Practical guide to antimicrobial stewardship

Transcription

Practical Guide
TO ANTIMICROBIAL STEWARDSHIP
IN HOSPITALS
Contents
Why implement antimicrobial stewardship
in hospitals ?
Introduction
The objective of this booklet is to provide practical
recommendations for healthcare workers in hospitals
to improve the quality of antibiotic prescribing and
thereby improve patient clinical outcomes.
Most of the recommendations within this booklet have
been adapted from the IDSA Guidelines [Dellit et al., 2007],
the Australian Hospital Stewardship Guidance produced
by the Australian Commission on Safety And Quality in
Healthcare [Duguid et al., 2010], National Stewardship Guidance
from Scotland [Nathwani et al., 2006], the UK [ DOH-ARHAI, Start smart
then Focus, 2011] and, although less literature is available, from
other countries whenever possible.
We hope that this booklet will inform, encourage and support
health professionals wishing to pursue the implementation
of antimicrobial stewardship initiatives, as well as combating
antimicrobial resistance.
Prof. Dilip Nathwani, MB; DTM&H, FRCP
Dr Jacqueline Sneddon, MRPharmS, MSc, PhD
Consultant Physician and Honorary Professor of Infection
Ninewells Hospital and Medical School
Dundee, Scotland, UK
[email protected]
Project Lead for Scottish Antimicrobial Prescribing Group
Healthcare Improvement Scotland
Glasgow, Scotland, UK
[email protected]
1. Antimicrobial use
p.2
2. Combating antimicrobial resistance
p.4
3. Defining antimicrobial stewardship
p.6
4. G
oals of antimicrobial stewardship
and evidence for success
p.7
5. Implementation of Antimicrobial
Stewardship Programs
p.11
How to implement an Antimicrobial
Stewardship Program?
1. Assess the motivations
p.13
2. Ensure accountability and leadership
p13
3. Set up structure and organization
p.15
4. Define priorities and how to measure
progress and success
p.16
5. Identify effective interventions for your setting
p.17
6. Identify key measurements for improvement
p.25
7. Educate and Train
p.32
8. Communicate
p.34
Additional resourcesp.38
Bibliography p.40
1
Animal
non-therapeutic
Why implement antimicrobial stewardship in hospitals?
Today, up to 85% of antibiotics have a non-human use and up to
75% have a non-therapeutic use. Antibiotic use in hospitals and the
community is common and often inappropriate [Figure 2]. In hospitals,
up to 50% of antimicrobial use is inappropriate [Dellit et al., 2007].
Why implement
antimicrobial stewardship
in hospitals?
Figure 2. “Unnecessary“ Antimicrobial Therapy.
• 192 patients/36 Unnecessary Regimens
• 576 (30%) of 1941Antimicrobial Days
50
40
30
33%
32%
20
16%
10
Figure 1. Current use of antibiotics in the United States.
t
an
nd
du
The last 50 years have witnessed the golden age of antibiotic discovery
and their widespread use in hospital and community settings. Regarded
as very effective, safe and relatively inexpensive, antibiotics have
saved millions of lives. However, this has led to their misuse through
use without a prescription and overuse for self-limiting infections
[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].
D
Lo urat
ng ion
er o
th f T
an he
Ne rap
ed y
ed
No
nb
ac N
ter on
ial inf
Sy ect
nd iou
ro s/
Co
m
lon
e
iza
tio
n/ Tr
Co ea
nt tm
am en
ina t o
tio f
n
➔ Misuse and over-use of antibiotics
10%
0
Re
1. Antimicrobial use
Adapted from Hecker MT. et al. Arch Intern Med. 2003;162:972-978.
Antimicrobial Prescribing Facts: The 30% Rule
➤ ~
30% of all hospitalised inpatients at any given
time receive antibiotics
➤ Over 30% of antibiotics are prescribed
6% 9%
Human therapeutic
Implementation of
inappropriately in the4 community
infection control measures
CDA
Targ
Abx optimization
intervention
3.5
15%
70%
Animal therapeutic
Animal
non-therapeutic
➤ Up to 30% of all surgical prophylaxis is
inappropriate
➤ ~
Incidence of CDAD/1000 patients-days
Human non-therapeutic
3
2.5
30% of hospital pharmacy costs are due to
antimicrobial use
2
1.5
➤ 1
0-30% of pharmacy costs can be saved by
Source: www.pewhealth.org
1
antimicrobial stewardship programs
0.5
[Hoffman et al., 2007; Wise et al., 1999; John et al., 1997]
0
1 jan 2003
2
1 Apr 2003
1 Apr 2004
Four-week period
1 Apr 2005
3
➔ The rising threat of antimicrobial resistance
Antimicrobial resistance has been identified as a major threat by the
World Health Organisation due to the lack of new antibiotics in the
development pipeline and infections caused by multi-drug resistant
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].
2. Combating antimicrobial resistance
Figure 3 explains why antimicrobial resistance cannot be solved with
single interventions alone. All 3 aspects of the “three pillars” must
be addressed. To ensure this happens at a hospital level requires a
strong collaboration between infection prevention, environmental
decontamination and antimicrobial stewardship teams [Moody et al., 2012].
Figure 3. The 3 key drivers for resistance.
Antimicrobial exposure (dose, duration, type of antibiotic)
drives selection of resistant bacteria
To overcome the threat of antimicrobial resistance, a three-pillar
approach has been advocated:
1 Optimise the use of existing antimicrobial agents
Antimicrobial Use
2 P revent the transmission of drug-resistant organisms through
infection control
INFLUENCERS:
• Human antimicrobial consumption
• Agriculture antimicrobial consumption
3 Improve environmental decontamination
Germicides, Sub-MIC
residues, ionic surfactants
Rationale for cohorting, private rooms,
handwashing, active surveillance…
Double Room
Room A
Patient A
Double Room
Room A
Patient B
Double Room
Room A
Patient A
Double Room
Room A
Patient B
Room A
Patient A
Room A
Patient B
Bedrail, call button, telephone,
commode, doorknob
Infection Control
Environment
INFLUENCERS:
• Hand hygiene
• Epidemiology
• Outbreak investigations
• Cohorting
• Active surveillance
INFLUENCERS:
• Germicides
• 10% hypochlorite (sporicidal) for C. difficile
• Cleaning Policy & Practice (What surfaces? How often?
Is terminal cleaning enough? (NO!))
White patients =
non-infected/non-colonized
with MDRO
Blue patients =
infected or colonized
with MDRO
Susceptible organism
Resistant organism
Adapted from Owens RC Jr. et al. Diagn.Microbiol. and Infect. Dis. 2008; 61:110-28.
4
5
3. Defining antimicrobial stewardship
Antimicrobial stewardship [AS] is one of the key strategies to overcome
resistance.
It involves the careful and responsible management of antimicrobial use.
4. G
oals of antimicrobial stewardship and
evidence for success
The four main goals of antimicrobial stewardship are listed below with
examples of evidence that stewardship programs can help achieve
these goals. [McGowan et al,. 2012; Davey P et al., (Cochrane Database), 2013]
“Antimicrobial stewardship:
Goal 1: Improve patient outcomes
➤ is an inter-professional effort, across
the continuum of care
➤ involves timely and optimal selection, dose and
duration of an antimicrobial
➤ for the best clinical outcome for the treatment or
prevention of infection
➤ and minimal impact on resistance and other
ecological adverse events such as C. difficile”
[Nathwani et al., 2012]
“
6
“
www/cdc.gov/getsmart/healthcare/inpatient-stewardship
Improve infection cure rates
l
Reduce surgical infection rates
l
Reduce mortality and morbidity
Table 1. Example of how appropriate antibiotics improve patient
outcome and reduce healthcare costs.
InappropriateAppropriate
AntibioticsAntibiotics
Characteristic
(n=238)(n=522)
➤ with minimal toxicity to the patient
The right antibiotic
for the right patient,
at the right time,
with the right dose, and
the right route, causing
the least harm to
the patient and future patients
l
Demographics
Age, mean ± SD (yr)
Male
57.7 ± 15.8
48.7%
59.9 ± 16.5
54.2%
Chronic health state
Immunosuppressed
Chronic dialysis
Nursing home resident
Coronary artery disease
Chronic obstructive pulmonary disease
Congestive heart failure
Malignancy
Diabetes mellitus
Charlson score, mean ± SD
32.4%
14.7%
13.4%
11.7%
21.6%
21.6%
23.1%
27.5%
4.8 ± 3.7
34.3%
7.1%
18.2%
7.9%
17.2%
18.1%
34.1%
20,1%
4.8 ± 3.7
Disease severity
Acute Physiology and Chronic Health
23.2 ± 6.6
23.9 ± 6.7
Evaluation II, mean ± SD
Need for mechanical ventilation
Need for vasopressors
Organ failures, mean ± SD
Treatment with drotrecogin alfa (activated)
62.6%
59.9%
2.3 ± 1.0
3.8%
51.5%
58.0%
2.2 ± 1.1
4.4%
Infection characteristics
Nosocomial
Community-acquired
Healthcare-associated
Additional factors
Length of stay before infection (mean ± SD)
Length of stay before infection (median)
Hospital mortality
69.3%
5.9%
24.8%
15.3 + 20.7
9
51.7%
48.7%
11.1%
40.2%
7.5 + 14.9
1
36.4%
Adapted from Shorr AF. et al., Crit. Care Med. 2011;39:46-51.
7
Goal 2: Improve patient safety
(Minimize unintended consequences of antimicrobials)
Goal 3: Reduce resistance
6
20
0
Ja 7
n
20
Ja 08
n
20
0
Ja 9
n
20
10
0
n
Ja
20
0
n
Ja
n
20
0
2
Adapted from Valiquette L et al., Clin. Infect. Dis. 2007;45:S112-121.
20
5
Four-week period
40
20
0
1 Apr 2006
n
1 Apr 2005
6
1 Apr 2004
4
1 Apr 2003
20
0
1 jan 2003
60
n
0
0
Ja
0.5
80
5
50
3
1
100
20
0
100
1.5
n
2
0
Ja
150
4
2.5
50
Ja
200
3
100
Ja
3.5
150
3
250
200
2
CDAD
Targeted Abx
Abx optimization
intervention
FQ consumption (DDD/1000 PD)
Implementation of
250
n
2
Ja 000
n
2
Ja 001
n
20
Ja 02
n
2
Ja 003
n
2
Ja 004
n
2
Ja 005
n
2
Ja 006
n
2
Ja 007
n
2
Ja 008
n
2
Ja 009
n
20
10
4
Patient-days of antibiotic use/1000 patient-days
Figure 4. Example of robust stewardship program with strict
implementation of infection control measures leading to sustained
reduction in C. difficile infection [CDI] cases during an epidemic.
Figure 5. Example of a reduction of fluoroquinolone use
associated with decreased MRSA and fluoroquinoloneresistant P. aeruginosa isolation rates.
Ja
Reduce C. difficile colonization or infection by controlling the use
of “high-risk” antibiotics [Valiquette et al,. 2007].
l
R estricting relevant agents can reduce colonization or infection with
Gram-positive or Gram-negative resistant bacteria.
FQ-resistant P. aeruginosa rate (%)
l
R educe antimicrobial consumption, without increasing mortality
or infection-related readmissions e.g. 22%-36% reduction in
antimicrobial use [Dellit et al., 2007].
l
60
ea
nia
MRSA rate (%)
50
Am S
er ou
ica th
Oc
29%
20%
40
30
20
20
Ja 07
n
20
Ja 08
n
20
0
Ja 9
n
20
10
Ja
n
20
0
n
20
0
n
Ja
20
0
n
Ja
Ja
n
20
0
n
Ja
op
e
Eu
r
34%
20
0
0
32%
Ja
Am N
er or
ica th
10
Adapted from Lafaurie et al., J. Antimicrob. Chemother. 2012;67:1010-5.
As
8
ia
23%
23%
9
806,3931,446,883
2003
473,1741,354,129
2004
244,1601,555,048
2005
419,6132,005,202
• 192 patients/36 Unnecessary Regimens
• 576 (30%) of 1941Antimicrobial
Days
2006
983,6902,172,756
2007
675,0361,990,967
33% 2008
32%
817,5032,557,972
2009
1,278,3012,782,519
2010
2,175,9273,456,373
2011b
1,770,8272,406,399
10%
16%
10,350,787
23,224,961
an
nd
du
n/
tio
Figure 6. Barriers to providing a planned AMS Programme.
29%
20%
32%
34%
lon
iza
1 Apr 2006
*Method A: Inflation rate determined using the annual US consumer price index for Medical
Care Commodities.
**Method B: Inflation rate determined using an Anti-Infective Specific Index (see article).
Co
As
ia
23%
23%
ric
a
Adapted from Beardsley J et al. Inf. Control. Hosp. Epidemiol., 2012;33:398-400.
29%
Af
No
nb
ac
Note: data are US dollars
a
April-December 2000
b
January-June 2011
2,064,441
Re
Co Trea
nt tm
am en
ina t o
tio f
n
ter Non
ial inf
Sy ect
nd iou
ro s/
m
e
Total savings
920,070
t
Yearly average
1 Apr 2005
nia
548,0021,267,638
2002
1 Apr 2003
1 Apr 2004
North America
67%
Four-week period
Europe65%
Asia53%
Oceania48%
South America
46%
Africa13%
ea
2001
1 jan 2003
Oc
158,161229,076
Am S
er ou
ica th
2000 Method B**
0.5
Table 3. Implementation of Antimicrobial Stewardship Programs
worldwide
0
0
Am N
er or
ica th
Method A*
a
2
For1.5example, depending on the continent, stewardship programs
100
are planned in a further 20-30% of cases and funding is the most
1
important
barrier.
50
pe
Year
200
ro
Table 2. Example of annual savings associated with the implementation
of an Antimicrobial Stewardship Program.
250
3
A recent
global survey outlined the range of stewardship activities
across
2.5 the continents [Table 3, Figure 6]. This survey provides some
150
understanding about current or planned activity and barriers.
Eu
6% 9%
S avings achieved15%
by reducing
antibiotic costs can be greater than
Animal therapeutic
the cost of the intervention or program (from $200,000 to $900,000
depending on the studies) [Dellit et al., 2007]. Such cost-effectiveness
70%emerging
Animal [Stevenson et al., 2012; Davey et al., (Cochrane
data are sparse but
non-therapeutic
Database), 2013].
l
Th
Ne erap
ed y
ed
n
ha
CDAD
5. 4Implementation
of Antimicrobial
Implementation of
Abx optimization
Targeted Abx
intervention
3.5Stewardship Programs
Goal 4: Reduce healthcare costs
therapeutic
(without adverselyHuman
impacting
quality of care)
uman non-therapeutic
Patient-days of antibiotic use/1000 patient-days
0%
5%
10%
15%
20%
No barriers
Lack of Information Technology
Prescriber opposition
25%
30%
35%
40%
Administration not aware
Higher priorities
Lack of funding/people
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?
1. Assess the motivations
l
How to implement
an Antimicrobial Stewardship
Program?
EIGHT KEY STEPS
for implementing an
Antimicrobial Stewardship Program (ASP)
1 Assess the motivations
nalyse your situation and what problems you want to address.
A
There are many international guidelines available (see page 38),
but you will need to adapt them to your local situation.
where you are and where you want to go, with
quantitative figures. One of the ways of obtaining these data is
to measure the quantity and quality of antibiotic use (see Chapter 6).
l Define
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
- Provision of microbiological support
- Restricting availability of certain antibiotics (formulary restriction)
- Automatic therapeutic substitution
- IV antimicrobial batching
- Promoting education.
[Goff et al., 2012]
2 Ensure accountability and leadership
3 Set up structure and organization
2. Ensure accountability and leadership
To ensure a successful Antimicrobial Stewardship Program:
4 Define priorities and how to measure
5 Identify effective interventions for your setting
6 Identify key measurements for improvement
7 Educate and Train
8 Communicate
12
program should be supported by the senior hospital
management, who are accountable for the outcomes.
l The
l
A team of people and resources should be allocated by the
head of the organization to implement and evaluate the program.
l
T he ASP team members must possess power, expertise, credibility
and leadership. These individuals need to convince managers
and healthcare staff of the added value of the program.
A key component of a stewardship program is leadership and
culture of antibiotic use. This can be set out as a driver diagram
(see pages 14 and 16 for more details).
13
Table 4. Driver Diagram Overarching Driver: Leadership and Culture.
Secondary
Driver
Key Change
Concepts
Specific Change Ideas
Promote
a culture
of optimal
antibiotic
use within
the facility
Engage
administrative and
clinical leadership
to champion
stewardship effort
1. Identify clinical providers as champions to be
thought leaders about antibiotic stewardship.
3. Set up structure and organization
The key components of the structure and governance of the ASP are :
2. Work with administrators to ensure that
they understand the rationale and goals for
stewardship programs and interventions and
provide support (financial and non-financial).
3. Engage a physician champion and core
team to enhance the focus of antimicrobial
stewardship into the current process of care.
4. Bring disciplines together to improve
communication and collaboration about
improving antibiotic use, including, as
appropriate:
- Infection preventionists;
- Hospitalists;
- Intensivists;
- Emergency department physicians;
- Microbiologists;
- Pharmacists;
- Nurses; and
- Infectious disease experts.
5. Consider having the multidisciplinary group
perform a gap analysis of antimicrobial use
at the facility to identify priority areas for
improvement.
Adapted from www.cdc.gov/getsmart/healthcare/improve-efforts/driver-diagram/
overarching-driver
edicated resources, including dedicated personnel time for
1 D
stewardship activities, education, and measuring/monitoring
antimicrobial use.
2 A multidisciplinary AS team [AST] with core membership of:
- an infectious diseases physician (or lead doctor or physician
champion)
- a clinical microbiologist
- a clinical pharmacist with expertise in infection.
Other members could be specialist nurses, for example infection
prevention or stewardship nurses, quality improvement /risk
management/patient safety managers and clinicians with an
interest in infection.
3 Governance within the hospital’s quality improvement and
patient safety governance structure
4 Clear lines of accountability between the chief executive,
clinical governance, drug and therapeutics committee, infection
prevention and control committees, and the AST. Figure 7 illustrates
such an organization structure.
Figure 7. Model of Antimicrobial Prescribing Pathway and Organization
in Acute Hospitals in Scotland.
Medical Director
Drugs and Therapeutics Committee
Chief Executive
Antimicrobial
Stewardship Team
(AST)
Specialty-based Antimicrobial Pharmacist
with responsibility for antimicrobial prescribing
Infection Control Manager
Risk Management or Patient Safety Committee
Clinical Governance Committee
Infection prevention and control Committee
Dissemination/feedback
Ward Based clinical pharmacists
Prescribing support/feedback
PRESCRIBER
14
Microbiologist/ Infectious Diseases Physician/clinician
Adapted from Nathwani D. et al., J. Antimicrob. Chemother. 2006;57:1189-1196.
15
4. Define priorities and how to measure
5. Identify effective interventions
for your setting
The objectives of the ASP and how they are going to be achieved
and measured need to be agreed by all the key stakeholders
and communicated clearly.
A range of stewardship interventions has been reviewed in the IDSA
guidelines [Dellit et al., 2007].
One way of doing this is to produce a Driver Diagram. A Driver
Diagram is a logic chart with three or more levels, including:
l A goal or vision,
l The high-level factors needed to achieve this goal (called
‘primary drivers’)
l Specific projects and activities that would act upon these factors.
For more complex goals, each primary driver could have its own set
of ‘secondary drivers’ (or lower level drivers).
Driver diagrams can help an ASP team to:
l Explore the factors that need to be addressed to achieve a specific
overall goal,
l Show how the factors are connected,
l Act as a communication tool for explaining a change strategy
l Provide the basis for a measurement framework.
When establishing a new stewardship program, it is best to start with
the core strategies and focus on achieving and maintaining them
before adding some of the supplemental strategies.
Table 5. Antimicrobial Stewardship Toolkit: Quality of Evidence to
support interventions.
Core Strategies
Supplemental Strategies
Formulary restrictions and
preauthorization*
Prospective audit
with intervention and feedback*
Multidisciplinary stewardship team*
Figure 8. Example of a Driver Diagram for Antimicrobial Stewardship
Adapted from www.cdc.gov/getsmart/healthcare/improve-efforts/
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
Adapted from Dellit et al. Clinical Infectious Diseases 2007; 44:159-77.
* Strategies with strongest evidence and support by IDSA.
Two core ASP strategies have emerged:
➤ “ Front–end strategies” where antimicrobials are made
available through an approval process (formulary restrictions
and preauthorization).
➤ “ Back-end“ strategies are where antimicrobials are reviewed
after antimicrobial therapy has been initiated (prospective audit
with intervention and feedback)
16
17
5.1. Front end strategies
ADVANTAGESADVANTAGES OF
of FRONT-END STRATEGIES BACK-END STRATEGIES
Immediate reduction in use and
expenditure of restricted antibiotics
Timely de-escalation of antibiotics
Reduction in inappropriate use
A review of back-end versus front-end strategies reveals that
back-end strategies, although more labour-intensive, are:
l
More widely practiced
l
More easily accepted by clinicians
l
Provide a higher opportunity for educational opportunities.
They probably provide a more sustained impact of improving the
overall quality of antimicrobial prescribing [Chung et al., 2013].
An example of such a system from Singapore is illustrated below.
Figure 9. Front- and Back-end Antimicrobial Stewardship Strategy.
BACK-END STRATEGY
Preauthorization
and restriction
Prospective audit
and feedback
Antibiotic prescription
(by primary team)
Antibiotic prescription
(by primary team)
First few doses permitted
for selected antibiotics
Day1: review dose and
possibility of IV-to-oral switch
Institution restriction criteria
for selected antibiotics
Day 4: review appropriateness
considering microbiological
culture results
Day 7: review duration
of therapy
Antimicrobial stewardship team or infectious diseases physician
Approval
Intervention to optimize
antibiotic treatment
Patient
Adapted from Chung GW et al. Virulence 2013; 4:1-7.
18
Hospital ASPs should include an Antimicrobial Prescribing Policy that
is regularly reviewed and updated.
A template for a hospital antimicrobial policy prepared in the UK by
the Specialist Advisory Committee on Antimicrobial Resistance [SACAR]
and the important messages that need to be incorporated into the
policy [MINDME] are illustrated in Tables 6 and 7 from the Australian
Stewardship Guidelines [Duguid et al., 2010].
Table 6. Summary of contents of the SACAR template for hospital
antimicrobial policy.
Title page
• name of policy, date, version, review date, and contact details
for normal hours and out-of-hours enquiries
Introduction section
• statement as to whether the guideline is mandatory or for guidance
only, contents and a local procedure for microbiological samples
Summary list of available antimicrobials
• unrestricted, restricted (approval of a specialist is required) or
permitted for specific conditions
Regimens for treatment of common infections
• treatment, prophylaxis and rules for switching from intravenous
to oral administration
Adapted from Specialist Advisory Committee on Antimicrobial Resistance36 (SACAR)
Antimicrobial Framework. J. Antimicrob. Chemother. 2007;60:i87–i90.
Continues unless intervened by ASP
FRONT-END STRATEGY
5.1.1. Antimicrobial Prescribing Policy
Table 7. The Golden Rules of Antimicrobial Prescribing “MINDME”.
M Microbiology guides therapy wherever possible
I Indications should be evidence based
N Narrowest spectrum required
D Dosage appropriate to the site and type of infection
M Minimise duration of therapy
E Ensure monotherapy in most cases
Adapted from Antibiotic Expert Group. Therapeutic guidelines: antibiotic. Version 14.
Melbourne: Therapeutic Guidelines Limited; 2010.
19
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
microbiology and antimicrobial susceptibility patterns, as well as local
resource and priorities, clinician preference/views and potential risk
or unintended consequences.
This involves determining the list of restricted antimicrobial agents
(broad spectrum and later generation antimicrobials) and criteria for
their use combined with an approval system which is subject to
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
education for all relevant healthcare professionals.
Table 8. Example of the United Kingdom Specialist Advisory Committee
on Antimicrobial Resistance recommended guidelines.
Treatment of:
• Urinary tract infections
• Upper respiratory tract infections
• Lower respiratory tract infections (community and hospital acquired pneumonia,
and exacerbations of chronic obstructive pulmonary disease)
• Soft tissue infections (injuries or bites, cellulitis, chronic ulcers and necrotising
fasciitis)
• Central nervous system infections (bacterial meningitis, viral encephalitis
• Gastrointestinal infections such as food poisoning and intra-abdominal sepsis
• Genital tract infections
• Bloodstream infections
• Eye, ear, nose and throat infections
• Sepsis of unknown origin
• Specific confirmed infections; for example, treatment regimens for methicillinresistant Staphylococcus aureus, Clostridium difficile and tuberculosis
• Endocarditis
Prophylaxis use for:
• Prevention of bacterial endocarditis (which patients should receive prophylaxis)
• Endoscopic procedures (which individuals, considered at high risk, should receive
prophylaxis; for example, neutropenic patients)
• Surgical procedures (recommendations for all common surgical interventions,
including timing of initial dose and exceptional circumstances for repeat doses)
• Splenectomy patients (provide details of both the immunisation and antimicrobial
prophylaxis requirements)
Adapted from Specialist Advisory Committee on Antimicrobial Resistance (SACAR)
Antimicrobial Framework. J. Antimicrob. Chemother. 2007;60:i87–i90.
20
5.2. Back-end strategies
5.2.1. Antimicrobial review methods
Antimicrobial review methods are employed post-prescription and
outlined in the following table. The most appropriate interventions
for your institution should be chosen, according to local resources.
Table 9. Antimicrobial Review Methods.
Commonly used
• Review of indication for antibiotic and compliance with policy/guideline/formulary ;
note any recording of exception
• Review of appropriateness of antibiotic choice, dose, route and planned duration;
review of drug allergy, review of agents that may provide duplicative therapy
[potential overlapping spectra]
• Review of directed therapy based on culture and susceptibility test results
• Potential for conversion from IV to oral route
• Review requirement for therapeutic drug monitoring
• Review any antibiotic related adverse events
Less commonly used and
dependent on local resources
• Clinical review by AST of specific resistant pathogens [e.g MRSA] or site of infection
[e.g blood stream infections]
• Specific review of high cost/high use/novel agents
• Review of optimal dose [ PK/PD] in relation to dose and frequency; renal
adjustment, need for extended infusion, review of any potential drug interactions
• Review of directed therapy based on microscopy or PCR or other rapid tests *
• Review of empiric or directed therapy based on biomarkers *
* 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.
Adapted from Johannsson B. et al. Inf. Control. Hosp. Epidemiol. 2011; 32:367-374.
21
Table 10. Overview of prescribing from baseline PPS (May 2009)
and follow up PPS (September 2011).
➤ appropriate use of guidance,
Scotland
Acute
Hospitals
Europe
Scotland
Acute Hospitals
➤ indication for antibiotic,
7,573
73,060
11,604
➤ choice of agent,
➤ route [IV vs. oral] of administration of treatment,
Number of patients (%)
prescribed antimicrobials
2,289
(30.2%)
21,197
(29.0%)
3,728
(32.3%)
➤ timeliness of treatment,
Number of patients
(%) prescribed single
antimicrobial
1,432
(62.6%)
14,403
(67.9%)
2,268
(60.8%)
➤ likelihood of on-going infection or not,
Number of prescriptions
(%) for parenteral
antimicrobials
1,731
(51.8%)
17,947
(60.5%)
2,147
(47.8%)
➤ use of investigation,
➤ interpretation of microbiology with a view to
(%) with indication
recorded in notes
2,538
(75.9%)
22,456
(75.7%)
3,811
(86.8%)
de-escalation or stopping therapy,
➤ duration of therapy.
(%) compliant with local
policy
1939
(81.0%)
17,223
(82.5%)
2,245
(82.8%)
Number of surgical
prophylaxis prescriptions
(%) with duration single
dose
146
(49.3%)
927
(27.0%)
287
(59.5%)
Number of surgical
(%) with duration = 1 day
57
(19.3%)
723
(21.1%)
81
(16.8%)
Number of surgical
(%) with duration >1 day
93
(31.4%)
1783
(51.9%)
114
(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]
22
☺
☺
☺
☺
☺
☺
➔
Feedback on antimicrobial prescribing should be provided regularly
to prescribers in the critical care setting, and areas of high and/
or poor quality antimicrobial use.
Number of patients
surveyed
➔
The types of interventions selected, how they are delivered and by
whom, will be determined by local resources, need and available
expertise.
Measure
➔
Follow up PPS
(Sept 2011)
➔
Baseline PPS (May 2009)
Point-of-care interventions can include:
➔
During clinical review, a range of point-of-care stewardship
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
prescribing.
➔
The audit and feedback process can be managed by either the medical
infection specialist or specialist pharmacist. However, depending on
the intervention, specialist nurses or clinical pharmacists can also be
trained to support this process.
These data can be used in an audit process to provide structured
feedback to prescribing teams and to define areas for improvement.
At a national level, as illustrated in an example for Scotland [Table 10],
such point prevalence surveys can be used to establish baseline
prescribing information and identify priorities for quality
improvement. This information has contributed to the development
of national prescribing indicators. [Malcolm et al., 2012]
➔
5.2.2. Audit and direct feedback to prescribers
☺
Adapted from Malcolm W, Nathwani D, et al. Antimicrob. Resist. infect. Control. 2012;2:3.
23
5.2.3. Use of diagnostic tools
The role of rapid diagnostics and biomarkers in antimicrobial
stewardship is recognised as a key recommendation by the IDSA.
➤ T he IDSA policy statement for combating antimicrobial
resistance and saving lives recommends “Greater Investment
in Rapid Diagnostics R&D and Integration into Clinical Practice”
as one of the key strategies. [Dellit et al., 2007]
Individual health
Public health
Overall impact
Continued illness
Continued
transmission
Increasing burden
of disease
Mis- or over-use of
antibiotics
Antibiotic-related
adverse events
Waste of antibiotic
resources
Antibiotic resistance
and C. difficile
infection
Breakdown in disease
control and in spread
of resistant pathogen
Failure of health
system to treat
infection
Lack of diagnosis
Syndromic
treatment
Integration of diagnostics with other AMS interventions, to provide fast
accurate identification and susceptibility testing, will achieve
better clinical outcomes and timely streamlining/de-escalating
of empiric broad-spectrum antibiotics in seriously ill patients.
Many studies have assessed algorithms based on procalcitonin
(PCT) as a rapid-reacting biomarker of bacterial infection for antibiotic
stewardship. Recent systematic reviews showed benefits of PCT
among patients with respiratory tract infection and sepsis by significantly
reducing antibiotic exposure as well as a trend towards reduced
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].
Near-patient rapid tests, e.g. influenza, Strep A, can be useful to
identify patients with bacterial versus viral infections.
Molecular diagnostics or screening tests providing a faster
result play an important role in pathogen detection in critically
ill patients which will improve antibiotic stewardship and clinical
outcomes [Afshari et al., 2012].
However, the availability of these interventions in resource-limited
environments is likely to be a challenge to their introduction.
24
“If you cannot measure it, you cannot improve it”
Lord Kelvin 1824-1907
Measurement of prescribing performance is essential to evaluate
the impact of stewardship interventions on clinical practice and
demonstrate benefits for patients.
Establishing what to measure, the frequency of measurement and
how the data will be communicated and acted upon are also key.
Figure 10. The high cost of poor diagnosis of infection.
No treatment
6.Identify key measurements
for improvement
In addition to the audit and feedback described in section 5.2.2, three other
types of measurement are commonly used within stewardship programs:
l Surveillance of antimicrobial use and resistance.
l Data collection for quality improvement.
l Analysis of hospital datasets to evaluate positive and negative
consequences of interventions.
6.1. S urveillance of antimicrobial use
and resistance
Monitoring trends in antimicrobial use and resistance within a hospital
over several years and also identifying small changes in a single ward
over a one-month period, are essential to:
l Adapt empiric treatment according to local resistance trends
l Demonstrate changes in practice over time.
l Identify wards with high antimicrobial usage or use of non-policy
antimicrobials and define targeted interventions required
➤ Measure improvement after implemented interventions
Surveillance of antimicrobial use and resistance is important:
l at hospital, local, regional, national levels (i.e.: Strama [http://
en.strama.se], Wales [Heginbothom M and Howe R, 2012], Australia [www.
health.sa.gov.au/INFECTIONCONTROL])
l and at global level (i.e.: ECDC: consolidation of resistance data
at the European level [EARSS.net] with consolidation of antibiotic
use [ESAC.net], CDC National Antimicrobial Resistance Monitoring
System [cdc.gov/NARMS])
25
DDD/1000 BD per Quarter
1.5
6.1.1. How is antimicrobial use data collected
and analysed?
ntimicrobial use at individual patient level, using an electronic
A
prescribing system through the Hospital Information System.
l Data from hospital pharmacy computer systems, showing
antimicrobials delivered to each ward and used as a proxy measure
for antimicrobials administered to patients.
l The measure used is Defined Daily Dose (DDD) which represents
the average daily maintenance dose of an antimicrobial for its main
indication in adults. For instance, the DDD of oral amoxicillin is
1000 mg, so a patient receiving 500 mg every 8 hours for 5 days
consumes 7.5 DDDs.
l Usage data may then be divided by a measure of hospital
activity such as number of admissions or in-patient bed days to
provide more meaningful trend analysis. In-patient bed days is
more commonly used as this data can usually be obtained earlier
than admissions data.
l Other denominators are also used and their strengths and limitations
have been described [Monnet et al., 2007; Berrington et al., 2010]
l
1.5
1.5
ABC Calc is a simple computer tool to measure antibiotic
1.5
consumption in hospitals and hospital wards. It transforms aggregated
1.5
data
provided by hospital pharmacies (generally as a number
1.5 packages or vials) into meaningful antibiotic utilisation rates.
of
50
1
02
03
20 0
06 4
01
02
03
20 0
07 4
01
02
03
20 0
08 4
01
02
03
20 0
09 4
01
02
03
20 04
10
01
02
03
20 04
11
01
02
03
04
[http://www.escmid.org/research_projects/study_groups/esgap/abc_calc/]
1.5
1.5
Figure 12. Pareto chart displaying use of « restricted » antibiotics in a
in Lanarkshire.
1.5
hospital
20
05
01
No of episodes
of use
02
03
20 0
06 4
01
02
03
20 0
07 4
01
02
03
20 0
08 4
01
02
03
20 0
09 4
01
02
03
20 04
10
01
02
03
20 04
11
01
02
03
04
Piperacillin/Tazobactam use in Monklands (Feb 2010)
6
5
Cumulative percent
4
1.5
3
2
1
0
18
14
5 inhibitor
4 26combinations
(ITU) 17 (J01CR)
15 ERU
2
7
Beta-lactam/beta-lactamase
No of episodes
of use
Cephalosporins (J01D)
Carbapenems
(J01DH)
Fluoroquinolones
(J01MA)
Ward
50%
100
80
60
40
20
0
Cumulative percentage
20
0
1.5
Pareto
charts are useful to provide an overview of antimicrobial
(J01CR) that have high total usage
usage
at ward levelinhibitor
and combinations
identify wards
1.5Beta-lactam/beta-lactamase
Carbapenems (J01DH)
(J01MA)
or1.5Cephalosporins
high use of(J01D)
restricted
antimicrobials. InFluoroquinolones
the example
below 50%
of piperacillin/tazobactam use occurs within 3 wards therefore
1.5
interventions to reduce use should focus on these wards.
1.5
Source: Steve McCormick, Lead Antimicrobial Pharmacist, NHS Lanarkshire - presented
at “Quality Improvement within Acute Medicine” Workshop organized by the Scottish
Antimicrobial Prescribing Group and Society for Acute Medicine - June 2010.
Resistance (%)
No of episodes of use
2005
60
6.1.2.
How is antimicrobial resistance
data2009
2010
2006
55
2011 100
2007
50 6 collected and analyzed?
5
80
2008
45
Figure 11. Trends in Specific Antibacterial Group Usage for All-Wales
hospitals from 2005–2011.
Cumulative percent
4
60
Cumulative percentage
65
Hospital level data may be transferred to a national database for
further analysis.
40 3
Resistance
data is obtained from the Microbiology laboratory through
40
35 2
20
1
computer
systems.
Hospital
level
data
may
then
be
transferred
to
30
0
0
18
14
5
4
26
(ITU)
17
15
ERU
2
7
25
national databases. Examples from two UK countries, Wales and
No of episodes of use
20
50%
Scotland,
are shown
in FiguresWard
13 and 14.
15
1.5
1.5
30
2008
10
Figure
13. All-Wales resistance rates for E. coli bacteraemia
2009 (2005
5
25
2010
to 2011).
0
Adapted from Heginbothom M and Howe R. A Report from Public Health Wales
Antimicrobial Resistance Programme Surveillance Unit. 2012.
Resistance (%)
CXM
FQ
GEN
15
PTZ
2009
2010
2011
2005
2006
2007
2008
10
5
3GC
AMO
ne
ta x
im
e
ce
fta
zid
im
e
ge
nt
am
i
cin
cip
ro
flo
xa
cin
m
er
op
en
em
pip
/ta
zo
tri
m
en
op
rim
3G
CF
O
3G
C/
AG
ria
ce
ft
COA
ce
fo
xim
xo
e
v
0
icl
a
Beta-lactam/beta-lactamase inhibitor combinations (J01CR)
Cephalosporins (J01D)
Carbapenems (J01DH)
Fluoroquinolones (J01MA)
CARB
ro
20
0
50
1
02
03
20 0
06 4
01
02
03
20 0
07 4
01
02
03
20 0
08 4
01
02
03
20 0
09 4
01
02
03
20 04
10
01
02
03
20 04
11
01
02
03
04
1.5
COA
fu
1.5
AMO
20
ce
Resistance (%)
1.5
3GC
ox
1.5
65
60
55
50
45
40
35
30
25
20
15
10
5
0
m
1.5
-a
1.5
co
1.5
CARB
CXM
FQ
GEN
PTZ
Adapted from Heginbothom et al. A Report from Public Health Wales Antimicrobial
Resistance Programme Surveillance Unit. 2012.
6
100
ntage
27
f use
26
Figure 14. Antimicrobial resistance (with 95% confidence intervals) in
K. pneumoniae isolated from blood cultures in 2008 (n=512), 2009
(n=672) and 2010 (n=715).
30
Structural indicators
• Availability of multi-disciplinary antimicrobial stewardship team
• Availability of guidelines for empiric treatment and surgical prophylaxis
• Provision of education in the last 2 years
2008
2009
2010
25
Resistance (%)
Table 11. AMS program measures for quality improvement.
Process measures
• Amount of antibiotic in DDD/100 bed days
- Promoted antibiotics
- Restricted antibiotics
• Compliance with acute empiric guidance (documented notes and policy
compliance)
• % appropriate de-escalation; % appropriate switch from IV to oral
• Compliance with surgical prophylaxis (<60 min from incision, <24 hours and
compliance with local policy
• Compliance with care “bundles” – all or nothing (3-day antibiotic review bundle,
ventilator-associated pneumonia, community-acquired pneumonia, sepsis)
20
15
10
5
co
-a
m
ox
icl
av
ce
fu
ro
xim
e
ce
ftr
iax
on
e
ce
fo
tax
im
e
ce
fta
zid
im
e
ge
nt
am
ici
cip
n
ro
flo
xa
c
m
in
er
op
en
em
pip
/ta
zo
tri
m
en
op
rim
3G
CF
O
3G
C/
AG
0
Outcome measures
• C. difficile rates
• Surgical Site Infection (SSI) rates
• Surveillance of resistance
• Mortality: Standardized Mortality Rates (SMRs)
Adapted from Scottish Antimicrobial Prescribing Group (SAPG), Report on Antimicrobial
Use and Resistance in Humans in 2010.
Balancing measures
At national level, resistance surveillance is particularly important
to identify emerging resistance in common pathogens or multiresistant organisms such as Gram negative bacteria which produced
extended spectrumNational
beta lactamase
(ESBL) or carbapenemase enzymes.
data: compliance with indication documented
• Mortality
• SSI rates
• Readmission within 30 days of discharge
• Admission to ICU
• Rate of complications
• Treatment-related toxicity (e.g. aminoglycoside-related toxicity)
and overall median throughout data collection period
Medical and surgical admissions
100
ChangesChemother.
to guidance means
some times Morris et al.
Adapted from Dumartin et al. J. Antimicrob.
2011;66:1631-7;
are not achivable. Consultants have discussed
Inf. Control. Hosp. Epidemiol. 2012;33[3]:500-506.
95
6.2. Data
collection for quality
improvement
90
Surgical admissions
Surgical median
ccountability (e.g. targets)
A
National data: compliance with policy (antibiotic choice)
l Improvement
100
and overall median throughout data collection period
l Research.
95
l
at 100% this month
100
90
80
70
60
50
40
30
20
10
0
A common quality improvement methodology is the “Plan- DoStudy- Act” model.
goal =95.00
Data collection
What form
are as part
of theatre checklist
we trying to
accomplish?
Not
recording on sheet
How will we know
that a change is
an improvement?
Plan
Act
in line
What changesReview
can we
make that
+5 new theatres
with SIGN guidelines
will result in improvement?
Do
Study
www.ihi.org/knowledge/Pages/HowtoImprove/ScienceofImprovementHowtoImprove
Month
M
Ap
r-1
1
ay
-11
Ju
n11
Ju
l-1
1
Au
g11
Se
p11
Oc
t-1
1
No
v-1
1
De
c-1
1
Ja
n12
Fe
b12
M
ar
-12
Ap
r-1
M 2
ay
-12
Ju
n12
A range90of such measures for antimicrobial stewardship programs have
85
been proposed.
They can be summarized as four types (see Table 11):
80 process, outcomes and balancing (are the changes causing
structural,
new problems?) [www.abs-international.eu; Dumartin et al., 2011].
with
ALL
19 theatres
6.2.1. Examplesantibiotic
ofWorking
measures
for
improvement
pharmacy
reporting and 17
11
-20
1-2 06
0
3-2 07
0
5-2 07
0
7-2 07
0
9-2 07
11 007
-20
1-2 07
0
3-2 08
0
5-2 08
0
7-2 08
0
9-2 08
11 008
-20
1-2 08
0
3-2 09
0
5-2 09
0
7-2 09
0
9-2 09
11 009
-20
1-2 09
0
3-2 10
0
5-2 10
0
7-2 10
01
9-2 0
11 010
-20
1-2 10
0
3-2 11
01
1
11
l-1
1
Au
g11
Se
p11
Oc
t-1
1
No
v-1
1
De
c-1
1
Ja
n12
Fe
b12
M
ar
-12
Ap
r-1
M 2
ay
-12
Ju
n12
Ju
-11
n-
Ju
ay
M
Ap
r-1
1
85
Antimicrobial
stewardship is part of many patient safety programs. To
measure the performance of these programs, data is primarily used
for 3 purposes [Solberg
et al., 1997]: Medical median
Medical admissions
Target
this with Microbiology and Antibiotic Pharmacy.
Agreement reached.
Quality improvement programs often use annotated run charts to display
data and show the effects of changes. Figure 15 shows an example of
a run chart used to measure improvement of administration of surgical
antibiotic prophylaxis on time.
28
29
Figure 17. New cases of CDI and the number of OBDs before and after
the introduction of revised antibiotic guidelines.
Introduction of revised antibiotic guidelines
60
50
Cases/predicted values
Month
15 000
Move to Riverside Building
14 000
13 000
40
12 000
30
11 000
20
OBDs
+5 new theatres
10 000
10
9 000
0
8 000
ril
M 05
ay
Ju 05
ne
Ju 05
A ly
Se ugu 05
pt st
em 0
5
O ber
No ctob 05
ve er
0
m
De b 5
ce er
m 05
Ja ber
n 0
Fe uary 5
br 0
ua 6
M ry 0
ar 6
ch
Ap 06
ril
M 06
ay
Ju 06
ne
Ju 06
A ly
Se ugu 06
pt st
em 0
6
O ber
No ctob 06
ve er
De mb 06
ce er
m 06
Ja ber
n 0
Fe uary 6
br 0
ua 7
M ry 0
ar 7
ch
07
Ap
Figure 16.a. Indication documented in patient’s notes.
National data: compliance with indication documented
National
data:
compliance
with indication
documented
and overall
median
throughout
data collection
period
and overallMedical
medianand
throughout
collection period
surgical data
admissions
OBD
CDI
Predicted values (negative binomial regression)
OBD = Occupied Bed Days
Changes
to guidance 2011;66:2168-74.
means some times Adapted from Talpaert et al., J. Antimicrob.
Chemother.
Changes to guidance means some times
ApAp
r-1r-1
MM 1 1
ay ay
-11-11
Ju Ju
n- n11 11
Ju Ju
l-1 l-1
1 1
AuAu
g- g11 11
Se Se
p- p11 11
OcOc
t-1 t-1
1 1
NoNo
v-1v-1
1 1
DeDe
c-1c-1
1 1
Ja Ja
n- n12 12
Fe Fe
b- b12 12
MM
ar ar
-12-12
ApAp
r-1r-1
MM 2 2
ay ay
-12-12
Ju Ju
n- n12 12
Note: non-zero y-axes.
Source: Empirical Prescribing Indicator Report April 2011 – June 2012. Scottish Antimicrobial Prescribing Group August 2012.
2.5
2.0
1.5
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
MRSA Resistance to Clindamycin (%)
National data: compliance with policy (antibiotic choice)
National
data:median
compliance
with policy
(antibioticperiod
choice)
and overall
throughout
data collection
and overallMedical
medianand
throughout
collection period
surgical data
admissions
Prescriptions
Resistance
Ja
n
Fe
b
M
ar
Ap
Mr
ay
Ju
n
Ju
Au l
g
Se
p
Oc
No t
v
De
c
Figure 16.b. Antibiotic choice compliant with policy.
100
100
90
90
80
80
70
70
60
60
50
50
40
40
30
30
20
20
10
10
0
0
MRSA Resistance to Ciprofloxacin (%)
Target
Target
A
300
Ja
n
Fe
b
M
ar
Ap
Mr
ay
Ju
n
Ju
Au l
g
Se
p
Oc
No t
v
De
c
Medical median
Medical median
Surgical median
Surgical median
Working with
ALL 19B theatres
Prescriptions
2.5
1.75
Working
with
ALL 19 theatres
antibiotic
pharmacy
reporting
and 17
Resistance
1.50
antibiotic pharmacy
reporting
and
17
2.0
at 100%
month
1.25 this
at
100%
this month
1.5
1.00
200
goal =95.00
0.75
goal =95.00
1.0
0.50
100
0.5
0.25
Data collection
0.0
0.00
Data
collection
0
form
as part
-0.25
-0.5
formchecklist
as part
-0.50
of theatre
-100 of theatre checklist
-1.0
-0.75
-1.00
-1.5
Not recording on sheet
-200
-1.25
-2.0
-1.50
-2.5
-300
-1.75
Review in line
Review
in line
+5 new theatres
with SIGN
guidelines
+5 new theatres
Seasonal pattern of antibiotic prescriptions and MRSA, showing 1-month lag.
A Mean monthly seasonal variation for quinolone prescription and MRSA isolates resistant to
Month
ciprofloxacin calculated by seasonal-trend
decomposition procedures based on LOESS (STL) method.
Month
B Mean monthly seasonal variation for macrolide and licosamide prescription and MRSA
resistant to clindamycin calculated by STL method. Prescription data source: IMS Health,
Xponent, 1999-2007. Resistance data source: The surveillance Network Database-USA (Focus
Diagnostics, Hendon, VA). Abbreviation: MRSA, methicillin-resistant Staphylococcus aureus.
60
Introduction of revised antibiotic guidelines
Adapted from Sun L, et al. Clin. Infect. Dis. 2012;55:687-94.
50
d values
Medical admissions
Medical admissions
Surgical admissions
Surgical admissions
400
11 11
-20 -20
1-2 10-26 06
0 0
3-2 30-27 07
0 0
5-2 50-27 07
0 0
7-2 70-27 07
0 0
9-2 90-27 07
11 10107007
-20 -20
1-2 10-27 07
0 0
3-2 30-28 08
0 0
5-2 50-28 08
0 0
7-2 70-28 08
0 0
9-2 90-28 08
11 10108008
-20 -20
1-2 10-28 08
0 0
3-2 30-29 09
0 0
5-2 50-29 09
0 0
7-2 70-29 09
0 0
9-2 90-29 09
11 10109009
-20 -20
1-2 10-92 09
0 0
3-2 31-02 10
0 0
5-2 51-02 10
0 0
7-2 71-02 10
0 0
9-2 91-02 10
11 10110 010
-20 -20
1-2 11-02 10
0 0
3-2 31-12 11
01 01
1 1
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-11-11
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85
85
Fluoroquinolone Prescriptions (thousands)
90
90
Macrolide/Lincosamide Prescriptions (millions)
arewith
not Microbiology
achivable. Consultants
havePharmacy.
discussed
this
and Antibiotic
this with Microbiology and Antibiotic
AgreementPharmacy.
reached.
Figure 18. Correlation between antibiotic use and resistance.
Agreement reached.
95
95
30
Ja
n
Fe
b
M
ar
Ap
Mr
ay
Ju
n
Ju
Au l
g
Se
p
Oc
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n
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b
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ar
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Mr
ay
Ju
n
Ju
Au l
g
Se
p
Oc
No t
v
De
c
[Talpaert et al., 2011, Vernaz et al., 2009, Mamoon et al., 2012].
Compliance with policy is a process measure.
100
100
95
95
90
90
85
85
80
80
2.5
2.0
1.5
1.0
0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
MRSA Resistance to Clindamycin (%)
-200
6.2.2. Examples of measures used
for accountability e.g. targets
100
100
Prescriptions
Resistance
1.75
1.50
1.25
1.00
0.75
0.50
0.25
0.00
-0.25
-0.50
-0.75
-1.00
-1.25
-1.50
-1.75
This provides information about effects of antimicrobial interventions
-300
on clinical outcome, i.e. how restriction of cephalosporins and
fluoroquinolones has resulted in reduced Clostridium difficile
rates by linking antimicrobial usage data and microbiology data
1
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Source: Scottish Patient Safety Program.
MRSA Resistance to Ciprofloxacin (%)
Fluoroquinolone Prescriptions (thousands)
ALL 19 theatres
2008
reporting and 17
2008
2009
at
100%
2009 this month
2010
2010
Resistance
Resistance
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(%)
25
100 25 goal =95.00
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20
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70
form as part
60 15
of theatre checklist
15
50
40 10
10
30
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20 5
10 5
0
0
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2.0
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0.5
0.0
-0.5
-1.0
-1.5
-2.0
-2.5
100
Linkage
of hospital datasets such as hospital admissions, laboratory
data 0and patient outcomes allows measurement of the impact of
stewardship
interventions on patient morbidity and mortality.
-100
this with Microbiology and Antibiotic Pharmacy.
Agreement reached.
Working with
antibiotic pharmacy
Prescriptions
Resistance
300
6.3.200 Analysis of hospital datasets
Figure 15. Improvement in administration of on-time surgical
Changes to guidance means some times
antibiotic prophylaxis.
30
30
400
Macrolide/Lincosamide Prescriptions (millions)
40
Move to Riverside Building
15 000
14 000
13 00031
7. Educate and Train
Education is a key component of any Antimicrobial Stewardship
Program. It should include healthcare professionals from all care
settings, as well as patients and the public.
Educating patients and the general public about hygiene and
antibiotic use is also important, and may indirectly support hospital
education efforts. National and regional public health campaigns,
including education aimed at parents and children, have had a variable
level of success [Huttner et al., 2010].
By increasing people’s knowledge and understanding of how
antimicrobials should be used to treat common infections and why
inappropriate use may lead to resistance and loss of effective treatments,
this valuable resource can be protected for future generations.
Some examples of public awareness campaigns:
l www.e-bug.eu
l www.ecdc.europa.eu/en/eaad
l www.cdc.gov/getsmart
7.1. Who should receive education
in hospitals?
7.2. How should an education program be
designed?
Prescribers and other healthcare staff with modules adapted to
their background including:
Programs should take into account local recommendations for
antimicrobial stewardship, if available. If not, they could be inspired by
international policies (see section on “Additional Resources”, page 38).
l
Undergraduate curriculum
l
Internship
l
Professional training for new staff
l
Continuing professional development for all prescribers
l
Postgraduate education
Educational measures recommended in the literature to improve
antibiotic use in hospitals are shown in Table 12.
Table 12. Main antimicrobial stewardship strategies recommended in the
international literature to improve antibiotic use at the hospital level.
Passive educational measures • Developing/updating local antibiotic guidelines
The content of education should be adapted to each profession
and include:
l
Basic knowledge of infection management,
l
Basic microbiology
l Importance of prudent prescribing in tackling antimicrobial resistance.
l
B est practices for prescribing to support safe and effective prescribing,
administration and monitoring of antimicrobial therapy.
The training is usually delivered by the antimicrobial management
team and may include competency assessment.
32
• Educational sessions, workshops, local conferences
Active interventions
• Clinical rounds discussing cases
• Prospective audit with intervention and feedback
• Reassessment of antibiotic prescriptions, with streamlining
and de-escalation of therapy
• Academic detailing, educational outreach visits
Adapted from Pulcini C and Gyssens IC. Virulence 2013;4:192–202.
An evaluation process should be included in the education program
to measure attendance, understanding and assimilation, using regular
training assessment tools such as attendance forms, completion
certificates, questionnaires, tests etc.
33
8. Communicate
Figure 20. Start Smart … Then Focus approach.
Communication is a key component of the success of an ASP.
Clear, simple communication should show the vision and the
benefits of the program, with core clinical messages.
The “Start Smart - Then Focus” approach in the UK is a good
example of such an approach [Figures 19 and 20].
Clean contaminated
surgery
ANTIMICROBIAL STEWARDSHIP
Right drug, right dose, right time, right duration…
…every patient
Start Smart
• Initiate prompt effective
antibiotic treatment within
one hour of diagnosis
(or as soon as possible)
in patients with life
threatening infections
Clinical review check microbiology,
make and document decision*
* A repeat dose dose of prophylaxis may be required for prolonged procedures or where there is
significant blood loss. A treatment course of antibiotics may also need to be given (in addition to
appropriate prophylaxis) in cases of dirty surgery or infected wounds. The appropriate use and choice
of antibiotics should be discussed with infection specialists for each case.
Another approach is to identify and communicate to prescribers
specific situations where antibiotics should be withheld and guidance
in relation to the duration of antibiotic use, which is often an area of
misuse (Table 13, page 36).
2. IV/oral switch
3. Change: to narrow
spectrum agent
4. Continue
and review
after 4 hours
•D
ocument clinical
indication and dose on
drug chart and clinical
notes
• E nsure relevant
microbiological
specimens taken
Contaminated surgery
1. STOP
• C omply with local
prescribing guidance
• Include review/stop
date or duration
ONE DOSE
within 60 minutes before
knife to skin
D
O
C
U
M
E
N
T
Clinical review & decision* at 48 hours
Do not start antibiotics
in the absence of evidence
of bacterial infection
• T ake history of relevant
allergies
Clean surgery involving
placement of
a prosthesis or implant
Surgical prophylasis
Figure 19. Start Smart … Then Focus approach.
Then
focus
Single dose surgical prophylaxis*
5. OPAT**
DOCUMENT DECISION
The importance of communicating, sharing and learning from
data is also important.
Face-to-face meetings with prescribers, where there is an opportunity
for reflection about their prescribing practices, or attending multidisciplinary teams, web-ex conferences, etc. are all important in
promoting learning about prudent prescribing.
* Antimicrobial Prescribing Decision
** Outpatient Parenteral Therapy
Figures 19 and 20 are adapted from Department of Health Advisory Committee on
Antimicrobial Resistance and Healthcare Associated Infection (ARHAI) ANTIMICROBIAL
STEWARDSHIP:“START SMART - THEN FOCUS” Guidance for antimicrobial stewardship
in hospitals (England) November 2011.
34
35
Table 13. Specific Situations where Antibiotics should be
withheld
• Respiratory tract syndromes
- Viral pharyngitis
- Viral rhinosinusitis
- Viral bronchitis
- Noninfectious cardiopulmonary disorders misdiagnosed as pneumonia
• Acute Otitis Media (AOM) (for selected cases, refer to article)
• Skin and Soft Tissue Infections (SSTI)
- Subcutaneous abscesses (for selected cases, refer to article)
- Lower extremity stasis dermatitis
• Asymptomatic bacteriuria and pyuria, including catheterized patients
• Microbial colonization and culture contamination
THE KEYS TO SUCCESS
A number of interventions are key to the success of a
hospital-based Antimicrobial Stewardship Program.
➤ Establish a clear aim/vision that is shared by all the
stakeholders and that conveys a sense of urgency.
Stewardship should be a patient safety priority.
➤ Seek management support, accountability
and secure funding.
• Low-grade fever
Adapted from Wlodover et al., Infect. Dis. Clin. Pract. 2012;20:12-17.
Table 14. Practice Guideline Recommendations regarding
duration of therapy
• Community-acquired pneumonia (CAP)
5 days
• Health care-acquired pneumonia
8 days
• Skin and Soft Tissue Infections (SSTI)
5 days
• Urinary Tract Infections (UTI)
- Cystitis
- Pyelonephritis
- Catheter associated
3-5 days a
5-14 days a
7 days b
• S. aureus bacteremia
- Low risk of complications,
- High risk of complications
2 weeks
4-6 weeks
• Intra-abdominal infection
4-7 days
• Surgical antibiotic prophylaxis,
1 dose c
a
b
c
Depending on antibiotic
Prolonged to 10-14 days for delayed response
Up to 24h, witout exception
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.
➤ Establish effective communication structures
within your hospital.
➤ Start with core evidence-based stewardship
interventions depending on local needs,
geography and resources and plan measurement
to demonstrate their impact.
➤ Ensure all healthcare staff are aware of the
importance of stewardship. Empower them
to act and support with education using a range
of effective strategies.
➤ Ensure early or short term wins and then
consolidate success/gains while progressing
with more change or innovation.
36
37
Additional Resources
Global Resources for implementing and measuring the impact of
hospital Antimicrobial Stewardship Programs
Africa
Antimicrobial Stewardship and Infection Control African Network : www.
ischemo.org/index.php/sections/isc-wg-antimicrobial-stewardship-andinfection-control-african-network
Best Care…Always! (BCA) campaign supporting South(ern) African
healthcare organisations: www.bestcare.org.za/Antibiotic+Stewardship
South African Antibiotic Stewardship Programme : www.fidssa.co.za/A_
SAASP_Home.asp
Suleman F, Meyer H. Antibiotic resistance in South Africa: your country
needs you! S. Afr. Pharm. J. 2012;79:44-46.
Asia-Pacific
Duguid M and Cruickshank M (eds) (2011). Antimicrobial stewardship
in Australian hospitals, Australian Commission on Safety and Quality in
Health Care, Sydney.
Ghafur A, Mathai D, Muruganathan A, et al. “The Chennai Declaration”
Recommendations of “A roadmap- to tackle the challenge of antimicrobial
resistance” - A joint meeting of medical societies of India. Indian Journal
of Cancer 2013;49.
Ho PL, Cheng JC, Ching PT et al. Optimising antimicrobial prescription
in hospitals by introducing an antimicrobial stewardship programme
in Hong Kong: consensus statement. Hong Kong Med 2006;12:141-8.
Teng CB, Lee W, Yeo CL et al. Guidelines for Antimicrobial Stewardship
Training and Practice. Ann. Edu. Sg. 2012;41 No.1.
Europe
Allenberger F, Gareis R, Jindrák V, Strulens MJ. Antibiotic stewardship
implementation in the EU: the way forward. Expert Rev. Anti Infect. Ther.
2009;7:1175-1183.
Cooke J, Alexander K, Charani E, et al. Antimicrobial stewardship: an
evidence-based, antimicrobial self-assessment toolkit (ASAT) for acute
hospitals. J. Antimicrob. Chemother. 2010;65:2669-2673.
38
Department of Health Advisory Committee on Antimicrobial Resistance and
Healthcare Associated Infection (ARHAI) ANTIMICROBIAL STEWARDSHIP:
“START SMART - THEN FOCUS”.
ESCMID Study Group for Antibiotic Policies (ESGAP): www.escmid.org/
index.php?id=140
Guidance for antimicrobial stewardship in hospitals (England) ARHAI
Antimicrobial Stewardship ; http://www.dh.gov.uk/prod_consum_dh/
groups/dh_digitalassets/documents/digitalasset/dh_131181.pdf
Guidelines for Antimicrobial Stewardship in Hospitals in Ireland. SARI
Hospital Antimicrobial Stewardship Working Group http://www.hpsc.ie/
hpsc/A-Z/MicrobiologyAntimicrobialResistance/InfectionControlandHAI/
Guidelines/File,4116,en.pdf
Monnet D, Kristinsson K. Turning the tide of antimicrobial resistance:
Europe shows the way. Euro Surveill 2008;13.
Nathwani D, on behalf of SMC/HAI. Antimicrobial prescribing policy and
practice in Scotland: recommendations for good antimicrobial practice in
acute hospitals. J. Antimicrob. Chemother. 2006;57:1189-1196.
US
ASHP statement on the pharmacist’s role in antimicrobial stewardship and
infection prevention and control. Am. J. Health .Syst. Pharm. 2010;67:575-7.
CDC: http://www.cdc.gov/getsmart/healthcare/
Dellit TH, Owens RC, McGowan JE, Jr. 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.
Drew RH, White R, MacDougall C, et al. Insights from the Society of
Infectious Diseases Pharmacists on antimicrobial stewardship guidelines
from the Infectious Diseases Society of America and the Society for
Healthcare Epidemiology of America. Pharmacotherapy 2009;29:593-607.
Goff D, Bauer KA, Mangino JE, et al. Antibiotic stewardship management
of infections. Beyond the cost of Antimicrobials. Pharmacy practice News.
August 2012:1-12 [useful suggestions for ASP in resource limited settings].
Owens RC. Antimicrobial stewardship: concepts and strategies in the
21st century. Diag. Micro. Infect. Dis. 2008;61:110-128.
39
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40
41
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Practical guide to antimicrobial stewardship

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