The Conversion of Levaquin: Cost Benefits and Antibiotic Stewardship
This presentation by Dan Lefkowitz, D.O., explores the financial advantages and importance of converting Levaquin from IV to PO administration. It emphasizes the role of Antibiotic Stewardship Programs in promoting appropriate antibiotic use to combat resistance and enhance patient outcomes.
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Presentation Transcript
The Conversion of Levaquin from IV to PO: The cost benefits Dan Lefkowitz, D.O. PGY-1 Norton Community Hospital
Disclosures None. I do not work for any pharmaceutical companies and I have never received any payment from any pharmaceutical company.
Fact or Myth Approximately 20-50% of antibiotic use in US acute care hospitals are unnecessary or inappropriate The misuse of antibiotics has contributed to the growing problem of antibiotic resistance Antibiotic Stewardship Programs reduce adverse events, reduce treatment failures, reduce C diff infection rates, and resistance all while saving hospitals money
Antimicrobial Stewardship Program Defined Antimicrobial Stewardship Programs (ASP) are: coordinated interventions designed to improve and measure the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen, dose, duration of therapy and route of administration
Goal of ASP Enhancing patient health outcomes, reducing resistance to antibiotics, and decreasing unnecessary costs
Introduction Why is this important? Proper use Decrease costs Terminology Conversion = PO/Total Use as a % DOT = days of therapy
Our Goals Improve responsible antibiotic use at NCH Increase rate of conversion of IV to PO Levaquin prior to discharge Reduce costs of Levaquin (Levofloxacin) PO Levaquin costs less than IV, if we can convert from IV to PO sooner (without compromising therapy) there will be a decreased cost Convert 45% from IV to PO prior to discharge 45% of all patients receiving Levaquin converted to PO prior to discharge
Measurements Monthly Levaquin usage = DOT/1000 patient days Method to standardize Levaquin usage over time across different facilities Conversion ratio Percentage of patients converted from IV to PO Levaquin prior to discharge
Unique Factors about Levaquin The basis of this project depends on an inherent factor of Levaquin Review one of the goals: Reduce costs of Levaquin PO Levaquin costs less than IV, if we can convert from IV to PO sooner (without compromising therapy) there will be a decreased cost
Quick Definition/Review Bioavailability The proportion of a drug that is absorbed and able to have an effect IV Bioavailability is 100% PO is generally less due to incomplete absorption and first pass metabolism
Unique Factors about Levaquin Levaquin PO has a bioavailability of 99% with peak plasma concentration of 1-2 hours after a PO dose Food prolongs time to peak by 1 hour and decreases peak concentration by approximately 14% Therefore, the plasma concentration of IV = PO (AUC), extent of exposure with PO tablet
Unique Factors about Levaquin Conversion from IV to PO is NOT de-escalating therapy and does not compromise therapy Therefore, the only time IV is superior is at the time of the first dose as IV is instantaneous and PO still takes time for absorption.
Unique Factors about Levaquin Caveats: Patients with malabsorption issues Bariatric surgery Inflammatory bowel disease Patients who are NPO (for surgery, etc.) Must be coordinated around meals
Order Set Development After discussing with the Director of Pharmacy, we brainstormed to develop an order set An order set was developed to switch from IV to PO automatically after the first dose
Preliminary Results Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Feb 2018 Mar 2018 April 2018 July 2017 Jan 2018 Avg 33.89 24.79 58.67 42% Levaquin IV* 22.29 40.23 41.87 33.01 34.25 27.34 50.43 21.68 33.83 Levaquin PO* 16.34 29.45 46.7 16.18 22.83 3.91 46.17 14.45 27.06 TOTAL* 38.63 69.68 88.57 49.19 57.08 31.25 96.6 36.13 60.89 % Conversion 42% 42% 53% 33% 40% 13% 48% 40% 44.4% % Conversion YTD Avg 42% 42% 46% 43% 42% 37% 39% 39% *DOT/1000 patient days
Preliminary Results Average Monthly Conversion for FY 2018 Average Monthly Conversion 42%
Cost Data Avg Monthly Use Avg Monthly Cost Cost Levaquin IV* Levaquin PO* TOTAL* $3.81 33.89 $129.11 $0.34 24.79 $8.43 58.67 $137.54
Cost Data Avg Monthly use at 0% conversion Avg Monthly Cost at 0% conversion Current Avg Monthly Savings Avg Monthly Use Avg Monthly Cost Potential TOTAL Yearly Savings Cost Levaquin IV* Levaquin PO* TOTAL* $3.81 58.67 $223.53 33.89 $129.11 $94.42 $0.34 0.00 $0.00 24.79 $8.43 -$8.43 58.67 $223.53 58.67 $137.54 $85.99 $1,031.87 *Savings of goal compared to 0% conversion
Cost Data Savings at Goal-45% conversion Potential Monthly Savings at 45% conversion Avg Monthly use at Goal of 45% conversion Avg Monthly Cost at Goal of 45% conversion Potential Yearly Savings at 45% conversion Avg Monthly use at 0% conversion Avg Monthly Cost at 0% conversion Avg Monthly Use Avg Monthly Cost Cost Levaquin IV* $3.81 58.39 $222.47 33.89 $129.11 32.12 $122.36 $6.75 Levaquin PO* $0.34 0.00 $0.00 24.50 $8.33 26.28 $8.93 -$0.60 TOTAL* 58.39 $222.47 58.39 $137.44 58.39 $131.29 $6.15 $73.80 *Savings = current spending compared to goal of 45% conversion
Cost Data Savings ABOVE goal 65% conversion Potential Monthly Savings at 65% conversion Avg Monthly use at Goal of 65% conversion Avg Monthly Cost at Goal of 65% conversion Potential Yearly Savings at 65% conversion Avg Monthly use at 0% conversion Avg Monthly Cost at 0% conversion Avg Monthly Use Avg Monthly Cost Cost Levaquin IV* $3.81 58.39 $222.47 33.89 $129.11 20.44 $77.86 $51.25 Levaquin PO* $0.34 0.00 $0.00 24.50 $8.33 37.95 $12.90 -$4.57 TOTAL* 58.39 $222.47 58.39 $137.44 58.39 $46.67 $560.08 *Savings = current spending compared to goal of 65% conversion
Cost Data Cost savings does not include savings related to decreased length of stay Does not consider all use at 21 Ballad Health Facilities
Directions going forward Order set not as visible as possible
Directions going forward Goal of 45% not yet met. Currently 42% for FY2018 Monthly reminder to residents on service on use Educate residents and attendings on unique characteristics of Levaquin that enable PO dosing without compromising therapy Did significantly below goal October and December 2017 Will attempt to identify underlying etiology
Directions going forward Will also try to create a hard stop in the EMR to ensure physicians use PO as often as possible Starting the process for antibiotic Time Outs Some data shows often cultures come back and patients are not switched to narrower spectrum agents
Lastly... We did not compare to Cipro as is it not on formulary as it does not cover pseudomonas. Cipro is slightly less expensive, although it is BID whereas Levaquin is once daily Converting IV to PO for Levaquin is 1:1 Converting IV to PO for Cipro is 1:1.25
Summary Levaquin PO has a unique bioavailability of 99% Can save thousands of dollars per year by safely converting from IV to PO Levaquin without compromising care
Acknowledgements Inpatient pharmacy team at Norton Community Hospital Cindia Elkins, Pharmacy Director at Norton Community Hospital Norton Community Hospital Internal Medicine Residency Program Norton Community Hospital Research Committee
Thank you Questions?
