Evaluation of the introduction of an antimicrobial drugs formulary in a general hospital in Slovenia • Jure Peklar, Franci Tratar and Aleš Mrhar Pharm World Sci 2004; 26: 361–365. © 2004 Kluwer Academic Publishers. Printed in the Netherlands. J. Peklar (correspondence, e-mail: jure.peklar@zzzs.si): National Health Insurance Institute of Slovenia (ZZZS) Miklošic ˇeva 24, 1524 Ljubljana, Slovenia F. Tratar, General Hospital Celje, Oblakova 5, 3000 Celje, Slovenia A. Mrhar, Faculty of Pharmacy, University of Ljubljana, Aškerc ˇeva 7, 1000 Ljubljana, Slovenia Key words Antimicrobials Drug formulary DDD/ATC Hospital setting Slovenia Abstract Objective: To analyse the consumption of antimicrobials in a general hospital prior and after implementation of a drug formulary and the economic evaluation of the implementation. Method: Data were obtained from medical documentation collected over a one-month period for all in-patients in four major hospital departments prior to and after the implementation of a drug formulary. The ATC/DDD methodology was used to analyse consumption of antimicrobials. Patients were grouped in therapeutic groups according to their disease and the clinical and economic outcome of the implemented intervention was estimated. Retrospectively, pharmacoeconomical cost–effectiveness analysis was undertaken from the hospital’s point of view. Results: The overall use of antimicrobials after implementation in DDD/100 bed-days increased by 16.8%. However, the drug formulary was successfully implemented in 1999, saving 33.7% DDD/100 bed-days of antimicrobials restricted by the formulary. At the same time, treatment time was shortened by 26.5%, with an overall saving of 35.1% per patient. Conclusions: The importance of a drug formulary for antimicrobials was demonstrated in terms of its clinical and economic outcome. A practical case of co-operation between physicians and clinical pharmacists in such a project was also revealed. Accepted February 2004 Introduction In Slovenia, as in the world at large, the consumption and cost of medications have been increasing in recent years. 1, 2 . The major reasons are similar: ageing of the population and increasingly expensive medicines. An associated problem is that, due to widespread use of antibiotics, there are currently only a few of them that are completely free from bacterial resistance and no- body knows how long they will remain so 3 . Hospitals worldwide are trying to control both ma- jor problems in treating infectious diseases – increas- ing resistance and growing expense of medication and thereby clinical outcome 4–7 . It is estimated that the use of antimicrobial agents in developed countries is inappropriate in 20 to 60% of cases 8 . Excessive use of antibiotics is costly, may promote resistance, prolong hospitalisation and produce unnecessary nephrotoxic- ity 7 . Rational therapy with antimicrobial medicines is the objective of every health manager, but the burn- ing question is how to achieve it? There are some control stratagems that do not di- minish quality of care, such as: antimicrobial utilisation teams, antibiotic order sheet, audit of use, computer- assisted management, drug-use reviews, education, formulary practice, and restricted drug policies 9 . An antibiotic formulary is one of the most frequently used measures for antibiotic use control in hospitals in countries throughout the world. 7–14 Formularies con- tain lists of restricted antibiotics, which can generally be prescribed only under the authority of a microbiol- ogist or patient consultant. In the Celje General Hospital, physicians from the Infectious Diseases Department and clinical pharma- cists from the Hospital Pharmacy set up a ’committee for antibiotics’ that drew up a new approach to con- trolling the consumption of antimicrobial drugs 15 . Due to increasing expenditure on antimicrobials and suspected over-use of some groups of antibiotics, they established a drug formulary for ordering antimicrobi- als. All antibiotics, antiviral and antimicotic drugs for parenteral use (Anatomic Therapeutic Classification – ATC groups J01, J02 and J05) were listed, with the ex- ception of the newest that were reserved to combat only the most resistant strains of microorganisms (such as super-resistant hospital infections). In establishing this new approach, the committee considered all the modern guidelines for treating infectious diseases ap- proved in Slovenia and Europe, and also achieved a consensus in this sensitive field of therapy within the hospital. All this was in the context of the basic clinical outcome – the complete recovery of the patient. 10 The effects of formularies depend particularly on how ef- fectively they are implemented. For prolonged effect, both formularies and policies need continuous moni- toring, feedback and updating (at least every two years). The prescription of some basic antimicrobials (group A) was not restricted – penicillins, first- and sec- ond-generation cephalosporins, gentamycin, and all macrolides other than parenteral erythromycin. These are mostly used perorally, with a low risk of develop- ing bacterial resistance. Use of groups B–D was re- stricted and authorisation was required. Group B contained antimicrobials that were ap- praised by the committee as being used too early and too liberally after admission of patients to the hospital. These were quinolones, aminoglycosides (except streptomycin and tobramycin) and third-generation cephalosporins. All physicians had to indicate the pur- pose of the medication, i.e., for prophylactic use (e.g., preoperational), empirical treatment or targeted treat- ment (based on microbiological analysis). The most restricted antimicrobials in the drug formulary were available only on prescription of the head of department, a member of the committee for antimicrobials, or an infectiologist. Group-C drugs comprised: acyclovir, amphotericin B, cepho- perason, parenteral erythromycin, fluconazol, fucidin, imipenem/cilastatin combination, chloramphenicol, short research article 361