1. Selection of opportunities for improvement (Outline for problem)
HTAN was the highest ceftriaxone user in Malaysia from 2012 to 2014. Ceftriaxone is a third generation cephalosporin, where increased usage will result in increasing resistance rate towards it, leading to the emergence of multidrug-resistant organisms (e.g. extended spectrum beta lactamase, ESBL). Hence, we aimed to reduce ceftriaxone usage in HTAN.

2. Key Measures for improvement
Ceftriaxone usage was measured using indicator of Defined Daily Dose (DDD) per 1000 patient-days, using standard of less than the upper limit of yearly national ceftriaxone usage (<60), based on National Surveillance on Antibiotic Utilization, Ministry of Health.

3. Process of gathering information
A cross-sectional study was conducted in medical, orthopedic and surgical wards, via universal sampling. We included all patients who were on ceftriaxone treated for pneumonia during antibiotic round and excluded pediatric patients.

4. Analysis and Interpretation
In verification study, ceftriaxone usage was 90.67. Identified contributing factors were unnecessary treatment (45.46%), no de-escalation or intravenous-to-oral switch (27.27%), and inappropriate choice or duration of antibiotic (27.27%).

5. Strategy for Change
Strategies implemented in the 3 cycles were addition of ceftriaxone into Antibiotic Request Form and fortnightly antibiotic round (to ensure ceftriaxone is initiated by specialist, forms signed by specialist, doctors review ceftriaxone use after 72 hours of initiation, trace pending cultures and justify to continue or de-escalate or oralise ceftriaxone), renewal of Antibiotic Request Form to be more user friendly (1 column for empirical and 1 column for definitive to ease form filling, instead of both under the same column), continuous teaching sessions (by medical consultant to all specialists and medical officers and teaching by senior ward pharmacist to all ward pharmacists to inform about the changes in latest national antibiotic guidelines and no difference in outcome in treating pneumonia with ceftriaxone or alternative e.g. amoxicillin/clavulanate), and dialogue with pharmacy staffs and nurses (to ensure strict adherence to Standard Operation Procedure in prescribing and supplying ceftriaxone, i.e. only when antibiotic request form is completed).

6. Effects of change
Ceftriaxone usage was successfully reduced from 90.67 (verification study) to 12.33 (Evaluation) and achieved sustainability with improvement to 27.32 (Re-evaluation 3). ABNA gap was reduced to -32.68. Appropriateness of ceftriaxone use was increased from 37.04% (Jan-June 2016) to 54.55% (July-December 2018).

7. The next step
Monthly antibiotic rounds, persistent monitoring on Antibiotic Request Form enforcement were continued. Development of an intravenous-to-oral conversion guideline and expansion of Antibiotic Request Form to other antibiotics (cefoperazone, cefoperazone/sulbactam) are carried out since 2016. Antibiotic Request Form has been introduced to cluster hospitals (Hospital Jempol and Hospital Tampin) since 2018.