This ppt is useful for B.Sc.(N). Sem.-3 students. This content is prepared according syllabus of INC 3rd Semester students of B.Sc.(N).

1. Unit - 7
Antibiotic Stewardship
By, Ahmed Sodha
M.Sc.(N). – M.S.N.

2.  INTRODUCTION
 Anti-biotic:- A Drug Used To Treat Infections Caused By
Bacteria And Other Microorganisms.
 Stewardship:- Supervising, Or Managing Of Something. Or
The Careful And Responsible Management Of Something.
 Antibiotic Stewardship:- It Is The Effort To Measure And
Improve How Antibiotics Are Prescribed By Clinicians And
Used By Patients.

3.  ANTIBIOTIC STEWARDSHIP PROGRAM (ASP)
• Antibiotic Stewardship Program Is A
Coordinated 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.
 Definition:-
• The Antibiotic Stewardship Is A Collective Set Of
Methodologies Used In Order To Enhance The Appropriate
Antibiotic Use & Reduce The Deleterious Effects Of
Antibiotic Use And Also Includes The Awareness Of The
Related Aspects Like Antibiotic Resistance, Toxicity &
Economic Burden.

4.  Purposes Of Antibiotic Stewardship Program (ASP):-
• The First Aim Of ASP Is The Optimization Of Proper Use Of
Antibiotics In Order To Ensure Better Clinical Implications &
Reduction Of Harmful Effects.
• The Second Aim Is To Make The Antibiotic Usage Cost-
effective.
• The Third Aim Is To Maintain It’s Quality In Patient Care.
• The Fourth Aim Is To Reduction Of Any Collateral Damage
In Case Of Multidrug Resistant Microbial Infections.
• The Fifth Aim Is To Prevent The Generation And Spread Of
Antimicrobial Resistance (AMR) Or Anti-Biotic Resistance
(ABR). [The More Antimicrobials We Use, The Higher The
Resistance]

5.  The 5 R Approach To Antibiotic Stewardship Program:-

6.  The 5 R Approach To Antibiotic Stewardship Program
(ASP):-
• To Foster A Culture Of Continuous Improvement, Experts
Have Recommended ‘The 5 R Approach To ASP’.
• 1. Responsibility:- Everyone Who Uses Antimicrobials
Acknowledges That Use Can Cause Harm.
• When We Do Use An Antimicrobial, We Should Take
Actions That Reduce The Risk For Future Public’s Health.
• 2. Reduction:- Whenever We Can, We Need To Look For
Ways To Reduce Our Reliance On Antimicrobials

7. • 3. Refinement:- When We Use Antimicrobials, We Should
Ensure That We Are Using The Right Drug, At The Right
Dose, At The Right Time, Treating The Right Bug, For The
Correct Length Of Time.
• 4. Replacement:- Consider Non-antimicrobial Products
That Could Be Used To Promote Good Health And Prevent
Disease.
• 5. Review:- We Should Be Critical Of Every An Antimicrobial
Was Used And Decide On A Specific Strategy For Making
Further Improvements And Reductions In Use.

8.  CORE ELEMENTS OF HOSPITAL ANTIBIOTIC
STEWARDSHIP PROGRAM (ASP):-
• 1. Leadership Commitment:- It Includes The Dedication Of
Necessary Human, Financial & Information Technology
Resources.
• 2. Accountability:- A Single Leader Must Be Appointed For
Noticing The Program Outcomes.
• 3. Drug Expertise:- A Single Pharmacist Leader Must Be
Appointed To Improve Antibiotic Use.
• 4. Action:- The Recommended Actions Must Be
Implemented.
Ex. Deciding & Implementing The Antibiotic Timeout During
The Second Antibiotic Treatment In A Patient.

9. • 5. Tracking:- The Antibiotic Prescription & The Antibiotic
Resistance Must Be Tracked, Monitored & Recorded
Frequently.
• 6. Reporting:- Reporting Must Be Done By The Requisite
Persons To The Doctors, Nurses Staff Regarding The
Antibiotic Usage & Resistance If Any.
• 7. Education:- The Clinicians Must Be Properly Educated
About The Appropriate Prescription & Resistance Of
Antibiotics.

10.  SIGNIFICANCE / IMPORTANCE OF ANTIBIOTIC
STEWARDSHIP PROGRAM (ASP):-
 Patient Care:- The Quality Of The Care Of Patient
Improves If Antibiotic Stewardship Program (ASP) Is Being
Practiced In A Hospital Environment.
 Safety:- The Safety Of The Patient Enhances Due To The
Implementation Of The Antibiotic Stewardship Program
(ASP).
 Treatment Failure Reduction:- The Antibiotic Stewardship
Program (ASP) Implementation Reduces The Treatment
Anomalies As Less Antibiotic Resistance Is Observed.

11. ANTI-MICROBIAL RESISTANCE

13.  What Are Antimicrobials?
• Antimicrobials – Including Antibiotics, Antivirals,
Antifungals And Antiparasitics – Are Medicines Used To
Prevent And Treat Infections In Humans, Animals And
Plants.
 What Is Antimicrobial Resistance?
• Antimicrobial Resistance (AMR) Occurs When Bacteria,
Viruses, Fungi And Parasites Change Over Time And No
Longer Respond To Medicines Making Infections Harder To
Treat And Increasing The Risk Of Disease Spread, Severe
Illness And Death.
• As A Result Of Drug Resistance, Antibiotics And Other
Antimicrobial Medicines Become Ineffective And Infections
Become Increasingly Difficult Or Impossible To Treat.

14. • Antibiotics Are Becoming Increasingly Ineffective As Drug-
resistance Spreads Globally Leading To More Difficult To
Treat Infections And Death Hence New Anti-bacterial Are
Urgently Needed.
• However, If People Do Not Change The Way Antibiotics Are
Used Now Those New Antibiotics Become Ineffective.
 Role Of A Nurse In AMR Reduction:-
• Can Help Minimize The Inappropriate Use Of Antibiotics.
• Can Help Practice Appropriate Infection Control Practices.
• Can Educate Patients & People On The AMR Issues & On
How To Prevent Them.

15.  Multidrug-Resistant Organisms (MDRO):-
• Multidrug-resistant Organisms Are Organisms That Are
Resistant To Multiple Antibiotics Or Antifungals. MDROs
Can Be Difficult To Treat, And Therefore, Can Cause Serious
Illness Or Even Death.
 Common MDRO Include:-
• Vancomycin-Resistant Enterococci (VRE)
• Methicillin-Resistant Staphylococcus Aureus (MRSA)
• Extended-Spectrum Β-Lactamase (ESBLs) Producing Gram-
Negative Bacteria
• Carbapenem Resistant Enterobacteriaceae Or Carbapenem
Resistant Pseudomonas.
• Multidrug-Resistant TB (MDR-TB) is Caused By An
Organism That is Resistant To At Least Isoniazid And
Rifampin, The Two Most Potent TB Drugs.

16.  Methicillin-Resistant Staphylococcus Aureus
(MRSA):-
 Introduction:-
• Staphylococcus Aureus Is A Bacterium That Is Carried On
The Skin Or Nasal Lining Of Up To 30 Percent Of Healthy
Individuals. In This Setting, The Bacteria Usually Cause No
Symptoms.
• However, When The Skin Is Damaged, Even With A Minor
Injury Such As A Scratch Or A Small Cut From Shaving,
Staphylococcus Aureus Can Cause A Wide Range Of
Problems.
• These Problems Can Range From A Mild Pimple To Severe
Illness, Especially In Young Children, Older Adults, And
People With A Weakened Immune System.

17.  Where Did Methicillin-Resistant Staphylococcus Aureus
(MRSA) Come From?
• Initially, Most Staphylococcus Infections Were Sensitive To
Penicillin. In The 1950s, Many Infections Became Resistant
To Penicillin And Methicillin (A Related Drug Developed To
Treat These Germs).
• Thus, The Term Methicillin-Resistant Staphylococcus
Aureus (MRSA) Was Derived.
• MRSA Must Be Treated With Alternate Antibiotics.

18.  How is Methicillin-Resistant Staphylococcus Aureus
(MRSA) Spread?
• You Can Be "Colonized" With MRSA, Meaning That You
Carry The Bacteria On Your Skin Or In Your Nose But You
Have No Signs Or Symptoms Of The Illness.
• You Can Become Colonized With MRSA By Touching The
Skin Of Another Person Who Is Colonized With MRSA, And
By Touching A Contaminated Surface (Such As A Door
Handle, Phone etc.)

19.  Treatment Of MRSA:-
• Treatment Of MRSA Usually Includes A 7- To 10-day Course
Of An Antibiotic Such As Trimethoprim-Sulfamethoxazole,
Clindamycin, Minocycline, Linezolid, Or Doxycycline.
• It Is Very Important To Carefully Follow The Instructions For
Taking The Antibiotic; This Means Taking It On Time And
Finishing The Entire Course Of Treatment, Even If You Feel
Better After A Few Days.
• In The Hospital, If You Are Colonized But Not Infected With
MRSA, You May Be Treated With Mupirocin Ointment And
Chlorhexidine Soap.

20.  Prevention of MRSA & MDRO Infections in A
Healthcare Setting
3. Antimicrobial Usage Restrictions
2. Environmental Preventive Measures
• Cleaning & Disinfection
• Preventing Understaffing & Reducing
Overcrowding of Patients
1. Core Preventive Measures
• Standard Precautions
• Contact Precautions
• Surveillance
• Decolonization

21.  Prevention of MRSA & MDRO Infections in A Healthcare
Setting:-
• The Following Are The Key Preventive Measures Of The
MRSA & MDRO Infections Spread In Healthcare Setting:
1. Core Preventive Measures
2. Environmental Preventive Measures
3. Antimicrobial Usage Restrictions

22. 1. Core Preventive Measures:- This includes following
preventive measures:
 Standard Precautions:-
• It Includes The Very Basic Measures Like The Use Of PPE
Like Gloves, Gown, Face Masks, Eye Shield, Etc. That Must
Be Used Appropriately In A Healthcare Facility.
• Hand Hygiene Is Another Very Important Standard
Precautions In Order To Decrease The Spread Of The MRSA
& MDRO And Must Be Followed & Monitored At All Levels
In Healthcare Setting.
• Keep Hands Clean By Washing Thoroughly With Soap And
Water. Hands Should Be Dried With A Single-use Towel Like
A Paper Towels.
• Alcohol-based Hand Sanitizers Are A Good Alternative For
Disinfecting Hands If A Sink Is Not Available.

23.  The Contact Precautions:-
• The Contact Precautions Like Wearing Of The Gloves,
Gown, Mask etc. Must Be Practiced Strictly While Dealing
With The Suspected Or Confirmed Cases Of Colonized Or
Infected MRSA/MDRO Cases In Hospital Environment.
• Avoid Touching Other People's Wounds Or Bandages.
• Use Of Disinfectant On Surfaces Like Tables, Counters,
Doorknobs, Phones, Computer etc.

24.  Surveillance:- The Periodic Or Routine Inspection Within A
Healthcare Facility Must Be Done At The Following Two
Levels:
a) Patient’s Surveillance:- Screening Must Be Done To
Detect Carriers Known As The Main Reservoir Especially
During Admission To The Hospital & The Incident Cases
That Is Who Get MRSA Infection From The Hospital
Environment Later.
b) Healthcare Workers Surveillance:- The Healthcare
Workers Must Be Screened Especially Those Working In
The High-risk Areas Like ICU, Burn Units, Surgical Areas,
Dialysis Wards Etc.
 Decolonization:-
• Nasal 2% Mupirocin, Chlorhexidine Gel Washing & Systemic
Antibiotics Can Be Used For Decolonization Of Healthcare
Workers & Colonized Patients With Or Without Symptoms.

25. 2. Environmental Preventive Measures:- This includes
following preventive measures:
 Cleaning & Disinfection:-
• Enhanced Cleaning & Disinfection Of The Hospital
Environment Results In The Reduction & Control Of The
MRSA & MDRO Outbreaks.
 Preventing Understaffing & Reducing Overcrowding of
Patients :-
• The Patient-staff Ratio Must Be Conductive & Maintained
In A Healthcare Facility In Order To Make The Infection
Prevention Policies More Effective.

26. 3. Antimicrobial Usage Restrictions:-
• The Over Usage Of Antibiotics Must Be Avoided & Its
Overuse Must Be Monitored As Far As Possible By
Educating, Updating & Supervising The Patients, Families &
The Staff.