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Formulating
Institutional Antibiotic
Policy
MARY ANN D. LANSANG, MD, FPCP, FPSMID
PHICS 23RD ANNUAL CONVENTION
MAY 19, 2017
Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an inst...
The Development of Antimicrobial Resistance
From: Faces of Antimicrobial Resistance, IDSA, 2017
2020 Targets of the Action Plan
(5-year time frame)
- Reduce by 30% carbapenem-resistant
Enterobacteriaceae infections acq...
November 14 – 20, 2016
WHO Global Priority Pathogens List
for R&D of New Antibiotics
(released 27 Feb 2017)
# Mycobacteria not included – already...
WHO Global Priority Pathogens List
for R&D of New Antibiotics
WHO Global Priority Pathogens List
for R&D of New Antibiotics
Yearly resistance rates of E. coli to
ceftriaxone, gentamicin and imipenem
ARSP, 2006 - 2015
2015 carbapenem resistance ra...
Yearly resistance rates of K. pneumoniae to
carbapenems
ARSP, 2006 - 2015
Imipenem: 2014 = 6.9%; 2015 = 11.1%; Meropenem: ...
Yearly resistance rates of S. aureus
ARSP, 2006-2015
MRSA rate for bloodstream infections, 2015: 60.25% (n=570)
From: Philippine Action Plan to Combat Antimicrobial Resistance, 2015
“… the concerted implementation of systematic,
multi-disciplinary, multi-pronged interventions
in both public and private ...
Strategies for controlling AMR:
inter-related approaches
Antibiotic
stewardship
• Surveillance
• Antibiotic policies &
gui...
Core elements of the
DOH AMS Program
Strategies for controlling AMR:
inter-related approaches
Antibiotic
stewardship
• Surveillance
• Antibiotic policies
& gui...
Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an inst...
Why do we need a hospital
antibiotic policy? (1)
• High level of antibiotic use in hospitals. CDC report (MMWR, 7Mar2017):...
From: Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing within Hospitals
Cli...
Why do we need a hospital
antibiotic policy? (2)
• To improve patient outcomes through appropriate
antibiotic use: the RIG...
Outline
Context: global and local actions; the infection control unit
and the
antimicrobial stewardship program of an inst...
Hospital antibiotic policy
development cycle
Ideal organizational structure
for the AMS program
From:
From:
All hospitals should have a hospital antibiotic
policy to promote rational antimicrotial
prescribing and dispensing ...
From:
From:
All hospitals should adopt or adapt to their local
context the National Antibiotic Guidelines to
guide clinicians in...
From:
Simple and clear clinical pathways
should be created to guide and
standardize treatment for timely
and appropriate m...
Example of clinical pathway: Severe sepsis
(from The Medical City)
Summary of strategies to improve antibiotic use (1)
Pulcini & Gryssens. Virulence 2013; 4:192-202
Passive educational meas...
Summary of strategies to improve antibiotic use (2)
Pulcini & Gryssens. Virulence 2013; 4:192-202
Supportive/supplemental ...
Carrot or stick approach to
improving antibiotic use?
Carrot or stick approach to
improving antibiotic use?
Positive
Clinical
Impact
Positive
Financial
Impact
Political
Expediency
Resource
Requirements
Ease of
Implementation
0 = N...
Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an inst...
Ideal organizational structure
for the AMS program
Clinicians/
Prescribers
Patients
Patient’s
relatives
Public? PhilHealth?
DOH timelines for selected core
elements of the AMS Program
2015 WHO WPRO and Philippines partnership:
Pilot AMS Program implementation in Hospitals
TRAINING OF TRAINORS
WORKSHOP ON ...
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
Formulating Institutional Antibiotic Policy
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Formulating Institutional Antibiotic Policy

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A Lecture given by Dr. Mary Ann Lansang during the 23rd PHICS Annual Convention at the Crowne Plaza Manila last May 19, 2017

Published in: Health & Medicine
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Formulating Institutional Antibiotic Policy

  1. 1. Formulating Institutional Antibiotic Policy MARY ANN D. LANSANG, MD, FPCP, FPSMID PHICS 23RD ANNUAL CONVENTION MAY 19, 2017
  2. 2. Outline Context: global and local actions; the infection control unit and the antimicrobial stewardship program of an institution Why: the need for an institutional antibiotic policy How: evidence-guided recommendations, best practices, and experiences in the formulation of antibiotic policies in an institution Who: stewards of rational antibiotic use and stakeholders
  3. 3. The Development of Antimicrobial Resistance From: Faces of Antimicrobial Resistance, IDSA, 2017
  4. 4. 2020 Targets of the Action Plan (5-year time frame) - Reduce by 30% carbapenem-resistant Enterobacteriaceae infections acquired during hospitalization -Maintain the prevalence of ceftriaxone-resistant N. gonorrhoeae to zero -Reduce by at least 30% MRSA bloodstream infections compared to 2014 rates -Reduce by 30% MDR Pseudomonas spp. Infections acquired during hospitalization compared to 2014 rates - Reduce by 25% ciprofloxacin-resistant non-typhoidal Salmonella infections compared to 2014
  5. 5. November 14 – 20, 2016
  6. 6. WHO Global Priority Pathogens List for R&D of New Antibiotics (released 27 Feb 2017) # Mycobacteria not included – already established as a global priority.
  7. 7. WHO Global Priority Pathogens List for R&D of New Antibiotics
  8. 8. WHO Global Priority Pathogens List for R&D of New Antibiotics
  9. 9. Yearly resistance rates of E. coli to ceftriaxone, gentamicin and imipenem ARSP, 2006 - 2015 2015 carbapenem resistance rates: Ertapenem: 4.2% (n=3,036); Imipenem: 3.5% (n=6,132); Meropenem: 3.4% (n=5,794)
  10. 10. Yearly resistance rates of K. pneumoniae to carbapenems ARSP, 2006 - 2015 Imipenem: 2014 = 6.9%; 2015 = 11.1%; Meropenem: 2014 = 7.6%; 2015 = 11.9%; Ertapenem: 2014 = 10%; 2015 = 15.3%
  11. 11. Yearly resistance rates of S. aureus ARSP, 2006-2015 MRSA rate for bloodstream infections, 2015: 60.25% (n=570)
  12. 12. From: Philippine Action Plan to Combat Antimicrobial Resistance, 2015
  13. 13. “… the concerted implementation of systematic, multi-disciplinary, multi-pronged interventions in both public and private hospitals in the Philippines to improve appropriate use of antimicrobials…”
  14. 14. Strategies for controlling AMR: inter-related approaches Antibiotic stewardship • Surveillance • Antibiotic policies & guidelines • Antibiotic manage- ment programs Prevention of spread • Infection prevention & control in healthcare settings • Isolation when needed • Hand hygiene • Environmental hygiene Reduction • Usage control • Appropriate use • Human • Animal • Environmental
  15. 15. Core elements of the DOH AMS Program
  16. 16. Strategies for controlling AMR: inter-related approaches Antibiotic stewardship • Surveillance • Antibiotic policies & guidelines • Antibiotic manage- ment programs Prevention of spread • Infection prevention & control in healthcare settings • Isolation when needed • Hand hygiene • Environmental hygiene Reduction • Usage control • Appropriate use • Human • Animal • Environmental
  17. 17. Outline Context: global and local actions; the infection control unit and the antimicrobial stewardship program of an institution Why: the need for an institutional antibiotic policy How: evidence-guided recommendations, best practices, and experiences in the formulation of antibiotic policies in an institution Who: stewards of rational antibiotic use and stakeholders
  18. 18. Why do we need a hospital antibiotic policy? (1) • High level of antibiotic use in hospitals. CDC report (MMWR, 7Mar2017): • 56% of patients discharged from 323 US hospitals received antibiotics • 37% of antibiotic prescribing could be improved • Patients with multiple pathogens are concentrated in hospitals • Close proximity of patients with multiple healthcare worker contacts • Sicker, more vulnerable patients in the hospitals • Transfer of patients with MDR organisms into the hospital from the community, another facility, or another country
  19. 19. From: Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing within Hospitals Clin Infect Dis. 2006;42(Supplement_2):S90-S95. doi:10.1086/499407
  20. 20. Why do we need a hospital antibiotic policy? (2) • To improve patient outcomes through appropriate antibiotic use: the RIGHT indication, choice, dose, route of administration, timing, duration • To minimize harm to the patients (and future patients) • To reduce health care-related costs: shorter hospital stay, use of less costly antibiotics, less ADRs • To prevent or control the emergence of AMR
  21. 21. Outline Context: global and local actions; the infection control unit and the antimicrobial stewardship program of an institution Why: the need for an institutional antibiotic policy How: evidence-guided recommendations, best practices, and experiences in the formulation of antibiotic policies in an institution Who: stewards of rational antibiotic use and stakeholders
  22. 22. Hospital antibiotic policy development cycle
  23. 23. Ideal organizational structure for the AMS program
  24. 24. From:
  25. 25. From: All hospitals should have a hospital antibiotic policy to promote rational antimicrotial prescribing and dispensing practices.
  26. 26. From:
  27. 27. From: All hospitals should adopt or adapt to their local context the National Antibiotic Guidelines to guide clinicians in the management of infectious diseases and in the selection of the most appropriate antimicrobial agent.
  28. 28. From: Simple and clear clinical pathways should be created to guide and standardize treatment for timely and appropriate management of infections.
  29. 29. Example of clinical pathway: Severe sepsis (from The Medical City)
  30. 30. Summary of strategies to improve antibiotic use (1) Pulcini & Gryssens. Virulence 2013; 4:192-202 Passive educational measures Developing/updating local antibiotic guidelines Educational sessions, workshops, local conferences Clinical rounds discussing cases Active interventions Prospective audit with intervention & feedback Reassessment of abtic prescriptions, with streamlining & de-escalation of therapy Academic detailing, educational outreach visits Restrictive measures Limiting no. of abtics on the hosp. formulary Antibiotic order form (compulsory) Automatic stop order Formulary restriction & pre-authorization Limiting reporting of susceptibilities by the micro lab Regulating contacts with the pharma industry
  31. 31. Summary of strategies to improve antibiotic use (2) Pulcini & Gryssens. Virulence 2013; 4:192-202 Supportive/supplemental measures Multidisciplinary AMS team Consultancy service (infectious diseases, pharmacy, microbiology) Computer-assisted management program Parenteral to oral conversion Therapeutic drug monitoring service
  32. 32. Carrot or stick approach to improving antibiotic use?
  33. 33. Carrot or stick approach to improving antibiotic use?
  34. 34. Positive Clinical Impact Positive Financial Impact Political Expediency Resource Requirements Ease of Implementation 0 = None 5 = High 0 = None 5 = High 0 = Impossible 5 = Win/Win 0 = Impossible 5 = None 0 = Impossible 5 = Easy Prioritize potential interventions
  35. 35. Outline Context: global and local actions; the infection control unit and the antimicrobial stewardship program of an institution Why: the need for an institutional antibiotic policy How: evidence-guided recommendations, best practices, and experiences in the formulation of antibiotic policies in an institution Who: stewards of rational antibiotic use and stakeholders
  36. 36. Ideal organizational structure for the AMS program
  37. 37. Clinicians/ Prescribers Patients Patient’s relatives Public? PhilHealth?
  38. 38. DOH timelines for selected core elements of the AMS Program
  39. 39. 2015 WHO WPRO and Philippines partnership: Pilot AMS Program implementation in Hospitals TRAINING OF TRAINORS WORKSHOP ON THE ANTIMICROBIAL STEWARDSHIP ADVOCACY PACKAGE (March and September 2015) Baguio General Hospital and Medical Center CAR Jose B. Lingad Memorial Regional Hospital Region III Rizal Medical Center NCR Research Institute for Tropical Medicine NCR Corazon Locsin Montelibano Memorial Regional Hospital Region VI Vicente Sotto Memorial Medical Center Region VII Northern Mindanao Medical Center Region X Southern Philippines Medical Center Region XI

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