Antimicrobial Stewardship

Question 1

classify antimicrobial agents

Answer 1

• -Antibacterial – acts against a bacterium
• -Antimycobacterial – acts against a mycobacterium (e.g., M. tuberculosis that causes TB)
• -Antifungal – acts against a fungus (e.g., Candida or Aspergillus)
• -Antiviral – acts against a virus (e.g., HIV, influenza, HCV)
• -Antiparasitic – acts against a parasite (e.g., Plasmodium falciparum that causes malaria)

Question 2

what is the role of antibiotics?

Answer 2

-Modern life could not survive without antibiotics
-protection for people with weakened immune systems – cancer patients, AIDS patients, transplant recipients, premature babies
-Surgical antibiotic prophylaxis
-

Question 3

what is the frequency of antibiotic use?

Answer 3

• antimicrobials are commonly used medications
• 1/3 patients received antibiotics on any given day
• 1/20 residents received antibiotics on any given day

Question 4

why do we prescribe antibiotics?

Answer 4

1) To treat the suspected infection
- -We don’t yet know the pathogen causing the infection = empiric treatment (“Start smart”)
- -We have identified the pathogen causing the infection = targeted treatment (“then focus”)
2) To prevent infection in situations associated with increased infection risk = prophylaxis
- -Medical prophylaxis – chemotherapy, transplant immunosuppression, post-splenectomy
- -Surgical antimicrobial prophylaxis – clean-implant, contaminated surgical procedures
3) For reasons other than an infection – e.g., anti-inflammatory properties (azithromycin), prokinetic properties (erythromycin)

Question 5

what is the empirical antibiotic therapy?

Answer 5

Empiric antibiotic therapy refers to starting antibiotic therapy that covers the most probable causative organism(s) before the resistance pattern and/or causative organism are known.

Question 6

what is the targeted antibiotic therapy

Answer 6

Antibiotic therapy is initiated after a culture and sensitivity report is available.

Question 7

what are the principles of perioperative antibiotic therapy?

Answer 7

1) Perioperative antibiotic prophylaxis
- -Aim: To reduce the incidence of postoperative surgical site infections
- -Antibiotic of choice
a) First-line: intravenous cefazolin
b) In patients with beta-lactam allergy: clindamycin or vancomycin
c) Add intravenous metronidazole for:
- -Patient with small intestinal obstruction
- -Appendectomy
- -Colorectal surgery

Question 8

metronidazole is used for perioperative antibiotic prophylaxis in what cases?

Answer 8

–Patient with small intestinal obstruction
–Appendectomy
–Colorectal surgery
increased risk o anaerobic infection. Remember metronidazole is usually used for anaerobic abdominal and pelvic infections, clindamycin for anaerobic thoracic infections (not always)

Question 9

give examples of antibiotic that is used not to kill bacteria but to reduce inflammation

Answer 9

azithromycin in cystic fibrosis, used for years

Question 10

give an example of an antibiotic that is used as prokinetic?

Answer 10

erythromycin in diabetic gastroparesis

Question 11

what kind of impacts have antibiotic resistance?

Answer 11

1) Loss of productivity and income
- -Total GDP effect: $2.9 trillion by 2050
2) An additional $10000-40000 per infection
3) 700,000 deaths/year, Up to 9.5M / year by 2050
4) 33,000 deaths (> 100 airplanes / year)

Question 12

how man deaths approximately every year are attributed to AMR (antimicrobial resistance)

Answer 12

10 million

Question 13

what multidrug-resistant bacteria

Answer 13

A pathogen is termed as MDRGN when resistance is demonstrated to at least three antibiotic classes (see “Treatment of multiresistant pathogens” below).

Question 14

Give examples of multidrug-resistant G+ bacteria

Answer 14

• Meticillin resistant Staphylococcus aureus (MRSA) (common cause ofhospitalacquired pneumonia)
• Vancomycin resistant enterococci (VRE) (common cause of intrabdominal infections,hospitalacquired urinary tract infections)
• Penicillin resistant Streptococcus pneumoniae

Question 15

give examples of multidrug-resistant G- bacteria

Answer 15

• -Enterobacteriaceae that produce extended-spectrum beta-lactamases (ESBLs) and carbapenemases (CPE)
  1) Klebsiella pneumoniae
  2) E. coli

Question 16

When was the last new antibiotic that was discovered?

Answer 16

oxazolidinones that target ribosomes (linezolid)

Question 17

what are the consequences of AMR?

Answer 17

1) We get it wrong: Empiric treatment fails while we’re waiting to find out the causative pathogen
- -Delayed appropriate treatment of sepsis
- -Increased morbidity/duration of illness
- -Increased mortality
- -Increased healthcare costs – ICU, longer hospital stays, more expensive antimicrobials, complicated infections

2) We’re afraid of getting it wrong, so we use broader spectrum antimicrobials
- -Selection of even more resistant bacteria

3)Even the broader spectrum antimicrobials can’t be relied upon to work: Return to the pre-antibiotic era?
High mortality from previously treatable infectious diseases
–Elective surgery, chemotherapy, transplantation too risky

Question 18

what is the antimicrobial stewardship?

Answer 18

• -Programmes and interventions that aim to optimize antimicrobial use
• -Originated within human healthcare
• -Increasingly applied in broader contexts “One Health”

Question 19

what is the one-health approach?

Answer 19

Antibiotic resistance can arise in bacterial pathogens affecting humans, animals, and the environment. Strengthening detection and control of resistance requires the adoption of a “One-Health” approach that promotes the integration of public health and veterinary disease, food, and environmental surveillance. Improved detection can be achieved through appropriate data sharing, enhancement, expansion, and coordination of existing surveillance systems, and the creation of a regional laboratory network that provides a standardized platform for resistance testing and advanced capacity for genetic characterization of bacteria including whole-genome sequencing.

Question 20

what are the principles of the One-Health approach?

Answer 20

1) Stresses that AMR is a growing European and global health problem in both humans and animals, leading to limited or poor options for the treatment whilst diminishing the quality of life and to important economic consequences in terms of augmenting healthcare costs and productivity losses
2) Recognizes that the development of AMR is accelerated by excessive and inappropriate use of antimicrobial agents which together with poor hygiene or poor infection control, creates favorable conditions for the development, spread, and persistence of resistant microorganisms in both humans and animals
3) Underlines the need of an active holistic risk-based approach based on One0helath perspective with the purpose of reducing the use of antimicrobials as much as possible and to maximize coordinated efforts between the human health sector and veterinary sector in the fight against AMR

Question 21

what are the goals of antimicrobial stewardship?

Answer 21

1) To ensure the best clinical outcome for patients
2) To minimize unintended consequences of antimicrobial use:
- -Complications associated with vascular catheters placed to administer IV drugs
- -Adverse drug reactions – allergies, side effects
- -Clostridium difficile infection (CDI)
- -Emergence of antimicrobial resistance (AMR)

3)To minimize healthcare costs without compromising the quality of care

Question 22

1 in 5 patients treated with antibiotics are harmed. True/False

Answer 22

True

Question 23

what does antimicrobial stewardship mean?

Answer 23

1) Right antibiotic for the patient in front of you considering age, medical condition, antimicrobial resistance risks, pregnancy, etc
2) Right dose duration and route for the condition you are treating
3) Minimize adverse consequences
- -Cause the least amount of harm to that patient considering drug interactions, allergy, and toxicity
- -Least harm to future patients by increasing antimicrobial resistance
4) Bacterial infections only - Do not prescribe for viral infections
5) Infection Prevention
- -Promote the use of immunization to minimize infections
- -Practice good infection control to minimize the spread of infections/AMR

Question 24

do viral infections require to be treated with antibiotics?

Answer 24

Bacterial infections only - Do not prescribe for viral infections, one of the important reasons for emerging antibiotic resistance, the other one is the use of antibiotics in agriculture

Question 25

what are the best ways of infection prevention?

Answer 25

• -Promote the use of immunization to minimize infections

- -Practice good infection control to minimize the spread of infections/AMR

Question 26

what are the principles of antimicrobial agent choice?

Answer 26

1) clinical assessment: what is the likely site of infection
2) Acquisition: where do you think the patient got the infection?
- is it community acquire, hospital-acquired? local antibiotic resistance rates?
3) previous antibiotic use, including GP/other hospitals
4) previous microbiology results
5) the history of allergy

Question 27

what is the most important aspect of empirical antimicrobial agent choice?

Answer 27

clinical assessment

Question 28

does previous microbiology results are important in antibacterial agent choice?

Answer 28

yes

Question 29

Do you know how long common illnesses last?

Answer 29

1) ear infection-4 days
2) sore throat-1 week
3) common cold-10 days
4) sinus infection-2.5 weeks
5) postinfectious cough-3 weeks

Question 30

antimicrobial stewardship team is composed of?

Answer 30

Microbiologist, ID physician, antimicrobial pharmacist, surveillance scientist, ward nurses, OPAT nurse, IPC nurse

Question 31

antimicrobial stewardship in hospitals is composed of?

Answer 31

1) Antimicrobial stewardship teams
- -Microbiologist, ID physician, antimicrobial pharmacist, surveillance scientist, ward nurses, OPAT nurse, IPC nurse
2) Bedside consultation and direct interaction with prescribers
3) Restricted access to broad-spectrumantimicrobials
4) Prescribing audit and feedback

Question 32

how antimicrobial restriction is organized?

Answer 32

either through formulary limitation or by the requirement of pre-authorization and justification before use—is the most effective method of achieving the process goal of controlling antimicrobial use

Question 33

what does START SMART mean regarding antibiotic therapy?

Answer 33

1) start antibiotics only if there is clinical evidence of bacterial infection
2) obtain appropriate cultures before starting antibiotics
3) document in both drugs charts and medical notes the indication, drug name, and dose, route, and frequency, treatment duration
4) ensure antibiotics are given within 4 hours of prescription (with 1st hour for septic and neutropenic patients)
5) at 24-48 hours review the clinical diagnosis, review the laboratory and radiology results and choose one of these options:
- stop antibiotics
- switch from IV to po route
- change antibiotics (narrow the spectrum)
- continue current regimen
- the outpatient parenteral antibiotic regimen

Question 34

what factors need to be considered when prescribing the most appropriate antibiotic?

Answer 34

• history of drug allergy
• recent culture results
• potential drug interactions
• potential adverse effects
• age of the patient and pregnancy status
• renal and hepatic failure-require dose adjustment

Question 35

what are the pre-operative recommendations for preventing surgical site infections?

Answer 35

1) Avoid hair removal at the surgical site, if hair must be removed using single patient clippers and not razors
2) wash the patient or make sure that the patient has showered
3) use the right drug for the right time for the right duration for antibiotic prophylaxis
- according to local prescribing guidelines
- within 60 minutes before skin incision, 15 minutes is required between the end of antibiotic administration and tourniquet application
- single dose only

Question 36

what are the intra-operative recommendations for preventing surgical site infections?

Answer 36

1) use 2% chlorhexidine and 70% isopropyl alcohol for skin preparation. If the patient is sensitive povidone-iodine
2) make sure that:
- patient body temperature is maintained at above 36 celsius
- SpO2 >95%
- glucose <11mmol/L
3) additional antibiotic if surgery is prolonged, major intraoperative blood loss,
4) cover the surgical site with sterile dressing prior to the removal of drapes at the end of surgery

Question 37

what are the post-operative recommendations for preventing surgical site infections?

Answer 37

1) remove the wound dressing for 48 hours post-op unless clinically indicated
2) use aseptic techniques for wound inspection
3) hand hygiene is mandatory before and after the wound is inspected