Antimicrobial stewardship

Question 1

Define antimicrobial stewardship

Answer 1

Concerned. with the optimal selection, dosage, duration of antimicrobials that results in the best clinical outcome for the treatment and prevention of infection with minimal impact on resistance. It involves promoting and monitoring judicious use of antimicrobials to preserve their effectiveness. Encompasses optimising prescribing practice to reduce resistance and unnecessary prescribing.

Question 2

Why is this so important?

Answer 2

There is an increase in antimicrobial resistance but a reduction in the amount of new antimicrobials coming to market. Now looking at developing new antimicrobials but also modification of existing.

Question 3

What is the 20 year vision for AMR?

Answer 3

• reduce need for abs/unintentional use
• optimise use
• innovation, supply, access

Question 4

What is the UK 5 year action plan 2019-24?

Answer 4

• halve the healthcare associated gram negative bloodstream infections
• reduce the number of specific drug resistant infections by 10%
• reduce the UK AM use by 15%, and 25% reduction in use in the community
• 10% reduction in the use of reserve and watch Abs

Question 5

What schemes are in place to support the delivery of the action plans set out by the NHS?

Answer 5

NHS improvement schemes to support delivery

1. NHS standard contract for acute providers - now includes a target to reduce AB use by 1% from the 2018 baseline
2. Commissioning for quality & innovation indicators (CQUINS) –> set targets for CCGs and prescribed specialist services - part of the income is conditional on meeting these targets. It is to improve quality of services and create new improved patterns of care. There are AMR CQUINS e.g. 2019/20 = adherence to guidelines for treating UTIs in the older population

Question 6

What is the purpose of AMS / motivation?

Answer 6

1. Reduce total antibiotic use
2. reduce inappropriate ab use
3. improve susceptibility profiles of hospital pathogens
4. Improvement in clinical markers e.g. length of stay, mortality rates
5. Increase appropriate use of abs - selection, dosing, route, duration

Question 7

Why do we want to increase AMS/susceptibility profiles?

Answer 7

1. Want to increase survival as AMR reduces it
2. Reduce morbidity as AMR increases it.Resistance leads to inappropriate use of agents that will not be as effective which reduces the health outcomes of patients. It also results in toxicity and adverse effects so want to reduce these
3. Costs - reduce costs that AMR causes, reducing inappropriate hospital admissions and length of stays
4. Patient safety - the impact of multi-drug resistant pathogens is huge as patients have increased duration of hospital stays, increased mortality, allergies, medication errors. More likely to pick up opportunistic infections in hospital which further increases mortality/morbidity
5. increase multidisciplinary team working and open culture

Question 8

What are the common AMS strategies?

Answer 8

1. Formulary restriction
2. review and audit, feedback by pharmacist for appropriateness of Rx
3. Prior approval
4. Education/guidelines
5. streamlining/de-escalation
6. IV to oral
7. Antibiotic cycling
   Also strategies such as start smart then focus, target

Question 9

Who are the core members of the AMS team?

Answer 9

Clinical pharmacist with infectious disease expertise
Clinical microbiologist
and/or infectious. disease physician

Question 10

Who are other members of the AMS team?

Answer 10

Infection control nurse
Hospital epidemiologist
Non clinical management
IT specialist

Question 11

What is the effectiveness of AMS

Answer 11

Better adherence to prescribing policies
Reduced antibiotic durations
Reduced resistant infections

Question 12

What is start smart then focus?

Answer 12

Start: do not start antibiotics if there is no evidence of a bacterial infection.

• use guidelines for prompt effective treatment
• document on drug. chart/notes
• get cultures first
• single dose prophylaxis where appt

Focus: Review every 48hrs and with an action plan. Can stop, switch (IV to oral), change, continue, OPAT.
Document everything

Question 13

What is target?

Answer 13

Treat antibiotics responsible, guidance, education, tools

For changing prescriber and patient attitudes

Question 14

What are some benefits of formulary. restrictions?

Answer 14

Cost effecive
Ensures guidelines are followed and appt use of abs - effective and direct control
Improves susceptibility profiles of hosp pathogens
Minimises adverse events/toxicity = safer

Question 15

What. are the benefits. of de-escalation?

Answer 15

• reduced risk of infection e.g. entry site
• may be able to discharge earlier but need to ensure adherence (thus reduce costs, morbidity)
• More specific/narrower spectrum - reduces resistance, CDI, adverse effects

Question 16

Why may a Dr not de-escalate or switch IV to oral?

Answer 16

• autonomy, preference
• pt may not meet criteria
• worries surrounding adherence
• local resistance patterns

Question 17

Mrs B takes her 5 year old daughter to the GP after sudden onset of fever (38.2) and runny nose for 2 days, was complaining that her left ear was painful. The GP can see a red, bulging eardrum.

• what is she likely to be suffering from
• Based on current primary care guidelines, should the GP prescribe antibiotics?

Answer 17

Likely to be otitis media - common in children and classic symptoms such as fever, ear pain, bulging eardrum ( in the middle ear).

No. She does not have discharge after eardrum perforation and is not under 2, is not systemically very unwell and does not have signs /symptoms of a more serious condition. Thus, would advise it is a self limiting infection that clears up within 2-3 days but can last up to 1 week. Symptoms can be managed with self care, regular doses of paracetamol is sufficient. Monitor symptoms and seek medical help if becomes seriously unwell, does not clear up within a few days/week.

Question 18

Mrs Cs daughter is 6 years old. She has had a cough for 5 days, at the beginning she had a fever of 39.1, conjunctivitis, rhinorrhoea, diarrhoea but these have resolved after 3 days. However her cough has persisted and she would like antibiotics. What is the likely cause of this illness, are antibiotics required?

Answer 18

It is likely caused by a viral infection that is generally self limiting, especially as most of her symptoms have already cleared.
Antibiotics are not required because they would be ineffective against viral pathogens so would not work and would just increased resistance patterns. - inappropriate.

Question 19

What are the ways in which community pharmacists contribute to AMS?

Answer 19

• education or other HCP and the public, counselling when providing Rx
• Vaccinations
• promoting public health campaigns e.g. catch it kill it bin it, hand washing
• hygiene - infection prevention

Question 20

What are the ways in which hospital pharmacists contribute to AMS?

Answer 20

• checking antimicrobials prescribed are appt
• encouraging pt adherence
• antimicrobial stewardship committee/formulary decisions
• review, audits, CQUINS
• start smart then focus implementation
• education of other HCP, creating guidelines
• Hygiene - bare below elbows etc
• Provision of advice to other HCP as expert knowledge.
• medicines optimisation
• following guidelines

Question 21

Are education and guidelines. an important. part of a good AMS programme?

Answer 21

Yes - alone they are less effective but part of a programme they are very useful