This document discusses antimicrobial resistance (AMR) and strategies for combating it. It begins by defining AMR and explaining that microorganisms can develop resistance to multiple antimicrobial agents, becoming "superbugs." It then discusses the global toll of AMR, listing bacteria identified by the CDC as urgent, serious, or concerning threats. The document emphasizes the need for antimicrobial stewardship programs in healthcare facilities to optimize antibiotic use and reduce resistance. It outlines components of stewardship programs like developing treatment guidelines, monitoring antibiotic use and resistance trends, and improving prescribing and de-escalation of therapy. The goal of stewardship is to use the right drug, for the right person, for the right duration. The document stresses

1. Dr. Soha Al-Marsafy
Infection control consultant
Member of GAHAR accreditation standards
development for hospitals
Antimicrobial resistance
know how to fight your enemy

2. •Antimicrobial
resistance (AMR)
What
•overuse & misuse
of antimicrobials
Why
•All people
Who
•to do to prevent
what
•Control & treat
How

3. Resistance is not new

4. What is antimicrobial resistance
(AMR)?
• The inherited or acquired ability of
microorganisms to resist the action of
the antimicrobial agent
• Sometimes, microorganisms develop
resistance to more than one
antimicrobial agent, and are referred
to as “superbugs”.

5. • 700,000 people die of AMR every year
because available antimicrobial drugs
have become less effective at killing
resistant pathogens.
• A list of 18 bacteria & fungi by the CDC
that endanger human health, classifying
them as either:
• Urgent threats
• Serious threats
• concerning threats

6. • Urgent threats
• Candida auris
• Carbapenem-resistant Enterobacteriaceae
• Drug-resistant Neisseria gonorrhoeae
• Serious threats
• ESBL-producing Enterobacteriaceae
• Vancomycin-resistant Enterococci (VRE)
• Methicillin-resistant Staphylococcus aureus
(MRSA)
• Concerning threats
• Clindamycin-resistant group B Streptococcus

7. “Antibiotics are like fire extinguishers.
We don’t want to use them all the time
but we are happy we have them on the
wall.”
John Rex

8. Sledgehammer
• Antibiotics can be broad Affect many
different species of bacteria
• BUT broad spectrum antibiotics contribute
more to resistance
Broad Spectrum Antibiotics

9. Scalpel
• More targeted Antibiotics can be narrow
spectrum
• Effect one or two kinds of bacteria
• Narrow spectrum antibiotics
contribute less to resistance
Narrow Spectrum Antibiotics

10. Superbugs Are Growing More Resistant to
Hand Sanitizer, Scientists Warn
DAVID NIELD
3 AUG 2018

11. • Proteases - Pumps - Porins
• Penicillin-binding protein (PBP) change
• Point mutations & target modifications
• PRE-DETERMINED
• PLASMID-MEDIATED
The ‘Ps’ of resistance

12. SHARING THE RESTISTANCE
AHRQ SAFETY PROGRAM FOR LONG-TERM CARE:
HAIs/CAUTI
Centers for Disease Control and Prevention. Antibiotic Resistance Threats
in the United States, 2013.

13. Antimicrobial Resistance (AMR)
a plasmid-borne colistin resistance
gene, mcr-1, heralds the emergence
of truly pan-drug resistant bacteria
Colistin-resistant E.Coli infection;
female 46 years old patient in 2016
McGann P, et al. Antimicrob Agents Chemother. 2016. pii: AAC.01103

14. become
antibiotic
resistant
Resistant
bacteria
can spread
like other
microbes
e.g. by
shaking
hands
Resistant
bacteria
can be
carried by
anyone
healthy
or
ill
The use of
antibiotics
in animals
and
agriculture
contributes
to the
problem
The more a
person takes
antibiotics,
the more
likely they
are to carry
antibiotic
resistant
THE BUGS ARE WINNING??!!

15. Resistant infections
• More difficult to treat
• Other antibiotics need to be used which may not
work as well or can be more toxic
• More coast on the patient and hospital
• Usually require longer hospital stays
• More likely to spread to others

17. Fighting Back!
AMR
PREVENTION CONTROL

18. PREVENTION
1. Prevent infections, prevent the spread of resistance
2. Developing new drugs and diagnostic tests
3. IMPROVING ANTIBIOTIC PRESCRIBING
(STEWARDSHIP)
4. Tracking the outcomes
The CDC has recommended four necessary
actions to prevent antimicrobial resistance

19. HOW TO START AN
ANTIMICROBIAL
STEWARDSHIP IN
YOUR INSTITUTION

20. ANTIMICROBIAL STEWARDSHIP
• Antimicrobial stewardship is an activity
that promotes
–Appropriate selection of antimicrobials
–Appropriate dosing of antimicrobials
–Appropriate route and duration of
antimicrobial therapy

21. GOALS OF ANTIMICROBIAL
STEWARDSHIP
What is antimicrobial stewardship?
Antibiotic stewardship refers to a set of commitments and activities
designed to “optimize the treatment of infections while reducing the
adverse events associated with antibiotic use.”
The goal is…
– to have the RIGHT DRUG
– for the RIGHT PERSON
– over the RIGHT TIME FRAME
AHRQ SAFETY PROGRAM FOR LONG-TERM CARE:
HAIs/CAUTI

22. GOALS OF ANTIMICROBIAL
STEWARDSHIP
• Primary goal
Optimize clinical outcomes
• Secondary goal
Reduce healthcare costs without adversely
impacting the quality of care

23. Hand hygiene

24.  Apply to all patients receiving care in hospitals,
regardless of their diagnosis or presumed infection
status
 Designed to reduce the risk of transmission of
microorganisms from both recognized and
unrecognized sources of infections
 Under standard precautions, blood and body fluids
of all patients are considered potentially infectious
Standard Precautions

26. Isolation precaution

27. Proper use of antibiotics

28. Difference between colonization & infection
Colonization Infection
Normal white count, no
left shift.
WBCs elevated or
decreased with left shift.
Normothermia. Hyperthermia or
hypothermia.
Usually not associated
with heavy growth of
pathogen on gram
stain.
More often associated with
heavy growth of pathogen
and a gram stain.
Not associated with
other signs of an
infection.
Usually associated with
other signs of infection.

29. 1- colonization usually occurs in patients who are
chronically ill with chronic tracheostomies or
chronically ventilated
2- mixed flora may grow on gram stain in absence of
infection
3- squamous epithelial cells > 10 = contamination
4- some organisms are almost never considered
pulmonary pathogen ( coagulase –ve staph ,
enterococcus , gram + ve bacilli ( except Nocardia ) ,
streptococcus except ( pneumoniae , agalactiae ,
pyogenes , anginosus ) & candida spp
29

30. Sputum cultures :
Signs and symptoms must be present :
1- leucocytosis or left shift
2- fever , chills
3- cough , SOB
4- decrease oxygen saturation
5- increase purulent secretions
6- increase suction needs in trachestomy and
ventilated patients
30

31. Blood cultures :
False positive :
1- bacterial growth occurs after 72 hr of
incubation
2- if common skin commensals ( eg staph
coagulase –ve ) appear except in prescence of
prosethtic material + signs of infection or two
blood c/s from two separate sites at two
different times
3- only one set positive out of two or more
31

32. 3. Converting from intravenous to oral antibiotic
administration
1. Initiating empiric therapy
2. Tailoring antibiotic therapy ("antibiotic time-out")
Management of patients with suspected or
proven bacterial infection consists of initiation
of empiric therapy ( prior to availability of
definitive microbiology data), followed by
adjustment once microbiology data become
available definitive treatment.
4. Using the shortest effective duration of therapy
5. Pharmacokinetic monitoring

33. – Hospital -acquired pneumonia
– Urinary tract infections
– Skin and soft tissue infections
– Empiric coverage of MRSA infections
– Surgical prophylaxis
Facility-specific clinical practice guidelines and
pathways for these common infections
(ANTIBIOTIC POLICY)
Based on susceptibility patterns, and drug
availability
IN OUR HOSPITAL

34. Combination therapy
•Synergistic (1+1>2); Additive (1+1=2);
Antagonistic(1+1<2)
•Combination of 2 static drugs are usually additive
(exception Sulfonamide with Trimethoprim is
synergistic)
•Combination of 2 –cidal drugs with different MOA is
additive or synergistic
•Combination of –cidal + -static is ANTAGONISTIC
(rarely additive if organism is less sensitive to-cidal)
•e.g. Penicillin + Tetracycline ANTAGONISTIC but
Rifampicin + Dapsone in leprosy is additive

35. Pharmacokinetics
•ABSORBTION
•Oral route: used in non life threatening infections
•Intravenous route: serious life threatening infections.
•Topical: localized infection
•DISTRIBUTION
•The drug must reach the required site of action at
adequate dose in adequate amounts in the active form for
sufficient time like CNS, eye, prostate gland. Like : use of
inhalation antibiotic in complicated pneumonia.
•Pus cavities are avascular; low concentrations of
antibiotics are achieved. Incision and drainage of pus is
done prior to antibiotics.

36. Antimicrobial coverage :
2- MRSA :
Vancomycin - linezolide ,
tygecycline - ceftaroline -
septrin - clindamycin -
teicoplanin
1- pseudomonas :
Tazocin-aminoglycosides -
ceftazidime - cefepime -
fluoroquinolones –
Carbapenem - ceftolozane-
tazobactam - Polymixin
3- anaerobes :
Metronidazole - dalacin –
tazocin- unasyn - augmentin -
carbapenem -moxifloxacin -
tygacil
36

37. Antibiogram
summary of antibiotic susceptibility data for bacterial
isolates recovered by a microbiology laboratory over a
defined period of time (usually one year).
Antibiograms may be used by pharmacist
1. to guide choice of empiric antibiotic therapy
2. to develop facility-specific clinical protocols
3. to monitor resistance trends.
The data are most useful when stratified by inpatient
versus outpatient source, hospital site (eg, intensive
care unit, general ward, emergency department)
and population (eg, pediatric versus adult)

38. Antibiogram
1.Analyze and present a cumulative
antibiogram report at least annually
2. Include only final, verified test results.
3. Include data for species with ≥30 isolates.
4. Include only diagnostic (not surveillance) cultures.
5. Eliminate duplicates by including only the
first isolate of
a species/patient/analysis period,
irrespective of site or antibiotic
susceptibility profile.
6. Include only antibiotic agents routinely tested and
calculate the percent susceptible from results
reported.
The Clinical and Laboratory Standards Institute guideline on
antibiogram preparation recommends the following:

39. 39
aimed.
net.au

40. Process measures
Monitor antibiotic use prescribing
Antibiotic use : Controversy regarding best
methods for monitoring use
• DDD = defined daily dose
• DOT = days of therapy
Outcomes measures

41. TODAY’S FOCUS
What is antimicrobial stewardship?
Antibiotic stewardship refers to a set of commitments and activities
designed to “optimize the treatment of infections while reducing
the adverse events associated with antibiotic use.”
The goal is…
– to have the RIGHT DRUG
– for the RIGHT PERSON
– over the RIGHT TIME FRAME

42. TODAY’S FOCUS
• Penicillin allergy
• Up to 10% of the general population and 15%
of hospitalized patients list penicillin as an
allergy

43. PENICILLIN ALLERGY
• Penicillin “allergic” patients are more likely to
– Received fluroquinolones, vancomycin, clindamycin
– Harbor drug resistant organisms such as MRSA and VRE
– Develop C diff colitis
• Increased mortality
– Experience --
• treatment failure, infection recurrence, death from MSSA
bacteremia
• treatment failure in gram negative bacteremia
• a delay in empiric antimicrobial treatment
• a surgical site infection

44. PENICILLIN ALLERGY
• Pencillin “allergic” patients are more likely to
– Develop new antibiotic “allergies” with alternative therapies
– Have an allergic reaction to vancomycin than cefazolin
– Have side effects or toxicities from second-line therapies
• Penicillin allergic patients have higher drug costs
– Higher outpatient antibiotic costs per patient
– $300 more per patient per day of inpatient antibiotic therapy
– $1253 more in length of stay costs per patient per admission
• Penicillin allergic patients have longer hospital stays
– 10% longer hospital stays, estimated cost of $21.5 million per
year.

45. PENICILLIN ALLERGY: ACCURATE
DIAGNOSIS?
• Less than 10% of these allergies are confirmed
when tested
• Childhood viral rashes are often misdiagnosed
as drug rashes
– Only 7-16% of kids with “drug allergy” during an
infection later test positive to the drug.
• Even if a patient is truly allergic, most people
“outgrow” penicillin allergy
– Over 50% of people with confirmed allergy to
penicillin ‘lose their allergy’ after 5 years

46. BETA LACTAMS

47. CEPHALOPSORIN VS PENICILLIN
• Overall cross-reactivity based on multiple
studies is actually very low:
– Reported (but unconfirmed) penicillin allergy:
0.1%
– Confirmed penicillin allergy: 2%
– Above exclude patients with penicillin anaphylaxis

48. PENICILLIN ALLERGY

49. OUR EFFORTS
• Cascading susceptibilities
• Drug desensitization
• Drug challenge

50. Cascading Susceptibilities
• Definition
– a strategy of reporting antimicrobial susceptibility
test results in which secondary (e.g., broader-
spectrum, more costly) agents may only be
reported if an organism is resistant to primary
agents within a particular drug class

51. Old New

52. Graded Challenge/Test Doses
1%/10%/20%
Scheduled Maintenance Dosing
Ampicillin 2000 mg IV once
Observe for 30 minutes
Ampicillin 200 mg IV once
Observe for 30 minutes
Ampicillin 20 mg IV once
Observe for 30 minutes
Monitoring
• Vital signs every 30 minutes
• Rescue meds available
(diphenhydramine,
epinephrine,
methylprednisolone)
• Update allergy profile after
challenge

53. Graded Challenge (GC)
• Non-life threatening reaction and using agent with
similar side chain
• Severe Type1 IgE mediated allergy and using Agent
with dissimilar side- chain
When to Use
• Severe-delayed reactions such as SJS or DRESS
• When a reaction is likely (a recent reaction to the
same agent)
Contraindications
• Tests for existence of true allergy
• Allows allergy de-labeling
Pros/Cons

54. Desensitization
Monitoring
• Requires 1:1 nursing ratio
• ICU admission likely
required
• Airway box at bedside
• Vital signs every 30 minutes
• Rescue meds available
(diphenhydramine,
epinephrine,
methylprednisolone)
• Desensitization establishes a
temporary tolerance so allergy
on profile is relevant and should
remain there
18 step process
1. Ampicillin IV Desensitization Protocol (Goal dose 2 grams)
1. 0.01 mg (0.01mg/mL) IV once in 50 mL of 0.9% NS
2. 0.02 mg (0.01 mg/mL) IV once in 50 mL of 0.9% NS once, 15 min after previous dose
3. 0.04 mg (0.01 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
4. 0.08 mg (0.01 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
5. 0.16 mg (0.1 mg/mL)IV once in 50 mL of 0.9% NS, 15 min after previous dose
6. 0.32 mg (0.1 mg/mL) IV once in 50 mL of 0.9% NS , 15 min after previous dose
7. 0.64 mg (0.1 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
8. 1.2 mg (0.1 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
9. 2.4 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
10. 4.8 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
11. 10 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
12. 20 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
13. 40 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
14. 80 mg (10 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
15. 160 mg (250mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
16. 320 mg (250 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
17. 640 mg (250 mg/mL) IV once in 50 mL of 0.9% NS, 15 min after previous dose
18. 1600 mg (250 mg/mL) IV once 50 mL of 0.9% NS, 15 min after previous dose

55. Additional Information About
Infections and Symptom
Management

56. Monthly Meetings
 Be held monthly to review progress
 All individuals responsible for the QI
program should attend the meetings

57. Fever and Older Adults
 Do you know why a resident DOES NOT
need a fever to have an infection?
• Fever may be absent in 30-50% of older
adults with serious infections
• Factors such as chronic diseases,
medications, and time of day can affect
an older person’s temperature

58. Suspected UTI
Cloudy or Smelly Urine:
To Culture or Not?
 Urine changes have many causes
• foul-smelling urine may be caused by dehydration,
hygiene, medication, diet, or infection
 Will overdiagnose infection in one-third of cases
 Improved toileting and fluid intake is often better
treatment than antibiotics; hydration and perineal
hygiene can prevent recurrence
 Culture should be ordered only if new urinary
symptoms are present
*Archives of Internal Medicine. 160: 678-682, 2000.

59. When to Order a Urine Culture
Diagnostic Pathway
Fever of >37.9°C (100 °F) or 1.5°C (2.4 °F) increase above
baseline, on 2 occasions over the last 12 h?
2 or more symptoms/signs
of other infection?
Do not order
urine culture
YES
Order urine culture if you
observe 1 or more:
• New onset burning urination
(dysuria)
• Urinary catheter
• New or worsening:
oUrgency
oFrequency
oFlank pain
oGross hematuria
oUrinary incontinence
oSuprapubic pain
NO
YES
Order urine culture if you
observe 2 or more:
• New onset burning urination
(dysuria)
• New or worsening:
oUrgency
oFrequency
oFlank pain
oGross hematuria
oUrinary incontinence
oSuprapubic pain
NO
Order urine culture if
you observe 1 or more:
• New CVA tenderness
• Shaking chills (rigors)
• New onset of delirium
Urinary catheter?

60. Suspected Respiratory Infection
 Symptomatic care:
• Monitor vital signs
• Encourage fluid intake
• Acetaminophen 650 mg q 6 hrs PRN for fever
and pain reduction
• Nasal saline 2 sprays to each nostril PRN for
nasal congestion
• Guaifenesin 2 teaspoons every 4 hours as
needed for cough
• Antihistamines, especially Benadryl, should
be AVOIDED

61. Suspected Skin/Soft Tissue Infection
 Appropriate care:
• Mobility – encourage mobility (passive
or active)
• Acetaminophen 650 mg as needed or
prior to cleaning/dressing changes
• Cleanse wounds with each dressing
change with saline or warm water; do
not use antiseptic cleansers
• Apply dressing as needed

62. Infectious Diseases Society of America
2022 Guidance on the Treatment of
• Extended-Spectrum β-lactamase
Producing Enterobacterales (ESBL-E)
• Carbapenem-Resistant Enterobacterales
(CRE),
• Pseudomonas aeruginosa with Difficult-
to-Treat Resistance (DTR-P. aeruginosa)

63. Preferred Antibiotics for the Treatment of
Infections Caused by MDR P. aeruginosa
P. aeruginosa isolates test susceptible to
traditional non-carbapenem β-lactam
agents (ie, piperacillin-tazobactam,
ceftazidime, cefepime, aztreonam), they
are preferred over carbapenem therapy.

64. P. aeruginosa isolates resistant to carbapenems but
susceptible to traditional β-lactams, use of a novel
β-lactam agent that tests susceptible
(eg, ceftolozane-tazobactam, ceftazidime-
avibactam, imipenem-cilastatin-relebactam) is also
a reasonable treatment option