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3151 finals > ASP > Flashcards

ASP Flashcards

1
Q

Antibiotic resistance

A

a. When bact changes and become resistant to AB used to treat the infection it cause
b. Resistant microbes are prevalent, increasingly encountered
c. Antimicrobial use is key driver for resistance

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2
Q

Infection prevention

A

1) Hand hygiene, disinfection, sterilization
2) Pt vaccination

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3
Q

Antimicrobial stewardship

A

1) Optimal selection of drug, dose, route, duration of AB
a) AST results
b) Optimise clinical outcome: truly needed for pt
c) Minimise toxicity, selection of pathogenic org, emergence of resistance
d) Reduce healthcare cost w/o adverse impact quality of care

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4
Q

Aims and levels of antimicrobial stewardship program

A

a. ASP: multi-faceted approach towards antimicrobial stewardship
b. Interdisciplinary approach
i. TEAM –> leads program

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5
Q

Levels of AS

A

MICRO
MESO
MACRO

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6
Q

MICRO: small system

A

□ Individuals – clinicians, caregivers, pt
□ Antimicrobial stewards, review appropriateness

  • culture based
  • indication, evidence based
  • narrow spectrum
  • dose appropriate
  • duration of therapy
  • monotherapy
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7
Q

MESO: medium

A

□ Regions, cluster (NUHS, Sing health, NHG), institutions
□ EPIC healthcare software
- Surveillance, to track interventions and usage of AB
-Has antimicrobial use licensing and crediting framework (SG one, not follow US anymore)

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8
Q

MACRO: large

A

□ Gov, national, ministry
□ ONE HEALTH ANTIMICROBIAL RESISTANCE WORKGRP
-AVA, MOH, NEA, PUB
-Aim to reduce emergence and prevent spread of drug-resistant org
◊ Education
◊ Surveillance, risk assessment
◊ Research
◊ prevention and control of infection
◊ Optimisation of antimicrobial use
□ Involve national plan –> affects prescribing guidelines

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9
Q

Core elements of ASP in healthcare institution

A

1) institution leadership commitment
2) accountability
3) pharmacist
4) action-strategies, interventions
5) tracking
6) reporting

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10
Q

Institution leadership commitment

A

§ Leadership buy-in (key first step) start any ASP
§ Support from leaders critical for success
□ CEO, CMB, DIVISION HEAD, PHARM HEAD, NURSING HEAD, ID HEAD

§ Necessary human, financial, IT resources allocated
§Create culture to advocate app, safe use of antimicrobials

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11
Q

Accountability (leaders, co-leaders) — physician’s role

A
  • Interacts with medical staff the most
  • determine program goals
    • Able to influence other prescribers
  • Settle difference of opinion b other ASP mem and prescribers
    *BRIDGE to executive leadership
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12
Q

physician qualification

A
  • Ideal if ID trained
  • Interest in AB use, pt safety
  • Diplomatic and collegial
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13
Q

pharm role and qualification

A
  • Make interventions
  • Determine program goals
  • Coordinate data needs
  • Bridge Department of Pharmacy
  • Ideal if ID trained
  • Interest in AB use, pt safety
  • Diplomatic and collegial
  • Comfortable advising physicians and other providers
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14
Q

Pharmacist

A

i. Empowered to lead implementation efforts to improve AB use
ii. ID trained (preferred)
iii. Eg stewards:
1) Verify penicillin allergy
2) Avoid duplicate anaerobic coverage
3) Reassess ab therapy
4) Avoid treatment of asymptomatic bacteriuria
5) Shortest effective AB duration

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15
Q

Action-strategies, interventions

A

Strategies employed in ASP (Priority interventions to improve ABx use)

1) Formulary restriction and pre-authorization of ABx
2) Prospective audit and feedback of ABx (PAF)
3) Facility-specific evidence-based treatment guidelines

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16
Q

Formulary restriction and pre-authorization of AB definition

A
  • Prescriber gain approval
    • Phone
    • Filled up form
    • Official ID consult
      Before pharmacy dispense AB
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17
Q

formulation restriction PROS

A
  • Reduce initiating unnecessary AB
  • Optimize empiric AB choice
  • Opportunity to advise/ discuss AB selection
    • Send appropriate cultures
    • Other diagnostic test

Before certain AB needed

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18
Q

formulation restriction CONS

A
  • Impact use of restricted agents only
  • Real-time, resource intensive
    • 24/7 needed
  • Avoid paper forms
  • Mindful of potential delay in initiating treatment
  • Start pt for 24hr, need approval by 1day
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19
Q

PAF definition

A
  • External review by expert in antimicrobial use
    • ID trained
  • At 48-72hrs after prescription
  • (may) follow till discontinuation

Churn out list of pt given the AB
- look through if drug appropriate
- intervene, stop, adjust dose

  • Need to check with dr, what exactly went through and is their main concern
20
Q

PAF Pros

A
  • Provide more clinical data to enhance uptake of recommendations
  • Greater flexibility in timing of interventions
  • Address duration of therapy
21
Q

PAF cons

A
  • Impact use of audited agents only
    *Recommended action generally optional, may not be followed
22
Q

Facility-specific evidence-based treatment guidelines definition

A
  • Include diagnosis, choice, duration or AB
  • Evidence-based and hosp treatment preferences
    • Based on local susceptibilities
    • Formulary options
    • Pt mix
  • Guidelines: empower recommendations to be made
  • but only 80% of cases fit
23
Q

guideline PROS

A
  • Determine appropriateness of use
  • Influence prescribing habits, infection management
  • Enhance pre-authorization and prospective review and feedback
  • More engaging for clinicians
  • Opportunity for sustained learning
    • Local antibiogram
  • Don’t audit ceftriaxone, but after guidelines, went down 30% (Follow guideline recc)
24
Q

guideline CONS

A
  • Need method to identify cases
  • Limited impact if not used by prescribers
    *promote awareness and uptake among staff
25
Other strategies
□ Common infection-based (syndromic) interventions -Pneumonia, UTI, SSTI -Include: diagnostic, choice, duration of AB □ Provider/ prescriber-based interventions -AB time-out ◊ Think and see if AB needed? Culture done? -Assess penicillin allergy (is it true allergy) □ Nursing based interventions -Optimise microbiology cultures - IV --> PO transitions - Prompt AB reviews (time out) □Microbiology-based interventions □Pharmacy-based interventions
26
Pharmacy-based interventions
-Document indications for AB -Automatic change from IV --> PO AB therapy - Dose adjust and optimisation - Duplicative therapy alerts ◊ Augmentin + metronidazole (both covers anaerobes unnecessary) - Time-sensitive automatic STOP ORDERS ◊ But may forget to order and continue ◊ Suitable for SSI - Detect and prevent AB related DDI
27
Microbiology-based interventions
- Selective reporting of antimicrobial susceptibility test results -Comments in microbiology report ◊ Eg: Although susceptible, may grow resistant - Coagulase neg staph: contaminant (evaluate pt for TRUE infection before treating bact)
28
Tracking -- Monitor of process and outcome measurements
§ Measurement is critical (point of reflection) □ Assess impact of interventions -,Any difference made? □ Identify opportunities for improvement § Outcomes to be measured/ tracked □ Process outcome (PAF, guideline etc) □ AB use outcomes (qty, DDD, DOT)
29
Process outcome
1) Percentage of prescription that adhered to guidelines 2) Number of cases of pre-authorization request received and approved i) Who (department) ii) What infections iii) How often is this AB needed 3) Number of PAF (Prospective audit and feedback) carried out, interventions done and accepted
30
AB use outcomes (qty)
- Drug consumption and cost ◊ Track which has high consumption -Average day of therapy for each prescribed course ◊ De-escalated? - MEASURE OF CONSUMPTION (DDD, DOT)
31
DEFINED DAILY DOSES DDD (per 1000-pt days)
Assumed average maintenance dose per day for drug used for its main indication in adults
32
measurement of DDD
* Approximation of 1 average pt day of treatment across drugs with varying potencies and dosage intervals * Allow comparison b. all AB 1) conver to g 2) Convert to DDD a. Based on number of days AB used b. WHO assigned DDD value 3) Divide based on 1000 pt days a. Pop standardised, normalised and adjusted i. Can monitor trends, compare over years
33
adjust DDD for activity and pop GEOG AREA
- GEOG AREA i. DDD/ 1000 inhabitants - SHORT COURSE AB i. DDD/ inhabitant per yr - HOSP DRUG CONSUMPTION i. DDD/ 1000 bed days ii. DDD/ 1000 discharges
34
DDD ADV
* Allow standardized comparisons of aggregate AB use b. hosp in diff locations and countries * Allow estimate of use in country with limited access to computerized pharm data * Change estimate of drug use if recc daily dose altered The approved DDD does not change
35
DISADV of DDD
* Will not accurately estimate DOT when administer daily dose NOT EQUAL to DDD * Not used to compare relative use b. diff AB classes * Not used in children, renal impaired etc * Underestimate drug use due to titration/ reduced dose used * Approved DDD may change as new dosage approved * Crete confusion when compare drug use over time
36
DAY OF THERAPY DOT (per 1000-pt days)
unit of measure is defined as one day in which a patient is given a drug, regardless of dose - number of dose admin/ dosage strength
37
DOT measures
* Document the total number of antibiotic days of therapy. * This is calculated by counting each antibiotic that each resident/patient is prescribed. Example: A 7-day course of amoxicillin (one antibiotic) equals 7 antibiotic days
38
DOT ADV
* Measure AB in children * Not influenced by changed in recc DDD * Not influenced by discrepancies b. DDD and preferred daily dose
39
DOT disadv
* Overestimate use of drugs given in multiple doses per day * Difficult to measure w/o computerized pharm records
40
Other outcomes to be measure/ tracked
□ Incidence of MDROs □ Percentage of drug-resistant isolates from ALL clinical samples - Lab has 2 samples: ◊ Clinical ◊ Screening sample (colonisation) □ Clinical or pt outcomes -Mortality -Length of stay/ hosp -AB associated ADR: CDAD
41
TRACKING by comparison/ benchmark
Global point prevalence survey of AB consumption and resistance (Global PPS) □ Global network of hosp conducting point prevalence surveys □ Provide quantifiable measures to assess and compare QTY, QUALITY of antimicrobial prescribing and resistance in hospitalized adults, children, neonates worldwide □ 53 countries: -Diff hosp in the country will carry out Cross sectional at 8am that 1 day -Churn out pt chart ◊ On AB According to guideline? CAP or HAI? Indicated?
42
Identify problems based on global point prevalence
b) WITHIN INSTITUTE: Can compare over departments c) WITHIN NATIONAL: compare b. the hosps d) WITHIN GLOBAL: diff countries LDC vs DC
43
Reporting
i. Provide regular updates ii. Include process and outcome measures --> address national & local issues iii. Share areas of improvements + further improvements iv. Accountability to institution leadership, stakeholders v. Justify funding vi. Keep stakeholders and leadership informed of work done ASP --> CULTURE vii. Keep stakeholders reminded and engaged in ASP
44
reporting benefits of ASP
Incr app use of Abx Improve infection cure rates Decr treatment failure Decr CDAD infection, ADR, Abx resistance Decr hosp cost, length of stay
45
Education
Comprehensive effort to improve hosp Abx use Education alone not effective stewardship intervention Education modalities ◊ Presentation, posters, emails, ward rounds ◊ Discussion with ASP team ◊ ASP intervention notes Education effective when tailored to target audience Educate staff, pts/ consumers, caregivers
46
Social determinants of AB prescribing
Social influence such as ◊ Rs b. clinicians ◊ Rs b. clinicians & pt Risk , fear, anxiety, emotions Kiasu feeling, must cover as much bact
47
TEAM SPORT
Abx is global issue Communication, teamwork Identify area of improvement in Abx decision making Effective changes related to Abx decision making

3151 finals (9 decks)

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