The Conversion of Levaquin from IV to PO

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

New Order Set

Preliminary Results July 2017 Aug 2017 Sep 2017 Oct 2017 Nov 2017 Dec 2017 Jan 2018 Feb 2018 Mar 2018 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% 53% 33% 40% 13% 48% 40% 44. 4% % Conversion YTD Avg 42% 46% 43% 42% 37% 39% *DOT/1000 patient days April 2018 Avg 33. 89 24. 79 58. 67 42%

Preliminary Results

Preliminary Results

Preliminary Results ● Average Monthly Conversion for FY 2018 Average Monthly Conversion 42%

Cost Data Cost Avg Monthly Use Cost Levaquin IV* $3. 81 33. 89 $129. 11 Levaquin PO* $0. 34 24. 79 $8. 43 58. 67 $137. 54 TOTAL*

Cost Data Cost Avg Monthly use at 0% Cost at 0% conversion Avg Monthly Use Avg Monthly Cost Current Avg Monthly Savings Levaquin IV* $3. 81 58. 67 $223. 53 33. 89 $129. 11 $94. 42 Levaquin PO* $0. 34 0. 00 $0. 00 24. 79 $8. 43 -$8. 43 58. 67 $223. 53 58. 67 $137. 54 $85. 99 TOTAL* Potential TOTAL Yearly Savings $1, 031. 87 *Savings of goal compared to 0% conversion

Cost Data Savings at Goal-45% conversion Avg Monthly use at Goal of Cost at Goal of 45% conversion Potential Monthly Savings at 45% conversion Cost Avg Monthly use at 0% conversion Avg Monthly Cost at 0% conversion Avg Monthly Use Avg Monthly 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 58. 39 $222. 47 58. 39 $137. 44 58. 39 $131. 29 $6. 15 TOTAL* Potential Yearly Savings at 45% conversion *Savings = current spending compared to goal of 45% conversion $73. 80

Cost Data Savings ABOVE goal 65% conversion Avg Monthly use at Goal of Cost at Goal of 65% conversion Potential Monthly Savings at 65% conversion Cost Avg Monthly use at 0% conversion Avg Monthly Cost at 0% conversion Avg Monthly Use Avg Monthly 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 58. 39 $222. 47 58. 39 $137. 44 58. 39 TOTAL* $46. 67 Potential Yearly Savings at 65% conversion $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 FY 2018 ● 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 Internal Medicine Residency Program Norton Community Hospital Research Committee

Thank you Questions?