The antimicrobial
management / stewardship
teams: Global perspectives Philip Howard
Consultant Antimicrobial Pharmacist
Twitter: @AntibioticLeeds
Draft WHO AMR Action Plan Dec-
14 1. Increasing AMR awareness through effective
communication, education and training
2. Strengthen the knowledge & evidence-base through surveillance & research
3. Reduce the incidence of infection through effective sanitation, hygiene & infection prevention measures
4. Optimise the use of antimicrobials medicines in human & animal health
5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions
Draft WHO AMR Action Plan Dec-
14 4. Optimise the use of antimicrobials medicines in human & animal health
• AMR driven by use & increasing due to OTC & internet sales, and food production
• Usage data lacking at patient level, or nationally in lower-income countries
• Antibiotics need to be seen as a public good to strengthen regulation
• Decisions to prescribe rarely based on definitive diagnoses. New “cheap” tools needed.
• Evidence-based prescribing & dispensing should be the standard.
Background & methodology
• Previous surveys of AMS looked at country or continental level only
• ESCMID-ESGAP & ISC-AMS Group project based around published standards, definitions & previous surveys
• Aim to measure the extent and components of global efforts in antimicrobial stewardship
• 43 questions survey was piloted in 11 countries in 6 continents then distributed through networks using on-line SurveyMonkey® software in Spring 2012
Do you have a hospital AMS
programme?
14%
53%
66%
67%
47%
46%
23%
29%
20%
22%
29%
25%
Africa
Asia
Europe
North America
Oceania
South America
58% have an ASP, 22% are planning one
Planned
Yes
Mean ASP duration: 3 years
(Europe 5yr to Africa 1yr)
29% 29%
15% 20%
9%
14% 17%
12%
23% 16%
7% 9%
Current AMS programme(763)
Planned AMS programme(348)
Hospitals top 3 barriers to providing a functional and effective AMS
programme
No barriers
Lack of informationtechnology supportand/or ability to get dataOpposition from prescribers–
Administration not awareof AMS programme
Other higher priorityinitiatives
Lack of personnel orfunding
AMS Governance AMS
Governance Africa Asia Europ
e
North
Americ
a
Oceani
a
South
Americ
a
Tota
l
Drug &
Therapeutics
26 39 333 61 30 53 542
60% 80% 96% 91% 88% 56% 85%
AMS
Committee
5 28 267 49 13 34 396
12% 57% 77% 73% 38% 36% 62%
AMS Policy
or Code of
Practice
3 25 182 23 19 41 293
7% 51% 52% 34% 56% 43% 46%
Published
AMS Strategy
3 21 169 21 13 28 255
7% 43% 49% 31% 38% 29% 40%
Published
AMS Annual
report
0 19 166 19 2 25 231
0% 39% 48% 28% 6% 26% 36%
Published
AMS Annual
plan
0 13 134 9 5 17 178
0% 27% 39% 13% 15% 18% 28%
AMS policies and strategies
31%
58%
73%
38%
43%
56%
Africa (13)
Asia (31)
Europe (257)
North America (55)
Oceania (23)
South America (45)
Published AMS policy 61%
90% formulary; 93% specific treatment and 92% prophylaxis
guidance
Automatic stop / review policy: 33% Reserve antibiotics:
62%
Micro/ID advice: phone 77%; ward rounds 50%; bacteraemia
56%
Dose optimisation: by request 62%, pharmacy authorised 24%
Use procalcitonin: avoid starting 17%, early stopping 15%
Data warehousing: (link lab results to prescribed antibiotics):
13%
6
13
18
32
18
9
18
3
8
8
15
6
12
10
8
6
11
5
1
8
9
9
9
8
6
8
8
8
7
3
4
14
6
4
6
2
6
2
7
4
5
2
3
9
2
5
4
8
3
2
7
9
4
5
3
3
5
8
4
4
5
5
2
1
8
3
4
2
2
8
3
7
3
1
2
7
3
4
5
1
1
3
2
AFRICA
ASIA
EUROPE
NORTH AMERICA
OCEANIA
SOUTH AMERICA
AVERAGE
Hours per week
Composition of AMS teams Antimicrobial or IDpharmacist
Infectious Diseases (ID)doctor
Medical Microbiologist
Infection control staff
Nurse
Admin support
Data analyst
Other pharmacist
Doctors in training
Other medical specialty
Pharmacy technician
Scientist or laboratorystaff
Surgeon
Pharmacy + Inf Dis: USA, Australia, Asia IPC Nurse: Africa
Pharmacy + Micro: UK
Infectious Diseases: Europe (non-UK) & South America (+ Nurse)
AMS ward rounds
AMS Ward
Rounds Africa (13) Asia (31)
Europe
(247)
North
America
(54)
Oceania
(22)
South
Americ
a (41)
Medical
wards weekly daily weekly daily daily daily
Surgical
wards
daily =
weekly
daily =
<weekly weekly daily < weekly daily
Paediatrics
wards
daily =
weekly
daily =
<weekly <weekly daily n/a daily
ITU daily daily daily daily twice
weekly daily
Reported effect on antimicrobial consumption:
• surgical rounds decreased consumption
• others types of AMS rounds, consumption remained
stable
Antimicrobial restriction & reporting
• 80% restrict some antimicrobials – 73% restrict carbapenems, 63% fluoroquinolones
– 58% cephalosporins (mainly UK in Europe)
– Pharmacy follow up supply in 65%
• 25% practice diversity & 12% cycle antimicrobials
• 19% have electronic prescribing for all patients. (2% Africa to 39% North America).
• Antimicrobial usage reporting – 85% report antimicrobial usage (82%
expenditure, 73% DDD, 67% DDD/OBD) at hospital level.
– Less at speciality level
– 55% link these data to resistance rates
– 48% link to infection rates
Communication about AMS Most common
communication
method
Africa Asia Europe North
America
Oceani
a
South
America
Empiric guidelines booklet booklet intranet intranet intranet staff
meetings
Directed guidelines Booklet /
intranet intranet intranet intranet intranet
staff
meetings
Surgical
prophylaxis
guidelines
booklet intranet intranet intranet intranet booklet
Antibiograms
(hospital resistance
map)
staff
meetings intranet
staff
meetings intranet intranet
staff
meetings
Antimicrobial usage Booklet /
staff
meetings
staff
meetings
staff
meetings
staff
meetings
staff
meetings
staff
meetings
Learning points
from incidents
staff
meetings
staff
meetings
staff
meetings
staff
meetings
staff
meetings
staff
meetings
Formulary booklet intranet intranet intranet intranet Booklet
/newsletter
Marked differences between higher & lower-income
continents
Education of staff on AMS • 89% of hospitals educated their healthcare staff • 96% of hospitals educated their senior and trainee doctors
– face to face training (trainees 68% and seniors 46%)
– written information (45% and 35% respectively) at induction
– short courses were provided for trainees (31%) and seniors (27%)
• Small number of hospitals did not educate senior doctors (6%) or trainee doctors (2%).
• Less than 25% had mandatory updates every one or two years.
• Nurses received less education, 27% face to face and/or 16% given written information at induction, 21% provided short courses and 15% received no specific education. Only 12% had mandatory updates.
• 94% educated pharmacists (mainly at induction): 43% face to face and/or 25% written information, 22% short courses.
• Few centres (17% or less) used e-learning across the different staff groups.
Antimicrobial Audits
Audit % of
hospitals Most common freq
Any antimicrobial
audit 80%
Point prevalence 68% Yearly > never
Surgical prophylaxis 71% Monthly >> yearly =
never
Cultures before antibiotics 41% Never > yearly
Compliance to guidelines 74% Yearly > monthly > never
Outcome of day 3 review 43% Never >> monthly
Duration on Rx 64% Never > monthly
Indication on Rx 66% Never > monthly
Infection care bundles 56% Never > monthly
Audit own practice 42% Never >> yearly
Glycopeptide /
aminoglycoside monitoring 51%
Never >> monthly >
yearly
Time to 1st dose in sepsis 35% Never >> monthly =
yearly
Formal review of ASP by 37%
80%
86%
65%
96%
71%
58%
20%
14%
35%
4%
29%
42%
0% 20% 40% 60% 80% 100%
direct expenditure (87)
usage of broad spectrum agents (96)
length of stay / mortality metrics (40)
inappropriate prescribing (80)
healthcare acquired infections (66)
antimicrobial resistance (67)
No benefit shown Positive benefit shown
• Despite inherent limitations (e.g.
response bias, convenience
sampling), this survey suggests AMS
can reduce antimicrobial resistance
and expenditure
• This survey should encourage a
strategy to promote worldwide
Antimicrobial Stewardship
Programmes.
Conclusion
• To all who took a time to complete the survey
• ESCMID-ESGAP, ISC-AMS & UKCPA Infection Management Group members who tested and refined the survey.
– Karin Thursky, Amani Alnimr, Wendy Lawson, Shaheen Mehtar, Wattal Chand, Jim Hutchinson, Barry Cookson & many more
• Wider distribution
– Jason Newlands, Tracey Guide, Chris Jay, Sean Egan, Antony Zorzi, Diane Jacobsen & many more
Thank you
The antimicrobial
management / stewardship
teams: Global perspectives Philip Howard
Consultant Antimicrobial Pharmacist
Twitter: @AntibioticLeeds