training for antimicrobial stewardship programmes in hospitals under a very high magnification of...
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TRAINING FOR ANTIMICROBIAL STEWARDSHIP PROGRAMMES IN
HOSPITALS
Under a very high magnification of 50,000x, this scanning electron micrograph (SEM) shows a strain of Staphylococcus aureus bacteria taken from a vancomycin intermediate resistant culture (VISA). CDC/ Matthew J.
Arduino, DRPH Photo Credit Janice Haney Carr http://phil.cdc.gov/phil/details.asp
Purpose and specific objectives
Raise awareness and build capacity to:• improve patient outcomes – reduce morbidity
and mortality from infection• develop and implement antimicrobial
stewardship programmes (AMS) in hospitals• improve the use of antimicrobials• contain and prevent emergence of
antimicrobial resistance (AMR)
Training outcomes: Addressing international health security
• Recognise the importance of the emergence of AMR as an international heath security issue.
• Recognise the need for LOCAL ACTION through AMS in hospitals
• Recognise that AMS programmes contribute to addressing the emergence of AMR.
Training outcomes: Antimicrobial stewardship
• Recognise the need for, the role and function of, and membership of, a multidisciplinary team approach
• Understand the essential functions of AMS• Describe the components of an AMS
programme• Identify options for implementation
Training outcomes: Leadership
• Understand the role of hospital administration in sponsoring and supporting the establishment of AMS programmes
• Participants will commit to take the overall accountability for antimicrobial management and control and ensure that an antimicrobial stewardship programme is developed, implemented, and outcomes are monitored and evaluated
Training outcomes: Action plan
• Able to use the toolkit and checklist(s) to undertake an assessment / situational analysis of respective current hospital status
• Develop an implementation strategy• Share experiences.
SESSION ONE:THE ANTIMICROBIAL RESISTANCE EMERGENCY
This illustration depicts a three-dimensional (3D) computer-generated image of a cluster of drug-resistant Campylobacter bacteria, which were arranged in a mass of curly-cue shaped organisms. The artistic recreation was based upon scanning electron micrographic imagery. CDC/ Melissa Brower http://phil.cdc.gov/phil/details.asp
The antimicrobial resistance emergency
• What is the problem with antibiotic resistance?• How does the use of antibiotics contribute to the
problem?• Why promote the prudent use of antibiotics?• How do we promote prudent use of antibiotics?
After this session, the participants will have a greater awareness of why controlling the use of antibiotics is important for patient safety, effective health care and for health budgets.
What is antimicrobial resistance (AMR)?
• Medicines for treating infections lose effect because the microbes change:– mutate– acquire genetic information from other microbes to develop resistance
• AMR is a natural phenomenon accelerated by use of antimicrobial medicines. Resistant strains survive and aggregate.
Types of AMR
1. Antibacterial resistance (e.g. to antibiotics and other antibacterial drugs)
2. Antiviral resistance (e.g. to anti-HIV medicines)
3. Antiparasitic resistance (e.g. to anti-malaria medicines)
4. Antifungal resistance (e.g. to medicines used to treat Candidiasis)
Selection of resistant bacteria
http://www.reactgroup.org
Antimicrobial resistance threats
• Methicillin-resistant Staphylococcus aureus (MRSA)
• Carbapenem-resistant Enterobacteriaceae (CRE)
• Extended-spectrum beta-lactamase-producing Enterobacteriaceae (ESBL)
• Multidrug resistant Salmonella• Multidrug resistant Pseudomonas• Neisseria gonorrhoeae
• Clostridium difficile• Vancomycin-resistant enterococci
(VRE)• Streptococcus pneumoniae • Mycobacterium tuberculosis• Influenza Virus• Plasmodium falciparum• Human Immunodeficiency Virus (HIV)• Candida and other fungal infectionsCenters for Disease Control and Prevention. Antibiotic resistance threats in the United States 2013.
http://www.cdc.gov/drugresistance/pdf/Detect-Protect-against-AR.pdf
Why do we need to address AMR?
• Resistance to first-line medicines leads to– use of second- or third-line drugs
• less effective, more toxic, and more costly
• As more resistance is acquired, we are eventually left without any effective drug therapies
Why do we need to address AMR?
• AMR – negative impact on patient outcomes – major threat for patient safety – increases health expenditure– loss of options for common infections
• People are dying from these resistant pathogens
AMR: mortality impactDeaths (%)
Outcome (# studies) Resistant Not resistant
RR (95% CI)
Escherichia coli resistant to: 3rd gen. cephalosporins
Bacterium attributable mortality (n=4)
23.6 12.6 2.02 (1.41 to 2.90)
Fluoro-quinolones
Bacterium attributable mortality (n=1)
0 0
Klebsiella pneumoniae resistant to: 3rd gen. cephalosporins
Bacterium attributable mortality (n=4)
20 10.1 1.93 (1.13 to 3.31)
Carbapenems Bacterium attributable mortality (n=1)
27 13.6 1.98 (0.61 to 6.43)
Staphylococcus aureus resistant to: Methicillin (MRSA)
Bacterium attributable mortality (n=46)
26.3 16.9 1.64 (1.43 to 1.87)
World Health Organization (2014). Antimicrobial resistance. Global report on surveillance
increased risk of death
AMR: mortality and economic impact
50 deaths per million 540 deaths per million 77 deaths per million
AMR: economic impact
* U.S. dollars ** Yeung, S. et al. 2004. Antimalarials Drug Resistance, Artemisinin-based Combination Therapy, and the Contribution of Modeling to Elucidating Policy Choices. Am J Trop Med Hyg.71(Suppl. 2): 179-86. *† Revenga, A. et al. 2006. The Economics of Effective AIDS Treatment: Evaluating Policy Options for Thailand. Washington, DC: The World Bank. ‡ http://www.upmc-cbn.org/report_archive/2006/11_November_2006/cbnreport_111006.html § This is the cost for medicine provided through the Green Light Committee (GLC).
Disease First-Line Cost (USD*)**
Second-Line Cost (USD*)
Increase
HIV/AIDS*† $482/patient/year $6,700/patient/year 14 fold increase
TB‡ $20/course $3,500/course§ 175 fold increase
Malaria**
$0.10–0.20/adult course
(chloroquine/ sulfadoxine-pyrimethamine)
$1.20–3.50/adult course
(artemisinin-based combination therapy)
6-35 fold increase
increased cost
AMR develops quickly
http://www.cddep.org/sites/cddep.org/files/resistance_timeline.png
New antibiotics are scarce
World Health Organization (2014). Antimicrobial resistance. Global report on surveillance infographic
Factors that contribute to AMR
Key factors that contribute to the emergence and spread of AMR include:• poor hygiene and infection control• high population density• inappropriate antimicrobial prescribing by health
providers • inappropriate self-medication by patients• poor compliance• antimicrobial overuse in agriculture/livestock
industries – farming/aquaculture
Inappropriate antibiotic use drives AMR
Inappropriate antimicrobial prescribing in the Western Pacific region:• CHINA: 43% paediatric pneumonia treatment is
inappropriate2
• MALAYSIA: high levels of antibiotic use that are non-compliant to guidelines3-4
• VIETNAM: 30% antimicrobials unneccesary5
• AUSTRALIA: 20% hospital prescriptions do not follow treatment guidelines6
• USA: 50% antibiotics in hospitals are inappropriate1
Community acquired infections
Herman Goossens, Marc J W Sprenger, Community acquired infections and bacterial resistance, BMJ VOLUME 317 5 SEPTEMBER 1998 www.bmj.com
Hospitals and AMR
Developing institution-based AMR containment strategies is important because:• Patients with hospital-acquired infections have higher morbidity
and mortality than those without AMR pathogens• Hospitals contribute to the emergence of resistant bacteria• Hospitals amplify resistance, since the bacteria can spread
quickly among patients• Patients who acquire resistant infections in hospitals have the
potential to disseminate resistant bacteria into their homes and communities
• Hospitals consume a disproportionate share of healthcare budgets in developing countries
Examples (1)
• Multidrug-resistant tuberculosis (MDR-TB) and extensively drug resistant tuberculosis (XDR-TB)– In early 2006, an extensively drug-resistant TB (XDR-TB)
strain (resistant to 3 of the 6 classes of second-line drugs) killed 52 of 53 individuals with identified cases in South Africa. These patients with resistant (and untreated) TB had opportunity to spread this disease to others and XDR-TB has since been identified in all regions of the world.
• The first-line pharmaceutical treatment (chloroquine) for malaria is no longer effective in 81 of the 92 countries where malaria is a major health problem
Examples (2)• Penicillin has substantially lost its effectiveness against
pneumonia, meningitis, and gonorrhoea in many countries– Penicillin and erythromycin resistance is an emerging problem in
community-acquired S. pneumoniae in Asia, Mexico, Argentina, and Brazil as well as in parts of Kenya and Uganda.
– Widespread resistance of N. gonorrhea has necessitated the replacement of penicillin and tetracycline with more expensive first-line medicines, to which resistance quickly emerged. In the Caribbean and South America, azithromycin resistance was found in 16–72 percent of isolates in different locations, resulting in the recommendation that this medicine in turn be replaced by ceftriaxone, spectinomycin, or the quinolones. The high cost of other options, however, such as third-generation cephalosporins makes their use prohibitive in many developing countries.
Examples (3)
• 80% Staphylococcus aureus isolates in US are penicillin-resistant and 32% are methicillin-resistant
• Exemplar of international spread: New Delhi Metallo-beta-lactamase-1 (NDM-1) producing Escherichia coli; which spread from India to many countries including the UK, Sweden, Austria, Belgium, France, Netherlands, Germany, the USA, Canada, Japan, China, Malaysia, Australia, and Korea
• Multidrug-resistant S. enterica serotype paratyphi (S. paratyphi) infections have been associated with an increase in the reported severity of disease and emerged as a major public health problem in Asia
Summary session one
• AMR is an increasingly serious threat to global public health that requires action across all government sectors and society.
• AMR is present in all parts of the world. New resistance mechanisms emerge and spread globally.
• Infections with antibiotic resistant bacteria increase:– morbidity and mortality– length of stay in hospitals– associated healthcare costs.
SESSION TWO:ANTIMICROBIAL STEWARDSHIP
Carbapenem-Resistant Enterobacteriaceae. Centers for Disease Control. Melissa Dankel. 2014. Photo credit:James Gathany
Antimicrobial stewardship
This session will address the following key questions:• Why do we need Antimicrobial Stewardship
(AMS) Programmes?• What is an AMS Programme?• What are the benefits of an AMS program?• How should AMS programs be established?
Antimicrobial stewardship
This session will discuss in detail:• Core structures of an AMS programme• Core functions of an AMS programme• How to plan and implement an AMS programme
After this session, participants will have an understanding of how AMR can be addressed in hospitals through the establishment of effective AMS programmes.
Keys to success: Governance• Effective antimicrobial stewardship AMS programs
– improve the appropriateness of antimicrobial use– reduce patient morbidity and mortality– reduce institutional bacterial resistance rates– may reduce healthcare costs
• The overall accountability for hospital antimicrobial management lies with the hospital administration. – is responsible for ensuring an AMS programme is
developed and implemented, and outcomes are evaluated – management support and collaboration is essential to the
success of AMS teamsDuguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals 2011. Sydney, NSW: Australian Commission on Safety and Quality in Health Care. 2011
Keys to Success: Leadership
• From the top: hospital administration• From opinion leaders: influential
physicians or surgeons• From system: Drug and Therapeutics
Committee, Pharmacy, Microbiology, Infection Control
Keys to Success: Teamwork
• International literature strongly suggests that the most effective approach to AMS involves multidisciplinary AMS teams with the responsibility and resources for implementing a programme to improve antimicrobial prescribing.
• Teams are more likely to be effective in leading and sustaining changes in clinical practice if they have access to, and training in, effective quality improvement methods and knowledge.
Duguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals 2011. Sydney, NSW: Australian Commission on Safety and Quality in Health Care. 2011
Keys to Success: Proven Strategies• Successful hospital stewardship programs include a range of
interventions including – education and behaviour changes strategies– audit and feedback– pre and post prescription; restrictive and directive
strategies• Similarly, in the community, multifaceted approaches
combining audit and feedback, interactive educational meetings, and educational outreach for patients and the public were more likely than single-strategy approaches to reduce inappropriate antibiotic use
David Y. Hyun, Adam L. Hersh, Katie Namtu, Debra L. Palazzi, Holly D. Maples, Jason G. Newland, Lisa Saiman, Antimicrobial Stewardship in PediatricsHow Every Pediatrician Can Be a Steward JAMA Pediatr. 2013;167(9):859-866. doi:10.1001/jamapediatrics.2013.2241
Why AMS is essential in hospitals
The development of antibiotic resistance strains in hospitals is intensified because:• high level of antibiotic use• concentration of patients with multiple pathogens • close proximity of patients and multiple health care worker
contacts - patient to patient transfer of organisms and pathogens
• immunosuppressed patients more vulnerable• transfer of patients infected with resistant organism into
hospitals from the community, another facility or internationally
Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2006;42 Suppl 2:S90-5
Establishing AMS programmes
PATIENTMicrobiology
Clinical Pharmacist
Antibiogram
Nursing Leadership
Education
Physicians Timely and appropriate antibiotic management
Infection Control
Hospital Leadership
Antimicrobial stewardship program goals
• To improve patient outcomes, i.e. reduce morbidity and mortality from infection
• To prevent or slow the emergence of antimicrobial resistance
• To reduce adverse drug events, including secondary infections related to inappropriate antibiotic use
• To reduce health care–related costsOhl CA, Dodds Ashley ES. Antimicrobial Stewardship Programs in Community Hospitals: The Evidence Base and Case Studies. Clinical Infectious Diseases. 2011;53(suppl 1):S23-S8.
What is antimicrobial stewardship?
Coordinated approach to improve the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen:• right choice of antibiotic• right route of administration• right dose• right time• right duration• minimise harm to the patient and future patients.
The fundamental challenge
Reducing unnecessary use of antimicrobial therapy and broad spectrum drugs (which contribute to the development of antimicrobial resistance)
Providing timely and appropriate empirical broad spectrum antimicrobial therapy for individual patients (consistently shown to improve outcomes)
Core strategies: Behaviour change
• Educate / Persuade– changing knowledge and attitudes about
antimicrobial use– providing access to locally appropriate standard
treatment guidelines • Audit / Feedback
– active educational measures, e.g. audit and feedback to support implementation of guidelines
Duguid M and Cruickshank M (eds) (2010). Antimicrobial stewardship in Australian hospitals, Australian Commission on Safety and Quality in Health Care, Sydney
Core strategies: Restrict/Direct
• Restrict / Direct– Pre-prescription strategies
• restrict availability of selected antimicrobial agents unless criteria are met and formal approval granted
– Post-prescription strategies• review antimicrobial prescriptions and provide expert
advice with a focus on broad-spectrum empirical therapy to promote streamlining or discontinuing therapy, as indicated, on the basis of investigation results and clinical response.
Duguid M and Cruickshank M (eds) (2010). Antimicrobial stewardship in Australian hospitals, Australian Commission on Safety and Quality in Health Care, Sydney
Fundamental attributes of AMS programmes
• Leadership– Must have executive management leadership
• Multidisciplinary– Must have multidisciplinary support
• Customised / locally adapted– Must be institution specific or bespoke and tailored to individual
institutional needs• Patient-focussed
– Must be focussed on the goal of achieving the best outcomes for patients• Multifaceted
– Must implement a combination of interventions customised to specific health care needs which are affordable and achievable within available resources
Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2006;42 Suppl 2:S90-5.
Establishing AMS programmes
PATIENTMicrobiology
Clinical Pharmacist
Antibiogram
Nursing Leadership
Education
Physicians Timely and appropriate antibiotic management
Infection Control
Hospital Leadership
AMS governanceHospital Executive
Clinical Governance
AMS Committee
AMSTeam
Drug and Therapeutics CommitteePatient or
Medication Safety
Committee
Infection Prevention &
Control Committee
Divisional Management
Medical Director
External Sites
Nursing Champions
Clinical Pharmacists
Antimicrobial Prescribers
Executive Level
Committee Level
Frontline Healthcare
http://www.cec.health.nsw.gov.au/__documents/programs/hai/quah/fact-sheet-ams-teams-and-committees.pdf
AMS Committee and AMS Team
• The AMS committee– consisting of
• the AMS team members• executive representatives• key stakeholders
– provides support and direction to the AMS program– ensures alignment with the wider healthcare strategy
• The AMS team consists of staff with regular, everyday duties to support the AMS program
http://www.cec.health.nsw.gov.au/__documents/programs/hai/quah/fact-sheet-ams-teams-and-committees.pdf
AMS Committee
Multidisciplinary:• Hospital administrator• Infectious diseases physician when available or opinion
leading prescriber• Pharmacist• Clinical microbiologist • Infection prevention & control professional• Nursing leadership• Hospital epidemiologist • Information systems specialist
AMS Team
• Infectious diseases physician when available or opinion leading prescriber
• Pharmacist• Clinical microbiologist • Infection prevention & control professional• Clinical nurse consultant or clinical nurse
educator
AMS Team options
http://www.cec.health.nsw.gov.au/__documents/programs/hai/quah/fact-sheet-ams-teams-and-committees.pdf
Accountability and leadership
Senior hospital management team must • Own and support AMS programmes• Allocate specific time and resources for AMS team to
implement and evaluate progress• Be realistic about what can be achieved initiallyAMS teams must have• Significant influence or ‘power’ in the hospital • Expertise• Credibility• Leadership
Drug and Therapeutic Committee
• Multidisciplinary decision making and advisory bodies to promote safe, effective, and economic use of medicines
• Key body to help preserve effectiveness of existing antimicrobials
Drug and Therapeutic Committee
• Develop, update and manage – antimicrobial formulary– policies on antimicrobial procurement and quality– antibiotic guidelines and protocols– policies to improve compliance with antibiotic
guidelines and protocols
Drug and Therapeutic Committee• Commission and support
– audits and evaluations of antimicrobial use– preservice and in-service education on rational use and
AMR– collection and management of antimicrobial
surveillance and resistance information for coordinated action with the Infection Control Committee
– education to patients on the use and abuse of antimicrobials and encouraging adherence
– pharmacovigilance activities for antimicrobials.
Partnership with Infection Control
The AMS Programme works in partnership with Infection Control to:• control the spread of antimicrobial resistance• optimise antimicrobial use
Paterson DL. The role of antimicrobial management programs in optimizing antibiotic prescribing within hospitals. Clinical infectious diseases: an official publication of the Infectious Diseases Society of America. 2006;42 Suppl 2:S90-5.
Infection prevention and control
What is antimicrobial stewardship?
Coordinated approach to improve the appropriate use of antimicrobials by promoting the selection of the optimal antimicrobial drug regimen:• right choice of antibiotic• right route of administration• right dose• right time• right duration• minimise harm to the patient and future patients.
AMS strategies — multifaceted
• Standard treatment guidelines• Essential medicines lists and formularies• Restriction and approval systems • Antimicrobial prescribing review• Audit and feedback• Selective reporting of susceptibility testing results• Education for prescribers, pharmacists and nurses• Drug use evaluation programs• Point-of-care interventions • Facility-specific antimicrobial susceptibility data
Antimicrobial policy
An authoritative and credible antimicrobial policy should be implemented and used as a base for AMS programmes. • The policy should include:
– endorsed standard treatment guidelines (STG) for using antimicrobial drugs
– the requirement to prescribe antimicrobials guided by the latest version of antimicrobial STG
– a list of restricted antimicrobials and the procedures for obtaining approval for these
– reference to the hospital’s policy on liaising with the pharmaceutical industry.
The antibiotic creed: MINDMe
*Specify duration therapy and advise to complete the prescribed course. Therapeutic Guidelines: Antibiotic, Version 14, Melbourne: Therapeutic Guidelines Ltd, 2010+ MINDME: This isn’t perfect – monotherapy is not what we strive for in some cases now – eg combination therapy is recommended for empiric severe sepsis, TB, HIV, rif/fusidic for MRSA etc This may be the wrong message for an area with HIV and TB as prevalent problems.
where appropriate +
Standard treatment guidelines• Standard Treatment Guidelines (STG) describe the preferred
medication, and non-pharmaceutical treatments, for common health problems; they guide providers in the selection of the most appropriate medicines
• Evidence-based, facility specific, and based on national guidelines and local susceptibility, standard treatment guidelines are a foundation stone to support good prescribing and antimicrobial use
• The aim of clinical guidelines is to improve treatment outcomes through changing practitioner knowledge, attitudes and behaviour, such that their practice accords with guideline recommendations
Changing attitudes
“It is more than just providing guidelines – it is about changing attitudes – increasing awareness of AMR – having people draw the link between their prescribing behaviour and the resistant pathogens they see. One needs to bring about an understanding of AMR as an issue, a culture of quality and safety …”
Buising, K. 2014
Essential medicines lists and formularies
• medicines deemed essential to satisfy health needs of the vast majority of patients
• consistent with standard treatment guidelines • support antimicrobial selection, use, and
effectiveness by eliminating unsafe and ineffective medicines
• allow the national EML and formulary to be adapted to a local context
• lead to cost effective medicines procurement and improved availability and use
Restrictions and approval systems
• prescribers prevented from accessing particular antimicrobial agents unless criteria are met and formal approval is granted by a nominated person
• approval may be required pre-prescription, or post-prescription within a specified time period (e.g. 48 hours).
• restrictive strategies require close collaboration with pharmacy, clinical microbiology and Infectious Diseases staff to be successful
Reserve antimicrobials
• restricted antimicrobials– limited to certain conditions and require approval -
phone/fax/electronic/• highly restricted or reserve antimicrobials
– require individualized approval from a nominated defined expert in treatment of infections
• The aim is to protect the remaining antimicrobials• There is some evidence that ‘rested’ antimicrobials
may be regaining strength
Antimicrobial restrictions
Antibiotic Policy, St Vincent’s Hospital, Sydney, Australia from Duguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals 2011. Sydney, NSW: Australian Commission on Safety and Quality in Health Care. 2011
Audit and feedback
Audit (practice review) and feedback is a proven and effective strategy to influence prescribing behaviour and an essential element of AMS• Post prescription review
– active review at 24-72 hours post prescription to check appropriateness and guide an individual case management
• Formal audit– Retrospective and often post discharge
Interactions with pharmaceutical industry
Interactions between medical professionals and the pharmaceutical industry may:• increase formulary-addition requests• affect prescribing practices possibly leading to
inappropriate prescribing behaviour, little patient benefit, and potential to promote AMR pathogens.
AMR surveillance
• to detect significant differences and shifts in susceptibility to antimicrobial drugs
• to achieve better results where epidemiological and microbiological efforts are effectively integrated
Drug quality assurance
• Treatment failure may result from antimicrobial resistance, but care should also be exercised to ensure treatment failure is not a result of loss of efficacy resulting from either fake drugs or degradation of once good quality drugs as a result of out of date or poor or inappropriate storage
Drug use evaluation
• Drug use evaluation (DUE) is a quality improvement activity which uses an ongoing cyclical process to improve quality use of medicines and health outcomes
1. Collect data
2. Evaluate
data
3. Feedba
ck evaluated data
4. Action
The iterative cycle of DUE includes:•measuring drug use•identifying drug use problems•developing a consensus approach•implementing strategies to improve drug use
AMS interventions
https://www.mja.com.au/journal/2013/198/5/prescribing-trends-and-after-implementation-antimicrobial-stewardship-program?0=ip_login_no_cache%3Ddcaee08cc16ceb2af76c4c4f56470055
Keys to success• Clear aims/objectives of agreed actions• High level management support• Strong multidisciplinary AMS team• Effective communication structures• Start with core evidence-based interventions• Monitor progress• Empower AMS users with integrated education and
feedback• Start slow. Progress one intervention at a time
AMS summary• AMS programs improve the appropriateness of antimicrobial use, reduce patient
morbidity and mortality, and reduce institutional bacterial resistance rates and healthcare costs.
• Overall accountability for development, implementation and evaluation of AMS programmes lies with the hospital administration.
• The support and collaboration of the hospital executive is essential.• AMS involves multidisciplinary teams with the responsibility and resources for
implementing a programme to improve antimicrobial prescribing.• Successful stewardship programs include a range of interventions :
– restrictive methods, such as requiring approval to prescribe an antimicrobial– review and feedback of current antimicrobial prescriptions – audit and feedback– standard treatment guidelines supported with active educational measures
Duguid M, Cruickshank M. Antimicrobial stewardship in Australian hospitals 2011. Sydney, NSW: Australian Commission on Safety and Quality in Health Care. 2011.
SESSION THREE:AMS ACTION PLANNING
http://antimicrobialstewardship.com/sites/default/files/styles/home_richmedia/public/hompage.jpg?itok=Q5FpEIio
http://www.tg.org.au/user-templates/interface-images/page/therapeutic-guidelines-logo.png
Interactive small group workshops • Participants will work in small groups to share knowledge and develop
individual implementation plans for their respective institutions.• Each small group will be tasked with addressing a set topic, e.g.
‘Establishment of core elements of hospital antibiotic stewardship programs’, and/or ‘Establishment of core members of the multidisciplinary antimicrobial stewardship team’.
• Participants will be encouraged to brain storm ideas, share experiences and then report back with challenges encountered, strategies, recommendations and lessons learnt. The session provides the opportunity to develop draft individual check lists and strategies for implementation as well as the potential for forging alliances between institutions for support assistance and knowledge sharing.
Situational Analysis
Participants will work in small groups to share knowledge and develop individual implementation plans for their respective institutions.Through situational analysis participants will define answers to the following key questions:• Where are we?• Where do we aspire to be?• What do we need to do to establish the basic
elements for an effective AMS programme?
1. ESTABLISHING CORE MEMBERSHIP OF MULTIDISCIPLINARY AMS TEAMS
• Participants are allocated into small groups. Possible allocation will by organisation/institution type, size, and classification.
• Individual groups will review the cases scenarios and the AMS team check list.
• Each member will complete individual institution specific team lists• The group collates the details and discusses:
– The most feasible and effective team in their context– Challenges in establishing the AMS team– Strategies developed to address challenges– Lessons learnt
• Each group prepares and provides a report back to the workshop.
AMS Committee options• Director of Clinical Governance AND/OR Hospital Executive• Infectious diseases (ID) Physician AND/OR Medical Microbiologist• AMS or Clinical Pharmacist AND/OR experienced pharmacist with
infectious diseases training• Infection control professional as Infection Prevention & Control
Committee Representative• Drug & Therapeutics Committee Representative• Nursing leadership• Hospital epidemiologist • Information systems specialist
AMS committees: option in smaller healthcare facilities
Hospitals may find they have access to some, but not all personnel required for an effective and comprehensive AMS Committee• smaller healthcare facilities may coordinate
AMS activities within their existing support networks through– Pooling resources– Teleconferencing etc.
AMS Team options
http://www.cec.health.nsw.gov.au/__documents/programs/hai/quah/fact-sheet-ams-teams-and-committees.pdf
2. ESTABLISHING CORE ELEMENTS OF HOSPITAL AMS PROGRAMMES
• Participants are allocated into small groups. Possible allocation will by organisation/institution type, size, and classification.
• Individual groups will review the cases scenarios and the AMS core elements check list.
• Each member will complete individual institution specific core elements lists
• The group collates the details and discusses:– The most feasible and effective AMS elements in their context– Challenges in implementing AMS elements– Strategies developed to address challenges– Lessons learnt
• Each group prepares and provides a report back to the workshop.
Where to from here?
• Five essential strategies– implementing clinical guidelines– establishing formulary restrictions– reviewing antimicrobial prescribing with
intervention and direct feedback– monitoring performance– ensure selective reporting of susceptibility testing
results
Further steps• Activities that may be undertaken depending on
local priorities and available resources– educating prescribers, pharmacists and nurses about
AMR and antimicrobial prescribing practice– Using point-of-care interventions including
• streamlining or de-escalation of therapy• dose optimisation• parenteral-to-oral conversion
– IT – electronic prescribing with clinical decision support– Publishing facility-specific antimicrobial susceptibility
data