medication containing the antibiotic piperacillin and the β-lactamase inhibitor tazobactam. The
combination has activity against many Gram-positive and Gram-negative bacteria including
Pseudomonas aeruginosa.
THREATS OF RESISTANCE DEVELOPMENT TO PIPERACILLIN AND
TAZOBACTUM
45
Drug utilization pattern according to gender:
A total of 65 cases of piperacillin and tazobactum use were identified between the period from
1/1/18 - 30/3/18 patient. The distribution of cases on gender basis is males (35.38%) and females
(64.61%).
druguse
50
40
30 druguse
20
10
0
male female
druguse
80.00%
60.00%
druguse
40.00%
20.00%
0.00%
male female
46
Drug utilization pattern according to age:
The age range was between 5yrs to 85yrs. The usage pattern of piperacillin and tazobactum
among various age groups are as follows: of 0-10 (6.15%), 11-20 (6.15%), 21-30yrs (10.76%)
and 31-40 (21.53%), 41-50 (12.30%), 51-60 (32.30%), 61-70 (7.69%), 71-80 (0%), 81-90
(3.07%) and 91-100 (0%). As per STGs, the percentage of piperacillin and tazobactum used
among it has’nt met the established criteria, and the rest met the criteria.
druguse
91-100
81-90
71-80
61-70
51-60
41-50 druguse
31-40
21-30
11-20
0-10
0.00% 10.00% 20.00% 30.00% 40.00%
47
90
80
70
60
50
40
30
20
10
0
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39 41 43 45 47 49 51 53 55 57 59 61 63 65
48
Drug utilization pattern according to indication:
In our study, the percentage of piperacillin and tazobactum indicated in the conditions are:-
1% 3% 5% 2%
0%
89%
Nephrology indications:
Hemodialysis – 12(18.46%)
Peritoneal dialysis – 7(10.76%)
Septic shock – 11(16.92%)
IJV -12(18.46%)
Pcnl + djs – 1(1.53%)
PCN -1(1.53%)
Obstructive uropathy – 3(4.61%)
Ckd – acute deterioration – 19(29.23%)
AKI – 10(15.38%)
LRIT-1(1.53%)
UTI – 1(1.53%)
Cellulitis – 1(1.53%)
Renal biopsy -1(1.53%)
49
Diabetic foot infection – 1(1.53%)
1.53%
Hemodialysis
Peritoneal dialysis
15.38% 18.46%
Septic shock
IJV
10.76%
Pcnl + djs
29.23% PCN
16.92% Obstructive uropathy
Ckd – acute deterioration
18.46% AKI
4.61% LRIT
1.53%
1.53%
Abdominal hysterectomy
1.53% 1.53%
Acute salpingitis
Foleys catheter
1.53% 1.53%
EVL
1.53% 1.53%
BILIARY STENT REMOVED,
HILAR STRICTURE
50
Pediatrics:
Blunt injury with pneunomediastinum – 1(1.53%)
Endotracheal tube – 1(1.53%)
Preoperative prophylaxis, of biliary tree surgery – 1(1.53%)
Centralvenous catheter with fever – recent abdominal surgery -1(1.53%)
Tracheitis -1(1.53%)
Nasocomial pneumonia -1(1.53%)
Post operative purulent wounds -1(1.53%)
Gynecology:
Pelvic peritonitis -1(1.53%)
Bartollins abscess -1(1.53%)
Abdominal hysterectomy -1(1.53%)
UTI -1(1.53%)
Acute salpingitis -1(1.53%)
Gastroenterology:
Foleys catheter -1(1.53%)
EVL -1(1.53%)
BILIARY STENT REMOVED, HILAR STRICTURE -1(1.53%)
Post adjunct chemotherapy -1(1.53%)
Acute cholangitis -1(1.53%)
Pulmonology:
RT – synpneumonic effusion, CAP, kochs -2(1.53%)
Pulmonary hypertension -1(1.53%)
51
Rt – synpneumonic
effusion , CAP , kochs
1.53% 1.53%
Pulmonary hypertension
Out of 65 cases 65 (99%) has met the established criteria, they are as per STGs. Illness most
frequently treated with piperacillin and tazobactum is ckd with acute deterioration (29.23%) .
Drug utilization pattern according to dose, ROA, Frequency, and the potential for
interaction
In this research, the criteria of appropriateness of piperacillin and tazobactum use at the dose,
dose frequency, dose duration were
1. The dose of piperacillin and tazobactum based on indication and duration given was
in all the indications studied, they met the benchmark requirement of 95%. Therefore
piperacillin and tazobactum was used appropriately so far as dose was concerned.
2. Out of 65 cases, dose frequencies were eight hours and 24 hours in 6cases (9.23%) and
59cases (90.76%) respectively.
3. Dose durations were mostly inappropriate for all the justified indications studied.
52
Frequency:
TID
OD
4. Drug interactions
The potential for piperacillin and tazobactum interaction with microlide antibiotics .Out of
65cases (100%), cases (87.69%) are reported without any potential interaction and cases (9.93%)
reported with interaction.
no interactions 87.69%
Doxycycline 3.01%
Azithromycin 3.46%
Clarithromycin 3.46%
53
Piperacillin and tazobactum interactions
drug interactions
no interactions doxycycline azithromycin clarithromycin
3% 4%
3%
90%
In our study, out of 65 cases, all cases met the threshold of 100% as per STG’s.
Outcomes: 89% drug is given without culture test. Dose, duration as per STG’s.patients
improved symatomatically and infection resolved almost cases. 33.84% are non indicated.
54
Descriptive Statistics:
SAMPLE
PARAMETERS SIZE MIN MAX MEAN SD VARIANCE MEDIAN
AGE 65 5 85 44.1846 ±18.67 348.77 48
DURATION 65 1 22 7.6 ±5.31 28.275 7
FREQUENCY 65 1 3 2.8153 ±0.583 0.340 3
DRUGINTERACTIONS 65 0 1 0.1230 ±0.33108 0.10961 0
55
CONCLUSION:
All patient folders evaluated with regards to HD,SEPTIC SHOCK, PNEMOMEDIATINM etc
were found to meet the standard criteria appropriate for piperacillin and tazobactum use with
respect to dose, and dose frequency.
However, in the case of dose duration the evaluation was found to be largely inappropriate for all
the justified indications. In addition,33.84% of piperacillin and tazobactum use for unjustified
indications was noted. This means that piperacillin and tazobactum has been deviated from
standard treatment guidelines hence it facilitates the development of resistant strains to
piperacillin and tazobactum and of no use in the near future, and it also effect the patient
economically.
RECOMMENDATION:
Health care providers must be periodically updated with the national standard treatment
guidelines. It is further recommended that the hospital’s management attention be drawn to the
draw backs observed regarding the inappropriate use and duration of piperacillin and
tazobactum, so that specific interventions could be initiated to improve its use for excellent
outcomes. Following the implementation of the interventions, another DUE should be conducted
to determine the level of adherence to the acceptable standards and its impact on patient
outcomes.
56
Name:
ANNEXURE
57
Ip no:
Department
Weight:
DOA:
DOD:
Diagnosis:
Indication:
Dose(mg):
Route : Oral IV
Frequency : OD BD TDS QID
Other(specify)
Date started _/_/2018 Date ended_/_/2019
Reason for ceasing : infection resolved
Side effects
Others (specify)
Contraindications:
Drug interactions: For
Culture and sensitivity test: m 1:
Outcome achieved:
Data collectors Name and Sign:
Form 2:
58
Age: Sex: Weight: Dept:
Diagnosis:
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