Principles of 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.

14. Problem Pathogens

15. .

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

31. Supplemental
Antimicrobial
Stewardship
Strategies
Computer
Surveillance
and Decision
Support
Microbiology
Laboratory
Comprehensive
Antimicrobial
Management
Programs
Process
Monitoring
and
Outcome
Measurement
s

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!

63. Presence Action Transformation

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