4/17/2013. Antimicrobial Stewardship: pengalaman di Belanda. Henri A. Verbrugh MD PhD. number of emerging infectious diseases events per decade

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1 Antimicrobial Stewardship: pengalaman di Belanda Henri A. Verbrugh MD PhD KE Jones et al., Nature 2008 EID is disease caused by a pathogen that has recently evolved or entered the human population for the first time, or which has occurred previously, but is increasing in incidence or expanding into an area in which it has not previously been reported, or which has significantly changed its pathological or clinical presentation. number of emerging infectious diseases events per decade KE Jones et al., Nature

2 number of emerging infectious diseases events per decade KE Jones et al., Nature 2008 number of emerging infectious diseases events per decade KE Jones et al., Nature 2008 exposure selection expansion sensitive population resistant clones/genes outbreak, epidemic, pandemic 2

3 exposure selection expansion sensitive population resistant clones outbreak, epidemic, pandemic Antibiotic control Infection control exposure selection expansion sensitive population resistant clones outbreak, epidemic, pandemic Antimicrobial Stewardship program Infection control Stewardship: Steward comes from old English language: Stig and weard = Hall and keeper : a person who manages another person s affairs or property MacDougall & Polk, Clin Microbiol Rev 2005;18:638 3

4 Antimicrobial Stewardship: An ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to improve patient outcomes, ensure costeffective therapy, and reduce adverse sequelae of antimicrobial use including antimicrobial resistance... MacDougall & Polk, Clin Microbiol Rev 2005;18:638 Goals of antimicrobial stewardship programs: optimize favorable clinical outcomes reduce health care costs minimize toxicity minimize emergence & spread resistance Goals of antimicrobial stewardship programs: optimize favorable clinical outcomes reduce health care costs minimize toxicity minimize emergence & spread resistance 4

5 Goals of antimicrobial stewardship programs: minimize emergence & spread resistance optimize favorable clinical outcomes reduce health care costs minimize toxicity antimicrobial stewardship core team: infectious diseases physician (internist/pediatrician) infectious diseases trained clinical pharmacist clinical/medical microbiologist information technology specialist infection control professional hospital epidemiologist Antimicrobial stewardship program: basic requirements organize a formal mandate from medical staff and hospital administration leadership collaborate with infection control team, policy by pharmaceutical therapeutics committee, execution by A-team surveillance antimicrobial use & resistance 5

6 Antimicrobial stewardship program core activities: prospective audit & intervention (A-I) formulary restriction (A-II) pre-authorization (B-II) Antimicrobial stewardship program supplementary activities: education (A-III) guidelines on use (A-I) antimicrobial cycling (C-II) antimicrobial order forms (B-II) combination empiric therapy (A-II) streamlining (A-I, A-II) dose optimization (A-II) 6

7 170 hospitals in 32 European countries survey 2001 Key indicators for stewardship: 1] drugs and therapeutics committee? 2] written antibiotic formulary? 3] formulary with list of restricted antibiotics? 4] written antibiotic policy? 5] antibiotic committee? 6] strategic goal to improve drug use? 170 hospitals in 32 European countries survey 2001 Key indicators for stewardship: 1] drugs and therapeutics committee?...86% 2] written antibiotic formulary?...77% 3] formulary with list of restricted antibiotics?...66% 4] written antibiotic policy?...57% 5] antibiotic committee?...52% 6] strategic goal to improve drug use?...51% 7

8 170 hospitals in 32 European countries survey 2001 Key indicators for stewardship: 1] drugs and therapeutics committee?...86% 2] written antibiotic formulary?...77% 3] formulary with list of restricted antibiotics?...66% 4] written antibiotic policy?...57% 5] antibiotic committee?...52% 6] strategic goal to improve drug use?...51% 22% did not have antibiotic committee nor a written antibiotic policy! 8

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10 Casus Belanda low levels of antibiotic use and resistance: how come??? Critical success factors Netherlands: summary: reliable clinical microbiological services for id/ast & surveillance pathogens & resistance (typing) clinical microbiologists & ID clinicians in the lead locally, provide expert advice to fellow clinicians on a daily basis evidence and consensus based local guidelines for antibiotic use and infection control (committees) 10

11 Critical success factors Netherlands: summary: empowerment of guidelines by local & national authorities national professional societies in the lead in providing framework for control of antibiotic use (SWAB) and infection prevention (WIP) competence to collaborate accross disciplinary boundaries recent development in the Netherlands: the A-team large outbreak K.pneumoniae OXA-48 in Maasstad hospital in Rotterdam 2011 Health inspectorate asked SWAB to come up with a strategy to combat emergence of resistance better SWAB position paper 2012: regard antimicrobial agents as separate class of medicines: they have profound ecological effects, should be strictly controlled (like narcotics, cytostatic agents) every hospital needs an antibiotic control team (A-team) and an antibiotic stewardship program if we do have: traffic control gun control narcotics control fire control environment control infection control.. 11

12 we certainly should also have many roadblocks remain, but many roadblocks remain, but you can always call me!!! 12