The document discusses antimicrobial stewardship (AMS), which aims to optimize antibiotic use and limit antibiotic resistance. It defines AMS and notes its importance as a component of health systems. An antimicrobial stewardship program (AMSP) establishes strategies to rationalize antibiotic use. Key elements of establishing an AMSP include assembling a multidisciplinary team, developing treatment guidelines, conducting education and audits, and monitoring compliance and outcomes. The goals are to improve patient outcomes, reduce costs and resistance, and sustain antibiotic effectiveness.

1. ANTIMICROBIAL STEWARDSHIP
DR. SOHINI BANERJEE
FINAL YEAR PGT

2. AMS (Antimicrobial Stewardship)
 Antibiotic stewardship is the effort to measure and
improve how antibiotics are prescribed by clinicians and
used by patients. Improving antibiotic prescribing and
use is critical to effectively treat infections, protect
patients from harms caused by unnecessary antibiotic
use, and combat antibiotic resistance.
(CDC)

3. Antimicrobial stewardship – an integral
component of health system.
 Stewardship is defined as “the careful and responsible management of
something entrusted to one’s care”.
 AMS is one of three “pillars” of an integrated approach to health systems
strengthening. The other two are infection prevention and control (IPC) and
patient safety.
 private, not for profit, or public health-care facilities; district, regional,
tertiary or quaternary/central healthcare facilities (size, patient mix and
available resources); health-care facilities with or without a fixed financial
budget; health-care facilities with or without their own pharmacy; and
health-care facilities with or without an on-site microbiology laboratory

4. AMSP (Antimicrobial Stewardship Program)
 Strategies taken to rationalize and optimize the use of
antimicrobials to improve patient outcomes, reduce
AMR and health-care-associated infections, and save
health-care costs amongst patients.
 Right Antimicrobials.
 Right Patient.
 Right Time.
 Right Dose, Frequency, ROA.

5. WHY!
 Antimicrobial Resistance
 Misuse and over-use of antimicrobials.
 Extensive use of antimicrobials in other sectors.
 Poor Research.

6.  Governance and structure.
 Objectives.
 Data collection and validation.
 Data analysis.
 Follow up.

7. The aim of an AMS programme is:
 to optimize the use of antibiotics.
 to promote behaviour change in antibiotic prescribing and
dispensing practices.
 to improve quality of care and patient outcomes.
 to save on unnecessary health-care costs.
 to reduce further emergence, selection and spread of AMR.
 to prolong the lifespan of existing antibiotics.
 to limit the adverse economic impact of AMR.
 to build the best-practices capacity of health-care professionals
regarding the rational use of antibiotics.
(WHO)

8. Planning
 Leadership-
1. Strong administration.
2. Commitment.
3. Necessary Funding.
4. Infrastructure.

9. Cont..
 Multidisciplinary AMS Team-
a)Ideally, a Clinician, a Clinical Microbiologist, a Nurse, a
Pharmacist, A lab technician. If available, infectious
disease specialist and a clinical pharmacologist.
b)Set of skills-
1. Expertise in Infection management.
2. Expertise in antimicrobials.
3. Expertise in patient care.

10. Cont..
 Infrastructure-
1. Automations- automated culture and sensitivity.
2. Facilities to test Biomarkers- CRP and procalcitonin.
3. Molecular tests- PCR.
4. Emergency laboratory.
5. Hospital Information System.

11. Cont..
 Framing of antimicrobial policy-
1. Hand book of system/ syndrome wise indications of
antimicrobials.
2. Adhere to the national and international guidelines.

12. Implementation
 Front end strategy (Formulatory Restriction)-
1. Classifying antimicrobial agents in restricted, semi-
restricted, unrestricted group.
2. Most ideal.
3. Restricts clinician’s freedom of choosing antimicrobials.
4. Not apt for emergency situation.

13. Cont..
 Back end strategy (Prospective audit and feedback)-
1. Most effective.
2. Constructive discussion about antimicrobial policy.
3. Daily follow-up.
4. Labor intensive.
5. Widely practiced, more easily acceptable by clinicians.
6. Opportunity to educate and train health care professionals.
7. Sustained improvement over quality of antimicrobial prescribing
practice.

14. Education and training
 Adequate motivation.
 Continuous education, training.
 Assessment.
 Behavior change.
 Face to face workshops.

16. List of AMS intervention improving Antibiotic prescribing
practices.
 Education.
 Treatment guidelines.
 Surgical prophylaxis guideline.
 Ward rounds.
 Audit and feedback.
 Dose optimization.
 Review of antibiotic treatment.
 Review of prescribed antibiotics-
a) De-escalation by prescriber.
b) De-escalation according to guideline.
c) De-escalation according to microbiology test report.

17. Cont..
 Prescribe when indicated.
 Site specific culture.
 Empirical & targeted therapy-
a) Infective syndrome caused by common etiological bacterial agent.
b) Should be modified to target approach based on APST report.
 Escalation and De-escalation approach based on patients clinical
condition and local antimicrobial resistance pattern.
 Site specific antimicrobials.
 Correct dose, frequency.

18. Cont..
 MIC guided therapy is most accurate.
 Therapeutic drug monitoring.
 Timely stoppage of antibiotics.
 Biomarkers guided therapy.

19. Monitoring the compliance to AMSP
 Policy adherence indicator.
1. Prescription compliance- percentage of time empirical Abx given,
modified, culture taken before Abx, Sx prophylaxis according to
policy.
2. Administrative indicator- percentage of time correct dose, route Abx
given.
 Antimicrobial usage outcome indicator-
a) DDD (Defined Daily Dosage) – average maintenance dose per day for
a drug.
b) DOT (Days of Therapy)- number of days patient receives at least one
dose of antibiotic.
 Clinical outcome- morbidity and mortality. (infection related death.)
 Microbiology outcome- MDR organisms.
 Financial outcome indicator- antimicrobial cost per patient, per day,
per admission.

20. Example#
 The AMS team pharmacist notes that during the past week, three patients admitted
to the internal medicine unit with non-severe CAP received a combination of
ceftriaxone and clarithromycin. Clinical guidelines at your hospital recommend
ampicillin alone for most non-severe CAPs.
 What can be done?
1. List all patients admitted with non-severe CAP to the internal medicine unit during
the last 2–3 months.
2. If samples (i.e. sputum, blood cultures) have been submitted, review medical
records for severity as well as microbiology test results. Also note down recorded
reasons for prescribing ceftriaxone/clarithromycin and whether a review (de-
escalation) of treatment has been carried out.
3. Hold a meeting with a smaller group of prescribers on the ward to discuss your initial
findings. Discuss further steps and possible actions (training of health personnel, ward
rounds, audit, etc.).
4. Hold a further meeting with the heads of the unit and all the medical staff (including
residents and fellows) to discuss why broad-spectrum antibiotics and frequent
combinations should be avoided for CAP. Agree on further action, such as targets for
changes to prescribing, training and other AMS interventions.
5. Continue active surveillance through audit for a specified time period and meet
again with the unit to discuss progress.

21. REFERENCES
 ANTIMICROBIAL STEWARDSHIP PROGRAMMES IN HEALTH - CARE FACILITIES IN
LOW -AND MIDDLE-INCOME COUNTRIES A WHO PRACTICAL TOOLKIT.
 The Core Elements of Hospital Antibiotic Stewardship Programs: 2019- CDC.
 Essentials of Medical Microbiology- Apurba S Sastry.

22. THANK YOU.