All about Antimicrobial Stewardship

1. Antimicrobial Stewardship
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2. Why we Need Antibiotics
Nearly One half of the
Hospitalized patients receive
antimicrobial agents.
• Antibiotics are valuable Discoveries of the
Modern Medicine.
• All current achievements in Medicine are
attributed to use of Antibiotics
• Life saving in Serious infections.
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3. What went wrong with
Antibiotic Usage
• Treating trivial infections / viral Infections with
Antibiotics has become routine affair.
• Many use Antibiotics without knowing the Basic
principles of Antibiotic therapy.
• Many Medical practioners are under pressure for short
term solutions.
• Commercial interests of Pharmaceutical industry pushing
the Antibiotics, more so Broad spectrum and Newer
Generation antibiotics. as every Industry has become profit
oriented.
• Poverty encourages drug resistance due to
under utilization of appropriate Antibiotics.
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4. Science magazine; July 18, 2008
• The last decade has seen the inexorable proliferation
of a host of antibiotic resistant bacteria, or bad bugs,
not just MRSA, but other insidious players as well.
...For these bacteria, the pipeline of new antibiotics is
verging on empty. 'What do you do when you're faced
with an infection, with a very sick patient, and you get
a lab report back and every single drug is listed as
resistant?' asked Dr. Fred Tenover of the Centers for
Disease Control and Prevention (CDC). 'This is
a major blooming public health
crisis.'"
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5. Spread of Antibiotic Resistance
• Indiscrimate use of
Antibiotics in Animals and
Medical practice
• R plasmids spread among
co-inhabiting Bacterial
flora in Animals ( in gut )
• R plasmids may be mainly
evolved in Animals spread
to Human commensal, -
Escherichia coli followed
by spread to more
important human
pathogens Eg Shigella spp.
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6. What is Misuse of Antibiotics?
Misuse of antibiotics can include any of the following
• When antibiotics are prescribed unnecessarily;
• When antibiotic administration is delayed in critically ill
patients;
• When broad-spectrum antibiotics are used too generously, or
when narrow-spectrum antibiotics are used incorrectly;
• When the dose of antibiotics is lower or higher than
appropriate for the specific patient;
• When the duration of antibiotic treatment is too short or too
long;
• When antibiotic treatment is not streamlined according to
microbiological culture data results.
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7. Costs Associated with
Increased Bacterial
Resistance
• ↑Treatment failures
• ↑Morbidity and mortality
• ↑Risk of hospitalization
• ↑Length of hospital stays
• ↑Need for expensive and broad
spectrum antibiotics
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8. Best way to keep the matters in Order
Every Hospital should have a policy which is
practicable to their circumstances.
Rigid guidelines without coordination will
lead to greater failures
The only way to keep Antimicrobial agents
useful is to use them appropriately and
Judiciously
(Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical
Clinics of North America NOV 2006)
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9. “ what is Stewardship”????
• The office, duties, and
obligations of a steward
• The conducting,
supervising, or
managing of something
especially : the careful
and responsible
management of
something entrusted to
one's care
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10. Therefore, Antibiotic
Stewardship…..
An activity that
includes
appropriate
selection, dosing,
route, and
duration of
antimicrobial
therapy.
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11. What is Antibiotic Stewardship?
• A program that encourages judicious (vs
injudicious) use of antibiotics
– Antibiotics are relatively so effective, non-toxic and
inexpensive…so easy to use…that they are prone to
abuse
• When the diagnosis is uncertain, antibiotics are often
prescribed…
– Stewardship strives to fine tune antibiotic Rx in regards
to
• Efficacy
• Toxicity
• Resistance-induction
• C. difficile-induction
• Cost
• Discontinuation
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12. Sobering Thoughts
The pipeline is drying up!
US FDA approval of new
antibacterials down 56% from
1983 to 2002
• Infectious diseases are still the
most common cause of death
worldwide.
• We are effectively living in
the post-antibiotic era
• Therefore, we must manage
carefully and responsibly
what we have
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13. Should restrict and rationalize
antibiotic use
Antimicrobial stewardship
+
Infection control program
Can limit the emergence and transmission of
antimicrobial-resistant bacteria
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14. Goals of Ab Stewardship
• Optimizing clinical outcomes while minimizing unintended
consequences of antimicrobial uses.
•Toxicity
•Selection of Pathogenic
organisms
•Emergence of Resistance
• A secondary goal is also the reduction of health care costs
without adversely impacting quality of care
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15. GUIDELINES FOR DEVELOPING AN
INSTITUTIONAL PROGRAM TO ENHANCE
ANTIMICROBIAL STEWARDSHIP
An institutional program to
enhance antimicrobial
stewardship
Antimicrobial Stewardship
Team
Antimicrobial Stewardship
Program
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16. Antibiotic Stewardship Team
• Infectious Disease Physician.
• Clinical Pharmacist with infectious disease training
• Clinical Microbiologist
• An information system specialist
• Infection control professional.
• Hospital epidemiologist (Optional)
Collaboration between the antimicrobial
stewardship team, the hospital infection
control, pharmacy and therapeutics
committees is essential
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17. ELEMENTS OF AN ANTIMICROBIAL
STEWARDSHIP PROGRAM
Active Antimicrobial Stewardship Strategies
Supplemental
Antimicrobial
Stewardship
Strategies
Computer
Surveillance and
Decision Support
Microbiology
Laboratory
Comprehensive
Multidisciplinary
Antimicrobial
Management Programs
Monitoring of Process
and Outcome
Measurements
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18. Active Antimicrobial Stewardship
Strategies
1. Prospective audit with intervention and
feedback.
• A medium-sized community hospital resulted
in a 22% decrease in the use of parenteral
broad-spectrum antimicrobials.
• They also demonstrated a decrease in rates of
C. difficile infection & nosocomial infection
compared with the preintervention period.
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19. 2. Formulary restriction & preauthorization
requirements for specific agents
 Most hospitals have a pharmacy and therapeutics
committee or an equivalent group
 They evaluates drugs for inclusion on the hospital
formulary on the basis of
 therapeutic efficacy
 toxicity
 cost
 They also limit redundant new agents with no
significant additional benefit.
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20. Supplemental Antimicrobial Stewardship
Strategies
• Education.
• Guidelines and clinical pathways.
• Antimicrobial cycling
• Antimicrobial order forms.
• Combination therapy.
• Streamlining or de-escalation of therapy.
• Dose optimization.
• Conversion from parenteral to oral therapy.
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21. Education
• Considered to be most essential part of
Stewardship Program:
– Antibiotics
– Resistance
– PK-PD
– Collateral damage ( unintended )
– Alignment of Ab to overcome anti-microbial resistance.
• Target Customers: Microbiologist and Clinicians.
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22. Most frequently employed
intervention
• Educational efforts include passive activities
 conference/ presentations
 student and house staff teaching sessions
 provision of written guidelines
 e-mail alerts
However, education alone, without incorporation of
active intervention, is only marginally effective and
has not demonstrated a sustained impact
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23. A good clinical practice saves
antibiotics
• Treatment should be limited
to bacterial infections, using
antibiotics directed against
the causative agent, given in
optimal dosage, interval and
length of treatment, with
steps taken to ensure
maximum patient
compliance with the
treatment regimen and only
when the benefit of
treatment outweighs the
individual and global risks
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24. Antimicrobial cycling and scheduled
antimicrobial switch.
“Antimicrobial cycling”
refers to
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the removal and substitution of a specific
antimicrobial or antimicrobial class to prevent or
reverse the development of antimicrobial resistance
within an institution or specific unit.

25. Choosing the drugs
• Substituting one
antimicrobial for another
may transiently decrease
selection pressure reduce
resistance
• But, reintroduction of the
original antimicrobial is
again however known to
develop resistance
• There are insufficient data to
recommend the routine use
over a prolonged period of
time
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26. Antimicrobial order forms.
• The use of automatic stop orders and the
requirement of physician justification for
continuation
• Decrease antimicrobial consumption in
longitudinal studies
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Use of peri-operative prophylactic order forms with
automatic discontinuation at 2 days resulted in a decrease
in the mean duration of antimicrobial prophylaxis (from 4.9
to 2.4 days)

27. Combination therapy
• Has a role in certain
clinical contexts
• Including use for
empirical therapy for
critically ill patients at
risk of infection with
multidrug resistant
pathogens
• To increase the breadth of
coverage and the
likelihood of adequate
initial therapy
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28. Limitations of Combination of Antibiotics
• The role of combination
antimicrobial therapy for the
prevention of resistance is
limited to those situations in
which there is
 A high organism load
 A high frequency of
mutational resistance during
therapy.
• Classic examples are
tuberculosis or HIV
infection.
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29. Streamlining or De-Escalation of
Therapy
–On the basis of culture and sensitivity
reports we can more effectively target the
causative pathogens, by elimination of
redundant combination therapy
–Resulting in decreased Ab exposure and
substantial cost savings
Dr.T.V.Rao MD 29

30. CDC vision for inpatient care
• Implementation of an antimicrobial
stewardship program in a healthcare facility
– regardless of inpatient setting – will help
ensure that hospitalized patients receive the
right antibiotic, at the right dose, at the right
time, and for the right duration. As a result,
there is reduced mortality, reduced risks of
Clostridium difficile-associated diarrhea,
shorter hospital stays, reduced overall
antimicrobial resistance within the facility,
and cost savings 30

31. Dose Optimization
Optimization of AB dosing based on
• Individual patient characteristics
• Causative organisms
• Site of infections
• PK-PD characteristics
• Systemic Plan from a broad spectrum to specific
narrow spectrum Ab, parenteral to oral Antibiotics.

32. Conversion from parenteral to oral
therapy
Enhanced oral bioavailability
among certain
antimicrobials—such as
fluoroquinolones,
oxazolidinones, metronidazole,
clindamycin, trimethoprim-
sulfamethoxazole, fluconazole,
and voriconazole
Therefore, allows for
conversion to oral therapy
once a patient meets
defined clinical criteria
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33. Computer Surveillance and Decision Support
• Computer physician order
entry (CPOE) as 1 of the
most important “leaps”
that organizations can take
to substantially improve
patient safety.
• CPOE has the potential to
incorporate clinical
decision support and to
facilitate quality
monitoring
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34. Our clinical Judgment carries many solutions…
These guidelines
are not a substitute
for clinical
judgment, and
clinical discretion is
required in the
application of
guidelines to
individual patients.
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35. Multifaceted strategies can address and decrease
antibiotic resistance in hospitals
• Antibiotic prescribing practices and decreasing
antibiotic resistance can be addressed through
multifaceted strategies including:
 Use of ongoing education
 Use of evidence-based hospital antibiotic
guidelines and policies
 Restrictive measures and consultations
from infectious disease physicians,
microbiologists and pharmacists
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36. Prudent prescribing to reduce
antimicrobial resistance
• Only use an antimicrobial
when clearly indicated.
• Select an appropriate
agent using local
antimicrobial prescribing
policy.
• Prescribe correct dose,
frequency and
duration.
• Limit use of broad
spectrum agents and de-
escalate or stop
treatment if appropriate
(Hospital).
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37. Practice rationalism in antibiotic use-
promote antibiotic stewardship
• 1 Antibiotic overuse contributes to the growing
problems of Clostridium difficile infection and
antibiotic resistance in healthcare facilities.
2 Improving antibiotic use through stewardship
interventions and programs improves patient
outcomes, reduces antimicrobial resistance, and saves
money. Interventions to improve antibiotic use can be
implemented in any healthcare setting—from the
smallest to the largest. 3
Improving antibiotic use is a medication-safety and
patient-safety issue.
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38. Continuous Medical Education
a Must ..
• Training and educating health
care professionals on the
appropriate use of antibiotics
must include appropriate
selection, dosing, route, and
duration of antibiotic therapy. To
ensure that training and education
is working, there should be
extensive collaboration between
the antibiotic stewardship and
hospital infection prevention and
control teams. Without
benchmarks, it is difficult to track
successes and weaknesses
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39. Good hand washing practices still reduces
antibiotic resistance and spread
Dr.T.V.Rao MD 39

40. Implementation of WHONET CAN HELP TO
MONITOR RESISTANCE
• Legacy computer systems,
quality improvement
teams, and strategies for
optimizing antibiotic use
have the potential to
stabilize resistance and
reduce costs by
encouraging
heterogeneous prescribing
patterns and use of local
susceptibility patterns to
inform empiric treatment.
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