Antimicrobial Stewardship
- 2. By FATMA ATEF IBRAHIM Faculty of Medicine Zagazig University 2019
- 4. Nearly One half of the Hospitalized patients receive antimicrobial agents. . Antibiotics are valuable Discoveries of the Modern Medicine. . All current achievements in Medicine are attributed to use of antibiotics. . . . Life saving in Serious infections.
- 5. -Treating viral Infections with Antibiotics has become routine affair. -Many use Antibiotics without the Basic principles of Antibiotic therapy. -Many Medical practionners are under pressure of short term solutions. -Commercial interests of Pharma-ceutical industry pushing the Antibiotics, more so Broad spectrum. --Poverty encourages drug resistance due to under utilization of appropriate Antibiotics..
- 6. When antibiotics are prescribed unnecessarily; When antibiotic administration is delayed in critically ill patients; When broad-spectrum antibiotics are used too commonly, or When narrow-spectrum antibiotics are used incorrectly; When the dose of antibiotics is lower or higher than appropriate for the specific patient; When the duration of antibiotic treatment is too short or too long; When antibiotic treatment is not streamlined according to microbiological culture data results
- 7. Antibiotic exposure is the single most important risk for C. difficile Infections Antibiotics account for nearly 1 in 5 drug-related adverse events Antibiotic Use Drives Resistance For an individual, getting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism Increasing use of antibiotics in healthcare settings increases the prevalence of resistant bacteria in hospitals
- 11. The ability of a microorganism to stop an antimicrobial agent from working against it. Standard treatments become ineffective, infections persist and may spread to others. New resistance mechanisms are emerging and spreading globally. Resistance increases the cost of health care with lengthier stays in hospitals and more intensive care required.
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- 17. The CDC has recommended four necessary actions to prevent antimicrobial resistance 1. Prevent infections, prevent the spread of resistance 2. Tracking 3. Developing new drugs and diagnostic tests 4. IMPROVING ANTIBIOTIC PRESCRIBTION/ STEWARDSHIP
- 19. Every Hospital should have a policy which is suitable to their circumstances. Rigid guidelines without coordination will lead to greater failures The only way to keep Antimicrobial agents useful is to use them appropriately and Judiciously (Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical Clinics of North America NOV 2006)
- 20. Antimicrobial stewardship + Infection control program Can limit the emergence and transmission of antimicrobial-resistant bacteria
- 22. The conducting, supervising, or managing of something especially . The careful and responsible management of something entrusted to one's care. THEREFORE,ANTIBIOTIC STEWARDSHIP…. An activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy.
- 23. The commitment to always use antibiotics appropriately and safely—only when they are needed to treat disease, and to choose the right antibiotics and to administer them in the right way in every case—is known as antibiotic stewardship. Objectives: Maximum antimicrobial benefit Avoid harm from adverse reactions and drug allergies Improve patient outcomes Decrease antimicrobial resistance Decrease healthcare costs
- 24. 1. Diagnosis (provided?/confirmation?) 2. Drug selection 3. Dose optimization 4. De-escalation opportunity 5. Duration of therapy
- 25. The Joint Commission antimicrobial stewardship standard is now in effect as of January 1, 2017. Applies to hospitals, critical access hospitals, and nursing homes 2015 White House Action Plan for Combating Antibiotic-Resistant Bacteria Establishment of antibiotic stewardship programs in all acute care hospitals and improved antibiotic stewardship across all healthcare settings by 2020
- 26. Healthcare Goals Optimizing clinical outcomes while minimizing unintended consequences of antimicrobial uses. •Toxicity •Selection of Pathogenic organisms •Emergence of Resistance Reduction of health care costs Without adversely impacting quality of care Community Goals -Retail Pharmacy – Future initiatives -Family Practice Clinics -Nursing Home *Develop a separate outpatient antibiogram for community use *Transition of care communication improvements *Culture review/follow up
- 27. An Institutional Program to enhance Antimicrobial Stewardship Antimicrobial Stewardship Program Antimicrobial Stewardship Team
- 28. Infectious Disease Physician. Clinical Pharmacist with infectious disease training Clinical Microbiologist An information system specialist Infection control professional. Hospital epidemiologist (Optional) Co-operation between the antimicrobial stewardship team, the hospital infection control, pharmacy and therapeutics committees is Essential
- 29. 1) Summarize the core elements of a hospital antimicrobial stewardship program 2) Describe the Joint Commission antimicrobial stewardship medication management standard, elements of performance, and recent survey experiences 3) Review antimicrobial stewardship quality improvement strategies from Arkansas hospitals of various sizes 4) Discuss successes and obstacles of implementing and maintaining an antimicrobial stewardship program
- 30. 1) Explore the aspects of a hospital antimicrobial stewardship program 2) Describe the Joint Commission antimicrobial stewardship medication management standard, elements of performance, and recent survey experiences 3) Discuss the improvement strategies that Arkansas hospitals are taking to improve antimicrobial stewardship 4) Examine the successes and challenges experienced surrounding an antimicrobial stewardship program
- 32. Develop guidelines, policies, and protocols that support optimal prescribing Priority efforts regarding Specific conditions Particular units or groups Specific antimicrobial drugs Educate Monitor and Report
- 33. Primary Strategies: Prospective audit with intervention and feedback Formulary Restriction Evaluate drug ,limit redundant ones Secondary Strategies: Education Confereces, Presentation, Teaching sessions , e-mail Guideline/clinical pathway development CO,DOSE,DURATIO De-escalation OR Streamlining C&S target CO –combination ttt Antimicrobial order sets Automatic stop order, physician justification ,Peri-operative Prophylactic Order Dose optimization Patient ,co , site ,Pk ,PD Parenteral to Oral conversion Enhanced oral bioavailability No longer recommended: Antimicrobial cycling substitution of a specific antimicrobial class to prevent development of antimicrobial resistance within a unit. Combination therapy Limitations of Combination Therapy
- 35. Formal statements that the facility supports efforts to improve and monitor antibiotic use Stewardship-related duties in job descriptions and annual performance reviews Ensuring staff from relevant departments are given sufficient time to contribute to stewardship activities Support training and education Ensuring participation from the many groups that can support stewardship activities
- 36. Stewardship program leader: Identify a single leader who will be responsible for program outcomes Physicians are highly recommended in this role Pharmacy leader: Identify a single pharmacy leader who will co-lead the program Key support: The work of stewardship program leaders is greatly enhanced by the support of other key groups in hospitals where they are available Clinician and department heads, infection control staff, hospital epidemiologists, quality improvement staff, laboratory staff, information technology staff, nursing
- 37. Implement policies that support optimal antibiotic use Document dose, duration, and indication Develop and implement facility specific treatment recommendations Utilize specific intervention, divided into three categories: Broad Pharmacy driven Infection and syndrome specific Avoid implementing too many policies and interventions Priority based on the needs of the hospital as defined by measures of overall use and other tracking and reporting measures.
- 38. Antibiotic “time-outs” Provide a reassessment of the continuing need and choice of antibiotics Review after 48 hours Prior authorization Restrict the use of certain antibiotics Based on the spectrum of activity, cost, or associated toxicities Ensure that timely expert review is done to avoid delay of therapy Prospective audit and feedback External reviews of antibiotic therapy by an expert in antibiotic use Major function of the ASP pharmacist
- 39. Automatic changes from intravenous to oral antimicrobial therapy Dose adjustments Dose optimization Automatic alerts in situations where therapy might be unnecessarily duplicative Time-sensitive automatic stop orders Detection and prevention of antimicrobial- related drug-drug interactions
- 40. Intended to improve prescribtion for specific syndromes Community-acquired pneumonia Urinary tract infections Skin and soft tissue infections Empiric coverage of MRSA infections Clostridium difficile infections Treatment of culture proven invasive infections Should NOT interfere with effective treatment for severe infection or sepsis
- 41. Monitor antibiotic use prescribtion Identify opportunities for improvement Assess impact of efforts Process measures Antibiotic use monitoring Controverse regarding best methods for monitoring usage DDD = defined daily dose DOT = days of therapy Outcomes measures
- 42. Center for Medicare & Medicaid Services Required e.g. MRSA, Clostridium difficile infections National Healthcare Safety Network (NHSN) Provides a mechanism for facilities to report and analyze antimicrobial use and/or resistance over time at the facility and national levels Somewhat complex Requirements and Setup outlined by CDC
- 43. Provide regular updates on antimicrobial prescribtion, antibiotic resistance, and infectious disease management Choose a form based on receptiveness at your institution: Presentations Posters , newsletters, emails ASP website Review de-identified cases where changes in antimicrobial therapy could have been made Target Customers: Microbiologist and Clinicians.
- 44. Requirements Computed annually Include only first isolate per patient Collaborative effort Limitations MICs Patient specific factors (e.g. infection history, past antimicrobial use, comorbidities, age) Single organism-antimicrobial combinations Cross-resistance and synergy not generally considered Combination antibiograms Generalization
- 46. Improves the chances of identifying the offending microorganism Administration of antimicrobials before culture collection may decrease culture yields More difficult to de-escalate therapy without cultures DO NOT DELAY THERAPY!!!!!!
- 47. Undertreating does not tend to be an issue Overtreating with unnecessary extensions of antimicrobial regimens are not uncommon Recommend durations based on published guidelines e.g. – HAP duration is now 7 days Encourage use of stop dates Right drug Right dose Right duration Recognize when not needed
- 48. Provide timely, reliable, and reproducible identification and antimicrobial susceptibility results Report unusual patterns of resistance Optimize communication of critical test result values and alert systems Provide guidance for adequate collection of microbiology specimens Provide, revise, and publish annual antibiogram Use cascade or selective reporting Perform testing for susceptibility to new drugs Broaden use of validated rapid diagnostic and rapid antimicrobial susceptibility testing
- 50. Initially, resistance, prescribtion patterns, and cost savings will likely improve dramatically Improvements eventually stabilize Continued decreases in antibiotic use and cost should be expected But, if programs are terminated, previous gains will begin to decline
- 51. ~60% of U.S. antibiotic expenditures for humans are related to care received in outpatient settings ~20% of pediatric visits and ~10% of adult visits in outpatient settings result in an antibiotic prescription In 2011, approximately one third of C. difficile infections in the U.S.were community- associated infections
- 52. Common Mishap Rhinosinusitis 98% are viral and antibiotics often do not help even when due to bacteria Common cold Over 200 viruses can cause the common cold Pharyngitis Only 5-10% are strept throat Uncomplicated UTI Should not treat in absence of symptoms Acute otitis media Watchful waiting appropriate in many cases
- 54. CDC - Core Elements of Hospital ASPs CDC - Core Elements of Outpatient Antibiotic Stewardship IDSA guidelines – Implementing an ASP ASP training programs SIDP MAD-ID Institution specific ASPs or guidelines Cleveland Clinic Foundation John Hopkins Hospital Nebraska Medical Center University of California, San Francisco ECHO – Antimicrobial Stewardship (launched on 6/16/17) http://echo.unm.edu/nm-teleecho-clinics/antimicrob
- 55. Antimicrobial Stewardship in a Rural Hospital Setting: 141-bed community hospital in rural Northwest Team: Pharmacist-led , Remotely located physician Intervention: Targeted review of six antimicrobials Pip/Tazo, imipenam, cilastatin, ertapenam, vancomycin, linezolid, daptomycin Weekly tele-conference “rounding” with the physician Streamlined Therapy Eliminated unnecessary combinations Recommended more narrow spectrum Dose optimization OUTCOMES: Decrease Cost and Resistant Infections
- 56. Antimicrobial resistance is a major problem and ASPs are a major part of the solution Learn the CDC core elements and understand how to employ them in your practice Question as many aspects of an antimicrobial prescriptions as possible Utilize your resources, including other pharmacists and technicians Educate others – the more people aware of the problem, the more people available to fix it
- 58. The Great Dilemma Treat patients with effective empiric antimicrobial treatment while maintaining the efficacy of our antimicrobials and keeping resistance to a minimum. A fine balance exists: Overuse = Misuse antimicrobial resistance Underuse = Immoral not to appropriately treat Responsibility to current and future patients Antibiotics are a limited resource
- 59. Use of ongoing education Use of evidence-based hospital antibiotic guidelines and policies Restrictive measures and consultations from infectious disease physicians, microbiologists and pharmacists Only use an antimicrobial when clearly indicated. Select an appropriate agent using local antimicrobial prescribtion policy. Prescribe correct dose , frequency and duration. Limit use of broad spectrum agents and de-escalate or stop treatment if appropriate . PRACTICE RATIONALISM IN ANTIBIOTIC USE PROMOTE ANTIBIOTIC STEWARDSHIP
- 60. Implementation of an antimicrobial stewardship program in a healthcare facility – regardless of inpatient setting – will help ensure that hospitalized patients receive the right antibiotic, at the right dose, at the right time, and for the right duration. As a result, there is reduced mortality, reduced risks of Clostridium difficile-associated diarrhea, shorter hospital stays, reduced overall antimicrobial resistance within the facility, and cost savings Use of peri-operative prophylactic order forms with automatic discontinuation at 2 days resulted in a decrease in the mean duration of antimicrobial prophylaxis (from 4.9 to 2.4 days)
- 61. Social media Twitter, Facebook, etc. CDC Get Smart Patient and provider materials Engage, educate, empower!
- 64. ANTIMICROBIAL STEWARDSHIP by Dr. T.V.Rao MD for Medical Professionals in the Developing world Email• doctortvrao@gmail.com Antimicrobial Stewardship: Program Implementation Successes and Lessons from The Joint Commission AAHP Fall Seminar 2017 Marsha Crader, PharmDMandy Langston, PharmDMegan Patch, MS, PharmD, BCPSElizabeth Smith, PharmD/Sarah Cochran Core Elements of Hospital Antibiotic Stewardship Programs Finding what fits Loria Pollack, MD, MPH Division of Healthcare Quality Promotion Centers for Disease Control and Prevention The Basics of Antimicrobial Stewardship Ryan Stevens, PharmD, BCPS Infectious Diseases Clinical Pharmacy Specialist Providence Alaska Medical Center Getting a grASP on Antibiotic Use and Resistance: Principles of Antimicrobial Stewardship Jacob M Kesner, PharmD UNMH PGY-2 Infectious Diseases Resident NMPhA 88th Annual Convention June 24th, 2017
- 66. Thank you