An evaluation of Fluoroquinolone

use in a Large Teaching Hospital

Melvani S1, Charles P2, Johnson P2, Speed B2, Kirsa S1, Grayson ML2
(1) Pharmacy Department (2) Infectious Diseases Unit
Austin & Repatriation Medical Centre, Victoria, Australia
 Background
• Fluoroquinolones
– primarily gram-negative spectrum
– only orally available class for P. aeruginosa.
– 38% increase (99/00), 58% increase (00/01)
• Ciprofloxacin restricted to the ID unit except ICU
• Norfloxacin restricted to the ID unit except for
– prostate biopsy prophylaxis, traveller’s diarrhoea,
uncomplicated UTI resistant to first line agents.
 Aims
• To determine the appropriateness of
Fluoroquinolone use with respect to indication,
dosage regimen and duration of therapy
 Method

• Inclusion criteria
– inpatients, outpatients, Emergency patients
– prescribed ciprofloxacin or norfloxacin in
hospital over a 3-week period
• Data collection
– retrospective
– pharmacist and ID doctor collected data
 Data collection
• Age, Gender, Weight, Serum creatinine
• Medical/surgical unit
• Allergies / ADRs
• Which fluoroquinolone prescribed?
• Indication for use
• Culture
– done before or after commencing antibiotic?
– result?
• Dose
• Duration
 Criteria for evaluation
• Appropriateness of therapy
– Australian Antibiotic Guidelines 11th edition
– Local guidelines
 Results
• 73 courses identified (71 pts)
• Patients
– mean age: 62 years, weight: 65kg
– CrCl < 30 mL/min in 13% of courses
– 63% males, 37% females
– 29% had significant ADRs to other antibiotics
• 68% received ciprofloxacin, 32% norfloxacin
• Bacterial isolate present in 62% of courses
– 34% P. aeruginosa
Fluoroquinolone Use by Units
ID
oncology 7% surgical
7% 20%

spinal
10%

other
medical
specialist
11%
medicine
18%
gastro
11% ICU
16%
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(% of courses, n = 73)

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Fluoroquinolone Indications

norfloxacin
ciprofloxacin
 Results cont.
• In 54% a fluoroquinolone was used after an
organism was isolated
– uncomplicated urinary tract infections (22%)
– skin and soft tissue infection (12%)
– pneumonia (12%)
• In 34% a fluoroquinolone was used empirically
– pneumonia (12%)
– sepsis of unknown origin (7%)
– neutropenic sepsis (3%)
• In 11%, norfloxacin as used for prophylaxis (SBP)
 Indications
• In 25% (18), the indication inappropriate
– 18% were inappropriate mainly due to the availability of a
narrower spectrum antibiotic
• especially in the treatment of UTIs (eg trimethoprim or amoxicillin
could have been used instead of norfloxacin).
– 7% were inappropriate due to spectrum of antimicrobial
activity not matching infection
• eg ciprofloxacin used as monotherapy for its gram positive cover ,
which is unreliable
• A further 7% (5) were considered questionable
– spontaneous bacterial peritonitis in chronic liver disease
 Drug Regimen and Duration
• In 89% (65), the dose and frequency was appropriate
– some doses too low for pseudomonas infections

• In 28% (18), the duration was non-concordant with

guidelines
– only 64 courses could be evaluated
– UTIs in males often undertreated (19%) and females
overtreated (9%)
 Discussion
• The indication was inappropriate in 25% of courses
– mainly in the treatment of urinary tract infections
– narrower spectrum antibiotics available
• Limitation
– clinical condition hard to ascertain in some cases
 Discussion cont.
• Why is ciprofloxacin use increasing at ARMC?
– increasing isolation of resistant gram-negative
organisms
– sicker patients, eg patients with chronic liver disease
– increasing trend to replace carbapenems and
aminoglycosides with ciprofloxacin
– expansion of appropriate indications
– higher number of hospital admissions
– alternative for patients with antibiotic allergies
 Key Areas for Improvement
• UTIs
– trial first line agents
– appropriate duration
• Empiric treatment of pneumonia in ICU
– guidelines developed with ICU
• Clarification of non-evidence based indications
– prophylaxis of SBP in chronic liver disease
• Clarification of dosing for P. aeruginosa infections
– utilise pharmacodynamic information