The 5x5 Antimicrobial Audit
Interventions in Practice
<Facilitator/Trainer Name>
<Date>
The 5x5 Antimicrobial Audit is a component of the QUAH Antimicrobial Stewardship Toolkit
Based on Prescribing Indicators developed by the Scottish Antimicrobial Prescribing Group (SAPG)
© Clinical Excellence Commission 2015
Disclaimer
• The information on the following slides are
designed to allow healthcare professionals to
practice interventions for the 5x5 Antimicrobial
Audit
• All patient cases are fictitious, and not intended
to guide prescribing in the conditions described
• Please refer to antimicrobial prescribing
guidelines endorsed in your facilities if you
require guidance for antimicrobial prescribing
Learning outcomes
• By the end of this session, participants will:
– Describe how to effectively communicate with
prescribers when making interventions
– Identify enablers and barriers to optimal
communication
– Apply communication techniques to case
scenarios
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When an intervention is needed
• When there is no clear indication for
antimicrobial therapy documented in the
patient’s notes, chart or electronic file
• When the choice of antimicrobial therapy
does not match guidelines for the stated
indication
AND
The prescriber has not given a reason for
divergence from guidelines
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Barriers to making interventions
• In your experience, have there been times
when you’ve been reluctant to discuss issues
to do with documentation or medication with
prescribers?
– Why were you reluctant?
– What did you do?
• What might be the outcomes of not making
an intervention in the 5x5 Antimicrobial
Audit?
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Enablers to making interventions
• In your experience, have you made a
recommendation to a prescriber that was
well-received?
– What did you do?
– Why do you think it was well-received?
• What might be the outcomes of making an
intervention in the 5x5 Antimicrobial Audit?
– Think in both the short and longer term
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Practice scenarios
• Everyone will have a chance to practice their
interventions today
• Need some volunteers for group discussion
• Pretend you are on the ward doing your usual
work as a nurse, pharmacist, doctor or other
healthcare professional
• Role plays should be conducted in pairs,
followed by debrief/discussion once out of
role play
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Case 1
• Mrs Beryl White was admitted to hospital yesterday. She is on
empiric antibiotics and is eligible for the 5x5 Antimicrobial Audit.
• She is on piperacillin-tazobactam 4.5g IV q8h and gentamicin 180mg
IV daily.
• The indication box on her medication chart is blank. You refer to her
notes and see she came in with fevers and rigor. She has been
feeling unwell for the last 5 days, and her medical history has been
documented, along with her obs. She has multiple co-morbidities
including diabetes and COPD.
• The impression on admission was that she has:
“?Sepsis ?UTI ?Chest infection”
• The plan was “Start IV ABs, fluids” plus investigations
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Case 1 – Mrs White
• You decide that the indication is not clear enough to
determine concordance with guidelines which contain:
– Severe sepsis: empirical therapy (no obvious source of
infection)
– Severe sepsis, urinary tract source
– Severe community acquired pneumonia
– Severe sepsis, febrile neutropenic patients
• The doctor looking after Mrs White today has just
stepped on to the ward
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Perform role play for case 1
Case 2
• Mr Jim Lee is a 75yo male admitted by
ambulance following a fall. He was diagnosed
with a fractured neck of femur, and went to
operating theatre for surgery to repair his hip.
• It is now 3 days after his surgery and you cannot
see any evidence of microbiology specimens or
results available. As he is on cephazolin 1g IV q6h
you deem he is eligible for the 5x5 Antimicrobial
Audit.
• The indication box on his medication chart for
cephazolin is blank.
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Case 2 – Mr Lee
• The progress notes mention his fall and “#(L)
NOF” but there is no mention of his antibiotics.
• You decide there is no indication documented for
cephazolin, even though you suspect this was
started as antibiotic prophylaxis just prior to his
surgery.
• You decide to call the orthopaedic surgery RMO.
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Perform role play for case 2
Case 3
• Mrs Anna Garibaldi is a 68yo female admitted to MAU
for pneumonia, by referral from her GP.
• The admission notes indicate Mrs Garibaldi has:
– Fever 38°C, sputum production and cough
– Obs (ED): RR 22, HR 85, BP 110/70, O2 sats 92% on room
air
– CXR: Left lower lobe (LLL) consolidation
– Imp: CAP
– Plan: IV ceftriaxone and azithromycin
• There are no microbiology results available, and you
determine she is eligible for the 5x5 Antimicrobial
Audit
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Case 3 – Mrs Garibaldi
• Mrs Garibaldi is on ceftriaxone 1g IV daily and
azithromycin 500mg IV daily.
• You decide that the indication is clear enough to
answer “yes” to Q1.
• You refer to your hospital guideline for CAP, which
recommends:
– Use of the SMART-COP or CORB score to determine
severity
– Use of IV benzylpenicillin and oral doxycycline for nonsevere CAP for hospital inpatients initially
– Use of IV ceftriaxone and azithromycin for severe CAP
initially
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Case 3
• Mrs Garibaldi does not have ‘severe’ CAP using
the SMART-COP or CORB criteria. She also does
not have any known drug allergies.
• The prescriber has not stated any reason for
selecting IV ceftriaxone and azithromycin instead
of the recommended IV benzylpenicillin and po
doxycycline.
• You decide to contact the doctor to recommend
guideline-concordant therapy.
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Perform role play for case 3
Case 4
• Mr Alexander Schneider is a 92yo male on the aged
care ward admitted for “acopia” about 10 days ago. He
was started on Augmentin Duo (amoxycillin +
clavulanate 500+125mg) i po bd and Flagyl
(metronidazole) 400mg po tds last night.
• There are no microbiology results available, and he
wasn’t on previous antibiotic therapy, so you
determine he is eligible for the 5x5 Antimicrobial Audit.
• You look at yesterday’s progress notes and notice that
Mr Schneider deteriorated a little yesterday, became a
little more drowsy than usual, spiked a fever (38°C) and
began coughing up sputum.
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Case 4 - Mr Schneider
• The notes stated that the evening doctor that reviewed him
diagnosed “likely mild hospital-acquired pneumonia”,
ordered extra bloods and a chest x-ray, and commenced
antibiotics.
• You look up the guidelines for hospital acquired pneumonia
and deem Mr Schneider to be at low risk of multi-resistant
organisms. Recommended antibiotic therapy is:
amoxycillin + clavulanate (875+125 mg) one tablet orally twice a
day (12-hourly) for 5 to 7 days.
• There is no documented reason for metronidazole, so you
decide to contact the team looking after him today.
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Perform role play for case 4
Case 5
• Mr Andrew Crispin is an 88yo frail elderly man
admitted with RUQ pain, anorexia, nausea and
vomiting, fever and jaundice.
• You are in ED and note that he has been commenced
on ampicillin 1g IV q6h and metronidazole 500mg IV
bd.
• Blood tests, an ultrasound have been order but no
microbiology results are available. You determine he is
eligible for the 5x5 Antimicrobial Audit.
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Case 5 – Mr Crispin
• You find a working diagnosis of “acute cholecystitis
?biliary obstruction” in the patient’s ED electronic
medical record, along with his medical history and
medication list.
• You look up your hospital’s antimicrobial prescribing
guidelines and the following antibiotics are
recommended:
amoxy/ampicillin 2g IV q6h PLUS gentamicin 4-5mg/kg IV
stat, then review according to renal function PLUS
metronidazole 500mg IV bd (or 400mg po bd)
• You cannot find a reason documented in the notes for
the omission of gentamicin, so you contact the doctor
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Perform role play for case 5
Case 6
• Mrs Kim Tran is a 73yo female admitted with
signs and symptoms of sepsis. She is febrile,
hypotensive and tachycardic.
• You note that she was commenced on IV
antibiotics earlier this morning, and deem her
eligible for the 5x5 Antimicrobial Audit.
• Mrs Tram is on the following antibiotics:
– flucloxacillin 2g IV 6-hourly
– gentamicin 360mg IV stat
– vancomycin 1g IV 12-hourly
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Case 6 – Mrs Tram
• You look through the notes for more information
on the indication, but it just states “probable
sepsis - ?origin”.
• There are no microbiology results available yet
today to guide her therapy, and she does not
appear to have any drug allergies.
• Flucloxacillin and gentamicin are recommended
in your hospital for severe sepsis with an
unknown source (CEC Sepsis Kills ED protocol).
• You decide to talk to the doctor about the
addition of vancomycin to Mrs Tram.
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Perform role play for case 6
Revision of learning outcomes
• By the end of this session, participants will:
– Describe how to effectively communicate with
prescribers when making interventions
– Identify enablers and barriers to optimal
communication
– Apply communication techniques to case
scenarios.
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Thank you
Questions?
For further information,
please contact:
<name and contact
details>
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