Critical steps in fluoroquinolones and carbapenems prescriptions: results from a prospective clinical audit B. G. S. Seligman, R. A. Ribeiro, R. de S. Kuchenbecker, A. O. Grings, R. P. dos Santos, A. R. L. Machado, F. C. Casali, F. Guzatto, V. D. Morais, G. Schroeder, N. M. Ku¨ plich, M. R. Pires, L. R. Konkewicz, T. Jacoby Introduction Antibiotic usage has emerged in the last decades as a main concern in hospital settings throughout the world (1–10). Emergence of resistant bacteria and multiplication of costs are added as new and more expensive drugs are used. Therefore, implementation of strategies for a more judicious use of antimicro- bial agents has become mandatory. In most hospitals in low resources settings, the inappropriate use of antibiotics can range from 20% to 60% (5). Data from developed countries show similar percentage of inappropriateness (7,11). Fluoroquinolones (FQ) and carbapenems (CP) are antibiotics with good activity against many resistant pathogens, but they also have great capacity of indu- cing further resistance (6,7,12,13). They should be preserved for treatment of severe infections and special situations in which other agents are contrain- dicated or ineffective (1,6,7,12,13). However, FQ are largely used empirically (10,14). Antibiotics account for a significant per cent of total health-care expenses (7,15). Rational prescribing of these drugs can minimise costs, still providing the best care for the patient. Hospital settings have been implementing infection control policies to prevent the emergence of resistant organisms and decrease costs (1,3–5,7–10,14,15). In this context, we under- took a clinical audit in order to evaluate the crit- ical pathways on FQ and CP orders in a teaching hospital, where electronic resources of infection control are available. Methods This investigation was conducted in Hospital de Clı ´n- icas de Porto Alegre, a 730 bed university hospital with 26,854 admissions per year in southern Brazil. A restrictive antimicrobial policy has been established since 1992. Glycopeptides and all broad-spectrum antibiotics are included in this policy. These antimi- crobial prescriptions are electronically reviewed by two Infection Control (IC) physicians. They evaluated clinical information provided by assistant doctors, as well as information about examinations (e.g. cultures, imaging, blood chemistry), previous antimicrobial use and risk factors for infection, which are also electron- ically available. Although this is a powerful method for antimicrobial prescription control (16), the lack of more detailed bedside information led our group to undertake a clinical audit. We characterised six differ- ent critical pathways on antimicrobial prescription. SUMMARY Antibiotic misuse is associated with emergence of resistance and high expendi- tures. Fluoroquinolones (FQ) and carbapenems (CP) are drugs with considerable potential of resistance development and its disseminated use is a concern. We undertook a prospective clinical audit to evaluate prescriptions of FQ and CP in a multistep process. Each prescription was unfolded in the following steps: indication for antimicrobial therapy; adequacy of initial prescription, dosage and route; previ- ous cultures; and parenteral–oral transition. There was no antibiotics indication in 8.9% of FQ and 1.5% of CP group (p = 0.07). In CP 25.8% of initial schemes were inappropriate (21% in FQ). Lack of switch to oral therapy comprised 25% of monthly costs of FQ. Inadequacy in initial choice accounted for 13.6% of CP expenses. We concluded that, in spite of infection control restrictive policies, inap- propriateness of antibiotic usage is worrisome. Clinical audit in a multistep approach may identify possible flaws in this process. Hospital Infection Control Committee, Hospital de Clı´nicas de Porto Alegre, Porto Alegre, Rio Grande do Sul, Brazil Correspondence to: Prof. Beatriz Graeff Santos Seligman, Hospital de Clı´nicas de Porto Alegre, Rua Ramiro Barcelos, 2350, sala 700, Porto Alegre, RS, Brazil Tel.: + 55 51 3328 3225 Fax: + 55 51 3332 6454 Email: seligman@via-rs.net or raribeiro@via-rs.net Disclosure None of the authors have any financial, personal or professional relationships with the pharmaceutical industry. doi: 10.1111/j.1742-1241.2006.00988.x AUDIT ª 2006 The Authors Journal compilation ª 2006 Blackwell Publishing Ltd Int J Clin Pract, January 2007, 61, 1, 147–152 147