Antimicrobial Stewardship-way forward Dr. Sonal Saxena Professor Lady Hardinge Medical College New Delhi
Lets save what we have!
What is Antibiotic stewardship? Optimal selection, dose and duration of an antibiotic resulting in the cure or prevention of infection with minimal unintended consequences to the patient including emergence of resistance, adverse drug events, and cost
Goals of Antibiotic stewardship Optimize patient safety:4ds Control costs Improve clinical outcome Reduce morbidity/mortality/hospital stay/adverse effects Dellit TH, et. al. Clin Infect Dis. 2007;44:159-177
Core Elements of Hospital Antibiotic Stewardship Programs Leadership Commitment: Dedicating necessary human, financial and information technology resources. Accountability: Appointing a single leader responsible for program outcomes. Drug Expertise: Appointing a single pharmacist leader responsible for working to improve antibiotic use. Action: Implementing at least one recommended action, such as systemic evaluation of ongoing treatment need after a set period of initial treatment (i.e. a ti ioti ti e out after 48 hours).
Tracking: Monitoring antibiotic prescribing and resistance patterns. Reporting: Regular reporting information on antibiotic use and resistance to doctors, nurses and relevant staff. Education: Educating clinicians about resistance and optimal prescribing.
Stewardship approaches Front end approach Physician without authority writes order for restricted drug Order arrives in pharmacy Pharmacist informs physician that the drug is restricted/non formulary Approval or alternative antibiotic selected Back end approach Physician writes order Antibiotic is dispensed Review of antibiotic Prescriber contacted and explained Antibiotic changed/continued
Strategies of Antibiotic stewardship Core Strategies Supplemental Strategies Formulary restrictions and preauthorization* Prospective audit with intervention and feedback* Multidisciplinary stewardship team* Streamlining / timely de-escalation of therapy* Dose optimization* Parenteral to oral conversion* Guidelines and clinical pathways* Antimicrobial order forms Education Computerized decision support surveillance Laboratory surveillance and feedback Combination therapies Antimicrobial cycling * Strategies with strongest evidence and support by IDSA. Dellit et al. Clinical Infectious Diseases 2007;44:159-77
Key Support in stewardship program Clinicians and department heads: As the prescribers of antibiotics Infection preventionists and hospital epidemiologists: coordinate facility-wide monitoring and prevention of healthcare-associated infections and can readily bring their skills to auditing, analyzing and reporting data. Assist with monitoring and reporting of resistance educating staff and implementing strategies
Quality improvement staff Information technology staff : are critical to integrating stewardship protocols into existing workflow. Nurses: Can assure that cultures are performed before starting antibiotics. Can review medications as part of their routine duties and can prompt discussions of antibiotic treatment, indication, and duration.
Implementing antimicrobial stewardship program Local flora and resistance patterns Estimate resources available Determine priority & planning interventions Engage decision makers and antibiotic prescribers Engage hospital administration Generate working plan Implement program
Other considerations Size of the hospital and identify the clear authority for the program. Also, before institutional interventions are made, it is important to discuss the scope of authority and obtain administrative approval. Infectious diseases pharmacists need oversight with physi ia s i ol e e t in the program, so when interventions are made, they are evidencebased and supported by the medical staff.
Convincing seniors/administration to implement ASP. Recruiting staff or adding extra work on existing staff. Creating more communication networks via net (IT) or personal Education and motivation to be made ongoing tool
Implement Policies Implement policies that support optimal antibiotic use. Avoid implementing too many policies and interventions simultaneously; always prioritize interventions based on the needs of the hospital as defined by measures of overall use and other tracking and reporting metrics.
Components of AMSP Written document Team Data Infection control Data analysis Strategies Prescription guidelines Prescription audit/feedback Implementation outcomes Prescription autonomy
AMSP document Clarity is the key programme to be understood/implemented by all hospital personnel Co er all aspe ts of the hospital s AMSP programme. ie, infectious conditions, prescriptions required for antimicrobials hospital drug formulary/essential antibiotic list
AMSP team Large hospitals separate teams for each of the major clinical departments, to push the programme Chaired respective HODs
Building ASP team 1. 2. 3. 4. 5. 6. ID consultant preferably with ID training Pharmacist Microbiologist Epidemiologist Infection control team member Administration representative
Role of microbiologist Evolving antibiotic policy Can guide the proper use of tests and the flow of results. Availability of rapid, accurate quality assured antibiotic test results. Creating readily usable and coherent antibiotic resistant data Can also guide empiric therapy by creating and interpreting a facility cumulative antibiotic resistance report (antibiogram). Creating communication network with ASP team and prescribers to ensure that lab reports present data in a way that supports optimal antibiotic use.
Using Rapid Diagnostic Tests to Optimize Antimicrobial Selection in Antimicrobial Stewardship Programs
Antimicrobial prescription guidelines Department wise for various conditions Involved the HOD and respective department member Regular review/update most current developments Treatment alogrithms
Prescription Autonomy Surveys at regular intervals Address issues effectively
Strategies to follo CustomizedLocal requirements Antimicrobial Resistance Data Cost/Efficacy Drug formulary
Antimicrobial resistance data analysis Frequency performed monthly, communicated half- yearly & annually Data analysed as per OPD/IPD/ICU CAI(?catheter),HCAI,ICU(and sub- units), Site of infection (or subsite) Ex: Urinary tract Specific pathogen(not groups like Gram+ve, Gram ve)sentinel drug/bug
Let data be at the heart of your learning/communication
Antimicrobial usage data analysis Sales data Dispensing data either comprehensive or sampled. Actual drug administered New adverse effects identified added to formulary if statistically significant DDD/DOT
Antimicrobial prescription audit/feedback Separate audit teams each major clinical department Chaired by the HOD Should target AMA compliance as per specific conditions Adverse drug effects identified Suggested improvements Recognition significant achievements by a dept.
AMSP Implementation Outcomes Pre/Post implementation Efficacy of AMSP activities Report to be made available to all hospital personnel
Education Engage: Make the problem real (e.g. harm caused by CLABSI), HCW ideas for improvement Educate: Present the evidence Execute: Deploy the tool kit, regular meetings Evaluate: Measurement and feedback, Recognition and visibility, Celebrate success, Assess reasons for failure
Limitations and pitfalls Staff: Infection preventionists Hospital epidemiologists Quality improvement staff Pharmacist Facilities Latest/rapid tests IT Resistant data Communication Motivation (nurses, prescribers, administrative staff) Education COST
Pitfalls Demonstrating a clear causal association between implementation and of ASPs and detection of resistance Decrease use of one increase use of another: squeezing the balloon Most studies observational so correlation over time at your center more appropriate
Pitfalls Inadequate lab resources Physician push back related to monitoring and restricting antibiotic use No a tago is Perceived loss of physician autonomy Lack of updated guidelines Obligation to referred physician or hospital
Practical approach
Resources Duguid M and Cruickshank M (eds.) (2011). Antimicrobial stewardship in Australian hospitals, Australian Commission on Safety and Quality in health Care, Sydney. http://www.safetyandquality.gov.au/wpcontent/uploads/2011/01/antimicrobial-stewardship-in-australianhospitals-2011.pdf Dellit TH et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America Guidelines for Developing an Institutional Program to Enhance Antimicrobial Stewardship. Clinical Infectious Diseases 2007;44:159-77. CDC Get Smart for Healthcare : http://www.cdc.gov/getsmart/healthcare/ Department of Health Advisory Committee on Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) ANTIMICROBIAL STEWARDSHIP: START SMART -THEN FOCUS. http://www.dh.gov.uk/prod_consum_dh/groups/dh_digitalassets/docu ments/digitalasset/dh_131181.pdf
Conclusion Each stakeholder needs to be involved & made to feel responsible Whole society to be involved if stewardship needs to succeed Health professionals need to lead by example in health facilities and take leadership in communities Feasibility, cost and effectiveness of interventions to be judged Multipronged approach may reap the maximum benefit Resistance upon us Up to us to act and act fast.
The way forward>>>> Appropriate antibiotic use is a patient safety priority Antibiotics are a shared resource and becoming a scarce resource. Inappropriate antibiotic use and resistant infections = Billions of $$ in excess healthcare costs To combat resistance: Think globally, act locally The Future of Stewardship = YOU
Strategies for reversing resistance trends and examples of successes How to implement or improve your antimicrobial stewardship program Antimicrobial stewardship strategies that will work for your facility How to measure the success of your stewardship program
Be the change that you wish to see in the world -Mahatma Gandhi THANK YOU