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Hospital Jasin

VOL: 3/2015

ANTIMICROBIAL STEWARDSHIP IN HOSPITAL

THE STORAGE OF RECONSTITUTED

ANTIBIOTICS

GETTING TO KNOW

AND

SODIUM BICARBONATE, SODIUM CITRATE MIXTURE

POTASSIUM CITRATE MIXTURE

ADVISOR : Dr. Zaleha Bt Md Noor

EDITORS: Nursahjohana Md Sahak

)zrul Azwa Mohd Latif

Low Jia (ui

CONTRIBUTORS: Ng Shy Pyng

Nur Athirah (aziqah Bt Mohd Sobri Adillah Ahmad

Shoniya A/P Jayasegaran

Tan Xin Yi

CONTENTS

An Overview of Antimicrobial Stewardship in Hospital

The Storage of Reconstituted Antibiotics Available in Hospital Jasin

All About Saxagliptin

Fruits And Diabetes

Drugs Comparison: Sodium Bicarbonate+ Sodium Citrate vs Potassium Citrate

The Top 20 Medicinal Expenditures in 2015

The Statistics on Adverse Drug Reactions

The Statistics on Medication Error

Pharmacy Activities

2

AN OVERV)EW OF

)N (OSP)TAL

By: Ng Shy Pyng

A. Antimicrobial Stewardship Team

General Roles of Antimicrobial Stewardship Team

Strengthens formulary restriction and approval systems

Regularly reviews antimicrobial prescribing with intervention and direct feedback to the prescribers.

Educates prescribers, pharmacists and nurses about good antimicrobial prescrib-ing practice and antimicrobial resistance

Evaluates compliance to clinical guidelines and reports on process measures, outcomes measures and antimicrobial resistance patterns to Hospital Infection and Antibiotic Control Committee (HIACC) and Hospital Director

is supported by

Hospital director

Head of various clinical departments

Head of pharmacy department

Head of Medical Microbiology

Antimicrobial Stewardship

Team Members

Head of AMS Team

Infectious Disease (ID) Physician Or Physician (if available)

Antimicrobial Pharmacist or Clini-cal Pharmacists

Clinical microbiologist or microbi-ologist

Other members may consist of: □ Information Technology Officer □ Infection Control Nurse □ Hospital Epidemiologist □ Ward Pharmacists □ Interested Clinicians

3

B. Antimicrobial Stewardship Activities

. Encourage formulation of local antibiotic guidelines and clinical pathways

. Surveillance & feedback on antimicrobial prescription and consumption behaviour.

. Carry out prospective audit on selected antibiotics to prevent deviation from local guidelines and provide the relevant feedback.

. Establish formulary restriction and pre-

authorization or approval system in using certain antibiotics.

. Establish an antimicro-bial order tool to encour-age the clinician to review basic clinical and laborato-ry information and to cate-gorize antimicrobial use as prophylactic, empirical and therapeutic.

Antimicrobial order tool also serves as a measure to decrease antimicrobial consumpution by imple-menting automatic stop orders and/or requiring clinicians to justify antimi-crobial use.

. Streamlining antimicrobial usage by:

Antimicrobials streamlined to narrowspectrum agents once cultures and sensitivities are availa-ble.

Deescalate an initially high dose to a standard dosage for a susceptible organism.

Discontinuing empiric therapy if an evidence of infection is absent

Discontinuing dual antimicrobial therapy if there is overlapped spectrum of activity

Advising on the optimal choice of antimicrobials for the specific clinical setting

. Antimicrobial selec-tion and dose optimiza-tion tailored to the pa-tient’s characteristics, causative organism, site of infection, and pharmacoki-netic and pharmacody-namic characteristics of the antimicrobial agent.

. Conversion of Intrave-nous (IV) antibiotics to an effective alternative Oral ( PO) formulation for cost reduction, elimination of adverse events associated with intravascular lines, increasing patient’s com-fort and mobility as well as allowing earlier discharge.

. Prepare a program of ongoing education for pharmacists, doctors and nurses to influence pre-scribing behavior and to provide knowledge that will enhance and increase acceptance of antimicrobi-al stewardship strategies.

4

C. Antimicrobial Stewardship Program Measurement

It is a key component to measure the effectiveness of program activ-ities. The following are the process and outcome measures that should be incorporated into Antimicrobial Stewardship Plan.

A. Process Measures

Rate of clinician acceptance of AMS recommendation.

Rate of adherence to documentation policy at time of antimi-crobial initiation (dose, duration and indication explicitly written)

Rate of review of Carbapenem and Polymyx inprescriptions by primary team at 72 hours

Rate of appropriate empirical prescription according to antimi-crobial guideline

B. Outcome Indicators

Specific antibiotic Daily Defined Dose over every 6 months

Cost differences (For intervention results in the anti-microbial being stopped or switched to a cheaper alternative or to oral dosage form.)

C. Other Suggested Indicators (Where applicable )

Readmission within 30 days

>Percentage of patient with AMS recommendation accepted being readmitted within 30 days.

Mortality within 30 days

>Rates of mortality within 30 days in patient with AMS intervention.

Reference:

Protocol on Antimicrobial Stewardship Program In Healthcare Facilities 2014

5

T(E STORAGE OF RECONST)TUTED ANT)B)OT)C )NJECT)ONS AVA)LABLE )N (OSP)TAL JAS)N

By: Shoniya A/P Jayasegaran

ANT)B)OT)CS )NJECT)ONS

BRAND NAME & MANUFACTURER

D)LUENT ROUTE OF ADM)N)STRA-

T)ON

)NFUS)ON RATE

STAB)L)TY AFTER RECONST)TUT)ON

Amoxycillin g +Clavulanic Acid

mg

Co-amoxiclav, Karnataka A/b & Pharma

WF) - ml slow bolus

WF)/NS - ml infuse

)V only Slow bolus- - min

)nfuse- - min

Use within mins

Ampicillin mg Standacillin, Sandoz

ml WF) Slow bolus - mins Use within hr

ml WF)/NS )nfusion - mins

ml WF) )M -

Ampicillin g+ Sulbactam

mg

Sulbacin, Uni-chem Laborato-ries

WF)/NS. Max inal conc be-tween - mg/

)nfusion - mins RT: hrs

F: days )M -

Benzathine Penicillin . MiU

Karnataka A/b & Pharma

ml or more WF)

)M - Single use

Benzylpenicillin MU


ml or more WF)

)M/Slow bolus/ )nfusion

At least min for each mg

RT: days

F: days

Benzylpenicillin MU

Karnataka A/b

& Pharma

ml or more WF)

)M/ Slow bolus/)nfusion

At least min for each mg

RT: days

F: days

Cefepime g Forpar, Cipla LTD ml WF)/D %/NS/Lactated Ringers

)nfusion Over mins RT: hrs

F: days

. ml WF)/D %/NS/WF) with Parabens or Benzyl Alco-hol/Lidocaine

)M -

Notes: . WF) = Water for injection . RT= Room Temperature - °C

. NS = . % NaCl . F = Refridgerated - °C

. D= Dextrose . Conc = concentration

6


BRAND NAME & MANUFACTUR-

ER


T)ON

)NFUS)ON RATE


Cefoperazone g

Bicafar, Duopharma

Final conc mg/ml with

D %/D %/NS

Bolus - min RT: hrs

F: days

ml of D %/ D %/ WF)/NS for each g of cefoperazone, further dilute with - ml D %/D %/NS

)nfusion min- hr

. ml WF)>+

. ml % lidocaine for inal concentra-tion mg/ml of g vial

)M -

Cefotaxime g Rekaxime, Duopharma

ml WF) Bolus - mins RT: hrs

)M gonorrhea -

Ceftazidime g Pharmaniaga ml Lignocaine . %

)M - Single use

ml WF) )V -

Ceftazidime g Cefatum, Duopharma

ml WF)/NS Bolus - RT: hours

F: days

Ceftriaxone g Unocef, Duopharma

. ml WF)/NS/ % dex-trose

Bolus/)nfusion Over min RT: hrs

F: days

mg/ml-. ml WF)/

NS/ % dex-trose

mg/ml- . ml WF)/

NS/ % dex-trose

)M -

Cefuroxime mg, . g

Anikef, Duopharma

mg: ml WF)

)M RT: hours

F: hrs mg: ml WF)

. g: ml WF) Bolus , ml

WF) nfusion

)nfusion

Slow bolus

min

- min

7


BRAND NAME & MANUFACTURER


T)ON

)NFUS)ON RATE


Cloxacillin Sodium mg,

mg


ml WF) for inal conc

mg/ml or ml WF) for

inal conc mg/ml

)M - Single use

WF) to give inal conc mg/ml or mg/ml

Bolus - min

WF) to give inal conc mg/ml then into ml Dose ≤ mg

or ml Dose > mg D %/NS

)nfusion - min

Gentamicin mg/ ml

Garasent , Duopharma

- )M - Single use

- ml of NS/D % conc < mg/ml

)nfusion - mins

)mipenem mg +

Cilastatin mg

Tienam, Merck Sharp

ml NS/D %/D %/ Manni-tol % & %

)nfusion < mg: over - mins

> mg: over - mins -

RT: hr

F: hrs

Meropenem mg, g

DBL Meropenem, (ospira

mg: ml WF)/NS mg/ml

g: ml WF)/NS mg/ml

Bolus mins F: hrs

mg & g: - ml WF)/

NS

)nfusion - mins

Piperacillin g + Tazobactam

mg

Tapicin, Yung Shin Phar-ma

ml WF)/D %/NS

Bolus - mins RT: hrs

F: days ml WF), D %/NS

Further diluted to

- ml

)nfusion - mins

Vancomycin (ydrochloride

mg

(ospira WF)/D %/NS )nfusion Over mins F: days

8

ALL ABOUT....

Available strength in (ospital Jasin are . mg & mg

By : NUR ATHIRAH HAZIQAH BINTI MOHAMAD SOBRI

)ndication

1) As add-on therapy in T2DM patients

inadequately controlled with

Metformin monotherapy & high risk of

hypoglycaemia, especially elderly

patients with co-morbidities

A Sulphonylurea (SU) & intolerant /

contraindicated for Metformin therapy

Metformin & SU combination therapy

2) In patients with renal failure where

Metformin is contraindicated

Not to be used in patients with HbA1c

>8% on single / combination OAD, as

insulin initiation is preferred.

Contraindication

History of serious hypersensitivity reactions

(e.g anaphylaxis, angioedema, exfoliative

skin condition) to any DPP4 inhibitor

Starting & Maintenance Dose

Normal to mild renal insufficiency

(CrCl > 50ml/min) : 5mg OD

Moderate to severe renal insufficiency

(CrCl < 50ml/min) : 2.5mg OD

HD patients : Dose taken following HD

PD patients : No study done yet

Special Precautions

Panceatitis

Hypoglycaemia with concomitant use

of SU or insulin

Pregnancy - Category : B

Lactation - Saxagliptin is secreted in the

milk of lactating rats at approximately

a 1:1 ratio with plasma drug concen-

trations. However, it is not known

whether it is secreted in human milk.

Monitoring : HbA1c 3-6 monthly

Adverse Reaction

Acute pancreatitis

Upper Respiratory Tract Infection (URTI)

Urinary Tract Infection (UTI)

Headache

Nasopharyngitis

Rash

Peripheral / facial oedema

Hypersensitivity reactions, including

anaphylaxis & angioedema

9

MORE ABOUT SAXAGL)PT)N...

Dose Conversion From Other DPP )nhibitors To Saxagliptin

Drug Name Usual Dose

Dosage Adjustment in Renal )nsuiciency

Dosage adjustment with concomitant use of strong CYP A / inhibi-tors**

Mild

CrCl ≥ mL/min *

Moderate

CrCl ≥ to <

mL/min *

Severe CrCl< mL/min or

ESRD requir-ing dialysis

Saxagliptin 2.5mg or

5mg OD

No

adjustment

needed

2.5mg OD 2.5mg OD

following HD 2.5mg OD

Sitagliptin 100mg

OD

No

adjustment

needed

50mg OD

25mg OD

without

regard to

time of

dialysis

No adjustment

needed

Linagliptin 5mg OD

No

adjustment

needed

No

adjustment

needed

No

adjustment

needed

Use of CYP3A4 or

P-gp inducers with

linagliptin is not

recommended

Alogliptin 25mg

OD

No

adjustment

needed

12.5mg OD

6.25mg OD

without

regard to

time of

dialysis

No adjustment

needed

Other )nformation

Physical description :

Saxagliptin 2.5mg : Pale yellow, biconvex, round tablet

Saxagliptin 5mg : Pink, biconvex, round tablet

Film-coated tablet —> Must not be split / cut

May be taken with or without food

Excreted through both renal & hepatic pathways

Storage : < 30’C

References : Formulari Ubat KKM

Saxagliptin Onglyza Guidance for Conversion, Feb

Onglyza Package Lealet Text 1o

FRUITS

AND D)ABETES

By : LOW JIA HUI

Can a diabetic patients take fruits?

The answer is YES! Fruits contains vitamin, minerals and ibres which are important to our health. (owever, fruits also contain carbohydrate thus the intake needs to be taken into ac-count during meal planning. Carbohydrates can be broken down to form glucose which will impact on sugar levels eventually.

(ow much fruits is OK to take ?

A diabetic patient is allowed to have - servings of fruits a day.

serving or exchange of fruits contains g of carbohydrates. The amount of fruits con-sumed needs to be included as part of car-bohydrate allowance of the day.

What are the recommended choices?

. Fresh, whole fruits are preferred.

- Contains ibre and anti-oxidants which are beneicial. - For preparing fruit salad, it is advisable to use fat-free yougurt or lime juice as dressings.

. Avoid the juice and dried fruits.

- Dried fruits and juices has added sugars and reduced ibre content. - Otherwise, choose dried fruit with no added sugar or % real fruit juice to avoid extra sugar.

. Avoid fruits with added sweeteners

- Canned, dried, frozen and other package fruits or fruity drinks are always added with extra sugar. - It is recommended to rinse the syrup of canned fruits before eating to eliminate the added sugar.

The Example of 1 Serving /

Exchange of Fruits

Medium Size

Slice

Pieces

Pieces of Grapes

Pieces of Duku/ Langsat

Pieces of Cemped-ak/ Nangka

Pieces of Dates

Pieces of Rambutans

piece of small banana

11

T)PS ON SERV)NG S)ZE MEASUREMENTS:

Carbohidrate Counters

A medium size apple or orange or / cup of canned fruit contains approximately g of carbohydrates. / - / cups of fruit juice may also contribute to g of carbohydrates. (owever, only teaspoons of dried fruits such as raisins can provide g of carbohydrates. Therefore, fruits can be taken in place of other less healthier choices such as izzy drinks and cake. )t can also be consumed to replace other starchy food eg. noodles in the meal plan as fruits provide added beneits in the form of nutrients and ibres.

The Plate Method

A small piece of whole fruit or / cup of fruit salad for dessert can be a good complement to the vegetables, small portion of starch and protein-containing food on the plate.

Glycaemic )ndex G) )ndex G)

)t is important to note that fruits with the same portion of carbohydrates may have difer-ent glycaemic index that determines how high and rapid peak blood sugars can achieve. Generally fruits with higher simple sugar has higher G) as the glucose are more rapidly and easily absorbed. For example, consuming a piece of banana will give rise to higher blood sugar level com-pared to a medium size apple, even though both contain equal amount of carbohydrates. For fruits with higher G), serving portion needs to be reduced to prevent blood sugar level being afected.

References : . NAD) Diabetes, Jilid ; Keluaran ;

. The Practical Guide for )nsulin Therapy for Patients with Type Diabetes

.https://www.diabetes.org.uk/Guide-to-diabetes/Enjoy-food/Eating-with-diabetes/Diabetes-food-myths/myth-fruit-diabetes

.http://www.diabetes.org/food-and-itness/food/what-can-i-eat/making-healthy-food-choices/fruits.html?referrer=https://www.google.com/

.http://www.webmd.com/diabetes/diabetic-food-list-best-worst-foods#

. http://www.health.harvard.edu/healthy-eating/glycemic_index_and_glycemic_load_for_ _foods

. http://www.healthline.com/health/diabetes/low-glycemic-fruits-for-diabetes#

. Glycaemic )ndex of Malaysian Common Fruits , Asia Pac J Clin Nurt ; : - . Available at http://apjcn.nhri.org.tw/server/

Fruits Low G)

Apple

Orange

Pear

Fruits Medium G)

Banana

Grapes

Papaya

Fruits (igh G)

Watermelon

Dates

12

Sodium Bicarbonate, Sodium Citrate

Mixture

PRODUCT Potasssium Citrate Mixture

Sodium bicarbonate

Tartaric acid

Citric acid anhydrous

Sodium citrate anhydrous

INGREDIENTS Potassium citrate

Citric acid anhydrous

Chloroform water

1. To relieve discomfort in mild urinary

tract infection

2. For symptomatic relief of dysuria

3. To enhance the action of certain

antibiotics, especially certain sul-

phonamides

4. In gout therapy: as alkalinizers to

prevent crystallization of urates

INDICATIONS 1. To alkalize urine in the treat-

ment of urinary tract infection

2. To prevent crystallauria during

treatment with sulphonamides

Drugs Comparison: Sodium Bicarbonate, Sodium Citrate Mixture

Potassium Citrate Mixture

By: Tan Xin Yi

1. Sodium Bicarbonate: acts as urinary alkaliser by increasing the excretion of free bicar-bonate ions in the urine -> raising urinary pH.

2. Sodium Citrate and Citric Acid: Rise in urinary pH increased the solubility of cysteine in the urine and ionization of uric acids to more soluble urate ion

3. Tartaric Acid (in combination with bicarbonates) : acts as acid component of efferves cent granules

4. Potassium Citrate: acts similarly as Sodium Bicarbonate

The dissolution of uric acid stones may be achieved by maintaining alkali urine.

Pharmacological Action:

End Result:

General Comparisons:

13

Sodium bicarbonate, sodium

citrate mixture

Product

Potassium Citrate Mixture

650mg of sodium per sachet Content of Sodium Sodium free

Urine alkalization

To relieve discomfort in

mild urinary tract infection

For symptomatic relief of

dysuria

Indications:

Uncomplicated Urinary Tract

Infection: Cystitis

Urine alkalization to provide

symptomatic relief of discomfort

Sodium citrate and sodium

bicarbonate has potential to

develop calcium stones

Indications:

Nephrolithiasis

Potassium citrate is preferred;

Reduced potential for develop-

ment of calcium stones

Adult: 4 g to 8 g (1 to 2 sachet),

dissolved in a glass of cold wa-

ter, BD to TDS

Children 6-12 years: 4 g (1 sa-

chet), dissolved in a glass of

cold water, BD to TDS

Dosages Children >6 years and adults:

10 ml, well diluted with water,

TDS

Children 1-6 years:

5 ml, well diluted with water,

TDS

Take on empty stomach Time of administration Take with or after meal

Mild laxative effect:

due to tartrate components

being incompletely absorbed

Side effects Rarely, hyperkalemia

Not recommended for patient in

whom on sodium intake re-

striction, for example

Hypertensive patient,

Patient with heart disease,

Pregnant women

Precautions Not recommended for patient

taking:

Potassium-sparing diuret-

ic,

Aldosterone antagonist,

eg. Spironolactone

Angiotensin-converting

enzyme (ACE) inhibitor

May cause abdominal cramps Gastrointestinal tolerability Citrate has better gastrointesti-

nal tolerance

References

1. Product leaflet Potassium Citrate Mixture. Malaysia: KCK Pharmaceutical Industries Sdn. Bhd. 2. Product leaflet UTIX Effervescent Granules. Malaysia: NoripharmaSdn. Bhd. 3. Jacqueline van S. Therapeutic use of alkalinizing agents.Prof Nurs Today. 2011; 15(2):p39-43.

14

THE

CHAPTER In Hospital Jasin Pharmacy

T(E TOP MED)C)NAL EXPEND)TURES )N JANUARY-NOVEMBER

By: ADILLAH AHMAD

15

NO. ITEM DESCRIPTION

Sodiu Chloride . % I l I je io

A o illi g Capsule

Cal iu La tate g Ta let

Hepari Sodiu IU/ l l I je io

Diphe h dra i e HCl E pe tora t Adult

Para eta ol g/ l S rup

Cele o i g Capsule

I suli Glargi e iu/ l La tus

A o illi g + Clavula ate g Ta let

Clo a illi Sodiu g Capsule

Mefor i HCl g Ta let

Clopidogrel g Ta let

Streptoki ase , , U its I je io

Cefuro i e A eil g Ta let

Ferrous Fu arate g Ta let

DRUGS MOST COMMONLY )MPL)CATED )N ADVERSE DRUG REACT)ONS JAN-NOVEMBER

By : LOW JIA HUI

No. Drugs Percentage % of )mplications

Tramadol . %

Paracetamol . %

Amoxicillin + Clavulanate . %

)sosorbide dinitrate . %

Phenytoin . %

Perindopril . %

Bisoprolol . %

Aspirin + Glycine . %

Simvastatin . %

Metformin . %

Piperacillin + Tazobactam . %

Diclofenac . %

)buprofen . %

MOST COMMON ADVERSE DRUG REACT)ONS ADR

REPORTED JAN-NOVEMBER

No. ADR Percentage % of reported ADR

Dizziness . %

Rashes . %

Periorbital Swelling . %

Vomitting . %

Cough . %

Swollen face . %

16

DRUGS MOST COMMONLY REPORTED )N

JANUARY– NOVEMBER

By : LOW JIA HUI

Drugs Percentage % of reported Medication Errors

No.

T. Rantidine . %

Mixt. Potassium chloride . %

T. Bisoprolol . %

C. Cloxacillin . %

T. Co-amoxiclav . %

Syp. Paracetamol . %

T. Simvastatin . %

T. Alendronate . %

T. Atenolol . %

Budesonide MD) . %

T. Carbimazole . %

T. Cefuroxime . %

)nj. Ceftriaxone . %

Syp. Chlorpheniramine . %

T. Metronidazole . %

Syp. Salbutamol . %

T. Aspirin + Glycine . %

Syp. Phenoxymethylpenicillin . %

17

AKTIVITI KENALI UBAT

Pameran Kenali Ubat Anda sempena (ari Bersama Pelanggan . . &

. .

Program Kenali Ubat Anda Unit Pemuli-han Carakerja . .

Lawatan Ke Rumah Pesakit Pemulihan Carakerja . .

By : IZRUL AZWA MOHD LATIFF

18

Pameran Kenali Ubat Anda sempena Jamuan Perkahwinan Duta Kenali Ubat Anda . .

Pameran Kenali Ubat Anda Bersempena Karnival Kesihatan Kluster Melaka — & . .

Ceramah Kenali Ubat Anda Bersempena (ari A)DS Sedunia Peringkat Negeri Melaka bersama Duta Kenali Ubat Anda

. .

DUTA KENALI UBAT ANDA HOSPITAL JASIN

Pn Lau (ui Yuan

En Faizatul Azreen

Pn Ranjani

19

Farewell for Cik Siti Maslizah, Pn Norsuhaida & En. Zaini

. .

(ospital Jasin (ari Raya Aidilitri

Celebration . .

20

Participation in Anugerah )novasi

KKM Peringkat Kebangsaan - September

Farewell For Pn Noorazlinda Yacob, New

Staf )ntroduction, Employee of The Month

Award & Birthday Celebration . .

21

Bengkel Pengurusan Stor Anjuran Unit Farmasi (ospital Jasin

. .

Morning Brief Meeting

CME Session

22

(MEI) Cik Low Jia Hui

(JUN) Hj Ibrahim Yusof

(JULAI) Pn. NoorazlindaYacob

(OGOS) Cik Tan Xin Yi

CME ORGAN)SED BY (OSP)TAL JAS)N P(ARMACY DEPARTMENT

DATE TOPIC

. . Echo-Training Bengkel Pembangunan CPD

. . Medication Safety

. . Montelukast

. . Dasar Ubat Nasional

. . Balance of Eicacies & Safety )n The Treatment of ACS

23

INFORMATION AT

YOUR FINGERTIPS

VISIT NOW

http://www.mimsgateway.com/Malaysia/Overview.aspx

For further information on drugs & M)MSGateway log-in information please call:

Drug )nformation Service D)S

Pharmacy Department ,

(ospital Jasin Ext /

hospital jasin - jabatan kesihatan negeri melaka 3.2015.pdf · x potassium-sparing diuret-ic, x...

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