Failure to Clarify Prolonged Azithromycin Use for Pneumonia Prophylaxis
Penalty
Summary
The facility failed to reduce the risk of adverse events and the development of antibiotic-resistant organisms by not clarifying the appropriate indication for the use of azithromycin as a prophylaxis for pneumonia in a resident with chronic recurrent pneumonia. The resident was admitted with multiple medical conditions, including dyslipidemia, chronic recurrent pneumonia, and atrial fibrillation, and had an active order for azithromycin 250 mg twice weekly for pneumonia prophylaxis without an end date. The order was continued per the primary medical doctor, and the plan of care reflected this ongoing use, but there was no documented clarification of the clinical guideline supporting this prolonged prophylactic use. Interviews and record reviews revealed that the nursing and pharmacy staff were aware of the order but did not question the appropriateness of azithromycin for pneumonia prophylaxis or the lack of a stop date. The registered nurse confirmed the order and its indication, stating that education had been provided regarding the need for stop dates and appropriate indications for antibiotics. The nurse practitioner noted that such use of azithromycin was atypical and was unable to identify a clinical practice guideline supporting it. The director of pharmacy acknowledged receiving the order but did not discuss it with the prescriber or the infection preventionist, and the issue was not brought to the Pharmacy and Therapeutics committee for peer review. The infection preventionist stated that the antibiotic stewardship program relies on communication from the pharmacist when new antibiotics are prescribed, but she was not notified when antibiotics were used for prophylaxis. She indicated that, had she been notified, she would have sought clarification from the prescriber, as azithromycin is generally used for prophylaxis in cases of bronchitis or COPD, not pneumonia. The facility's policy required the pharmacist to communicate new antibiotic orders to the infection control nurse, including the diagnosis and duration, but this process was not followed in this case, resulting in a failure to ensure the appropriateness of the antibiotic order.