Category: Professional Posters
Purpose: Fluoroquinolones are broad spectrum antibiotics commonly used for the treatment of a variety of infections. With increasing use of fluoroquinolones, there has been rising rates of resistance as well as increased incidences of disabling and potentially permanent side effects. The FDA has updated boxed warnings for the fluoroquinolone class of antibiotics. Dignity Health Mercy San Juan Medical Center has implemented a therapeutic interchange policy to reduce the use of levofloxacin. The purpose of this study is to examine the efficacy of a levofloxacin therapeutic interchange policy by analyzing levofloxacin days of therapy and hospital acquired Clostridium difficile rates.
Methods: We conducted a single center retrospective chart review study of the electronic medical record to identify Mercy San Juan Medical Center hospitalized patients who were prescribed levofloxacin between September 1, 2015 and May 31, 2019. In August of 2016, the Antimicrobial Stewardship Program distributed an advisory letter to medical staff to educate prescribers on the new boxed warning and encouraged them to use safer alternatives. In February 2017, we created a badge buddy with empiric antibiotic preferences based on types of infections and local resistance patterns, these were created to minimize the use of levofloxacin. In March 2017, the levofloxacin therapeutic interchange policy was implemented. This interchange allowed the Antimicrobial Stewardship Pharmacist to change levofloxacin to therapeutic equivalent antibiotics for the following indications: community acquired pneumonia, COPD exacerbation/pneumonia, urinary tract infection/pyelonephritis, sinusitis, bronchitis, and colitis/diverticulitis. Patients included were over the age of 18 and prescribed levofloxacin. Excluded patients were those in the intensive care units, received one time prophylactic dose for surgery, and patients not admitted to the hospital. The primary study endpoint was an analysis of antibiotic days of therapy before and after policy implementation. Secondary study endpoint will include Clostridium difficile rates.
Results: From the time medical staff was educated in August 2016 until May 2019, there has been a significant decline in levofloxacin days of therapy at Mercy San Juan Medical Center. Prior to any intervention, the mean levofloxacin days of therapy per 1000 patient days was 108 and decreased to 10 after the implementation of the interchange policy. Initially, the decrease was modest but continued to decline over the study period, and for the last 12 months had a maximum days of therapy of 4.87 and minimum of 1.74. For the last 12 months, the mean days of therapy was 3.27, a 97% reduction. As a secondary endpoint, we analyzed hospital acquired Clostridium difficile associated diarrhea rates. There was a mean of 8.6 CDAD infections per 10,000 patient days pre-implementation and 5.8 CDAD infections per 10,000 patient days post-implementation.
Conclusion: Levofloxacin therapeutic interchange policy significantly decreased the use of levofloxacin and reduced hospital acquired Clostridium difficile rates. One of the benefits of this policy is that it educated prescribers as shown by a decrease in inappropriate levofloxacin orders; it is commonly ordered when penicillin allergies are listed. Penicillin allergies has been the biggest limitation of this policy given that most allergies listed in the patient record are not true allergies or not concerning for cross reactivity with ceftriaxone usage. Overall, this therapeutic interchange policy has been successful in limiting the usage of levofloxacin.