This document summarizes the antimicrobial stewardship program (AMS) implemented at a 500-bed tertiary care hospital. The AMS program focused on education, developing an antibiogram to guide empiric therapy, monitoring antibiotic use and resistance, and getting support from hospital management. An evaluation found high rates of appropriate initial antibiotic therapy in the medical ICU according to treatment protocols, with a quarter to third of patients having antibiotics de-escalated. Mortality and length of stay in the ICU were comparable to international standards. However, the program was limited to the medical ICU and surgical prophylaxis, and broader implementation and monitoring across the hospital remained a challenge.

1. The presentation is solely meant for
Academic purpose

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

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)

16.  Type 3 – Imipenem/Meropenem , Teicoplanin
(Unknown) , Linezolid (Lung, SSTI),
Clarithromycin (lung)
 Type 4 - Tigecycline, Colistin, Flucanozole/
Caspofungin

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

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