Anikó Farkas , MD infectious disease physicianUniv. Teaching Hospital Josa András , Nyíregyháza

Infection management – why a promising theme for clinical audit?

introduction

Find personal and profession group motivations

Involvement of infection control team

Guarantee of successful audit

Management support

Enthusiasm of audit team

Good planning including communication with all of the

involved

Difficulties to overcome

1-2.: theme selection and objectives

Involve infection control nurses – in surgical

prophylaxis audit - (or medicine dispenser

nurses, pharmacist, microbiologist) and adapt

nosocomial data logger for clinical audit

Try to find connection points to ongoing

obligatory nosocomial surveillance or previous

voluntary surveys, studies, projects

Especially fruitful if audit is planned before

update is due in medical and nursing protocols

Objectives

be informed about common antibiotic misuse

(too low or too high doses, mode or length of

administration) possible sources: infectious disease consultant, icu personnel

Get data about and evaluate critical points of

patient care processes /outcomes,

specify/gather best practices (consensus)

Involve anaesthesia & infection control team into

quality improvement project

PATH: Performance Assessment Tool for quality improvement in Hospitals

designed by the WHO Regional Office for Europe to support hospitals in defining quality improvement strategies by

1) identifying areas for further scrutiny and

2) sharing best practices. This is done by providing tools for performance assessment, supporting hospitals questioning their own results and translating them into actions for improvement and by enabling collegial support (my contribution: infecion expert, presenter, peer) and networking.

Antibiotic resistance – a patient safety issue

• Trends are dramatic

• inappropriate use of antibiotics contributes to the situation

• Hospitals are obliged to use efficient control strategies

• European Antibiotic Awareness Day – a campaign to promote prudent use of antibiotics -

18th November every year

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2002 2007

Methicillin-resistant Staphylococcus aureus(MRSA), blood and spinal fluid

No data

<1%

1-5%

5-10%

10-25%

25-50%

>50%

Source: European Antimicrobial Resistance Surveillance System (EARSS), 2008.

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Postoperative surgical infections – a significant patient safety issue

• Key process in patient care (potentialy preventable)

• Frequent bad practice

• Has a significant impact on patient and cost increase

• Available evidences for effective prevention

• Available benchmarking

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Plan clinical audit (infection

therapy)

1. Frequent and severe (hospital stay, morbidity, mortality)

2. Department, where most of the patients are treated.

3. Involve departements, where infectious disease

consultation is rare.

4. Gather information from every critical point in infection

management: indication, dosage, dosage intervals,

change, stop, clinical decision support by monitoring

parameters, microbiology

3-4. audit criteria and test

1. Appropiate agent

2. Optimal amount

3. intravenously

4. Before surgical incision but within 1 hour

5. Single shot, if repeted, finished within 24 hr

Best result: administered by anaesthesia staff

Data sources: anestetic record, perioperative

recordings, medication sheet

What is misuse of antibiotics?

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Misuse of antibiotics can include any of the following18:

• 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.

18. Gyssens IC, van den Broek PJ, Kullberg BJ, Hekster Y, van der Meer JW. Optimizing antimicrobial therapy. A method for antimicrobial drug use evaluation. J Antimicrob Chemother. 1992 Nov;30(5):724-7.

Appropriate infection management involves as well

• Good prescribing• Good administration practice (appropiet solvent,

periodicity, infusion duration• Regular eveluation of diagnostic accuracy, reaction or

adverse reaction of the whole patient• Infection sanation as influence of antibiotics (including:

transitional and definitive change of attendant physician)• consultations : laboratory, imaging, infectious disease

physician, surgeon, pharmacist

Antibiotic stewardship

English directives: 1.Emergency situations

Begin with broad spectrum antibiotics within 1 hour

Ahead taken micriobiology specimens

2. Obligatory documentation – patient handover

• Clinical diagnosis or suspicion of infection

• Antibiotics doses and periodicity

• Planned duration

3.Chek of indication after 2 days:

Clinical dg, therapy cornerstones, duration

• stop (infection excluded)

• Better, data confirmed dg hypothesis – forward ahead

• Better – can switch to oral therapy

• Doubtful results or resistant bacteria- change

5-6. training and collection of data

At surgical antibiotic prophylaxis audit infection control

nurses doesn’t needed extra training

Form of data collecting: Sepsis: prospektive, lower

resiratory tract infections: at exmission, every exmitted

patient involved until 40 pts/departement reached or 3

month’s duration

8 departments, 10-58 data sheet, 246 in all.

pneumonia: 97 , bronchitis: 61 , mikrobiologic conformed

sepsis: 88

Training – new antibiotic

formulary

01/01/2013 new formulary (E 7-09/00-10

3 meeting had been organized for infection control

doctors and link nurses from every department. It was a

must to participate. There had been announced

complience will be controlled. Form of it had been

clinical audit. Resident doctors had been involved

7. Data analysis - standards

Prophylactic use: 90 %

Therapeutic antibiotic administration: 70-80%

Recommended subgroup analysis:

elective and emergency operations,

immundeficiency

Audit evaluation

planning

At comprehensive hospital audits questions must be limited at 10

Some points can be used in internal audit

Benchmarking values

We have created a significant database for further evaluations in a 5-

10 years perspective

For further planning of clinical audits

Clinical stuff and infection control committee must be involved at earlier

phases and a pilot study needed.

8-9. Root-cause analysis, feed-

back

Ertapanem prohibited

Imipenem preferred over meropenem (target: 20 %)

meg

Ceftriaxon preferred over cefotaxim in pneumonia

For parenteral use levofloxacin preferred over

moxifloxacin

Guidance of Institutional Infection Control and

Antibiotics Committee

10. Implementation of

modifications

During clinical audit/infectology bedside visit or telephone

call

Haemocultura positive cases are stewarded

Plan for bronchitis, pneumonia cases complience control

(levofloxacin, moxifloxacin, ceftriaxon, cefotaxim) or

following monthly consumption of critical antibiotics

Introduce in more departments periodical infectious

disease physician visits

11-12. plan repeated audits

Pneumonia/ antibiotic /th duration

Haemocultura surveillance and control

Toxic or expensive antibiotics

Str. pyogenes, S.aureus

Emerging infections: mediastinitis, endocarditis,

osteomyelitis, abscessus cerebri, sepsis

Combined antibiotic therapy

Nosocomial infections

Infections by mutiresistent bacteria

Contents1. SURGICAL ANTIBIOTIS PROFILAXIS (9 SPECIFICATIONS - 21 guidance)

2. Respiratory infections (5 clinical entity - 15 guidance)

3. SZEKVENCIÁLIS ANTIBIOTIKUM TERÁPIA

4. ENTERAL INFECTIONS (13 PATHOGENS - 13 guidance)

5. URINARY TRACT INFECTIONS (6 specifications - 6 guidance)

6. SEPSIS (13 clinical situations - 13 guidance)

7. ANTIBIOTICS IN NEUTROPÉNIÁ (3 guidance)

8. MRSA DEKOLONISATION (1 ajánlás)

9. EMERGENCY AND ICU GUIDELINE (15 CLINICAL SITUATIONS – 15 guidance)

A. Gram pozitív baktéria sensitivity inpatients (5 baktérium)

A. Gram negatív baktéria sensitivity inpatients (8 baktérium)

B. Priority in targeted antibiotic administration by bacteria and location of infection (18 groups - 55 guidance!)

C. Antibiotics daily costs (58 drugs - 20 groups)

Az antibiotikum alkalmazás helyes gyakorlata - (E 7-09/00-10 sz. előírás)

Emergency unit antibiotics protokol

Multifaceted strategies can address and decrease antibiotic resistance in hospitals

• Antibiotic prescribing practices and decreasing antibiotic resistance can be addressed through multifaceted strategies including:29-31

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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29. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4):CD003543.

30. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.

31. Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia. Clin

Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.

About European Antibiotic Awareness Day

• European Antibiotic Awareness Day is marked across Europe around 18 November.

• European Antibiotic Awareness Day provides a platform and support to national campaigns about prudent antibiotic use in the community and in hospitals.

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Thank you for your attention