Lecture 24 - Antimicrobial Stewardship Flashcards
What is antimicrobial stewardship?
taking care of antibiotics
programme of activities to improve how we use antibiotics in hospitals and community settings
What is a priority in healthcare?
reducing HAI
What interventions are there to reduce HAI?
infection control, antimicrobial stewardship, maintenance of buildings, education of staff and the public
What is antimicrobial stewardship part of?
the healthcare associated infection agenda
What is a HAI?
infection starting after 48 hours in hospital and can affect any part of the body
infection resulting from medical care or treatment in hospital, care homes, patients own home
What patients are at risk of HAI?
elderly
prolonged admission
recent prolonged admission
ICU/HDU
invasive procedures
broad spectrum antibiotics
co-morbidity
What are the important HAIs?
MRSA/S aureus
multiresistant gram negative
C difficile
When does the onset of C difficile occur?
after antibiotic therapy
What are the drugs most implicated in C difficile infection?
clindamycin, cephalosporins, quinolones, co-amoxiclav
What patients are most at risk of C difficile infection?
patients over 65
Symptoms of C difficile infection?
mild watery to severe bloody diarrhoea
How is C difficile transmitted?
patient, environment, staff contaminated by spores
spores ingested and produce toxins in lower GI tract which cause colitis
What is the decrease in C difficile due to?
having different less virulent strains circulating
What to broad spectrum antibiotics cause?
disrupt natural bowel flora allowing pathogenic organisms such as C difficile to flourish
What are less likely to cause C difficile infection?
narrow spectrum antibiotics that cause little disruption to the bowel flora
What are some patients with C difficile infection reported?
not been exposed to any antibiotics
How to minimise C difficile infection when using antimicrobials?
restriction of antibiotics with a high risk of C difficile infection
local antibiotic policies may exclude them
What does there need to be a balance between?
effectively treating the current infection and not causing harm in the future to both patient and wider population
Prevention of C difficile infection?
standard infection control precautions
antimicrobial stewardship
Management of C difficile infection?
isolation
medication review - antibiotics, PPIs
severity assessment
oral metronidazole or vanocymin
Key elements of antimicrobial stewardship?
prescribing guidance
information about antibiotic use and antimicrobial resistance
audit of clinical practice
education of healthcare staff and patients/public
What does a point prevalence survey provide?
a snapshot of antibiotic use at a given point in time
Key information about antimicrobial use?
% of patients prescribed an antimicrobial
% IV vs oral
types of infections treated
which antimicrobials being used and in which wards
What does a PPS involve?
staff collect data from patients medicines charts and notes
data collection tool - paper or online
analysis of data and comparison with previous PPS in same hospital or can compare between hospitals
identify areas for improvement e.g. use of policy antibiotics, use of IV route
Compliance audits?
quality improvement methodology to review clinical practice in real time
What do compliance audits involve?
collect and report data on a sample of patients every week or month and feed back data to staff involved in prescribing
Key measures for compliance audit?
reason for antimicrobial therapy documented in notes
choice of antibiotic compliant with local policy
Public education?
patients and public have poor knowledge about antibiotics and AMR
need to know about not using antibiotics for coughs, colds and how to manage themselves
also need to know how to take antibiotics when they are prescribed them
What does SAGP do?
aim is to improve use of antibiotics throughout all health and care settings in scotland
How will SAGP do this?
reduce unnecessary antibiotic use
ensure antibiotics are used correctly
educate healthcare staff, patients, public about antibiotic use
measure improvement in quantity and quality of antibiotic use and impact on clinical outcoes
reduce harm from antibiotics
Specific infection SAGP guidance?
neutropenic sepsis
community acquired pneumonia
UTI
staph areus bacteraemia
Where are antimicrobial management teams set up?
in each health board to oversee antimicrobial use
People in antimicrobial management teams?
minimum of a doctor, a microbiologist and an antimicrobial pharmacist
Where must antimicrobials be prescribed?
in hospitals documented on medicine chart or prescription form
in primary care on GP10 prescription
Who can prescribe antimicrobials?
usually doctors but also nurses, pharmacists etc
Who usually administers antimicrobials?
nursing staff
Who administers antimicrobials in primary care?
patients and carers
Obstacles to antimicrobial stewardship?
physician loss of autonomy
lack of resources
poor IT infrastructure
measure impact is difficult
lack of evidence for some aspects of stewardship
How does physician loss of autonomy affect this?
resistance of being told what to do
fear of antagonising patients or more senior clinicians
How can poor IT infrastructure affect this?
electronic prescribing
electronic data capture - audit
antibiotic usage data
What does an antimicrobial pharmacist do?
develops, reviews and implements policies and guidance
evaluates antimicrobial use data
audits compliance with policy and use of antibiotics
provides education for medical, pharmacy and nursing staff
may have a clinical role
Role of the pharmacist - hospital?
all medicine charts and prescriptions should be checked for compliance with antimicrobial policy for choice of antibiotic, route, frequency and duration
clinical pharmacists can promote use of policies at ward level and educate other staff
How many patients in hospital are prescribed an antibiotic?
up to 1/3
What is common in hospital pratice?
inappropriate use, wrong dosage regimens, penicillin use in allergic patients, prolonged courses, broad spectrum rather than narrow
Role of pharmacist - primary care?
monitor prescribing of all medicines
identify problems with quantity and quality of antimicrobial prescribing
feedback of prescribing info to prescribers is best way to influence and promote compliance with policy
Role of the pharmacist - community?
awareness of local antimicrobial prescribing policy
query use of non-policy antibiotics and inappropriate dosage or duration
patient education on self management of minor infections
pharmacy first initiative
provide advice to care homes on antibiotic use in high risk patients
