Implementing Antimicrobial Stewardship in a Hospital Setting

1. This presentation was presented at Apollo
International Forum on Infection Control
(AIFIC’ 2013), Chennai
The presentation is solely meant for Academic
purpose

2. Implementing Antimicrobial Stewardship
in a Hospital Setting

3. Guiding Document for Antimicrobial stewardship
Infectious Diseases Society of America and the
Society for Healthcare Epidemiology of America
Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship
Clinical Infectious Diseases 2007;44:159-77

4. Antimicrobial Stewardship Strategies
Primary:
Formulary restriction and preauthorization (BII) Can this be the
starting point in
Prospective audit with intervention and feedback.(AI) India ?
Secondary:
Education.(AII)
Guidelines and clinical pathways (AI)
Streamlining or de-escalation of therapy.(AII)

5. AMS Simplified
4 D’s of Antibiotics
The Right Drug
The Right Dose
The Right Duration
De-escalation
Glynn etal. Current Anaesthesia & Critical Care (2005) 16, 221–230

6. Antimicrobial Stewardship – Indi(a)genous!
Education.(AII)
Guidelines and clinical pathways based on local data (AI)
Streamlining or de-escalation of therapy.(AII)
To Educate and Promote Evidence based usage of antibiotics by
making Customized treatment protocols based on the hospital’s
own Microbiology data
Prospective audit with intervention and feedback.
Formulary restriction and preauthorization

7. Principles for Making Antibiotic Protocols
Site of Infection
Risk stratification for MDRs
Local microbiology data
De-escalation

8. Step 1:
Compile Local Hospital data
Based on site of infection Organism spectrum in general wards (Jan-Jun 2006)
Steno E.coli
Pneumoc 0.3% Burkhol Staph
– Geographic Variations 0.3% 0.3% Salmonela
Candida Kleb
( ICUs / Wards / Surgical 6%
2% E.coli Proteus
Site Infections etc.)
35% Enteroc
Pseudo
19% Acineto
1. % Distribution of Bugs Pseudo
Acineto
Candida
1%
Staph Pneumoc
1. % Susceptibility of Enteroc Proteus Kleb 7% Steno
antibiotics 5% 4% 20%
Burkhol
Salmonela

9. Step 2: Putting data in Toolkit making antibiograms
- The data needed for last 6 months ( minimum 3 months)
- Ward and ICU isolates data for Blood Stream Infections, Pneumonias,
IAIs, SSTIs and UTIs.
- User Friendly Tool kit to put in data based on Site of Infection
- Tool kit will be separate for Ward and ICU isolates
-Tool kit contains 5 most common pathogens, and most antibiotics in
decreasing order of sensitivity
- Tool kit will also contain the Validity period
Hospital surveillance data (Usually last 6 months) Validity of these data: Next one year (Max)
S. No Most common pathogens % prevalence S. Most sensitive antibiotics
No. pathogens in descending order.
1 1
2 2
3 3
4 4
5 5

10. Example of Toolkit containing
Antibiogram for Blood culture
Hospital surveillance data(Jan-10 till Dec 10) Validity of these data: Dec-2011
S. Most common % Most sensitive antibiotics
No
pathogens prevalence (% Sensitivity)
1 Pseudomonas 30% Colistin (98%) Imi (85%) Cef/Sul (79%) *Pip/Taz
(62%) *Amikacin (57%)
2 Klebsiella 25 % Imipenem (93%) Ertapenem (92%)
*Cef/Sul(76%) *Amikacin = Pip/Taz (65%)
3 Acinetobacter 14 % Colistin (98%) Cef/Sul (85%) Imipenem (82%)
*Pip/Taz(45%)
4 E.Coli 12 % Imipenem (95%) Ertapenem (94%) Cef/Sul (79%)
*Amikacin (70%) *Pip/Taz (67%)
5 Staph Aureus 9% Vancomycin (97%) *Ertapenem = Cef/Sul =
Pip/Tazo (70%)
Note: Cut off value to be used as empiric antibiotic is 80%
*Choices written in white have sensitivity less than 80%

11. Step -3. Patient types based on Risk stratification
Type 1 Type 2 Type 3
Health Care Contact No Yes Prolonged
Procedures No Minimum Major invasive
Procedures
Antibiotic Rx History No in last 90 days Yes in last 90 days Repeat multiple
antibiotics.
Patients Young – No co- Elderly
Characteristics morbid conditions. Few Co-morbid Immunocompromised,
conditions. or with many co-
morbid conditions.
Causative Pathogen Susceptible to ESBLs ESBLs /
could be Common narrow Pseudomonas
spectrum /Acinetobacter
antibiotics MRSA
Possible Antibiotic - No Need for - Use Non- - Use Anti-
recommendations Broad spectrum Pseudomonal pseudomonal
antibiotics broad spectrum Broad spectrum
antibiotics antibiotics
Ref: Based on stratification criteria suggested by Dr Yehuda Carmelli Slide 18

12. Step 4: De-escalation
Discontinuate /Taper down antibiotics if negative
cultures and patient improving
Diminish the number of antibiotics.
Shorten length of duration of antibiotics.
Narrow spectrum of antibiotics.

13. Antimicrobial Stewardship brings hospital specific protocols
to the patient bedside to enable evidence based treatment
Specific
Indication
Hospital specific
microbiology data
Patient risk
stratification
Options for Empiric
therapy and De-
escalation

14. AMS Update from India - 2013
- Golden Peacock award for AMS
in 2012 101 protocols (71hospitals) completed YTD
-Expanding this AMS model in other
countries (Vietnam, Russia, S Africa)
Indian society for critical care medicine
(ISCCM).
AMS Workshops on AMS organized in annual
Update ISCCM meeting for last 4 years
2012
The proposed national antibiotic policy MSD India – the one representative from
prepared by the Government of India pharmaceutical industry to highlight efforts on AMS
in 2011 also recommends a hospital during the 1st Global forum on antibiotic resistance
model of antimicrobial stewardship on organized by SHEA, the PHFI and the CDDEP in
similar lines as this programme on New Delhi on Oct 3-5,2011
AMS

15. Next goals in AMS

16. Proposed Outcome measures for AMS
Domain of Impact Indicator
Nosocomial infection Rate Incidence of nosocomial infections
Resistance pattern Proportion (%) of resistant isolates
- ESBL
- MRSA
- Pseudomonas/ carbapenem
Average length of stay in ICU Reduction in LOS
Prescription practices Reduction in rate of inappropriate prescription
practices
Utilization / Consumption of antibiotics Defined daily dosages (DDD)
Duration of antibiotic therapy Reduction in duration of antibiotic therapy
Mortality rates Reduction in mortality rates before and after
intervention
Cost of treatment Reduction in per unit cost of therapy

17. Drug Resistance Index (DRI)
DRI calculation
(Antibiogram +
DDD/100Bed days)
in progress

18. Strengths of AMS Initiative
• Simple (yet not simplistic !)
• Evidence Based
• User friendly
• Democratic (OF the hospital, BY the hospital
and FOR the hospital)