Last updated
Fluoroquinolones: A Patient Safety Priority
Share PrintDespite a plethora of safety warnings and concerns, including the first warning of Achilles tendon rupture and the most recent of aortic aneurysm, fluoroquinolones continue to be one of the most common antibiotic classes prescribed in the United States. Through a VISN-wide approach utilizing health care technology, VISN 4 sought to empower prescribers to heed these safety warnings and mitigate patient harm. By using a standardized note in the electronic medical record, VISN 4 implemented an intuitive, simple, and self-sustaining initiative that decreased its outpatient fluoroquinolone prescriptions by 46%.
Origin:
October 2019, Abie Abraham VA Clinic (Butler)
Adoptions:
10 successful, 2 in-progress
Awards and Recognition:
Veterans Health Administration Stewardship Strong Winner 2020, Published in the Journal of the American Pharmacists Association
Recent Updates
Overview
Problem
Fluoroquinolones represent one of the most prescribed antibiotic classes in the United States, being utilized for a host of genitourinary, respiratory, skin, and gastrointestinal infections. Starting in July 2008, this medication class has come under mounting scrutiny for its impact on patient safety. There have been 7 Food and Drug Administration (FDA) safe
...
Fluoroquinolones represent one of the most prescribed antibiotic classes in the United States, being utilized for a host of genitourinary, respiratory, skin, and gastrointestinal infections. Starting in July 2008, this medication class has come under mounting scrutiny for its impact on patient safety. There have been 7 Food and Drug Administration (FDA) safety warnings issued for fluoroquinolones regarding potential adverse events. These warnings include 4 Black Box Warnings (the most stringent warning the FDA can give for a drug on the market) and the recommendation that fluoroquinolones should not be prescribed for conditions for which effective alternative therapies are available.
In addition to the multitude of safety warnings, fluoroquinolones have been associated with multiple drug resistant bacterial strains and a strong association with Clostridium difficile infections compared with other common antibiotic classes.
Despite these recognized concerns, recent literature suggests that fluoroquinolones continue to be prescribed inappropriately in the ambulatory care setting. We sought to empower prescribers to heed to these FDA safety warnings and prescribe fluoroquinolones only for conditions where no effective alternative therapies are available. See more
In addition to the multitude of safety warnings, fluoroquinolones have been associated with multiple drug resistant bacterial strains and a strong association with Clostridium difficile infections compared with other common antibiotic classes.
Despite these recognized concerns, recent literature suggests that fluoroquinolones continue to be prescribed inappropriately in the ambulatory care setting. We sought to empower prescribers to heed to these FDA safety warnings and prescribe fluoroquinolones only for conditions where no effective alternative therapies are available. See more
Images
Food and Drug Administration (FDA) fluoroquinolone safety communications in chronological order with their primary subject of concern.
Solution
A standardized fluoroquinolone note was implemented throughout VISN 4 that was required to be entered with each prescription. The note served as a clinical decision support system that gave the prescriber a list of common infections disease conditions with preferred antibiotic quick orders (non-fluoroquinolone) for each condition that defaulted the correct d
...
A standardized fluoroquinolone note was implemented throughout VISN 4 that was required to be entered with each prescription. The note served as a clinical decision support system that gave the prescriber a list of common infections disease conditions with preferred antibiotic quick orders (non-fluoroquinolone) for each condition that defaulted the correct dose and duration. If a fluoroquinolone was still determined to be the best therapy, proper Veteran education and fluoroquinolone dosing was included for reference. It was theorized that clinical outcomes would be optimized, and harm mitigated, by preventing fluoroquinolone adverse drug reactions through decreased utilization.
See
more
Results
As a result of the note, VISN 4 saw a 46% decline in outpatient fluoroquinolone prescribing comparing Fiscal Year 2019 and Fiscal Year 2020 data. This statistically significant decrease in fluoroquinolone prescribing rate demonstrates that the note was effective in facilitating prescribing behavior change and ultimately mitigating Veteran harm.
Metrics
- The average fluoroquinolone monthly prevalence was 3.80 (SD, 0.59) per 1000 population before the intervention and 2.06 (SD, 0.29) after the intervention. The average monthly prevalence of fluoroquinolone prescribing was significantly lower after implementation of the program (difference of 1.74 per 1000 population, t = 9.18, p<0.0001).
Diffusion tracker
Does not include Clinical Resource Hubs (CRH)
Implementation
Timeline
-
1 Month
Obtain support from the Antimicrobial Stewardship Committee and the Pharmacy and Therapeutics Committee. -
1 Month
Review of the note by infectious disease clinicians and/or the antimicrobial stewardship committee for any facility specific desired modifications. -
1 Week
Building of the note within the electronic medical record by the Pharmacy Informaticist and/or the Clinical Applications Coordinator. -
1 Week
Distribution of education to the clinical staff in regards to note implementation. -
1 Day
Activation of the fluoroquinolone note in the electronic medical record.
Departments
- Infection control
- Pharmacy
- Infectious disease
Core Resources
| Resource type | Resource description |
|---|---|
PEOPLE |
|
PROCESSES |
|
Support Resources
| Resource type | Resource description |
|---|---|
PROCESSES |
|
Links
- Publication of the pilot program implemented at VA Butler Healthcare System in the Journal of the American Pharmacists Association. Implementation of a pharmacist-led fluoroquinolone stewardship program: Improving use within the ambulatory care setting
Risks and mitigations
| Risk | Mitigation |
|---|---|
| Antibiotic Preferences | Each facility can tailor the antibiotic quick orders embedded within the note to their local preferences. |
| Fluoroquinolone Ordering | Education is provided to prescribers on how to still order a fluoroquinolone from quick orders embedded at the end of the note. |
About
Origin story
Upon creation of an antibiotic stewardship committee in 2012, VA Butler Healthcare System has strived to be a leader of antibiotic stewardship in the ambulatory care setting. Inspired by a local patient who experienced adverse effects, tackling the inappropriate prescribing of fluoroquinolones was the first initiative undertaken by the committee. Since that
...
Upon creation of an antibiotic stewardship committee in 2012, VA Butler Healthcare System has strived to be a leader of antibiotic stewardship in the ambulatory care setting. Inspired by a local patient who experienced adverse effects, tackling the inappropriate prescribing of fluoroquinolones was the first initiative undertaken by the committee. Since that time, VA Butler Healthcare System has consistently had some of the lowest fluoroquinolone prescribing throughout the entire Veteran Health Administration.
Original team
David B. Portman PharmD, BCPS
CLC Pharmacy Program Manager
Michael R. Schmitt PharmD, MS
Health Informatics Specialist
Comment
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