IC12 Flashcards
Levels of antimicrobial stewardship
Macro (large systems): country, national, ministry
Meso (medium systems): region/cluster, institutions eg hospital
Micro (small systems): individuals, clinicians, patients/consumers, caregivers
What is antimicrobial stewardship?
Optimal selection of drug, dosing, route, duration of antibiotic therapy
Aim of antimicrobial stewardship
Optimise clinical outcome
Minimise toxicity, selection of pathogenic organisms and emergence of resistance
Core elements of antimicrobial stewardship
Institution leadership commitment
Accountability - appointing leaders
Pharmacy expertise
Action - stewardship strategies
Tracking
Reporting
Education
Stewardship strategies
Formulary restriction and pre authorisation of antibiotics
Prospective audit and feedback of antibiotics
Facility specific evidence based treatment guidelines
What is formulary restriction and pre authorisation of antibiotics?
Prescribers to gain approval (via phone call placed or form filled out or official ID consultation) before pharmacy can dispense antibiotics. If urgent, give first but limited quantity. Must get approval within 24h
Formulary restriction and pre authorisation of antibiotics pros and cons
Pro
- Reduces initiating unnecessary antibiotics
- Optimises empiric antibiotic choices
- Gives opportunity to advise/discuss about antibiotic selection and others like sending appropriate cultures or other diagnostic test
Cons
- impacts use of restricted agents only
- Is real time and resource intensive
- Avoid paper forms
- Be mindful of potential delay in initiating treatment
What is prospective audit and feedback of antibiotics?
External review by an expert in antimicrobial use (doctor or ID trained pharmacist), usually at 48-72h after prescription. May be followed till discontinuation. Type intervention properly. Can be cosigned by ASP pharmacist
Prospective audit and feedback of antibiotics pros and cons
Pros
- Provides more clinical data to enhance uptake of recommendations
- Gives greater flexibility in timing of interventions
- Can address duration of therapy
Cons
- Impacts use of audited agents only
- Recommended action generally optional and may not be followed
What is facility specific evidence based treatment guidelines
Include diagnostics, choice and duration of antibiotics; evidence based and hospital treatment preferences based on local susceptibilities, formulary options and patient mix
Facility specific evidence based treatment pros and cons
Pros
- Provide basis for determining appropriateness of use
- Influence prescribing habits and infection management
- Enhances pre authorisation and prospective review and feedback
- Is more engaging for clinicians
- Gives opportunity for sustained learning
Cons
- Must have a method to identify cases
- Limited impact if not used by prescribers, need to promote awareness and uptake among staff
What is defined daily doses
DDD is average maintenance dose per day for a drug used for its main indication in adults
DDD pros and cons
Pros:
- allows standardised comparisons of aggregate antibiotic use between hospitals in different locations and countries
- allows for an estimate of use in countries with limited access to computerised pharmacy data
- will change the estimate of drug use if the recommended daily dose is altered and approved DDD does not change
Cons:
- Will not accurately estimate DOT when the administered daily dose is not equal to the DDD and therefore, cannot be used to compare relative use between different antibiotic classes
- Cannot be used in children
- Will underestimate use for drugs that require reduced dosage when excretory function is impaired, such as with renal impairment
- Approved DDDs may change as new dosages are approved for existing drugs, which can create confusion when comparing use over time
DOT pros and cons
Pros
- Can be used to measure antimicrobial use in children
- Not influenced by changes in the recommended DDD
- Not influenced by discrepancies between the DDD and the preferred daily dose
Cons
- Will overestimate use for drugs that are given in multiple doses per day
- More difficult to measure without computerised pharmacy records
