4. 500 beds.
Tertiary care centre
with DNB training in
19 specialties .
AMS program
initiated in January
2010
5. 1. Education & Awareness
2. Evolving local Antibiogram
3. Management support – talking to the
“consultants”
4. Prioritisation – areas/drugs
5. Feedback – management & consultants
6. Surveillance
6. Initial period of 1 year (2009) – monthly CMEs
on Resistance / Basics of Antibiotics and
Common mistakes in antibiotic prescriptions.
The Hospital staff was sensitized to the
issues – 1. Antibiotics are important.
2. There is a trained person in charge.
3. Management is serious about this.
7. 1. Full time Microbiologist employed.
2. Reporting standardized as per CLSI
guidelines.
3. New indigenous software designed and
integrated into the LIS/HIS – captures reports
from the LIS and gives output as
“Antibiogram”
Location/Duration/Drugs/Bugs.
8. Monthly Meeting with Consultants and CMD
Compliance measures of AMS and Outcome
Measures to be presented every 3 months
Direct involvement and “pressure” from top
management crucial in keeping the
momentum.
9. Focus of – ICUs, Surgical Prophylaxis and
common infections with abuse potential
(ARI/AGE)
Focus on select antibiotics.
Risk stratification of patients and local data
(marriage between clinical category &
microbiology) – KIMS manual for empirical
therapy in sepsis/infection
10.
11. • ICUs – 6 monthly audit – Retrospective
analysis of case records of all culture positive
cases for choice of initial empiric therapy,
whether de-escalated after reports and total
duration of therapy.
• Surgical Prophylaxis – quarterly audit of
choice, timing and duration of antibiotic use
for prophylaxis in only clean surgeries.
12. 1. Resistance to sentinel antibiotics
2. MDRO isolation rates
3. Consumption of sentinel antibiotics
4. De-escalation rates
13. 2010 – 400 beds – 119820 patient days
2011 – 450 beds – 131424 patient days
2012 – 500 beds – 154692 patient days
Overall “sales” might have increased!!!
14. 3 months prospective study
All admissions in the MD -ICU
Non-sepsis syndromes excluded
N = 187 (of sepsis syndrome)
Classified as Type 1/2/3/4 as per criteria
De-escalation defined as withdrawal of
MDR-GNB cover (Carb/Tige/Colistin)
15. Type 1 – Ceftriaxone/Doxycycline/
Azithromycin
Type 2 –BL/BLI, Amikacin, Ertapenem,
Clarithromycin (Lung/Unknown),
Teicoplanin (Unknown) Linezolid (Lung,
SSTI)
17. Site of Infection Type 1 Type 2 Type 3 Type 4
SSTI (10) 5 2 3 0
Lung (45) 13 4 10 18
Intraabdominal (25) 2 4 17 2
Urinary tract (52) 0 16 26 10
CNS (1) 1 0 0 0
Unknown (20) 0 2 14 4
18. Patient Total Total culture Initial Antibiotic
Type Number positivity Appropriate antibiotic
1 21 8 7 (87.5%)
2 49 18 16 (88.88%)
3 83 41 37 (90.24%)
4 34 29 28 (96.55%)
19. Total culture
Patient Class De-escalation done
positivity
Type 1 8 1 (12.5%)
Type 2 18 6 (33.33%)
Type 3 41 11 (26.83%))
Type 4 29 7 (24.14%)
20. Expected mortality
Average Mortality as per APACHE-2
Patient Class
APACHE-II % scores (international
standards)
Type 1 13.8 10 15
Type 2 24.4 39 40
Type 3 29 44 55
Type 4 28 59 55
21. Average LOS in ICU
4.5
4.4
4.3
4.2
Average LOS
4.1
4
3.9
3.8
3.7
Pre-AMS (2008) Study period
22. Protocol based , patient risk stratification -
derived from history, physical examination &
simple labs –achieves high degree of
appropriateness, with comparable mortality!
(37% of patients were spared from empiric use
of carbapenems in ICU)
23. 1. Protocol based antibiotic use in MD-ICU
2. Top Management Support INCLUDES IT.
3. Closed ICU system – Intensivist Managed
4. Willingness among “most” of the clinicians to
“trust” the ID advice.
24. 1. Protocol based Antibiotic policy is safe.
2. Antibiotic Policy can be implemented.
3. Improvement in surgical prophylaxis use - >
90% compliance except for duration.
25. 1. Scope limited to Medical ICUs & Surgical
prophylaxis & Few antibiotics only.
2. Implementation in ICU monitored and
outcome surveillance done only twice in this
2 years.
3. Cost analysis not done
26. 1. Actions not taken based on surveillance
reports from wards - SHORTAGE OF
MANPOWER
2. Unable to demonstrate gain in resistance
profile nor significant reduction in
AUR/AUD