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The lack of electronic prescribing in English hospitals is hampering effective prescribing of antibiotics, says the Health Protection Agency.
Giving patients the right treatment is fundamental, said Dr Andrew Pearson, deputy director of the agency's centre for infections, particularly in the case of severe illnesses such as those caused by Clostridium difficile infections.
The bacterium C difficile is the most common cause of colitis linked to antibiotic use and is usually picked up in hospitals. The main symptom is diarrhoea, and risk factors for developing it include old age and long hospital stays.
“We have got to get some form of computerised monitoring of our prescribing,” Dr Pearson told delegates at a conference on healthcare associated infections in London last week. “The problem is that very few hospitals in the UK have electronic prescribing—just three. It is going to be interesting to see if the Healthcare Commission picks up on that.”
Karen Taylor, a health director for the National Audit Office, agreed: “Seven years on and nothing is being done to address this key issue.”
In the United States, computerised monitoring is carried out. Researchers at the University of Maryland used computer software developed by Cereplex to monitor antibiotic use at different hospitals. Prescribing errors were flagged up as error messages, said Dr Pearson.
“This was a very uncomplicated way of measuring the errors, and this dramatic effect is now being picked up by 44 hospitals in the States and will be piloted by one hospital here later in the year.”
But monitoring all drugs in detail would be difficult, he added, so targeting key areas such as antibiotic prescribing would be the most practical solution.
On the back of such monitoring, restricting the use of antibiotics can be effective in reducing cases of C difficile infection, said Professor Mark Wilcox, a consultant microbiologist at Leeds Teaching Hospitals NHS Trust.
Evidence shows that one of the most effective ways to reduce infection rates is to restrict the prescribing of cephalosporins and clindamycin, while other antibiotics, such as metronidazole and vancomycin, are considered low risk and are usually the mainstay of treatment.
Dr James Nash, director of infection prevention and control at East Kent Hospitals NHS Trust, helped implement a radical restriction of antibiotics to try and reduce the incidence of C difficile infection in three Kent hospitals.
An audit of antibiotic use in 2003 found that 15% of patients who had received ceftriaxone developed C difficile infection. The antibiotic was removed from the wards and used only for treating meningitis. This led to a dramatic fall in cases in 2004.
However, in 2005 cases of C difficile increased again following the arrival of the 025 strain, despite continuing restrictions on the use of ceftriaxone. Emergency policies were introduced including further restrictions on the availability of broad spectrum antibiotics (notably ciprofloxacin and coamoxiclav) and multiple infection control measures.
The policy changes required considerable negotiation between clinicians and microbiologists, but had positive effects for patients, with C difficile infection rates falling even further in 2006.
“It is difficult to know which is the biggest factor—is it changing the antibiotics or all the infection control measures? Changing antibiotic prescribing is the most difficult thing to do and it needs the help of management and the pharmacists in controlling access,” he told the BMJ after the conference.
But periodic audit was no substitute for all the benefits that would be seen with an efficient computerised prescribing system, he added, as new junior doctors make the same mistakes every year.
“Because we don't have electronic prescribing in place we only have an approximate idea of what antibiotics are being given and why.”
Professor Sir Liam Donaldson, England's chief medical officer, is expected to write to trusts this week to call for enhanced surveillance sampling for C difficile. This could ask for extra data on which antibiotics are being used, how they are given, at what dose, and for how long, Dr Pearson said.