Anti-microbial stewardship Flashcards
what is antimicrobial stewardship?
“An overarching program to change and direct antimicrobial use at a health care institution”
“an organisational or healthcare‑system‑wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.” [NICE guidelines]
how is a new antibiotic made?
Research to develop new antibiotics includes modification of existing ABx as well as search for new ones with novel MoA
Alter usual site for binding to D-Ala-D-Ala to also bind D-Ala-D-Lac (transpeptidase inhibition)
Another site altered that leads to cell membrane permeability
Third modification can facilitate inhibition of transglycosylase
Make more potent and effective again resistant organisms. Many other examples
what is CQUIN and relation to AMR/AMS
The Commissioning for Quality and Innovation (CQUIN) framework supports improvements in quality of services + creation of new, improved patterns of care
CQUIN scheme sets targets for CCGs and Prescribed specialist services (PSS) – part of income is conditional on meeting targets – new targets annually
-There are often CQUIN indicators relevant to AMR / AMS and infections
what is the purpose of AMS
Focus is on patient and public health but is known to also result in cost savings
Reduction in total or targeted antimicrobial use
Decrease in inappropriate antimicrobial use
Improvement in susceptibility profiles of hospital pathogens
Improvement in clinical markers (decreased length of stay, mortality)
Increase in appropriate antimicrobial use
Selection
Dosing
Route
Duration of therapy
what is the reasons of AMS
Multi-drug resistant pathogens have impact on patient care
Longer duration of stay
Increased morbidity & mortality
Increased costs (also significant % antimicrobial use inappropriate)**
Medication errors
Allergy identification
Drug toxicity
Adverse reactions
Drug-drug interactions
what does AMS toolkit mean and consist of?
UK has 2 toolkits:
TARGET (primary) &
Start Smart then Focus (secondary)
what is the difference between smart focus and then smart
smart focus - do not start the antibiotic in the absence of clinical evidence of bacterial infections
(take allergy history, initiate effective antibiotic treatment within one hour of diagnosis, obtain cultures, document clinical indications - severity, comply with the antimicrobial prescribing guidance)
then smart - clinical review and decision at 48-72 hours
clinical review, check microbiology and make a clear plan- document this decision
- stop
iv to oral
change antibiotic
continue
OPAT
all the decisions needs to be documented
who are the core members in the hospital AMS team
CORE members:
Clinical pharmacist with infectious disease expertise
Clinical microbiologist
AND/OR Infectious disease physician
Plus e.g.
IT specialist
Infection Control professional/nurse
Hospital epidemiologist (Lecture 9)
Non-clinical management
what other departments are involved (AMS collaboration)
Hospital infection control committee
Drugs & Therapeutics or Formulary committee
Patient safety committee
Finance department
Hospital information department
Trust clinical governance committee
Trust board
what does the core members use as strategy for AMS (AMS strategies)
Formulary Restriction (with prior approval / preauthorisation)
Review/audit and feedback
Education and Guidelines
Streamlining / De-escalation
IV to oral switch
Antibiotic cycling
Others
what is formulary restriction with pre-authorisation
Restrict dispensing of select (restricted) antimicrobials to specific:
Indication, Criteria, Prescriber, Service/ward, Patient group
Prior approval / pre-authorisation for some choices where prescriber contacts AMS team (e.g. pharmacist or microbiologist) for approval to prescribe certain items
Antimicrobial committee typically creates formulary
Approval personnel ensure adherence to formulary (pharmacist, physician, microbiologist)
what are the advantages and disadvantages of Formulary Restriction withpre-authorisation
Advantages: Direct control over antimicrobial use, ensure appropriate therapy, cost effective, automatic awareness, individual intervention by pharmacists possible
Disadvantages: Perceived loss autonomy for prescribers, need for AMS team access/advice (if approval needed), time-consuming, communication errors
how does Review /Audit & Feedback work with AMS
Pharmacist reviews each patient on ward round
Audit/feedback targeted to specific cases
Daily review of targeted antimicrobials for appropriateness
Steward (e.g. pharmacist) contacts prescriber with feedback and recommendations for alternative therapy
Antimicrobial committee creates guidelines (first, second line treatments)
what are the advantages and disadvantages of Review /Audit & Feedback
Advantages: Avoids loss autonomy of prescribers, individual education opportunities, shown to decrease unnecessary/inappropriate prescribing, does not impede therapy initiation, flexible
Disadvantages: Compliance with recommendations voluntary, workload of pharmacist, reactive rather than proactive, liability
how does education/ guidelines help with AMS
what are their advantages and disadvantages
Creation of guidelines for antimicrobial use
Can be issued by government, NHS Trust, PCT…
Group or individual education of clinicians by educators
Could be undergraduate, specialist level postgraduate, part of induction training
Antimicrobial committee creates guidelines - educators are pharmacists, nurses or physicians
Advantages:
May alter behaviour patterns
Voluntary
Avoids loss of prescriber autonomy
disadvantages:
Assumption that passive education will impact on behaviour
Mostly ineffective on its own
what does streamlining or de-escalation in terms of AMS mean and what are the advantages and disadvantages
Change from initial empiric antibiotic regimen to results-based
therapy in response to microbiologic laboratory report
organism grown
sensitivities to antimicrobials
Change from broad spectrum therapy to patient tailored therapy
Clinical personnel use laboratory results (biomedical scientist, microbiologist) to change therapy (pharmacist, physician, nurse)
Advantages: Avoids long-term use broad spectrum agents, patient-tailored therapy, targets organism, reduce risk resistance, reduce risk secondary infection, stop use of inappropriate agents, use of safer antimicrobials
Disadvantages: Pharmacist workload, sample processing time, testing required, resistance from prescriber
what does IV to oral switch mean in AMS and what is the advantages and disadvantages
Usually parenteral therapy started in hospital
Prolonged time and may be inappropriate
Many agents have good oral bioavailability
Quinolones, oxazolidinones, metronidazole, clindamycin, linezolid, rifampicin, macrolides…
Allow switch from IV to oral therapy with no loss of efficacy
Pharmacist key* to understanding e.g. bioavailability
advantages:
Avoids entry site infections
Cost savings
Earlier discharge
disadvantages:
compliance
what is antibiotic cycling and its advantages and disadvantages
Scheduled rotation of antimicrobials used
Theoretically avoids resistance to any single agent
Aims to reduce / slow overall emergence of resistance
Antibiotic committee created cycling protocol
Personnel to oversee adherence (pharmacist, physician)
Antibiotic mixing is an alternative strategy whereby consecutive patients receive a different antibiotic
Advantages: May reduce resistance by changing selective pressure
Disadvantages: Difficult ensure adherence / non-compliance, concerns on effectiveness, lack evidence*/well-designed studies, allergy or toxicity may preclude use of specific drugs
what is supplement strategies
Antimicrobial Order Forms
Decrease antimicrobial usage in practice
- Automatic stop orders
Particularly useful in prophylaxis
-Reduce inappropriate initiation
- Reduce mean duration of prophylaxis
what is the UK 20yr Vision of AMR
Deliver the Vision by:
reducing need for, and unintentional exposure to, antimicrobials
optimising use of antimicrobials
investing in innovation, supply and access
what is the current 5 year action plan targets include ?
Current 5-year action plan targets include to:
halve healthcare associated Gram-negative blood stream infections;
reduce number of specific drug-resistant infections in people by 10% by 2025;
reduce UK antimicrobial use in humans by 15% by 2024;
reduce UK antibiotic use in food-producing animals by 25% between 2016 and 2020 and define new objectives by 2021 for 2025; and
be able to report on the percentage of prescriptions supported by a diagnostic test or decision support tool by 2024.
what does AWARE stand for (5 year action plan)
AWaRe: Access, Watch and Reserve antibiotics list (WHO, 2019):
Access: Preferred option for a number of common infections (so promoting access to these
Watch: Includes most of “highest-priority critically important antimicrobials” and recommended only for specific, limited indications
Reserve: Those antibiotics recommended only for use as a last resort
Watch and Reserve also higher risk of resistance
