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Antimicrobial Stewardship

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Why we Need Antibiotics 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.

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What went wrong with Antibiotic Usage

• Treating trivial infections / viral Infections with Antibiotics has become routine affair.

• Many use Antibiotics without knowing the Basic principles of Antibiotic therapy.

• Many Medical practioners are under pressure for short term solutions.

• Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum and Newer Generation antibiotics. as every Industry has become profit oriented.

• Poverty encourages drug resistance due to under utilization of appropriate Antibiotics.

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Science magazine; July 18, 2008• The last decade has seen the inexorable proliferation of

a host of antibiotic resistant bacteria, or bad bugs, not just MRSA, but other insidious players as well. ...For these bacteria, the pipeline of new antibiotics is verging on empty. 'What do you do when you're faced with an infection, with a very sick patient, and you get a lab report back and every single drug is listed as resistant?' asked Dr. Fred Tenover of the Centers for Disease

Control and Prevention (CDC). 'This is a major blooming public health crisis.'"

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Spread of Antibiotic Resistance

• Indiscrimate use of Antibiotics in Animals and Medical practice

• R plasmids spread among co-inhabiting Bacterial flora in Animals ( in gut )

• R plasmids may be mainly evolved in Animals spread to Human commensal, - Escherichia coli followed by spread to more important human pathogens Eg Shigella spp.

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What is Misuse of Antibiotics?Misuse of antibiotics can include any of the following

• When antibiotics are prescribed unnecessarily; • When antibiotic administration is delayed in critically ill

patients; • When broad-spectrum antibiotics are used too generously, 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.

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Costs Associated withIncreased Bacterial

Resistance• ↑Treatment failures• ↑Morbidity and mortality• ↑Risk of hospitalization• ↑Length of hospital stays• ↑Need for expensive and broad

spectrum antibiotics

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Best way to keep the matters in Order

Every Hospital should have a policy which is practicable 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)

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“ what is Stewardship”????

• The office, duties, and obligations of a steward

• The conducting, supervising, or managing of something especially : the careful and responsible management of something entrusted to one's care

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Therefore, Antibiotic Stewardship…..

An activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy.

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What is Antibiotic Stewardship?

• A program that encourages judicious (vs injudicious) use of antibiotics– Antibiotics are relatively so effective, non-toxic and

inexpensive…so easy to use…that they are prone to abuse• When the diagnosis is uncertain, antibiotics are often prescribed…

– Stewardship strives to fine tune antibiotic Rx in regards to• Efficacy • Toxicity• Resistance-induction• C. difficile-induction• Cost • Discontinuation

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Sobering Thoughts

The pipeline is drying up! US FDA approval of new

antibacterials down 56% from 1983 to 2002

• Infectious diseases are still the most common cause of death worldwide.

• We are effectively living in the post-antibiotic era

• Therefore, we must manage carefully and responsibly what we have

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Should restrict and rationalize antibiotic use

Antimicrobial stewardship + Infection control program

Can limit the emergence and transmission of antimicrobial-resistant bacteria

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Goals of Ab Stewardship • Optimizing clinical outcomes while minimizing unintended

consequences of antimicrobial uses.

•Toxicity•Selection of Pathogenic organisms

•Emergence of Resistance • A secondary goal is also the reduction of health care costs

without adversely impacting quality of care

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GUIDELINES FOR DEVELOPING AN INSTITUTIONAL PROGRAM TO ENHANCE

ANTIMICROBIAL STEWARDSHIPAn institutional program to

enhance antimicrobial stewardship

Antimicrobial Stewardship Team

Antimicrobial Stewardship Program

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Antibiotic Stewardship Team

• Infectious Disease Physician. • Clinical Pharmacist with infectious disease training• Clinical Microbiologist• An information system specialist• Infection control professional. • Hospital epidemiologist (Optional)

Collaboration between the antimicrobial stewardship team, the hospital infection

control, pharmacy and therapeutics committees is essential

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ELEMENTS OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM

Active Antimicrobial Stewardship Strategies

Supplemental Antimicrobial Stewardship

Strategies

Computer Surveillance and Decision Support

Microbiology Laboratory

Comprehensive Multidisciplinary

Antimicrobial Management

Programs

Monitoring of Process and Outcome

Measurements

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Active Antimicrobial Stewardship Strategies

1. Prospective audit with intervention and feedback.

• A medium-sized community hospital resulted in a 22% decrease in the use of parenteral broad-spectrum antimicrobials.

• They also demonstrated a decrease in rates of C. difficile infection & nosocomial infection compared with the preintervention period.

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2. Formulary restriction & preauthorization requirements for specific agents

Most hospitals have a pharmacy and therapeutics committee or an equivalent group

They evaluates drugs for inclusion on the hospital formulary on the basis of

therapeutic efficacy toxicity cost They also limit redundant new agents with no

significant additional benefit.

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Supplemental Antimicrobial Stewardship Strategies

• Education.• Guidelines and clinical pathways.• Antimicrobial cycling • Antimicrobial order forms.• Combination therapy.• Streamlining or de-escalation of therapy.• Dose optimization.• Conversion from parenteral to oral therapy.

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Education• Considered to be most essential part of

Stewardship Program: – Antibiotics – Resistance– PK-PD– Collateral damage ( unintended ) – Alignment of Ab to overcome anti-microbial resistance.

• Target Customers: Microbiologist and Clinicians.

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Most frequently employed intervention

• Educational efforts include passive activities conference/ presentations student and house staff teaching sessions provision of written guidelines e-mail alertsHowever, education alone, without incorporation of

active intervention, is only marginally effective and has not demonstrated a sustained impact

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A good clinical practice saves antibiotics

• Treatment should be limited to bacterial infections, using antibiotics directed against the causative agent, given in optimal dosage, interval and length of treatment, with steps taken to ensure maximum patient compliance with the treatment regimen and only when the benefit of treatment outweighs the individual and global risks

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Antimicrobial cycling and scheduled antimicrobial switch.

“Antimicrobial cycling” refers to the removal and substitution of a specific

antimicrobial or antimicrobial class to prevent or reverse the development of antimicrobial resistance within an institution or specific unit.

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Choosing the drugs• Substituting one

antimicrobial for another may transiently decrease selection pressure reduce resistance

• But, reintroduction of the original antimicrobial is again however known to develop resistance

• There are insufficient data to recommend the routine use over a prolonged period of time

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Antimicrobial order forms.• The use of automatic stop orders and the

requirement of physician justification for continuation

• Decrease antimicrobial consumption in longitudinal studies

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)

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Combination therapy• Has a role in certain

clinical contexts• Including use for

empirical therapy for critically ill patients at risk of infection with multidrug resistant pathogens

• To increase the breadth of coverage and the likelihood of adequate initial therapy

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Limitations of Combination of Antibiotics

• The role of combination antimicrobial therapy for the prevention of resistance is limited to those situations in which there is

A high organism load A high frequency of

mutational resistance during therapy.

• Classic examples are tuberculosis or HIV infection.

Dr.T.V.Rao MD

Streamlining or De-Escalation of Therapy

–On the basis of culture and sensitivity reports we can more effectively target the causative pathogens, by elimination of redundant combination therapy

–Resulting in decreased Ab exposure and substantial cost savings

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CDC vision for inpatient care • 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

Dose Optimization Optimization of AB dosing based on• Individual patient characteristics• Causative organisms• Site of infections• PK-PD characteristics• Systemic Plan from a broad spectrum to specific

narrow spectrum Ab, parenteral to oral Antibiotics.

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Conversion from parenteral to oral therapy

Enhanced oral bioavailability among certain antimicrobials—such as fluoroquinolones, oxazolidinones, metronidazole, clindamycin, trimethoprim-sulfamethoxazole, fluconazole, and voriconazole

Therefore, allows for conversion to oral therapy once a patient meets defined clinical criteria

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Computer Surveillance and Decision Support

• Computer physician order entry (CPOE) as 1 of the most important “leaps” that organizations can take to substantially improve patient safety.

• CPOE has the potential to incorporate clinical decision support and to facilitate quality monitoring

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Our clinical Judgment carries many solutions…

These guidelines are not a substitute for clinical judgment, and clinical discretion is required in the application of guidelines to individual patients.

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Multifaceted strategies can address and decrease antibiotic resistance in hospitals

• Antibiotic prescribing practices and decreasing antibiotic resistance can be addressed through

multifaceted strategies including:

Use of ongoing education Use of evidence-based hospital antibiotic

guidelines and policies Restrictive measures and consultations

from infectious disease physicians, microbiologists and pharmacists

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Prudent prescribing to reduce antimicrobial resistance

• Only use an antimicrobial when clearly indicated.

• Select an appropriate agent using local antimicrobial prescribing policy.

• Prescribe correct dose, frequency and duration.

• Limit use of broad spectrum agents and de-escalate or stop treatment if appropriate (Hospital).

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Practice rationalism in antibiotic use- promote antibiotic stewardship

• 1 Antibiotic overuse contributes to the growing problems of Clostridium difficile infection and antibiotic resistance in healthcare facilities. 2 Improving antibiotic use through stewardship interventions and programs improves patient outcomes, reduces antimicrobial resistance, and saves money. Interventions to improve antibiotic use can be implemented in any healthcare setting—from the smallest to the largest. 3 Improving antibiotic use is a medication-safety and patient-safety issue.

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Continuous Medical Education a Must ..

• Training and educating health care professionals on the appropriate use of antibiotics must include appropriate selection, dosing, route, and duration of antibiotic therapy. To ensure that training and education is working, there should be extensive collaboration between the antibiotic stewardship and hospital infection prevention and control teams. Without benchmarks, it is difficult to track successes and weaknesses

Dr.T.V.Rao MD 39

Good hand washing practices still reduces antibiotic resistance and spread

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Implementation of WHONET CAN HELP TO MONITOR RESISTANCE

• Legacy computer systems, quality improvement teams, and strategies for optimizing antibiotic use have the potential to stabilize resistance and reduce costs by encouraging heterogeneous prescribing patterns and use of local susceptibility patterns to inform empiric treatment.

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