Antibiotic stewardship-ppt-latest

1. ANTIBIOTIC
STEWARDSHIP
BY
DR PRAMAN KUSHWAH
DrNB NEONATOLOGY
NICE HOSPITAL

2. “Person playing with penicillin is morally
responsible for the death of the man who finally
succumbs to infection with the penicillin- resistant
organism. I hope this evil can be averted.”
• SIR ALEXANDER FLEMING NEW YORK TIMES JUNE 26, 1945

3. ANTIMICROBIAL USE
• Antibiotics are one of the
miracles of modern Science
• Antibiotics saved millions of
lives
This has led to their misuse through use without a prescription and
overuse for self-limiting infections

4. Antibiotics continue to save lives every day
• Neonatal care
• Transplantation
• Chemotherapy for
malignancy
• Immunosuppression
• Safe surgery
• Safe obstetric care
• Intensive care
interventions

5. ANTIMICROBIAL RESISTANCE
30-50 % of
antibiotics
prescribed in
hospitals are
unnecessary
or
inappropriate

6. MISUSE

8. MECHANISMS OF ANTIBIOTIC RESISTANCE

9. ANTIBIOTIC TIMELINE

12. ANTIMICROBIAL STEWARDSHIP
“Coordinated Actions
designed to improve and
measure the appropriate
use of antimicrobials”
Optimal
antimicrobial
Drug Regimen
Optimal Dose
Optimal
Duration
Optimal Route

13. “A co-ordinated program that promotes the appropriate use
of antibiotics, improves patient outcomes, reduces microbial
resistance, and decreases the spread of infections caused by
multidrug-resistant organisms.”

18. ANTIMICROBIAL STEWARDSHIP PROGRAMME - Team

19. Getting STARTED

22. The CDC's
Core 7 Elements of hospital antibiotic stewardship
programs

23. PLANNING AND IMPLIMENTATION

25. ANTIMICROBIAL STEWARDSHIP IN
NICU

26. Symptoms of neonatal sepsis range from subtle to
severe, but are non-specific and may overlap with
many non-infectious clinical conditions in neonates.
Given the high risk of morbidity and mortality with
neonatal sepsis, and the poor positive predictive
value of ancillary laboratory tests
Empirical antibiotic treatment is often initiated,
targeting the most likely micro-organisms, based on
the clinical situation
Suspected sepsis is the most usual working diagnosis

27. Adverse effects of antibiotics in neonates
• Antibiotic-resistant neonatal sepsis
• Increase in rates of E. coli infections in VLBWs

28. • Broad spectrum
antibiotics exposure has
been associated with the
emergence of multi-drug
resistant gram-negative
bacilli and development
of invasive candidiasis.

29. • Prolonged duration of
empiric antibiotic
therapy for early onset
sepsis in extremely low
birth weight infants has
been associated with
increased risk of death
and Necrotizing
enterocolitis (NEC)

30. Unique Challenges in
Antibiotic Prescribing in the NICU
Signs and symptoms of sepsis in infants are non-
specific
Adequate blood quantities may not be feasible
to obtain for culture
Treatment guidelines are often not established
for infants, particularly for preterm neonates

31. • ASP IDSA 2016 Updates
facility-specific
guidelines for selected
common and important
infectious syndromes.
• Syndrome guidelines
should include a
recommended duration
of therapy for each
specific infectious
syndrome.

32. Certain clinical paradigms where the routine
use of antibiotics and choice of antibiotics is
being re-examined
2. CHOICE OF ANTIBIOTICS FOR LATE ONSET SEPSIS
1. EMPIRICAL ANTIBIOTICS FOR SUSPECTED SEPSIS IN TERM AND LATE PRETERM
INFANTS BORN TO MOTHERS WITH CHORIO-AMNIONITIS
3. CONTINUED ANTIBIOTIC USE IN THE NICU FOR CULTURE-NEGATIVE SEPSIS

33. Management of
NEONATES WITH SUSPECTED OR PROVEN EOS
“RISK - Babies Born To Mothers With Suspected Chorioamnionitis”
Recommendations –
20% treated solely on the basis of abnormal laboratory data

34. EOS Calculator
Physical examination
1. Blood culture use decreased from 14.5% to 4.9%
2. Empirical antibiotic use in the first 24 h decreased from 5.0% to 2.6%
3. Without increases in readmissions for EOS within 7 days of birth

35. Asymptomatic infant with EOS –
 Close observation of asymptomatic infants greater than 34 weeks
gestation born to mothers with suspected (not confirmed) intra
amniotic infection rather than initiation of empiric antibiotic therapy

36. Group of infants that receives a large proportion of antibiotics - VLBW
Higher prevalence of early
and late onset sepsis in
preterm/
VLBW infants
Concerns
about the reliability of
blood cultures
Difficulty in differentiating
clinical signs of
sepsis from non-infectious
symptoms

37. ANTIMICROBIAL STEWARDSHIP IN NICU
1
Identifying
patients who
need
antibiotic
therapy Using
local
epidemiology
2
Avoiding agents
with overlapping
activity Adjusting
antibiotics when
cultures results
become available
3
Monitoring
for toxicity,
and
optimizing
the dose,
route, and
duration of
therapy

39. NICU CARE BUNDLE
Small set of evidence-based
actions for a defined population
and care setting implemented
together in NICUs has been
associated with a reduction in
CLABSI rates
This multifaceted approach has
reduced the incidence of health
care–associated infection in
each center or groups of
centers where it has been
implemented

40. CLABSI PREVENTION CARE
BUNDLE

41. VAP BUNDLE
1. Head-of-bed elevation 300-450
2. Re-enforcement of hand hygiene practice
3. Sterile suction and handling of respiratory
equipment
4. Intubation, re-intubation and endotracheal
tube (ETT) suction as strictly indicated by unit
protocol
5. Change ventilator circuit if visibly soiled or
mechanically malfunctioning
6. Proper timed mouth care with normal saline
and suction of oro-pharyngeal secretion.
7. Daily evaluation for readiness for extubation
and sedation vacation for sedated patient

42. Antibiotic stewardship program for neonates

43. Implementing Antimicrobial Stewardship
1. Primary:
1. Formulary restriction and preauthorization (BII)
2. Prospective audit with intervention and feedback.(AI)
2. Secondary:
1. Education.(AII)
2. Guidelines and clinical pathways (AI)
3. Streamlining or de-escalation of therapy.(AII)
Needed to be applied
first in Developing
country like INDIA

45. 1. Education
• Educational efforts include passive activities, such as conference
presentations, student and house staff teaching sessions
• Provision of written guidelines or e-mail alerts
• Introduction of the order form led to significantly improved
compliance (from 17% to 78%)

46. 2. Guidelines and clinical pathways
• Recommendation
• Multidisciplinary development of evidence-based practice guidelines
incorporating local microbiology and resistance patterns can improve
antimicrobial utilization (A-I).
• Guideline implementation can be facilitated through provider
education and feedback on antimicrobial use and patient outcomes
(A-III).

47. Making Antibiotic Protocol
• Step 1 - Compile Local Hospital
data Based on  Site of infection
• Organism spectrum
• Geographic Variations
(NICU/PICU/WARDS)
• % Distribution of Bugs

48. Step 2: Risk Stratification for MDRs

49. Step 3: Local Microbiological data

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

51. Antimicrobial cycling and antimicrobial switch.
• “Antimicrobial cycling”
refers to the scheduled 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.

52. Antimicrobial order forms
• Antimicrobial order forms
Decrease antimicrobial consumption in longitudinal studies
through the use of automatic stop orders and the requirement of
physician justification.

53. Combination therapy:
prevention of resistance versus redundant antimicrobial coverage
• The rationale for combination antimicrobial therapy
includes broad-spectrum empirical therapy for serious
infections, improved clinical outcomes, and the
prevention of resistance

54. Streamlining or de-escalation of therapy
Dose Optimization
Parenteral to Oral conversion

55. AMS Simplified 4 D’s of Antibiotics
• The Right Drug
1
• The Right Dose
2
• The Right Duration
3
• De-escalation
4

57. Thank you