Antimicrobial Use Bundle is an approach to improve antibiotic use and reduce resistance through standardized practices. It involves collecting data on antibiotic initiation and follow up to ensure: 1) clinical rationale and appropriate testing is documented; 2) antibiotics are selected according to guidelines; and 3) treatment is reviewed on day 3 for de-escalation or switch to oral antibiotics. Studies show bundles improve compliance with best practices and lead to reduced costs, length of stay, and mortality when compared to usual care. Regular monitoring and feedback to clinicians is important for sustained implementation of antimicrobial stewardship bundles.

1. Antimicrobial Use BundleAntimicrobial Use Bundle
An idea whose time has come ?An idea whose time has come ?
Dr. Ashok Rattan,
Chief Executive,
Fortis Clinical research Ltd.,
Adviser,
Religare SRL Diagnostics labs in
Fortis / Escorts Hospitals, Delhi &
NCR

2. Antimicrobial Prescribing Facts
• ~ 1/3 of all hospitalised inpatients at any given time receive
antibiotics
• ~ up to 1/3 to ½ are inappropriate
• ~ up to 30% of all surgical prophylaxis in inappropriate
• Antimicrobials account for upwards of 30% of hospital
pharmacy budgets. Stewardship programmes can save up
to 10% of pharmacy budgets.
• Inappropriate and excessive use leads to resistance,
C.difficle & other ecological consequences, increased
morbidity, mortality, increased cost, increased litigation
and reduce quality of life

3. 100
80
60
40
20
0
19801975 1985 1990 1995 2000
1997
VISAVISA
VREVRE
PRSPPRSP
MRSAMRSA
MRSEMRSE
Percentage
of
Pathogens
Resistant to
Antibiotics
Increasing Incidence of Resistance in the US
MRSE, MRSA, VRE, PRSP, GISA
1980-2006
VRSAVRSA
2006

4. South Atlantic OceanSouth Pacific Ocean
North Pacific Ocean
North Atlantic Ocean
Indian Ocean
Arctic Ocean Arctic OceanArctic Ocean
North Pacific Ocean
United States of America
U.S.A.
Canada
Mexico
Brazil
U.S.A.
French Polynesia(Fr.)
Argentina
Uruguay
Paraguay
Chile
Bolivia
Peru
Ecuador
Colombia
Venezuela
Greenland (Den.)
Iceland
Madagascar
South AfricaLesotho
Swaziland
Mozambique
Tanzania
Botswana
Namibia Zimbabwe
Angola
Zaire
Zambia
Malawi
Burundi
KenyaRwanda
Uganda
Congo
Gabon
Somalia
Ethiopia
Sudan
EgyptLibya
Chad
Niger
Algeria
MaliMauritania
Morocco
Finland
Norway
Sweden
Turkey
Yemen
Oman
Saudi Arabia
Iran China
Mongolia
Russia
India
Indonesia
Malaysia
Australia
Japan
Antarctica
Kazakhstan
Hawaiian Islands
120° 60° 0° 60° 120° 180°
60°
30°
0°
30°
60°
180°150°120°90°30°0°30°60°90°120°150°
60°
30°
0°
30°
60°
60°
USA
34%
Latin America
45%
Europe
9-54%
Russia
40-90%
China
34-38%
Taiwan
Philipines
Singapore
> 20%
Africa
> 20%
ESBL is world wide in distribution
Multiple sources & references
India
30-80%

5. Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate (s)

6. NDM 1

8. Consequences of antibiotic use
•Clinical cure
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects

9. Antimicrobial Stewardship
Prudent use of antibiotics +
Infection control
Clinical cureClinical cure
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects

10. Antibiotic Stewardship
• Effective antimicrobial stewardship
– Audit & feedback
– Guidelines & algorithms
– Antibiotic order form
– Combination
– De escalation
– Dose optimization
– Parentral  oral
– Cycling

11. Antibiotic Stewardship
• Comprehensive Infection control
– Managing data and information
– Policies & procedures
– Regulatory requirements
– Employee health
– Prevent transmission, investigate
outbreaks
– Education & training
– Mobilize resources: human & financial

12. Antibiotic Guidelines

14. Linear Causation Process
Single intervention is effective
e.g. vaccination

15. Non linear web of causation
Multiple intervention required

16. Four processes working at 88% can summate to as little as
50% likelihood that each patient will experience
100% correct process

18. What Is a Bundle?
• A grouping of best practices that individually
improve care, but when applied together result in
substantially greater improvement.
• Science behind the bundle elements is well
established – the standard of care.
• Bundle element compliance can be measured as
“ yes/no.”
• “All or none” approach.

19. What is a bundle ?
• Structured way of improving process of care
& patient outcomes
• Small, straight forward set of practices (3 to
5) which when performed collectively, reliably
& continuously have been proven to improve
patient outcomes
• Data from these frequent measures is fed
back to those involved in the procedures
• Reduction in negative actions

20. • The premise of a bundle:
– Reduce variation in practice
– Build a collaborative environment
– Bring about change
– Promote problem solving ability of the staff

21. Antimicrobial Use Bundle
Initiation bundle:
1. 1. Clinical rationale for antibiotic initiation documented
2. 2. Appropriate samples for smear & culture collected &
submitted to the laboratory
3. 3. Antibiotic selected according to local policy & risk group
4. 4. Antibiotic ordered as per plan
1. (name, dose, route, frequency & tentative duration)
5. 5. Removal of foreign body or ID, as appropriate,
considered

22. Antimicrobial Use Bundle
Day 3 bundle:
1. 1. Was an antibiotic plan documented
1. (name, dose, route, frequency & planned duration ?)
2. 2. Review of diagnosis after lab reports ?
3. 3. If positive microbiology results, was there any
adaptation : streamlining or discontinuation
4. 4. Was IV -> oral switch considered & implemented
5. 5. Were all four above mentioned steps followed ?

23. Antimicrobial Use Bundle
For Surgical Prophylaxis:
1. 1. Agent selected matches local guidelines for
that operation and for that patient
2. 2. Timing of first dose in 30 min to 1 hour before
incision
3. 3. Antibiotic stopped by 24 hours after the pre
operative dose

24. Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form (Summary)Antimicrobial Use Bundle Data Collection Form (Summary)

25. Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form: InitiationAntimicrobial Use Bundle Data Collection Form: Initiation

26. Fortis HospitalFortis Hospital
Antimicrobial Use PlanAntimicrobial Use Plan

27. Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form: Day 3Antimicrobial Use Bundle Data Collection Form: Day 3

28. Fortis HospitalFortis Hospital
Antimicrobial Use Bundle Data Collection Form (Prophylaxis)Antimicrobial Use Bundle Data Collection Form (Prophylaxis)

29. Implementation of a care bundle for
antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• 903 bed tertiary care hospital in Michigen
• Decided to:
– Employ a trained pharmacist to perform antibiotic audit
– Daily monitoring of culture & susceptibility results
– Suggest changes to empirical & definitive antimicrobial
– Provide educational in service program focused on
hospitals own antibiogram
• Study:
– Retrospective control: Sept – Nov 2007
– Bundle intervention : Feb – Apr 2008
• Inclusion:
– Pts receiving antibiotics admitted into Medical & Surgical wards, 85
antibiotic orders to detect a 20% difference in compliance with
beta 0.2 and alpha of 0.05

30. Implementation of a care bundle for
antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• Compliance with Quality Indicators of Antibiotic Use
Indicator Control Intervention p .
1. Document indication 76 80 0.12
2. Appropriate cultures 70 76 0.09
3. Appropriate empirical 55 65 0.06
4. Appropriate deescalation 41/57 52/58 0.01
5. All indicators concurrently 13 43 <0.001

31. Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G:
Journal of Hospital Infection 2010: 74; 326- 331
• Intervention : 196 patients 204 courses
• Control : 226 208
• Modification proposed: 93 (46%) of 204 courses
– IV -> Oral switch : 48 (23%)
– Discontinuation : 16 (8)
– Change antibiotic : 32 (16)
– Dose modification : 4 (2)
• Compliance with suggestion: 70 / 93 (75%)
• Mean duration : 3.9 + 5.2 days 5 + 6 days
• Consumption :
• Cost :
• Mortality : 11.4 (%) 17.4
• Length of stay : 19 + 25 17 + 22

32. Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G:
Journal of Hospital Infection 2010: 74; 326- 331

33. Impact of standardised review of intravenous antibiotic therapy
72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G:
Journal of Hospital Infection 2010: 74; 326- 331

34. Other indicators forOther indicators for
Antimicrobial StewardshipAntimicrobial Stewardship
• Antimicrobial costsAntimicrobial costs
• Resistant trendsResistant trends
• Days on therapyDays on therapy
• Defined daily DoseDefined daily Dose

35. Attributable costs of HAI
Stone et al AJIC 2005; 33(9): 501-509
Infection Mean Cost
($ US)
SD Minimum Maximum
Surgical Site
Infection
25546 39875 1783 134602
BI 36441 37078 1822 107156
VAP 9969 2920 7904 12034
UTI 1006 503 650 1361

36. Socio-economic burden of hospital-
acquired infections (HAIs)
Incidence Duration of
Stay
Overall costs Specific costs %
7.8% 11 days GBP 2915 Hospital overheads /
capital charges /
management
33
Acquired
one or
more HAIs
whilst
in hospital
2.5 times
more than
uninfected
2.8 times
longer than
uninfected
Nursing care
Operations/
Consumables
Paramedics/ nurses
Antimicrobials
Others
42
7
6
4
2

38. “Whether ‘tis nobler in the mind to suffer
the slings and arrows
of outrageous… [prescribing]..
or take to arms against a sea of..
[resistance and diarrhoea]..
and by opposing [irrational antibiotics prescribing]
help end it..”
With apologies to William Shakespeare