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TO ANTIMICROBIAL STEWARDSHIP
IN HOSPITALS
Contents
1
Animal
non-therapeutic
antimicrobial stewardship 50
40
192 patients/36 Unnecessary Regimens
576 (30%) of 1941Antimicrobial Days
16%
1. Antimicrobial use 10
10%
0
Misuse and over-use of antibiotics
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The last 50 years have witnessed the golden age of antibiotic discovery
ial inf
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ng ion
and their widespread use in hospital and community settings. Regarded
ac N
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as very effective, safe and relatively inexpensive, antibiotics have
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saved millions of lives. However, this has led to their misuse through
Co
use without a prescription and overuse for self-limiting infections
Adapted from Hecker MT. et al. Arch Intern Med. 2003;162:972-978.
[Figures 1 and 2] [Hoffman et al., 2007; Wise et al., 1999; John et al., 1997] and
as predicted by Fleming in his Nobel Prize lecture, bacterial resistance
has appeared and is growing fast [www.nobelprize.org]. Antimicrobial Prescribing Facts: The 30% Rule
~
30% of all hospitalised inpatients at any given
Figure 1. Current use of antibiotics in the United States.
time receive antibiotics
Over 30% of antibiotics are prescribed
CDA
Human non-therapeutic Human therapeutic inappropriately in the4 community
Implementation of
infection control measures
Abx optimization
intervention Targ
6% 9% 3.5
Up to 30% of all surgical prophylaxis is
Incidence of CDAD/1000 patients-days
2.5
~
30% of hospital pharmacy costs are due to
70% Animal 2
non-therapeutic antimicrobial use
1.5
1
0-30% of pharmacy costs can be saved by
1
antimicrobial stewardship programs
Source: www.pewhealth.org 0.5
[Hoffman et al., 2007; Wise et al., 1999; John et al., 1997]
0
1 jan 2003 1 Apr 2003 1 Apr 2004 1 Apr 2005
Four-week period
2 3
Why implement antimicrobial stewardship in hospitals?
The rising threat of antimicrobial resistance Figure 3 explains why antimicrobial resistance cannot be solved with
single interventions alone. All 3 aspects of the three pillars must
Antimicrobial resistance has been identified as a major threat by the be addressed. To ensure this happens at a hospital level requires a
World Health Organisation due to the lack of new antibiotics in the strong collaboration between infection prevention, environmental
development pipeline and infections caused by multi-drug resistant decontamination and antimicrobial stewardship teams [Moody et al., 2012].
pathogens becoming untreatable [Goossens et al., 2011; Carlet et al., 2011].
How we address this global challenge has been the subject of much
discussion and many initiatives [Carlet et al., 2012]. Figure 3. The 3 key drivers for resistance.
INFLUENCERS: INFLUENCERS:
Hand hygiene Germicides
Epidemiology 10% hypochlorite (sporicidal) for C. difficile
Outbreak investigations Cleaning Policy & Practice (What surfaces? How often?
Cohorting Is terminal cleaning enough? (NO!))
Active surveillance
4 5
Why implement antimicrobial stewardship in hospitals?
involves timely and optimal selection, dose and l Reduce surgical infection rates
duration of an antimicrobial l Reduce mortality and morbidity
for the best clinical outcome for the treatment or Table 1. Example of how appropriate antibiotics improve patient
prevention of infection outcome and reduce healthcare costs.
Inappropriate Appropriate
with minimal toxicity to the patient Antibiotics Antibiotics
Characteristic (n=238) (n=522)
and minimal impact on resistance and other Demographics
Age, mean SD (yr) 57.7 15.8 59.9 16.5
ecological adverse events such as C. difficile Male 48.7% 54.2%
Chronic health state
[Nathwani et al., 2012]
Immunosuppressed 32.4% 34.3%
Chronic dialysis 14.7% 7.1%
Nursing home resident 13.4% 18.2%
Length of stay before infection (mean SD) 15.3 + 20.7 7.5 + 14.9
the patient and future patients Length of stay before infection (median)
Hospital mortality
9
51.7%
1
36.4%
www/cdc.gov/getsmart/healthcare/inpatient-stewardship
Adapted from Shorr AF. et al., Crit. Care Med. 2011;39:46-51.
6 7
Why implement antimicrobial stewardship in hospitals?
3
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Why implement antimicrobial stewardship in hospitals?
Database), 2013].
non-therapeutic For1.5example, depending on the continent, stewardship programs
100
are planned in a further 20-30% of cases and funding is the most
Table 2. Example of annual savings associated with the implementation important
1
barrier. 50
of an Antimicrobial Stewardship Program. 0.5
Table 3. Implementation of Antimicrobial Stewardship Programs
Year Method A* Method B** worldwide
0 0
2000 a
158,161 229,076 1 jan 2003 1 Apr 2003 1 Apr 2004 1 Apr 2005 1 Apr 2006
North America 67%
2001 548,002 1,267,638 Europe 65% Four-week period
2002 806,393 1,446,883 Asia 53%
2003 473,174 1,354,129 Oceania 48%
South America 46%
2004 244,160 1,555,048
Africa 13%
2005 419,613 2,005,202
192 patients/36 Unnecessary Regimens
576 (30%) of 1941Antimicrobial
2006 Days
983,690 2,172,756
Figure 6. Barriers to providing a planned AMS Programme.
2007 675,036 1,990,967
33% 2008
32% 817,503 2,557,972
2009 1,278,301 2,782,519 nia
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* Method A: Inflation rate determined using the annual US consumer price index for Medical
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** Method B: Inflation rate determined using an Anti-Infective Specific Index (see article).
ia
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Adapted from Beardsley J et al. Inf. Control. Hosp. Epidemiol., 2012;33:398-400. 23%
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Af
Table 3 and Figure 6 are adapted from First global survey of antimicrobial stewardship
(AMS), Howard P. et al., ESCMID Study Group for Antimicrobial Policies (ESGAP) & ISC
Group on Antimicrobial Stewardship ECCMID 2013, Berlin Presentation Nr. 2448.
10 11
How to implement an Antimicrobial Stewardship Program?
Program?
l What can be implemented will depend on local needs/issues,
geography, available skills/expertise and other resources.
For example, easier or less costly approaches can include:
- Simple clinical algorithms
- Prescribing guidance for treatment, surgical prophylaxis
- Intravenous (IV) to oral conversion
EIGHT KEY STEPS - Provision of microbiological support
- Restricting availability of certain antibiotics (formulary restriction)
for implementing an - Automatic therapeutic substitution
Antimicrobial Stewardship Program (ASP) - IV antimicrobial batching
- Promoting education.
1 Assess the motivations [Goff et al., 2012]
12 13
How to implement an Antimicrobial Stewardship Program?
Table 4. Driver Diagram Overarching Driver: Leadership and Culture. 3. Set up structure and organization
Secondary Key Change Specific Change Ideas
Driver Concepts
The key components of the structure and governance of the ASP are :
Promote Engage 1. Identify clinical providers as champions to be 1 D
edicated resources, including dedicated personnel time for
a culture administrative and thought leaders about antibiotic stewardship.
clinical leadership stewardship activities, education, and measuring/monitoring
of optimal 2. Work with administrators to ensure that
antibiotic
to champion they understand the rationale and goals for antimicrobial use.
stewardship effort stewardship programs and interventions and
use within 2 A multidisciplinary AS team [AST] with core membership of:
provide support (financial and non-financial).
the facility
3. Engage a physician champion and core - an infectious diseases physician (or lead doctor or physician
team to enhance the focus of antimicrobial champion)
stewardship into the current process of care.
4. Bring disciplines together to improve
- a clinical microbiologist
communication and collaboration about - a clinical pharmacist with expertise in infection.
improving antibiotic use, including, as
appropriate: Other members could be specialist nurses, for example infection
- Infection preventionists; prevention or stewardship nurses, quality improvement /risk
- Hospitalists;
- Intensivists; management/patient safety managers and clinicians with an
- Emergency department physicians; interest in infection.
- Microbiologists;
- Pharmacists; 3 Governance within the hospitals quality improvement and
- Nurses; and
- Infectious disease experts. patient safety governance structure
5. Consider having the multidisciplinary group
perform a gap analysis of antimicrobial use
4 Clear lines of accountability between the chief executive,
at the facility to identify priority areas for clinical governance, drug and therapeutics committee, infection
improvement.
prevention and control committees, and the AST. Figure 7 illustrates
Adapted from www.cdc.gov/getsmart/healthcare/improve-efforts/driver-diagram/
such an organization structure.
overarching-driver
Prescribing support/feedback
Ward Based clinical pharmacists Microbiologist/ Infectious Diseases Physician/clinician
14 15
How to implement an Antimicrobial Stewardship Program?
16 17
How to implement an Antimicrobial Stewardship Program?
18 19
How to implement an Antimicrobial Stewardship Program?
5.1.2. Clinical guidelines or care pathways 5.1.3. Formulary restrictions / approval systems
Clinical guidelines or care pathways should take into account local This involves determining the list of restricted antimicrobial agents
microbiology and antimicrobial susceptibility patterns, as well as local (broad spectrum and later generation antimicrobials) and criteria for
resource and priorities, clinician preference/views and potential risk their use combined with an approval system which is subject to
or unintended consequences. regular audit and feedback to the prescribers. It is essential that all
aspects of prescribing are supported by expert advice 24 hours a day.
Guidance on what advice to give for treatment and prophylaxis
is available in the Australian Guidelines (Table 8) although this will
depend on local burden and epidemiology. These guidelines and
policies should ideally be supported by a program of on-going
5.2. Back-end strategies
education for all relevant healthcare professionals.
5.2.1. Antimicrobial review methods
Table 8. Example of the United Kingdom Specialist Advisory Committee
on Antimicrobial Resistance recommended guidelines. Antimicrobial review methods are employed post-prescription and
outlined in the following table. The most appropriate interventions
Treatment of:
for your institution should be chosen, according to local resources.
Urinary tract infections
Upper respiratory tract infections
Table 9. Antimicrobial Review Methods.
Lower respiratory tract infections (community and hospital acquired pneumonia,
and exacerbations of chronic obstructive pulmonary disease) Commonly used
Soft tissue infections (injuries or bites, cellulitis, chronic ulcers and necrotising Review of indication for antibiotic and compliance with policy/guideline/formulary ;
fasciitis) note any recording of exception
Central nervous system infections (bacterial meningitis, viral encephalitis Review of appropriateness of antibiotic choice, dose, route and planned duration;
Gastrointestinal infections such as food poisoning and intra-abdominal sepsis review of drug allergy, review of agents that may provide duplicative therapy
Genital tract infections [potential overlapping spectra]
Bloodstream infections Review of directed therapy based on culture and susceptibility test results
Eye, ear, nose and throat infections Potential for conversion from IV to oral route
Sepsis of unknown origin Review requirement for therapeutic drug monitoring
Specific confirmed infections; for example, treatment regimens for methicillin- Review any antibiotic related adverse events
resistant Staphylococcus aureus, Clostridium difficile and tuberculosis
Endocarditis Less commonly used and
dependent on local resources
Prophylaxis use for: Clinical review by AST of specific resistant pathogens [e.g MRSA] or site of infection
Prevention of bacterial endocarditis (which patients should receive prophylaxis) [e.g blood stream infections]
Endoscopic procedures (which individuals, considered at high risk, should receive Specific review of high cost/high use/novel agents
prophylaxis; for example, neutropenic patients) Review of optimal dose [ PK/PD] in relation to dose and frequency; renal
Surgical procedures (recommendations for all common surgical interventions, adjustment, need for extended infusion, review of any potential drug interactions
including timing of initial dose and exceptional circumstances for repeat doses) Review of directed therapy based on microscopy or PCR or other rapid tests *
Splenectomy patients (provide details of both the immunisation and antimicrobial Review of empiric or directed therapy based on biomarkers *
prophylaxis requirements) * The lack of diagnosis and delay in microbiology remains a significant barrier to good stewardship and may
be a save of high cost. See Figure 10, page 27.
20 21
How to implement an Antimicrobial Stewardship Program?
5.2.2. Audit and direct feedback to prescribers These data can be used in an audit process to provide structured
feedback to prescribing teams and to define areas for improvement.
The audit and feedback process can be managed by either the medical At a national level, as illustrated in an example for Scotland [Table 10],
infection specialist or specialist pharmacist. However, depending on such point prevalence surveys can be used to establish baseline
the intervention, specialist nurses or clinical pharmacists can also be prescribing information and identify priorities for quality
trained to support this process. improvement. This information has contributed to the development
During clinical review, a range of point-of-care stewardship of national prescribing indicators. [Malcolm et al., 2012]
interventions are useful to provide direct and timely feedback to
the prescriber at the time of prescription or laboratory diagnosis,
and provide an opportunity to educate clinical staff on appropriate Table 10. Overview of prescribing from baseline PPS (May 2009)
and follow up PPS (September 2011).
prescribing.
Baseline PPS (May 2009) Follow up PPS
(Sept 2011)
Point-of-care interventions can include:
Measure Scotland Europe Scotland
appropriate use of guidance, Acute Acute Hospitals
Hospitals
indication for antibiotic, Number of patients 7,573 73,060 11,604
surveyed
choice of agent,
Number of patients (%) 2,289 21,197 3,728
prescribed antimicrobials (30.2%) (29.0%) (32.3%)
route [IV vs. oral] of administration of treatment,
Number of patients 1,432 14,403 2,268
timeliness of treatment, (%) prescribed single (62.6%) (67.9%) (60.8%)
antimicrobial
likelihood of on-going infection or not,
Number of prescriptions 1,731 17,947 2,147
(%) for parenteral (51.8%) (60.5%) (47.8%)
use of investigation, antimicrobials
(%) with indication (75.9%) (75.7%) (86.8%)
de-escalation or stopping therapy, recorded in notes
(%) compliant with local (81.0%) (82.5%) (82.8%)
policy
The types of interventions selected, how they are delivered and by prophylaxis prescriptions (49.3%) (27.0%) (59.5%)
(%) with duration single
whom, will be determined by local resources, need and available dose
expertise.
Number of surgical 57 723 81
Feedback on antimicrobial prescribing should be provided regularly prophylaxis prescriptions (19.3%) (21.1%) (16.8%)
(%) with duration = 1 day
to prescribers in the critical care setting, and areas of high and/
Number of surgical 93 1783 114
or poor quality antimicrobial use. prophylaxis prescriptions
(%) with duration >1 day
(31.4%) (51.9%) (23.7%)
One way of evaluating prescribing within a unit or hospital is through
regular point prevalence surveys (PPS) [Ansari et al., 2009; Seaton et al., 2007] Adapted from Malcolm W, Nathwani D, et al. Antimicrob. Resist. infect. Control. 2012;2:3.
22 23
How to implement an Antimicrobial Stewardship Program?
among patients with respiratory tract infection and sepsis by significantly l Identify wards with high antimicrobial usage or use of non-policy
reducing antibiotic exposure as well as a trend towards reduced antimicrobials and define targeted interventions required
costs and reduced length of ICU stay [Schuetz et al., 2011; Agarwal et
al., 2011; Heyland et al., 2011; Mann et al., 2011; Matthaiou et al., 2012]. Measure improvement after implemented interventions
Near-patient rapid tests, e.g. influenza, Strep A, can be useful to
Surveillance of antimicrobial use and resistance is important:
identify patients with bacterial versus viral infections.
l at hospital, local, regional, national levels (i.e.: Strama [http://
Molecular diagnostics or screening tests providing a faster en.strama.se], Wales [Heginbothom M and Howe R, 2012], Australia [www.
result play an important role in pathogen detection in critically health.sa.gov.au/INFECTIONCONTROL])
ill patients which will improve antibiotic stewardship and clinical l and at global level (i.e.: ECDC: consolidation of resistance data
outcomes [Afshari et al., 2012].
at the European level [EARSS.net] with consolidation of antibiotic
However, the availability of these interventions in resource-limited use [ESAC.net], CDC National Antimicrobial Resistance Monitoring
environments is likely to be a challenge to their introduction. System [cdc.gov/NARMS])
24 25
1.5
1.5
1.5
6.1.1. How is antimicrobial use data collected ABC Calc is a simple computer tool to measure antibiotic
1.5
and analysed? consumption in hospitals and hospital wards. It transforms aggregated
data
1.5
provided by hospital pharmacies (generally as a number
l ntimicrobial use at individual patient level, using an electronic
A
of
1.5 packages or vials) into meaningful antibiotic utilisation rates.
prescribing system through the Hospital Information System.
[http://www.escmid.org/research_projects/study_groups/esgap/abc_calc/]
1.5
l Data from hospital pharmacy computer systems, showing
1
02
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50
Pareto charts are useful to provide an overview of antimicrobial
20 0
20 0
20 0
20 0
1.5
10
11
antimicrobials delivered to each ward and used as a proxy measure
0
20
for antimicrobials administered to patients. usage at ward levelinhibitor
1.5Beta-lactam/beta-lactamase and combinations
identify wards
(J01CR) that have high total usage
Cumulative percentage
Piperacillin/Tazobactam use in Monklands (Feb 2010)
of use
1.5 6 100
l Usage data may then be divided by a measure of hospital 5 80
Cumulative percent
No of episodes
4
activity such as number of admissions or in-patient bed days to 1.5 3
60
40
2
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20 0
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provide more meaningful trend analysis. In-patient bed days is
05
10
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1 20
20
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more commonly used as this data can usually be obtained earlier 18 14 5 inhibitor
Beta-lactam/beta-lactamase 4 26combinations
(ITU) 17 (J01CR)
15 ERU 2 7
Cephalosporins (J01D) Carbapenems (J01DH) No of episodes
Fluoroquinolones of use
(J01MA)
than admissions data. 50% Ward
Cumulative percentage
Piperacillin/Tazobactam use in Monklands (Feb 2010)
50 6 collected and analyzed?
No of episodes of use
2007 2011 100
5 45 2008 80
4 Cumulative percent
60
Figure 11. Trends in Specific Antibacterial Group Usage for All-Wales Resistance data is obtained from the Microbiology laboratory through
Resistance (%)
40 3
40
35 2
hospitals from 20052011. computer1 systems. Hospital level data may then be transferred
20 to
30
0 0
1.5
national databases. Examples from two UK countries, Wales and
25 18 14 5 4 26 (ITU) 17 15 ERU 2 7
20 No of episodes of use
Scotland,
15
50%
are shown in FiguresWard
13 and 14.
DDD/1000 BD per Quarter
1.5 30 2008
10
Figure
5
13. All-Wales resistance rates for E. coli bacteraemia
2009 (2005
1.5
to 2011).
0
25 2010
3GC AMO COA CARB CXM FQ GEN PTZ
1.5 65
20
Resistance (%)
60 2005 2009
1.5 55 2006 2010
50 15 2007 2011
1.5 2008
45
10
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40
1.5
35
1.5 30 5
25
1
02
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Adapted from Heginbothom M and Howe R. A Report from Public Health Wales Adapted from Heginbothom et al. A Report from Public Health Wales Antimicrobial
Antimicrobial Resistance Programme Surveillance Unit. 2012. Resistance Programme Surveillance Unit. 2012.
26 27
ntage
6 100
How to implement an Antimicrobial Stewardship Program?
Figure 14. Antimicrobial resistance (with 95% confidence intervals) in Table 11. AMS program measures for quality improvement.
K. pneumoniae isolated from blood cultures in 2008 (n=512), 2009 Structural indicators
(n=672) and 2010 (n=715). Availability of multi-disciplinary antimicrobial stewardship team
Availability of guidelines for empiric treatment and surgical prophylaxis
30 2008 Provision of education in the last 2 years
2009
25 2010 Process measures
Amount of antibiotic in DDD/100 bed days
20 - Promoted antibiotics
Resistance (%)
- Restricted antibiotics
15 Compliance with acute empiric guidance (documented notes and policy
compliance)
10 % appropriate de-escalation; % appropriate switch from IV to oral
Compliance with surgical prophylaxis (<60 min from incision, <24 hours and
5 compliance with local policy
Compliance with care bundles all or nothing (3-day antibiotic review bundle,
0 ventilator-associated pneumonia, community-acquired pneumonia, sepsis)
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Adapted from Scottish Antimicrobial Prescribing Group (SAPG), Report on Antimicrobial Surgical Site Infection (SSI) rates
Use and Resistance in Humans in 2010. Surveillance of resistance
Mortality: Standardized Mortality Rates (SMRs)
At national level, resistance surveillance is particularly important Balancing measures
Mortality
to identify emerging resistance in common pathogens or multi- SSI rates
resistant organisms such as Gram negative bacteria which produced Readmission within 30 days of discharge
extended spectrumNational
beta lactamase (ESBL) or carbapenemase enzymes.
data: compliance with indication documented
Admission to ICU
and overall median throughout data collection period
Rate of complications
100 Medical and surgical admissions Treatment-related toxicity (e.g. aminoglycoside-related toxicity)
ChangesChemother.
Adapted from Dumartin et al. J. Antimicrob. to guidance means some times Morris et al.
2011;66:1631-7;
6.2. Data
95 collection for quality are not achivable. Consultants have discussed
Inf. Control. Hosp. Epidemiol. 2012;33[3]:500-506.
this with Microbiology and Antibiotic Pharmacy.
improvement
90
Agreement reached.
6.2.1. Examplesantibiotic
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85
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80 20 Data collection
rates by linking antimicrobial usage data and microbiology data
(%)
70
Resistance
form as part
Resistance
60 15
15 of theatre checklist [Talpaert et al., 2011, Vernaz et al., 2009, Mamoon et al., 2012].
50
40 10 Not recording on sheet
30
10 Figure 17. New cases of CDI and the number of OBDs before and after
20 5 Review in line the introduction of revised antibiotic guidelines.
10 5 with SIGN guidelines +5 new theatres
60 Introduction of revised antibiotic guidelines 15 000
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100 and overallMedical
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means some times
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95 are not achivable. Consultants have discussed
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Figure 18. Correlation between antibiotic use and resistance. reached.
Agreement reached.
90
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reporting and 17 2.5
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resistant to clindamycin calculated by STL method. Prescription data source: IMS Health,
Note: non-zero y-axes. Xponent, 1999-2007. Resistance data source: The surveillance Network Database-USA (Focus
Source: Empirical Prescribing Indicator Report April 2011 June 2012. Scottish Antimi- Diagnostics, Hendon, VA). Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.
60 Introduction of revised antibiotic guidelines 15 000
crobial Prescribing Group August 2012. Adapted from Sun L, et al. Clin. Infect. Dis. 2012;55:687-94.
50 Move to Riverside Building 14 000
30 13 00031
d values
40
How to implement an Antimicrobial Stewardship Program?
7. Educate and Train Educating patients and the general public about hygiene and
antibiotic use is also important, and may indirectly support hospital
Education is a key component of any Antimicrobial Stewardship education efforts. National and regional public health campaigns,
Program. It should include healthcare professionals from all care including education aimed at parents and children, have had a variable
settings, as well as patients and the public. level of success [Huttner et al., 2010].
By increasing peoples knowledge and understanding of how Some examples of public awareness campaigns:
antimicrobials should be used to treat common infections and why l www.e-bug.eu
inappropriate use may lead to resistance and loss of effective treatments, l www.ecdc.europa.eu/en/eaad
this valuable resource can be protected for future generations. l www.cdc.gov/getsmart
7.1. Who should receive education 7.2. How should an education program be
in hospitals? designed?
Prescribers and other healthcare staff with modules adapted to Programs should take into account local recommendations for
their background including: antimicrobial stewardship, if available. If not, they could be inspired by
international policies (see section on Additional Resources, page 38).
l Undergraduate curriculum
Educational measures recommended in the literature to improve
l Internship
antibiotic use in hospitals are shown in Table 12.
l Professional training for new staff
Table 12. Main antimicrobial stewardship strategies recommended in the
l Continuing professional development for all prescribers international literature to improve antibiotic use at the hospital level.
l Postgraduate education Passive educational measures
Developing/updating local antibiotic guidelines
The content of education should be adapted to each profession Educational sessions, workshops, local conferences
and include: Active interventions
l Basic knowledge of infection management, Clinical rounds discussing cases
Prospective audit with intervention and feedback
l Basic microbiology
Reassessment of antibiotic prescriptions, with streamlining
l Importance of prudent prescribing in tackling antimicrobial resistance. and de-escalation of therapy
l B est practices for prescribing to support safe and effective prescribing, Academic detailing, educational outreach visits
administration and monitoring of antimicrobial therapy. Adapted from Pulcini C and Gyssens IC. Virulence 2013;4:192202.
32 33
How to implement an Antimicrobial Stewardship Program?
34 35
How to implement an Antimicrobial Stewardship Program?
Table 13. Specific Situations where Antibiotics should be THE KEYS TO SUCCESS
withheld
Respiratory tract syndromes A number of interventions are key to the success of a
- Viral pharyngitis hospital-based Antimicrobial Stewardship Program.
- Viral rhinosinusitis
- Viral bronchitis
- Noninfectious cardiopulmonary disorders misdiagnosed as pneumonia Establish a clear aim/vision that is shared by all the
Acute Otitis Media (AOM) (for selected cases, refer to article) stakeholders and that conveys a sense of urgency.
Skin and Soft Tissue Infections (SSTI) Stewardship should be a patient safety priority.
- Subcutaneous abscesses (for selected cases, refer to article)
- Lower extremity stasis dermatitis
Asymptomatic bacteriuria and pyuria, including catheterized patients Seek management support, accountability
Microbial colonization and culture contamination and secure funding.
Low-grade fever
Adapted from Wlodover et al., Infect. Dis. Clin. Pract. 2012;20:12-17.
Assemble a strong coalition including a
multi-professional antimicrobial stewardship
team with a strong influential clinical leader.
Table 14. Practice Guideline Recommendations regarding
duration of therapy
Establish effective communication structures
Community-acquired pneumonia (CAP) 5 days
within your hospital.
Health care-acquired pneumonia 8 days
Skin and Soft Tissue Infections (SSTI) 5 days
Urinary Tract Infections (UTI) Start with core evidence-based stewardship
- Cystitis 3-5 days a interventions depending on local needs,
- Pyelonephritis 5-14 days a
- Catheter associated 7 days b
geography and resources and plan measurement
S. aureus bacteremia
to demonstrate their impact.
- Low risk of complications, 2 weeks
- High risk of complications 4-6 weeks
Ensure all healthcare staff are aware of the
Intra-abdominal infection 4-7 days
importance of stewardship. Empower them
Surgical antibiotic prophylaxis, 1 dose c
to act and support with education using a range
a
Depending on antibiotic
b
Prolonged to 10-14 days for delayed response of effective strategies.
c
Up to 24h, witout exception
36 37
Additional Resources
Global Resources for implementing and measuring the impact of
hospital Antimicrobial Stewardship Programs
Department of Health Advisory Committee on Antimicrobial Resistance and
Healthcare Associated Infection (ARHAI) ANTIMICROBIAL STEWARDSHIP:
Africa START SMART - THEN FOCUS.
Antimicrobial Stewardship and Infection Control African Network : www. ESCMID Study Group for Antibiotic Policies (ESGAP): www.escmid.org/
ischemo.org/index.php/sections/isc-wg-antimicrobial-stewardship-and- index.php?id=140
infection-control-african-network Guidance for antimicrobial stewardship in hospitals (England) ARHAI
Best CareAlways! (BCA) campaign supporting South(ern) African Antimicrobial Stewardship ; http://www.dh.gov.uk/prod_consum_dh/
healthcare organisations: www.bestcare.org.za/Antibiotic+Stewardship groups/dh_digitalassets/documents/digitalasset/dh_131181.pdf
South African Antibiotic Stewardship Programme : www.fidssa.co.za/A_ Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI
SAASP_Home.asp Hospital Antimicrobial Stewardship Working Group http://www.hpsc.ie/
hpsc/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/
Suleman F, Meyer H. Antibiotic resistance in South Africa: your country Guidelines/File,4116,en.pdf
needs you! S. Afr. Pharm. J. 2012;79:44-46.
Monnet D, Kristinsson K. Turning the tide of antimicrobial resistance:
Europe shows the way. Euro Surveill 2008;13.
Asia-Pacific Nathwani D, on behalf of SMC/HAI. Antimicrobial prescribing policy and
practice in Scotland: recommendations for good antimicrobial practice in
Duguid M and Cruickshank M (eds) (2011). Antimicrobial stewardship
acute hospitals. J. Antimicrob. Chemother. 2006;57:1189-1196.
in Australian hospitals, Australian Commission on Safety and Quality in
Health Care, Sydney.
Ghafur A, Mathai D, Muruganathan A, et al. The Chennai Declaration US
Recommendations of A roadmap- to tackle the challenge of antimicrobial
ASHP statement on the pharmacists role in antimicrobial stewardship and
resistance - A joint meeting of medical societies of India. Indian Journal
infection prevention and control. Am. J. Health .Syst. Pharm. 2010;67:575-7.
of Cancer 2013;49.
CDC: http://www.cdc.gov/getsmart/healthcare/
Ho PL, Cheng JC, Ching PT et al. Optimising antimicrobial prescription
in hospitals by introducing an antimicrobial stewardship programme Dellit TH, Owens RC, McGowan JE, Jr. et al. Infectious Diseases Society
in Hong Kong: consensus statement. Hong Kong Med 2006;12:141-8. of America and the Society for Healthcare Epidemiology of America
Guidelines for Developing an Institutional Program to Enhance Antimicrobial
Teng CB, Lee W, Yeo CL et al. Guidelines for Antimicrobial Stewardship
Stewardship. Clinical Infectious Diseases 2007;44:159-77.
Training and Practice. Ann. Edu. Sg. 2012;41 No.1.
Drew RH, White R, MacDougall C, et al. Insights from the Society of
Infectious Diseases Pharmacists on antimicrobial stewardship guidelines
Europe from the Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America. Pharmacotherapy 2009;29:593-607.
Allenberger F, Gareis R, Jindrk V, Strulens MJ. Antibiotic stewardship
implementation in the EU: the way forward. Expert Rev. Anti Infect. Ther. Goff D, Bauer KA, Mangino JE, et al. Antibiotic stewardship management
2009;7:1175-1183. of infections. Beyond the cost of Antimicrobials. Pharmacy practice News.
August 2012:1-12 [useful suggestions for ASP in resource limited settings].
Cooke J, Alexander K, Charani E, et al. Antimicrobial stewardship: an
evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute Owens RC. Antimicrobial stewardship: concepts and strategies in the
hospitals. J. Antimicrob. Chemother. 2010;65:2669-2673. 21st century. Diag. Micro. Infect. Dis. 2008;61:110-128.
38 39
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40 41
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