IC12 Antimicrobial Stewardship

Question 1

What are the aims and levels of antimicrobial stewardship program?

Answer 1

Levels:
1. Macro – national, government, countries
2. Messo – organizational, clusters, GPs, private hospitals, public hospitals
3. Micro – individuals, HCP, patients, caregivers

Aims:
1. Optimal selection of choice, dose, route and duration of antibiotics
a. Optimize clinical outcome
b. Minimize toxicity, selection of pathogenic organisms and emergence of resistance
c. Reduce healthcare cost without inversely impacting quality of care

2. prevent infection

Question 2

What are the Strategies of National Strategic Action Plan on Antimicrobial Resistance?

Answer 2

• aim: reduce emergence and spread of antimicrobial resistant organism
  1. Education
  2. Surveillance and risk assessment
  3. Research
  4. Prevent and control of infection
  5. Optimizing antimicrobial use

Question 3

What are the Core elements of ASP in healthcare facility + Strategies employed in ASP?

Answer 3

1. Institution Leadership Commitment
2. Accountability
3. Pharmacy Expertise
4. Action
5. Tracking
6. Reporting
7. Education

Question 4

What constitutes institution Leadership Commitment as one of the core elements of ASP?

Answer 4

• Get institution leaders to buy-in
• CEO, CMB, department heads
• To get funding and recognition
• To dedicate human, financial and information technology resources
• Leaders to create a culture that advocates appropriate and safe use of antimicrobials

Question 5

What constitutes accountability as one of the core elements of ASP?

Answer 5

Physician:
Responsibilities:

1. Lead the group
2. Determining program goals
3. Settling differences of opinion between ASP members and prescribers
4. Bridge to the institution leaders

Qualifications:

1. Trained in ID
2. Passion for antimicrobial use and patient safety
3. Diplomatic and collegial

Pharmacists:

Responsibilities:
1. Co-lead the group
2. Interventions
3. Determine program goals
4. Coordination of data needs (to support / tweak strategies)
5. Bridge to department of pharmacy

Qualifications:

1. Trained in ID
2. Passion for antimicrobial use and patient safety
3. Diplomatic and collegial
4. Comfortable advising prescribers and other providers

Question 6

What constitutes pharmacy expertise as one of the core elements of ASP?

Answer 6

• Engage and train pharmacist to look out for use of antibiotics and be an antimicrobial steward

Question 7

What are the 3 priority ASP interventions to improve antibiotic use? What are the pros and cons?

Answer 7

1) Formulary restriction and pre-authorization
Description: Prescriber to gain approval for prescription of specified agents through phone call/form filled / official ID consultation before dispensing

Pros:

1. Reduces unnecessary initiation of antimicrobials
2. Optimize empiric antibiotic choices (provide alternative and education for prescribers)
3. Chance to advise about antibiotic selection and others e.g. send cultures or other diagnostic tests

Cons:

1. Only effective against restricted agents
2. Real-time and resource intense
3. Logistic nightmare (should do using comp, not paper)
4. Might delay treatment since need to do before dispensing (within office hours/1 day)

2) Prospective audit and feedback
Description: External review by an expert (ID physician / pharmacist) 48-72 hours after prescription

Pros:

1. Provides more clinical data to enhance uptake of recommendations
2. Flexible timing for audit and feedback
3. Optimize duration of therapy

Cons:

1. Only effective for audited cases
2. Recommended actions are optional and may not be followed

3) Facility-specific evidence-based guidelines
Description: Use evidence to influence or draft guidelines on diagnosis, choice and duration of therapy, based on local susceptibilities, formulary options and patient mix

Pros:

1. Provide basis for determining the appropriateness of use
2. Influence prescribing habits and infection management
3. Enhance pre-authorization and prospective audit and feedback
4. Good sustained learning experience for prescribers

Cons:

1. Need a method to assess whether HCP are following the guidelines
2. Only effective if HCP are aware of the guidelines and increase uptake/ use of guidelines

Question 8

What constitutes tracking as one of the core elements of ASP?

Answer 8

• Process Outcome (in relation to the 3 priority interventions, diagnosis to prescription)
  o % of prescription that followed that adhered to guidelines
  o No. of cases of pre-authorization request received and approved
  o No. of PAF carried out, interventions done and accepted
• Antibiotic Use outcome (patients take antibiotics)
  o Average days of therapy for each prescribed course

o Drug consumption and cost

1. Defined Daily Dose (DDD) (per 1000 patients or 1000 bed days or 1000 discharged)
    Definition: Average maintenance dose per day of antimicrobial used in the hospital for a particular indication in adults
    Pros:
   * can get estimate drug use for places with limited access to computerized data
   * can use DDD to compare aggregate use of antibiotics to that of other hospitals
   * will change the estimate of drug use if recommended daily dose is altered and the approved DDD does not change
    Cons:
   * Can’t be used to measure drug use in children
   * Underestimate drug use in renal impaired patients (since dose is reduced)
   * Can’t use to compare drugs use from different classes (when the administered daily dose is not the same as DDD)
   * DDD may change as new dosages are approved for existing drugs, which can create confusion when comparing drugs use over time
2. Days of therapy (per 1000 patients or 1000 bed days or 1000 discharged)
   * Pros:
   o Not affected by changes in recommended DDD
   o Can be used for children
   o Not affected by differences in DDD and preferred daily dose
   * Cons:
   o Overestimate use of drugs for multiple dosed drugs per day??
   o Difficult to measure without computerized data

• Outcome Measures
  o Incidence of MDRO
  o % of drug resistant isolates from clinical samples (patients who are suspected to be infected)
  o Mortality
  o Duration of hospitalization
  o Antibiotics associated with ADR including C. difficile
• Utility of point prevalence survey in antimicrobial stewardship
  o Participate in Global Point Prevalence Survey (GPPS)
  o Quantifiable measures to assess and compare quantity and quality of antimicrobial prescribing and resistance in hospitals in different countries and different locations (regions)
  o Know where you are standing
  o Help to obtain evidence and data on antimicrobial use which is impt to report to the stakeholders for buy-in and funding

Question 9

What constitutes reporting as one of the core elements of ASP?

Answer 9

• Report process (regarding 3 priority interventions) and outcome measures
• Accountability to stakeholders and institution leaders
• Justification for further funding
• Show work done
• Show areas that can be improved
• Keep stakeholders and leadership informed of work done + remind and engage them in antimicrobial stewardship
• Benefits of reporting:
  o Optimizing / appropriate antibiotic use
  o Improving infection cure rates
  o Reducing:
  Treatment failure
   C. difficile
   Adverse effects
   Antibiotic resistance
   Hospital cost and stay

Question 10

What constitutes education as one of the core elements of ASP?

Answer 10

• for comprehensive approach
• Can’t rely on this solely
• Tailored to actions most relevant to target audience