Chapter 12

Audits for Monitoring the Quality of

Antimicrobial Prescriptions

Inge C. Gyssens
Department of Internal Medicine, and Department of Medical Microbiology and
Infectious Diseases, Erasmus University Medical Center, Dr. Molewaterplein 40,
3000 CA Rotterdam, The Netherlands

1. INTRODUCTION

Antibiotic therapy differs from all other types of pharmacotherapy. It is

based on the characteristics of not only the patient and the drug but also on the
nature of the infection and the microorganism causing the infection. There is a
complex relationship between the host, the pathogens, and the anti-infective
agents. The rational use of antimicrobial drugs is based on an understanding of
the many aspects of infectious diseases. Factors relating to host defence, the
identity, virulence, and susceptibility of the microorganism and the pharmaco-
kinetics and pharmacodynamics of antimicrobial drugs have to be considered.
Antimicrobial use is the major determinant of microbial resistance. To guaran-
tee the long-term efficacy of antimicrobial drugs, the quality-of-use should be
maximised and overconsumption (inappropriate use) eliminated. There are
major differences in antimicrobial consumption in different parts of the world
(Cars et al., 2001). However, much less is known about the quality of antimi-
crobial use. An optimal treatment for an infection is obtained when a maxi-
mum efficacy is combined with a minimal toxicity for the host, at a reasonable
cost and with a minimal development of microbial resistance. In healthcare
facilities, antimicrobial drugs are used in three types of situations (Table 1).
The quality of empiric therapy and antimicrobial prophylaxis is largely
determined by the availability of local surveillance data on microbial resistance

Antibiotic Policies: Theory and Practice. Edited by Gould and van der Meer
Kluwer Academic / Plenum Publishers, New York, 2005 197
198 Inge C. Gyssens

Table 1. Classification of the different types of antimicrobial therapy and definitions

Empiric therapy: Administration of antibiotics to treat an active infection in a blind

approach before the causative microorganism has been identified and its antibiotic
susceptibility determined
Definitive therapy: Administration of antibiotics targeted at a specific microorganism
causing an active or latent infection
Prophylaxis: Administration of antibiotics to prevent a possible infection (which is not yet
present or incubating)

and by the information that prescribers have on the local epidemiology of

infections and the causative organisms. The microbiology laboratory plays a
major role in the aggregation, analysis, and reporting of surveillance data and
provides a major contribution towards the choice of empiric therapy (“well-
educated guess”) or prophylaxis. Guidelines for empiric therapy and prophy-
laxis that are based on this surveillance should be available in every healthcare
facility. The accessibility of microbiology laboratory facilities is crucial for the
identification of a pathogen and determination of its susceptibility to facilitate
and streamline a definitive therapy with a spectrum of action that is less broad
than the blindly chosen empiric therapy. When the patient is in a stable condi-
tion, sequential therapy or step down therapy from parenteral to oral adminis-
tration is preferable and allows for outpatient therapy (Eron and Passos, 2001).
Antibiotic therapy should be streamlined at the earliest opportunity. Recent
studies have shown that the duration of antimicrobial therapy of some infec-
tions can be shortened. This chapter reviews the different methods of evalua-
tion of quality of use at the patient level. It cites the evidence supporting the
principles of prudent prescribing of antimicrobial (antibacterial and antifun-
gal) drugs.

2. OUTCOME PARAMETERS

Outcome measures of audits can be categorised in process outcome, patient

outcome, and microbiological outcome parameters.

2.1. Process outcome: prescribing behaviour

2.1.1. Definition

Traditionally, quality is measured by an in-depth analysis of medical

records, also called audits of practice. An audit of antimicrobial drug use is
defined as the analysis of appropriateness of individual prescriptions (Gould
et al., 1994). Although this approach is costly in manpower, an audit is certainly