Experience sharing of Quality improvement project in the Department of Obstetrics & Gynaecology of a heavy load tertiary level public facility

1. Antimicrobial
Resistance :
Hype or Fact?
Manju Puri
Director Professor & Former HOD
Department of Obstetrics & Gynecology
Lady Hardinge Medical College
New Delhi

2. AMR : Is it a
hype or fact?
For those who have experienced
the anxiety of an infection that
is drug-resistant, first-hand,
there is little that is needed to
prove the existence and the
importance of tackling AMR.

3. For majority of the people around the globe the threat of
drug resistance is either not known or seem a distant and
abstract risk

4. Obstetricians’ and AMR
• Rising antibiotic resistance will have
alarming secondary effects on safety
of child-birth including CS
• If AMR continues, much of the
progress, we have made in reducing
maternal and infant mortality in the
last century will be at a risk of being
undermined
We need to wake up before it is too late

5. Penicillin: An accidental discovery changed the course of medicine
1928

6. Antimicrobial Resistance is resistance of a microorganism to an antimicrobial agent
that was originally effective for treatment of infections caused by this microorganism
Antimicrobial resistance
2022
National Health Policy 2017
flagged AMR as a Key issue
WHO in 2001 declares AMR a
global public health problem

7. Magnitude of problem
• Deaths attributable to AMR every year as compared to other major causes of
deaths
300,000 Maternal
deaths per year

8. The Global Picture
Majority of deaths
will occur in Africa
and Asia – over 4
million in each
region.
10 million people a year

9. It is important to bridge the gap between global perceptions of AMR today
and how bad it is likely to become if the current trend is not altered

11. Rational Antimicrobial Therapy
Prevents
• Selection of pathogenic organisms like
Clostridium difficle
• Collateral damage and alteration of
patient’s microbiome especially GIT
• Toxicity or adverse effects of antibiotics
• Rising costs of treatment
• Discovery void of antibiotics
√
√
√
√
√

12. FACTS
Antibiotic Stewardship Programme Guidelines ( ICMR 2018)

13. Antibiotic void
> 35 years

14. Current
scenario…..

15. Smart of use of antimicrobials
• Intend to prevent infection
• Reduce colonization of
microorganisms at the time of
operation
• Needed for short duration (as
single preoperative shot)
Prophylactic
• Resolve an established infection
• Needed for longer duration
Therapeutic

16. Principles of
Optimal use of
Antibiotics:
For suspected
or proven
bacterial
infection
Initiating Empirical therapy*
• Choosing the right antibiotic
• Determine the optimum dose and route
• Initiate promptly
Tailoring therapy or Antibiotic time out
• Re-evaluation continuously; usually after 48-72 hrs
• Change to specific A/B; stop; adjust dose; add or subtract
Convert from intravenous to oral administration
Use for shortest effective dose
* Remember :
To take relevant cultures before starting A/B

17. 5 D’s of
Appropriate
or Smart
Antibiotic
therapy
Right Diagnosis/ Indication
Right Drug
Right Dose
Right Duration
De-escalation to pathogen-targeted
therapy

18. Principles of Optimal
use of Antibiotics:
For Surgical prophylaxis

19. Antimicrobial prophylaxis is justified for most clean-contaminated procedures
Ann Surg. 2009 Apr;249(4):551-6. Surg Infect (Larchmt). 2013 Feb;14(1):73-156

20. Guidelines for prevention of Infection after Gynaecologic
procedures
• Laparoscopy (diagnostic, tubal sterilization, operative except for
hysterectomy)
• Other transcervical procedures:
• Hysteroscopy (diagnostic or operative)
• Intrauterine device insertion
• Endometrial biopsy
• HSG/SSG*(H/o of PID or damaged tubes on HSG or laparoscopy)
• Oocyte retrieval
• D&C for non-pregnancy indication
• Cervical tissue biopsy, including LEEP or endocervical curettage
• Cystoscopy
ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172
NO ANTIBIOTIC REQUIRED
ACOG 2018

21. Guidelines for prevention of Infection after
Gynaecologic procedures
Uterine evacuation (including surgical
abortion, suction D&C, and D&E)
• Oral Doxycycline 200 mg
Metronidazole 1gm or Azithromycin
500mg single dose
Caesarean section
Hysterectomy
3rd and 4th degree perineal tears
Pelvic reconstructive surgery
colporrhaphy or vaginal sling or
mesh placement
• Cefazolin 2g I/V stat with in 60
min
• Metronidazole 500mg +
gentamicin 5mg/kg I/V
• Clindamycin 900 mg +gentamycin
5mg/Kg I/V
ACOG practice bulletin No. 195: Prevention of infection after gynecologic procedures. Obstet Gynecol 2018; 131:e172
ACOG 2018
ANTIBIOTIC PROPHYLAXIS
INDICATED

22. Antibiotic
Stewardship
It is a systematic measurement
and coordinated interventions
to promote optimal use of
antimicrobial agents

23. Antibiotic stewardship in Public Sector

24. Case study
25 yrs. Primigravida at term with preeclampsia underwent CS for Foetal distress
15/8/16
• Inj Ampicillin + Metronidazole
Day 2
Developed fever, tachycardia, tachypnoea, loose motions, discharge from wound;
blood and wound swab sent for C/S
• A/B stepped up: Meropenum and Ciprofloxacin
Day 6
BDCS coagulase negative staphylococcus (CoNS) sensitive to Vancomycin /Clindamycin ;
Pus C/S Methicillin sensitive (CoNS) sensitive to Linazolid/ Vancomycin/ Gentamycin;
• A/B changed : Vancomycin + Clindamycin added

25. Day 10
Pus C/S Acinobacter sensitive to Piptaz, Colistin,
• A/B changed: Piptaz added
Fever continued
Day 21
Exploratory laparotomy with peritoneal lavage
Day 26 (D6) breathlessness shifted to ICU intubated for assisted ventilation
Culture ET, central line Pseudomonas and Klebsiella Sensitive to Colistin.
• A/B stepped up to Colistin
Day 32 (D12) Extubated
Day 40 (D20) Discharged
Hospital acquired infection and Antimicrobial resistance

27. Key Messages
Prevention of infection is not about administering
antibiotics, antibiotics and antibiotics
AMR is a serious problem
It needs to be combated by Prudent or Smart use of antibiotics
Otherwise antibiotics will lose their efficacy
Return to the dark age of medicine……
It is more about use of aseptic precautions and rational use of antibiotics

28. Journey of Antibiotic
stewardship in the
Department of
Obstetrics &
Gynecology
LHMC

29. Point of Care Quality
Improvement Project on
Rational use of antibiotics
4 step approach

30. Steps in QI
Step IV Sustaining improvement
Step III
Developing and testing changes
PDSA cycle
Step II
Analyzing the problem and measuring
quality of care by identifying outcome
measure/s
Step I
Identifying a problem, writing an aim
statement, forming a team
Steps in QI

31. Step 1: Problem identification, forming a
team, and writing the aim statement
• AIM STATEMENT
We aim to increase the antibiotic prophylaxis (SSAB) in low-risk
patients undergoing elective major surgery from 0% to 60% by 8 weeks
QI TEAM MEMBERS
All consultants of Department of Obstetrics & Gynecology
Team leader
Communicator
Recorder

32. Step 2a: Analyzing and measuring quality of care
People
Place
Policy
Procedure
Major influence
Major influence
Minor influence
Minor influence
Problem
No dept antibiotic
policy in place
- No sensitization
- No awareness
- Reluctance to give SSAB
- Worried about asepsis
When to administer
Who will administer
Where to document
Non availability of
antibiotic in OT

33. Step 2b: Measuring quality of care:
Quality Indicators
Indicator Process indicator
Numerator No. of patients who received
SSAB
Denominator No of eligible patients who
underwent elective surgery
Frequency of
data analysis
Monthly
Data source (s) Case records
Indicator Outcome indicator
Numerator No. of patients who received
SSAB developing SSI
Denominator No of patients who received
SSAB
Frequency of
data analysis
Monthly
Data source (s) Case records

34. Act Plan
Study Do
Step 3 of Quality Improvement
Develop and test changes
Adopt
Adapt
Abandon
What are the results?
What did we learn?
What are we
going to do?
When and how
did we do it?

35. Step 3: Developing and testing changes
Change idea tested When was it done What was the result? What did we
learn?
1. • Formulation of AB policy,
detailed discussion,
finalization after agreement
• Sensitization Workshop for
residents on asepsis
• Roll it out in the department
July 1st, 2017 to Aug
30th , 2017
Build consensus of all involved
Not everyone was convinced due to fear of
sepsis
Adapt
Start small
2. • Implementation in one unit
• Sensitization workshop
conducted for residents and
NOs on AMR & asepsis
• Collected base line data on
outcome measure SSI
July 1st, 2017 to July
31st , 2017
35.6 % use
No ↑ SSI
Adapt
Sharing experience with other builds
confidence
3. Implementation in all units August 1st , 2017 Approx. 50% use Adopt
No ↑ SSI

36. Step 3: Developing and testing changes
Change idea tested When did you
try this? Date.
What was the result? What
did we learn?
4. Identified a coordinator
and nodal officers in each
unit with monthly
meeting in person with
presentation of data and
discussion of cases with
continuation of A/B
September 2017 SSAB use increased >60 %
Adopt
Increase in accountability and
ownership pays
SSAB remained above 60% Oct and Nov 17
↓ 59% in Dec 17 Need for Hardwiring

37. Change idea tested When did you
try this? Date.
What was the result? What
did we learn?
5.
6.
Addition of induction
training of residents and
regular sharing of data
by nodal officers with
coordinator
Hold meeting on fixed
day of the month with
nodal officers to review
data and have a WA
group with nodal officers
and unit heads as
members
March ’18
Sept ‘19
SSAB use increased 75% ADOPT
Lesson learnt
Wide dissemination and need for
continuous follow up is important
or sustenance
For a change to sustain it should
not be person centric but self
sustaining
Nov ‘18 to August ‘19 80 % - 90%
A meeting was missed in Aug and Sep ‘19 as the Coordinator
was on leave SSAB rate came down to 70-75%

38. Change idea tested When did you
try this? Date.
What was the result? What
did we learn?
7. Started sharing monthly
data during the monthly
statistics meeting
To show a ppt slide with
the SSAB usage and SSI
rate
Oct’19 Lesson learnt
Need for continuous follow up
for sustenance and sharing of
data keeps the momentum of
the change and everyone
interested
SSAB remained above 80% since Oct ’19 most of the months it is above 90%

39. Step 4: Sustaining
Improvement
• Continuous monitoring of process and outcome
indicator monthly
• Sharing of data
• Generate competition among units
• Appreciate those doing well

40. 0 0
2 1 0 0 1 0 0 1 1 0
1.5
0 0 1 0 1 0 0.9 0 0 0 0 1 0 0 0 0 0 1 1.1
4.2
0 0 0 0 0 0 0 0 0 0 0
1.3
2.1
35.2
49.3
52.2
62.5
59.2
67.7
75
71
80
74
71
78
75
72
80 81 81
75
86
81
89
84
88
90
73
76
88
96
94 93 94
90 90
81
97.597.7
91.8
100
78.5
96.2 96 96.1
90.7
96
0
10
20
30
40
50
60
70
80
90
100
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Apr-18
May-18
Jun-18
Jul-18
Aug-18
Sep-18
Oct-18
Nov-18
Dec-18
Jan-19
Feb-19
Mar-19
Apr-19
May-19
Jun-19
Jul-19
Aug-19
Sep-19
Oct-19
Nov-19
Dec-19
Jan-20
Feb-20
Mar-20
Apr-20
May-20
Jun-20
Jul-20
Aug-20
Sep-20
Oct-20
Nov-20
Dec-20
Jan-21
Feb-21
Mar-21
Apr-21
May-21
Jun-21
Jul-21
Aug-21
Sep-21
Oct-21
ANTIMICROBIAL STEWARDSHIP
SEPSIS-SAP % SAP % of all low risk (SAP/LOW RISK)
Implementation in one unit as pilot
Sensitizing workshop, Roll out to all units
Sharing of monthly data
Identification of unit nodals, Induction training of residents
Fixed day meeting , WA gp
Display of performance unitwise as bar charts

41. 0
5
10
15
20
25
30
35
40
45
50
Jul-17
Aug-17
Sep-17
Oct-17
Nov-17
Dec-17
Jan-18
Feb-18
Mar-18
Apr-18
May-18
Jun-18
Jul-18
Aug-18
Sep-18
Oct-18
Nov-18
Dec-18
Jan-19
Feb-19
Mar-19
Apr-19
May-19
Jun-19
Jul-19
Aug-19
Sep-19
Oct-19
Nov-19
Dec-19
Jan-20
Feb-20
Mar-20
Apr-20
May-20
Jun-20
Jul-20
Aug-20
Sep-20
Oct-20
Nov-20
TOTAL SEPSIS % AND SEPSIS % IN SAP
Total Sepsis % SEPSIS-SSAP %

42. To conclude
If we do not act now AMR will take us back to
the dark age of Medicine
We should use antibiotics responsibly to
prevent AMR by observing 5Rs
Antibiotics are essential for prevention and
treatment of maternal infections for
reducing maternal and perinatal mortality
and morbidity.
Antimicrobial resistance is not a hype it is a
fact

43. Acknowledgements
• Prof. Sushila Rathee Mentor
• Prof. SS Trivedi Advisor
• Dr Jagdish Chandra Visionary
• Dr Aparna Sharma QI Buddy
• Dr Shilpi Nain Partner
• Dr Sonal Saxena 24x 7 AMR
Consultation line
• All consultants and residents
Department of Obs & Gynae LHMC