Antimicrobial stewardship


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Antimicrobial stewardship

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  • Antimicrobial restriction—either through formulary limitation by this method or by the requirement of preauthorization and justification—is the most effective method of achieving the process goal of controlling antimicrobial use.
  • Antimicrobial stewardship

    2. 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.DR.T.V.RAO MD 2
    3. 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.DR.T.V.RAO MD 3
    4. 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 youre 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."DR.T.V.RAO MD 4
    5. 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. DR.T.V.RAO MD 5
    6. 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. DR.T.V.RAO MD 6
    7. 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 antibioticsDR.T.V.RAO MD 7
    8. 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)DR.T.V.RAO MD 8
    9. 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 ones careDR.T.V.RAO MD 9
    10. 10. THEREFORE, ANTIBIOTIC STEWARDSHIP….. An activity that includes appropriate selection, dosing, r oute, and duration of antimicrobial therapy.DR.T.V.RAO MD 10
    11. 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 • DiscontinuationDR.T.V.RAO MD 11
    12. 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 haveDR.T.V.RAO MD 12
    13. 13. SHOULD RESTRICT AND RATIONALIZE ANTIBIOTIC USE Antimicrobial stewardship + Infection control program Can limit the emergence and transmission of antimicrobial-resistant bacteriaDR.T.V.RAO MD 13
    14. 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 DR.T.V.RAO MD 14
    15. 15. GUIDELINES FOR DEVELOPING AN INSTITUTIONAL PROGRAM TO ENHANCE ANTIMICROBIAL STEWARDSHIP An institutional program to enhance antimicrobial stewardship Antimicrobial StewardshipAntimicrobial Stewardship Team Program DR.T.V.RAO MD 15
    16. 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 DR.T.V.RAO MD 16
    17. 17. ELEMENTS OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM Active Antimicrobial Stewardship Strategies Supplemental Monitoring of Process and Antimicrobial Outcome Measurements Stewardship Strategies Comprehensive Multidisciplinary Computer Surveillance Antimicrobial and Decision Support Management Programs Microbiology LaboratoryDR.T.V.RAO MD 17
    18. 18. ACTIVE ANTIMICROBIAL STEWARDSHIP STRATEGIES1. 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. DR.T.V.RAO MD 18
    19. 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. DR.T.V.RAO MD 19
    20. 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. DR.T.V.RAO MD 20
    21. 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. DR.T.V.RAO MD 21
    22. 22. MOST FREQUENTLY EMPLOYED INTERVENTION• Educational efforts include passive activities conference/ presentations student and house staff teaching sessions provision of written guidelines e-mail alertsHowever, education alone, without incorporation of active intervention, is only marginally effective and has not demonstrated a sustained impact DR.T.V.RAO MD 22
    23. 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 risksDR.T.V.RAO MD 23
    24. 24. ANTIMICROBIAL CYCLING AND SCHEDULED ANTIMICROBIAL SWITCH . “Antimicrobialcycling” refers tothe removal and substitution of a specific antimicrobial orantimicrobial class to prevent or reverse the developmentof antimicrobial resistance within an institution or specificunit. DR.T.V.RAO MD 24
    25. 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 timeDR.T.V.RAO MD 25
    26. 26. ANTIMICROBIAL ORDER FORMS. • The use of automatic stop orders and the requirement of physician justification for continuation • Decrease antimicrobial consumption in longitudinal studiesUse of peri-operative prophylactic order forms with automaticdiscontinuation at 2 days resulted in a decrease in the meanduration of antimicrobial prophylaxis (from 4.9 to 2.4 days) DR.T.V.RAO MD 26
    27. 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 therapyDR.T.V.RAO MD 27
    28. 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.DR.T.V.RAO MD 28
    29. 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 savingsDR.T.V.RAO MD 29
    30. 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 savingsDR.T.V.RAO MD 30
    31. 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. DR.T.V.RAO MD
    32. 32. CONVERSION FROM PARENTERAL TO ORAL THERAPY Enhanced oral bioavailability among certain antimicrobials— such as fluoroquinolones, oxazolidinones, metronidazole, clindamycin, tri methoprim- sulfamethoxazole, fluconazole, a nd voriconazole Therefore, allows for conversion to oral therapy once a patient meets defined clinical criteriaDR.T.V.RAO MD 32
    33. 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 monitoringDR.T.V.RAO MD 33
    34. 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.DR.T.V.RAO MD 34
    35. 35. MULTIFACETED STRATEGIES CAN ADDRESS ANDDECREASE 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 pharmacistsDR.T.V.RAO MD 35
    36. 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).DR.T.V.RAO MD 36
    37. 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.DR.T.V.RAO MD 37
    38. 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 weaknesse sDR.T.V.RAO MD 38
    40. 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 t reatment.DR.T.V.RAO MD 40
    41. 41. • Programme created by Dr. T.V.Rao MD for Medical Professionals in the Developing world • Email • doctortvrao@gmail.comDR.T.V.RAO MD 41