An 82-year-old woman presented with dry cough, shortness of breath, and inability to lie flat. Laboratory tests showed elevated white blood cell count and BNP level. The document discusses antibiotic stewardship, which aims to optimize clinical outcomes while minimizing unintended consequences of antibiotic use, such as emergence of resistance. It provides strategies for judicious antibiotic selection and use, including monitoring local resistance patterns, limiting duration of therapy, and tracking antibiotic use.

1. ANTIBIOTIC
STEWARDSHIP
IN THE
EMERGENCY
ROOM
Rashid A. M. Abuelhassan, MBBS, MRCEM

3. An 82 woman
c/o dry cough SOB and
can't lie down flat.
o/e: RR = 22 /min;
spO2=94%; others are
normal and no LL
edema
Labs : WBCs= Noramal ;
BNP= 680 pg/mL

4. Sir Alexander Fleming
(6 August 1881 – 11 March 1955)

9. • CDC report: Antibiotic Resistance
Threats in the United States
SEPTEMBER
2013
• C. difficile
• Carbapenem-resistant Enterobacteriaceae (CRE)
• Drug-resistant Neisseria gonorrhoeae
• MDR Acinetobacter
• DR Campylobacter
• ESBLs
• VRE
• MRSA
• MDR Pseudomonas
aeruginosa
• Strep pneumonia
• Fluconazole-resistant
Candida
• MDR & XDR TB
• VRSA
• Erythromycin-resistant Streptococcus Group A
• Clindamycin-resistant Streptococcus Group B
CDC Antibiotic Resistance Threats in the United States, 2013.

11. 18 Nov

15. How to fight back ?

16. Strategy ?
• assess local susceptibility rates
• selecting a good empirical antibiotic therapy
• monitoring resistance trends over time

17. What is antibiogram?
Antibiogram is a periodic summary of
antimicrobial susceptibilities of local bacterial
isolates submitted to the hospital's clinical
microbiology laboratory.

18. Antibiogram Example

22. What is Antimicrobial
Stewardship?
Using the right antibiotic
at the right time
at the right dose
for the right duration
The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria.
IDSA and the SHEA guidelines for developing an institutional program to enhance antimicrobial stewardship.

23. Primary goal
Optimize clinical outcomes while minimizing
unintended consequences of antimicrobial use, including
toxicity, the selection of pathogenic organisms, and the
emergence of resistance
The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria.
IDSA and the SHEA guidelines for developing an institutional program to enhance antimicrobial stewardship.

24. Goals of Antibiotic Stewardship
streamline therapy and improve outcomes
set duration of therapy
Improves handoff communication
Reduces the emergence of multi-drug
resistant pathogens
Reduces adverse drug reactions

25. Core Elements for outpatient
Antimicrobial Stewardship Programs
In patient and Nursing Home
1.Commitment
2.Accountability
3.Drug Expertise
4.Action
5.Tracking
6.Reporting
7.Education
Out patients and ER
• Commitment
• Action for policy and
practice
• tracking and reporting
• Education and
expertise.
http://www.cdc.gov/getsmart/healthcare/implementation/core-elements.html

26. Principles
1. Obtain Quality Cultures
1. Before antibiotics initiated (if possible)
2. Utilize Respiratory Therapy to obtain sputum samples
3. Avoid surface cultures
2. Establish source control if applicable
3. Indications are written with all antibiotic orders
4. Stream line to narrow spectrum antibiotics following culture results
5. Set antibiotic durations of therapy at time of prescribing or immediately
following clinical response

27. Quality Measures
• Multidisciplinary process to review antimicrobial
utilization and local susceptibility patterns
• Systems to prompt appropriate use of antimicrobial
agents
• Antibiotic orders include indication for use
• Clinician review of need/selection of antibiotics at
72 hours
• IV to PO program

31. AAEM Recommendations
1. Withhold antibiotics for uncomplicated RTI.
2. The modified Centor score.
3. Avoid antibiotics for uncomplicated abscesses.
4. Administer broad-spectrum antibiotics to
patients with septic shock early.
5. Consider cultures when initiating antibiotic.
6. Determine local antimicrobial susceptibilities
7. An Antibiotic Stewardship Champion.
8. A multidisciplinary, antibiotic usage, quality
improvement process
9. Antibiotic order sets and clinical decision
support systems.
10. Post-prescription culture review

33. Procalcitonin as a biomarker of
infectious diseases
Antibiotics can generally be
withheld in cases of suspected
respiratory infection or sepsis when
the likelihood of infection is low
and the PCT result is < 0.25 ng/mL.
1. Harbarth S et al. Am J Respir Crit Care Med 2001,164: 396-402
2. Kumar Meisner et al., Crit Care 1999,3:45-50
• Schuetz P, Chappa V, Briel M, Greenwald JL. Procalcitonin algorithms for antibiotic therapy decisions. Arch Intern Med. 2011;171:1322-1331. Abstract
• Schuetz P, Albrich W, Mueller B. Procalcitonin for diagnosis of infection and guide to antibiotic decisions: past, present and future. BMC Med. 2011;9:107.
• Riedel S, Melendez JH, An AT. Procalcitonin as a marker for the detection of bacteremia and sepsis in the emergency department. Am J Clin Path 2011;135:182-189.

34. Antimicrobial Stewardship in
Saudi Arabia
• Antibiotics awareness week only last November
• After it MOH guided to establish the program in all
her hospitals and advised to be added to the
CEBAHI
• STILL the Harmonizing body is under development
• There was individual activities

36. Nerds Zone
Antimicrobial Companion

38. Take home message
• Antimicrobial resistance is responsibility
of us all
• Stay up-to-date in local resistance or at
least recent national clinical guideline
• Think many time before prescribing Abx
and involve your patient abouth risks
• Help from the clinical pharmacist is not
shameful

40. • National Action Plan for Combating
Antibiotic-Resistant Bacteria (Goals)
MARCH
2015
• Slow emergence of resistant bacteria and prevent spread
• Strengthen National One-Health surveillance efforts to combat resistance
• Advance development and use of rapid and innovative diagnostic tests for
identification and characterization of resistant bacteria
• Accelerate basic and applied research and development of new
antibiotics, other therapeutics, and vaccines
• Improve international collaboration and capacities for antibiotic-resistance
prevention, surveillance, control, and antibiotic research and development
The White House. National Action Plan for Combating Antibiotic-Resistant Bacteria.