Prospective audit of aminoglycoside usage in a general hospital with assessments of clinical processes and adverse clinical outcomes.
A comprehensive, multiphasic review of gentamicin and tobramycin utilization was undertaken with audits of the microbiological sensitivity of Gram-negative pathogens; indications for the prescription of aminoglycoside agents; the utilization of assay services; the adequacy of clinical drug delivery by measures of serum antibiotic levels; and the assessment of adverse outcomes by markers of nephrotoxicity. The great majority of clinical isolates of target organisms (n = 4208) was more sensitive to gentamicin (96%) and to tobramycin (99%) than to all alternative agents, including first- and third-generation cephalosporin agents. A review of the indications for the prescription of aminoglycoside agents by clinical criteria showed that in 85.6% of 278 documented cases, the choice of agent was appropriate by clinical and microbiological criteria. In a substantial (77.6%) proportion of the 511 patients who were receiving therapeutic courses of an aminoglycoside agent, serum drug assays had been performed. Assay data could not be interpreted adequately in 52.6% of 3079 assayed cases as a result of inadequate data on administration regimens (39.7%) or sampling regimens (12.9%). Where sampling was documented adequately, there was extreme variation (zero to five hours) in post-dose sampling. In only 33.2% of cases could it be concluded unambiguously that the patients were receiving safer, adequate therapy for clinically significant infections, 5.6% of patients were receiving potentially toxic doses, and 8.6% of patients showed suboptimal concentration profiles. The majority of potentially toxic levels were associated with adverse effects.(ABSTRACT TRUNCATED AT 250 WORDS)
Li
S C
SC
Amalgamated Alfred, Caulfield and Royal Southern Memorial Hospital, Alfred Campus, Prahran, Vic.
Ioannides-Demos
L L
LL
Spicer
W J
WJ
Berbatis
C
C
Spelman
D W
DW
Tong
N
N
McLean
A J
AJ
D000617:Aminoglycosides / Q000008:administration & dosage* / Q000009:adverse effects / Q000097:blood / Q000627:therapeutic use; D001424:Bacterial Infections / Q000097:blood / Q000188:drug therapy; D003404:Creatinine / Q000097:blood; D005839:Gentamicins / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D006090:Gram-Negative Bacteria / Q000187:drug effects; D006769:Hospitals, General; D006801:Humans; D007674:Kidney Diseases / Q000097:blood / Q000139:chemically induced; D008485:Medical Audit; D008826:Microbial Sensitivity Tests; D010043:Outcome and Process Assessment, Health Care; D010818:Practice Patterns, Physicians'; D011446:Prospective Studies; D013997:Time Factors; D014031:Tobramycin / Q000008:administration & dosage / Q000009:adverse effects / Q000627:therapeutic use; D014739:Victoria
D000617:Aminoglycosides; D005839:Gentamicins; D003404:Creatinine; D014031:Tobramycin