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Failure of prescribers to adjust antibiotic dose to impaired renal function in daily clinical practice
Author(s) -
Vogtländer N. P. J.,
Van Kasteren M. E. F.,
Natsch S.,
Kullberg B. J.,
Hekster Y. A.,
Van Der Meer J. W. M.
Publication year - 2002
Publication title -
british journal of clinical pharmacology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 1.216
H-Index - 146
eISSN - 1365-2125
pISSN - 0306-5251
DOI - 10.1046/j.1365-2125.2002.161322.x
Subject(s) - medicine , renal function , medical prescription , antibiotics , odds ratio , creatinine , adverse effect , intensive care medicine , pharmacology , microbiology and biotechnology , biology
Dose adjustment of antibiotics to renal function is recommended for many antibiotics, which are eliminated by the kidney. Avoiding dose adjustment to renal function leads to unnecessary high plasma concentrations, adverse drug reactions, costs and workload for the nurses. The aims were to evaluate adherence to hospital guidelines concerning dose adjustment, investigate possible barriers to follow up guidelines, and addressing them through a multifaceted intervention aimed at improving adherence. The study was performed at a university hospital (953 beds). Data were collected in a pre‐intervention and a post‐intervention period of 3 months each. All consecutive patients with a first prescription of antibiotics at the wards of internal medicine, surgery and neurology were included. Renal function was calculated according to Cockroft & Gault's formula [1]. A table for dose adjustment of antibiotics to renal function was available for every doctor in the written antibiotic guidelines of the hospital. Sixty‐nine of 225 (31%) patients in the pre‐intervention period had an impaired renal function (renal clearance <50 ml min −1 ). They received 168 antibiotic prescriptions, of which 129 needed dose adjustment. The dose was actually adjusted in 58 of these 129 cases (45%). The risk for non‐adjustment above the age of 65 as well as 75 years was high (odds ratio 3.1 and 3.5, respectively). A serum‐creatinine level below 140 µmol l −1 was also an important factor for non‐adjustment (odds ratio 5.4). Barriers for not adjusting the dose were underestimation of the prevalence of renal insufficiency, and lack of time to calculate actual renal clearance. An intervention consisting of audit and feedback to prescribers and nurses, peer discussions with opinion leaders, written information to all prescribers, installation of a calculation program on the desktop of all computers on the wards, and distribution of stickers with a table to estimate renal function to paste in the antibiotic formulary was carried out. In the post‐intervention period, 68 of 224 (30%) patients had impaired renal function. Dose adjustment was necessary in 129 of 171 prescriptions. This was correctly done in 67 (52%) cases. We discovered a high prevalence of patients with impaired renal function in our hospital (30%). Especially in the elderly with a serum‐creatinine level in the normal range, renal function is overestimated and hence, overdosing of antibiotics takes place. Despite a multifaceted intervention, the rate of dose adjustment to renal function could only slightly been improved from 45% to 52% (not significant). The complexity of current care of these patients, and a high workload for physicians and nurses makes it hard to increase awareness for this problem in daily practice. Electronic support for prescribing linked to laboratory values may be of much help in the future.