Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Antibiotics are most common therapeutic agents used in hospitals across world, however, microbial world is becoming resistant day by day, posing special challenges to clinicians specially working in ICU set ups. There are multiple ways to curb this menace, if approached together in antibiotic stewardship way, can bring about wonders and retain therapeutic potentials of these drugs.
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
Description of the major classes of antimicrobial drug, resistant mechanisms developed by bacteria to combat the action of antimicrobials, and the control measures needed to limit this horizontal gene transfer.
Antibiotic stewardship explained in one presentation, which can be helpful to the medical field beginners and students as well as thorough information can be obtained regarding the subject matter.
Objectives:
1. To understand the purpose of implementing an antimicrobial stewardship program (ASP)
2.To recall the core elements of hospital and outpatient antibiotic stewardship programs as defined by the CDC
3. To recognize key interventions that an antimicrobial stewardship program can implement in both the hospital and community settings
Antibiotic policy and trends in antibiotic policy,
References
Infection control: Basic concepts and practices, 2nd edn.
www.cdc.org
Antibiotics guide: choices for common infections
Chennai Declaration
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Dr.sherin elsherbiny
Senior registrar clinical microbiology
AMR coordinator
Infection control auditor
Riyadh region
Meeqat General Hospital ,Madina,KSA
Description of the major classes of antimicrobial drug, resistant mechanisms developed by bacteria to combat the action of antimicrobials, and the control measures needed to limit this horizontal gene transfer.
Antibiotic stewardship explained in one presentation, which can be helpful to the medical field beginners and students as well as thorough information can be obtained regarding the subject matter.
Objectives:
1. To understand the purpose of implementing an antimicrobial stewardship program (ASP)
2.To recall the core elements of hospital and outpatient antibiotic stewardship programs as defined by the CDC
3. To recognize key interventions that an antimicrobial stewardship program can implement in both the hospital and community settings
Antibiotic policy and trends in antibiotic policy,
References
Infection control: Basic concepts and practices, 2nd edn.
www.cdc.org
Antibiotics guide: choices for common infections
Chennai Declaration
Infection Control and Antibiotic Stewardship Symposia presented in Milot, Haiti at Hôpital Sacré Coeur.
CRUDEM’s Education Committee (a subcommittee of the Board of Directors) sponsors one-week medical symposia on specific medical topics, i.e. diabetes, infectious disease. The classes are held at Hôpital Sacré Coeur and doctors and nurses come from all over Haiti to attend.
Advisor Live: Antimicrobial Stewardship - Why Now and How?Premier Inc.
This 90-minute webinar discusses strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
Join Premier’s free Advisor Live® webinar series for a special Get Smart About Antibiotics Week presentation on Thursday, November 19 from 12-1:30 p.m. EST. The panel for this 90-minute webinar will discuss strategies and tools for implementing antimicrobial stewardship programs, including methods for measuring antimicrobial use and resistance.
EXPERT PRESENTERS:
- Gina Pugliese, RN, MS, vice president, Premier Safety Institute®, moderator
- Arjun Srinivasan, MD, (CAPT, USPHS) medical director of the CDC’s Get Smart for Healthcare program, will highlight the national focus on antibiotic stewardship and reasons for the current urgency
- Michael Postelnick, RPh, BCPS AQ- Infectious Diseases, clinical manager and senior infectious diseases pharmacist for Northwestern Memorial Hospital, will share lessons learned from implementing their antibiotic stewardship program
- Craig Barrett, Pharm.D., BCPS, director safety solutions for Premier, Inc. will share strategies from Premier member hospitals striving for antimicrobial stewardship
This Manual of Procedures (MOP) was developed to assist and align the efforts in implementing AMS programs in all (Level I, II, and III) hospitals across the country. It seeks to serve as a guide to individual hospitals in the design and establishment of local AMS programs while providing a framework for national-level action and commitment.
Recommendations within this document are, as far as possible, based on review of published literature on strategies that have shown to be effective. Consultation with key members (Infectious Diseases physicians, clinical pharmacists, and Infection Control nurses) from eight (8) pilot hospitals as well as the National Antibiotic Guidelines Committee (NAGCom), other national Infectious Diseases societies and relevant DOH offices were undertaken to obtain a consensus opinion and ensure that this MOP is practical and feasible.
All attempts to consider the context of local culture and practices have been taken in the creation of this MOP. Nonetheless, we have chosen to only define core aspects of the national AMS program without being overly prescriptive. Hospitals are strongly encouraged to adapt this MOP to their individual setting in order to maximize its effectiveness, including reduce barriers to implementation and encourage shared ownership towards the goal of AMS.
Combating Drug Resistance in The Intensive Care Unit (ICU)Apollo Hospitals
Drug resistance of microbes has become a major stumbling block to treating patients successfully in the ICU. There is no doubt that microbes have the capacity to mutate or acquire drug destroying enzymes, but a multitude of errors by health care providers plays a major role in facilitating the development of resistance. The maintenance of drug use discipline in closed ICUs and having a responsive microbiology department are the first steps towards prevention of microbe resistance. Having an infection control committee that is able to collect and disseminate data is the next essential step. Education of health care providers to provide uniformity of health care according to set guidelines is the culmination of this towards the goal of minimizing the development of anti microbial resistance.
World Veterinary Day 2017 Presentation made at the College of Veterinary and Animal Science, Navania, Vallabhnagar, Udaipur by DR. BALWANT MESHRAM on the topic 'WVD: Past and the Present'
In India, bacteria that cause common infections, such as urinary tract and bloodstream infections, are becoming resistant to nearly all antibiotics. This resistance is due to a combination of factors: uncontrolled access to antibiotics, gaps in infection prevention and control (IPC) practices, and high rates of communicable diseases. Antibiotic resistance, or AR, is a serious problem throughout the country, and threatens to reduce the usefulness of antibiotics both in India and around the world.
Because of this emerging threat, India is committed to slowing the spread of AR. Two institutions within India’s Ministry of Health – the Indian Council of Medical Research and National Centre for Disease Control – each developed national networks of public and private hospitals to measure AR trends, prevent healthcare-associated infections (HAIs), and enhance appropriate use of antibiotics. The All India Institute of Medical Sciences is coordinating HAI measurement and prevention efforts in both networks. In addition, efforts in the state of Tamil Nadu focus on building district-level IPC capacity to prevent HAIs, focusing on maternal and neonatal patients.
The Indian Governamnet is is working closely with partners at the national and state level to:
Detect AR pathogens, including novel strains, by developing lab networks and lab expertise.
Use standardized surveillance to monitor and track AR infections in healthcare to learn how often these infections occur and to help develop strategies to prevent them.
Implement focused IPC activities and training.
Optimize use and reduce misuse of critical antibiotics through antibiotic stewardship programs.
Antibiotic Stewardship by Anushri Srivastava.pptxAnushriSrivastav
Stewardship is the act of taking good care of something.
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
WHO launched the Global Antimicrobial Resistance and Use Surveillance System (GLASS) in 2015 to fill knowledge gaps and inform strategies at all levels.
ACCORDING TO apic.org,
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials (including antibiotics), improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
ACCORDING TO pewtrusts.org,
Antibiotic stewardship refers to efforts in doctors’ offices, hospitals, long term care facilities, and other health care settings to ensure that antibiotics are used only when necessary and appropriate
According to WHO,
Antimicrobial stewardship is a systematic approach to educate and support health care professionals to follow evidence-based guidelines for prescribing and administering antimicrobials
In 1996, John McGowan and Dale Gerding first applied the term antimicrobial stewardship, where they suggested a causal association between antimicrobial agent use and resistance. They also focused on the urgency of large-scale controlled trials of antimicrobial-use regulation employing sophisticated epidemiologic methods, molecular typing, and precise resistance mechanism analysis.
Antimicrobial Stewardship(AMS) refers to the optimal selection, dosing, and duration of antimicrobial treatment resulting in the best clinical outcome with minimal side effects to the patients and minimal impact on subsequent resistance.
According to the 2019 report, in the US, more than 2.8 million antibiotic-resistant infections occur each year, and more than 35000 people die. In addition to this, it also mentioned that 223,900 cases of Clostridoides difficile occurred in 2017, of which 12800 people died. The report did not include viruses or parasites
VISION
Being proactive
Supporting optimal animal and human health
Exploring ways to reduce overall use of antimicrobials
Using the drugs that prevent and treat disease by killing microscopic organisms in a responsible way
GOAL
to prevent the generation and spread of antimicrobial resistance (AMR). Doing so will preserve the effectiveness of these drugs in animals and humans for years to come.
being to preserve human and animal health and the effectiveness of antimicrobial medications.
to implement a multidisciplinary approach in assembling a stewardship team to include an infectious disease physician, a clinical pharmacist with infectious diseases training, infection preventionist, and a close collaboration with the staff in the clinical microbiology laboratory
to prevent antimicrobial overuse, misuse and abuse.
to minimize the developme
updated statistics about antimicrobial resistance,causes and mechanism of antimicrobial resistances, national antimicrobial policy, national antimicrobial surveillance, new delhi b metallo-lactamase-1 bacteria
For decades microbes, in particular bacteria, have become increasingly resistant to various antimicrobials.
The World Health Assembly’s endorsement of the Global Action Plan on Antimicrobial Resistance (AMR) in May 2015, and the Political Declaration of the High-Level Meeting of the General Assembly on AMR in September 2017, both recognize AMR as a global threat to public health.
These policy initiatives acknowledge overuse and misuse of antimicrobials as a main driver for development of resistance, as well as a need to optimize the use of antimicrobials.
The Global Action Plan on AMR sets out five strategic objectives as a blueprint for countries in developing national action plans (NAPs) on AMR:
Objective 1: Improve awareness and understanding of AMR through effective communication, education and training.
Objective 2: Strengthen the knowledge and evidence base through surveillance and research.
Objective 3: Reduce the incidence of infection through effective sanitation, hygiene and infection prevention measures.
Objective 4: Optimize the use of antimicrobial medicines in human and animal health.
Objective 5: Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions.
Antimicrobial stewardship programmes optimize the use of antimicrobials, improve patient outcomes, reduce AMR and health-care-associated infections, and save health-care costs amongst others.
Today, AMS is one of three “pillars” of an integrated approach to health systems strengthening. The other two are infection prevention and control (IPC) and medicine and patient safety.
Linking all three pillars to other key components of infection management and health systems strengthening, such as AMR surveillance and adequate supply of quality assured medicines, promotes equitable and quality health care towards the goal of achieving universal health coverage
CDC has defined “Antimicrobial stewardship” as-
The right antibiotic
for the right patient,
at the right time,
with the right dose, and
the right route, causing
the least harm to the patient and future patients
Why AMSP is needed?
Antimicrobial Resistance (AMR)
Misuse and Over-use of Antimicrobials
Widespread Use of Antimicrobials in Other Sectors
Poor Antimicrobial Research
IMPLEMENTATION OF ANTIMICROBIAL STEWARDSHIP PROGRAM
Administrative Support (Leadership)
Formulating AMS Team
Infrastructure Support
Framing Antimicrobial Policy
Implementing AMS strategies
Education and Training
Should be publicly committed to the program.
Provide necessary funding and infrastructure support.
Multidisciplinary committee - responsible for framing, implementing and monitoring the compliance to antimicrobial policy of the hospital.
Led by the antimicrobial steward - infectious disease physician or infection control officer or clinical microbiologist.
Other members of AMS team - stewardship nurses
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LA HUG - Video Testimonials with Chynna Morgan - June 2024Lital Barkan
Have you ever heard that user-generated content or video testimonials can take your brand to the next level? We will explore how you can effectively use video testimonials to leverage and boost your sales, content strategy, and increase your CRM data.🤯
We will dig deeper into:
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Enterprise Excellence is Inclusive Excellence.pdfKaiNexus
Enterprise excellence and inclusive excellence are closely linked, and real-world challenges have shown that both are essential to the success of any organization. To achieve enterprise excellence, organizations must focus on improving their operations and processes while creating an inclusive environment that engages everyone. In this interactive session, the facilitator will highlight commonly established business practices and how they limit our ability to engage everyone every day. More importantly, though, participants will likely gain increased awareness of what we can do differently to maximize enterprise excellence through deliberate inclusion.
What is Enterprise Excellence?
Enterprise Excellence is a holistic approach that's aimed at achieving world-class performance across all aspects of the organization.
What might I learn?
A way to engage all in creating Inclusive Excellence. Lessons from the US military and their parallels to the story of Harry Potter. How belt systems and CI teams can destroy inclusive practices. How leadership language invites people to the party. There are three things leaders can do to engage everyone every day: maximizing psychological safety to create environments where folks learn, contribute, and challenge the status quo.
Who might benefit? Anyone and everyone leading folks from the shop floor to top floor.
Dr. William Harvey is a seasoned Operations Leader with extensive experience in chemical processing, manufacturing, and operations management. At Michelman, he currently oversees multiple sites, leading teams in strategic planning and coaching/practicing continuous improvement. William is set to start his eighth year of teaching at the University of Cincinnati where he teaches marketing, finance, and management. William holds various certifications in change management, quality, leadership, operational excellence, team building, and DiSC, among others.
Discover the innovative and creative projects that highlight my journey throu...dylandmeas
Discover the innovative and creative projects that highlight my journey through Full Sail University. Below, you’ll find a collection of my work showcasing my skills and expertise in digital marketing, event planning, and media production.
Memorandum Of Association Constitution of Company.pptseri bangash
www.seribangash.com
A Memorandum of Association (MOA) is a legal document that outlines the fundamental principles and objectives upon which a company operates. It serves as the company's charter or constitution and defines the scope of its activities. Here's a detailed note on the MOA:
Contents of Memorandum of Association:
Name Clause: This clause states the name of the company, which should end with words like "Limited" or "Ltd." for a public limited company and "Private Limited" or "Pvt. Ltd." for a private limited company.
https://seribangash.com/article-of-association-is-legal-doc-of-company/
Registered Office Clause: It specifies the location where the company's registered office is situated. This office is where all official communications and notices are sent.
Objective Clause: This clause delineates the main objectives for which the company is formed. It's important to define these objectives clearly, as the company cannot undertake activities beyond those mentioned in this clause.
www.seribangash.com
Liability Clause: It outlines the extent of liability of the company's members. In the case of companies limited by shares, the liability of members is limited to the amount unpaid on their shares. For companies limited by guarantee, members' liability is limited to the amount they undertake to contribute if the company is wound up.
https://seribangash.com/promotors-is-person-conceived-formation-company/
Capital Clause: This clause specifies the authorized capital of the company, i.e., the maximum amount of share capital the company is authorized to issue. It also mentions the division of this capital into shares and their respective nominal value.
Association Clause: It simply states that the subscribers wish to form a company and agree to become members of it, in accordance with the terms of the MOA.
Importance of Memorandum of Association:
Legal Requirement: The MOA is a legal requirement for the formation of a company. It must be filed with the Registrar of Companies during the incorporation process.
Constitutional Document: It serves as the company's constitutional document, defining its scope, powers, and limitations.
Protection of Members: It protects the interests of the company's members by clearly defining the objectives and limiting their liability.
External Communication: It provides clarity to external parties, such as investors, creditors, and regulatory authorities, regarding the company's objectives and powers.
https://seribangash.com/difference-public-and-private-company-law/
Binding Authority: The company and its members are bound by the provisions of the MOA. Any action taken beyond its scope may be considered ultra vires (beyond the powers) of the company and therefore void.
Amendment of MOA:
While the MOA lays down the company's fundamental principles, it is not entirely immutable. It can be amended, but only under specific circumstances and in compliance with legal procedures. Amendments typically require shareholder
Putting the SPARK into Virtual Training.pptxCynthia Clay
This 60-minute webinar, sponsored by Adobe, was delivered for the Training Mag Network. It explored the five elements of SPARK: Storytelling, Purpose, Action, Relationships, and Kudos. Knowing how to tell a well-structured story is key to building long-term memory. Stating a clear purpose that doesn't take away from the discovery learning process is critical. Ensuring that people move from theory to practical application is imperative. Creating strong social learning is the key to commitment and engagement. Validating and affirming participants' comments is the way to create a positive learning environment.
[Note: This is a partial preview. To download this presentation, visit:
https://www.oeconsulting.com.sg/training-presentations]
Sustainability has become an increasingly critical topic as the world recognizes the need to protect our planet and its resources for future generations. Sustainability means meeting our current needs without compromising the ability of future generations to meet theirs. It involves long-term planning and consideration of the consequences of our actions. The goal is to create strategies that ensure the long-term viability of People, Planet, and Profit.
Leading companies such as Nike, Toyota, and Siemens are prioritizing sustainable innovation in their business models, setting an example for others to follow. In this Sustainability training presentation, you will learn key concepts, principles, and practices of sustainability applicable across industries. This training aims to create awareness and educate employees, senior executives, consultants, and other key stakeholders, including investors, policymakers, and supply chain partners, on the importance and implementation of sustainability.
LEARNING OBJECTIVES
1. Develop a comprehensive understanding of the fundamental principles and concepts that form the foundation of sustainability within corporate environments.
2. Explore the sustainability implementation model, focusing on effective measures and reporting strategies to track and communicate sustainability efforts.
3. Identify and define best practices and critical success factors essential for achieving sustainability goals within organizations.
CONTENTS
1. Introduction and Key Concepts of Sustainability
2. Principles and Practices of Sustainability
3. Measures and Reporting in Sustainability
4. Sustainability Implementation & Best Practices
To download the complete presentation, visit: https://www.oeconsulting.com.sg/training-presentations
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Unveiling the Secrets How Does Generative AI Work.pdfSam H
At its core, generative artificial intelligence relies on the concept of generative models, which serve as engines that churn out entirely new data resembling their training data. It is like a sculptor who has studied so many forms found in nature and then uses this knowledge to create sculptures from his imagination that have never been seen before anywhere else. If taken to cyberspace, gans work almost the same way.
RMD24 | Debunking the non-endemic revenue myth Marvin Vacquier Droop | First ...BBPMedia1
Marvin neemt je in deze presentatie mee in de voordelen van non-endemic advertising op retail media netwerken. Hij brengt ook de uitdagingen in beeld die de markt op dit moment heeft op het gebied van retail media voor niet-leveranciers.
Retail media wordt gezien als het nieuwe advertising-medium en ook mediabureaus richten massaal retail media-afdelingen op. Merken die niet in de betreffende winkel liggen staan ook nog niet in de rij om op de retail media netwerken te adverteren. Marvin belicht de uitdagingen die er zijn om echt aansluiting te vinden op die markt van non-endemic advertising.
What are the main advantages of using HR recruiter services.pdfHumanResourceDimensi1
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2. Introduction
The antimicrobials are not a human
invention.
They were present/produced by fungi,
soil actinomycetes, and other
microorganisms for the last few
thousand of years.
To counteract the effects of these,
genes encoding for resistance have also
been present in nature for similar time
period.
3. Introduction
Introduction of these genes in
human/animal commensal flora or
pathogenic organisms together with the
introduction of antimicrobials for human
use has led to the present day epidemic
of antimicrobial resistance.
5. Antimicrobial use and
Resistance
A few million years ago, one species of finch
migrated to the rocky Galapagos from the mainland
of Central or South America.
From this one migrant species would come many -at least 13 species of finch evolving from the single
ancestor.
This process in which one species gives rise to
multiple species that exploit different niches is called
adaptive radiation.
On various islands, finch species have become
adapted for different diets: seeds, insects, flowers,
the blood of seabirds, and leaves.
The ecological niches exert the selection pressures
that push the populations in various directions.
6. Antimicrobial use and
Resistance
Darwinian theories of evolution and
survival of the fittest suggest that the
selection and maintenance of MDR
bacteria would not happen without
antibiotic exposure and the heavier the
exposure, the greater the resistance
problem.
Emergence of VRE due to vancomycin
use (?); carbapenem resistance in
Acinetobacter and other GNB.
7. Antimicrobial use and
Resistance
Emergence of VRE due to usage of broad
spectrum cephalosporins and clindamycin.
Fluoroquinolone with MRSA (quinolones
are known to modulate phage induction
and and horizontal gene transfer)
High-level fluoroquinolone resistance
(mainly caused by gyrA mutations) has
also been shown to be associated with
CTX-M enzymes (co-carriage on
conjugative plasmids).
8. Antimicrobial use and
Resistance
As bacteria are thought to have evolved
3500 million years ago, 60-70 years is
but „a second in a day‟ in evolutionary
time.
Despite this, we have seen the
development, even since their early use,
of antibiotic resistance in many bacterial
species.
9. Antimicrobial use and
Resistance
Antibiotic resistance genes were
present at very low levels prior to the
introduction of antibiotics and it is largely
the selective pressure of antibiotic use
and the resulting exposure of bacteria,
not only in humans but also in animals
and the environment, which has caused
the rise.
10. Causal associations between antimicrobial use and
the emergence of antimicrobial resistance.
Changes in antimicrobial use are
paralleled by changes in the prevalence
of resistance.
Antimicrobial resistance is more
prevalent in health care–associated
bacterial infections, compared with
those from community-acquired
infections.
11. Causal associations between antimicrobial use and
the emergence of antimicrobial resistance
Patients with health care–associated
infections caused by resistant strains are
more likely than control patients to have
received prior antimicrobials.
Areas within hospitals that have the highest
rates of antimicrobial resistance also have
the highest rates of antimicrobial use.
Increasing duration of patient exposure to
antimicrobials increases the likelihood of
colonization with resistant organisms.
12. Antibiotic Use
Antibiotic Use
Causes Resistance
Maintains Resistance
Don’t forget antibiotic
use to modulate
resistance and control
outbreaks eg. patient
decontamination
regimens
By Patient-staff-patient
Spreads Resistance
Patient-patient
?Patient-environment / equipment – patient
Cross Infection
13. What is antimicrobial stewardship?
Stewardship – „careful and
responsible management
of something entrusted to
one‟s care‟.
Antimicrobial stewardship
refers to the „careful and
responsible management
of antimicrobials entrusted
to the care of ……
Usually medical
microbiologists, infectious
diseases physicians,
antimicrobial pharmacists,
infection control nurses
etc.
14. Antimicrobial Stewardship
An antimicrobial stewardship program is
an ongoing effort by a health care
institution to optimize antimicrobial use
among hospitalized patients in order to
improve patient outcomes, ensure costeffective therapy, and reduce adverse
sequelae of antimicrobial use (including
antimicrobial resistance).(MacDougall and Polk
2005, Clin Microbiol Rev,18).
15. Antimicrobial Stewardship
Antimicrobial stewardship entails diverse
interventions aimed at reducing
inappropriate antimicrobial use while
optimizing antimicrobial drug selection,
dosing, route and duration of therapy in
order to maximize clinical cure or
prevention of infection and to limit
unintended consequences, such as the
emergence of resistance, adverse drug
events and the selection of pathogenic
organisms. (Dellit TH et al 2007 Clin Infect Dis,44)
16. Antimicrobial Stewardship
The optimal selection, dosage, and
duration of antimicrobial treatment that
results in the best clinical outcome for the
treatment or prevention of infection, with
minimal toxicity to the patients and minimal
impact on subsequent resistance.
4 D‟s of optimal antimicrobial therapy are:
right Drug, right Dose, De-escalation to
pathogen directed therapy, and right
Duration of therapy.
17. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
Infectious Diseases Physicians:
Design, implementation, and function
of the program.
Supervision by an infectious diseases
physician is necessary to ensure that
therapeutic guidelines, antimicrobial
restriction policies, or other measures
are based on the best evidence and
practice and will not put patients at risk.
1.
18. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
2. Clinical and Hospital Pharmacists
Pharmacists often act as the effector
arms for antimicrobial stewardship
programs
They are well positioned for this effort
because of their role in processing
medication orders and their familiarity
with the hospital formulary.
19. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
However, the broad responsibilities of
these pharmacists generally do not
allow adequate time for a
comprehensive review of antimicrobial
therapy.
In addition, these pharmacists may not
have adequate training in infectious
diseases to feel comfortable providing
recommendations for complex cases.
20. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
3. Clinical Microbiologists
The clinical microbiology laboratory is a
key component in the function of
antimicrobial stewardship programs.
Summary data on antimicrobial resistance
rates allow the antimicrobial stewardship
team to determine the current burden of
antimicrobial resistance in the hospital,
facilitating decisions as to which
antimicrobials to target for restriction or
review.
21. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
Preparation of antibiograms specific to
certain patient care areas, especially
intensive care units, may allow
identification of local problems and
focussed antimicrobial stewardship and
infection control efforts
Dissemination of antibiograms to
clinicians may allow better selection of
empirical therapy based on local
susceptibility patterns.
22. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
The microbiology laboratory can also
encourage focused antimicrobial selection
by cascade reporting of susceptibility
results: depending on the organism‟s
susceptibility, only certain (usually
narrower-spectrum) antimicrobials are
reported.
Hidden susceptibility results should be
made available upon request in cases
where toxicity, allergy, co-infections, or
other considerations make first-line therapy
suboptimal.
23. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
4. Infection Control Staff and Hospital
Epidemiologists
Infection control staff gather highly detailed
data on nosocomial infections which may
assist in the antimicrobial stewardship
team‟s evaluation of the outcomes of their
strategies.
In turn, antimicrobial stewardship
programs may be able to assist in efforts to
control outbreaks by focused monitoring
and/or restriction of antimicrobials in the
targeted units
24. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
Any antimicrobial stewardship program
should either be fully integrated with or
work closely with a hospital‟s infection
control program; such collaboration has
the opportunity to synergistically reduce
antimicrobial resistance and improve
patient outcomes.
25. ROLES OF INDIVIDUALS IN ANTIMICROBIAL
STEWARDSHIP PROGRAMS
5. Hospital Administrators
No
antimicrobial stewardship program is
likely to be successful without at least
passive endorsement by hospital
leadership.
Program funding, institutional policy, and
physician autonomy are core issues in the
development of antimicrobial stewardship
programs that must be addressed by
hospital administration.
26. ROLES OF INDIVIDUALS IN
ANTIMICROBIAL
STEWARDSHIP PROGRAMS
Without adequate support from hospital
leadership, program funding will be
inadequate or inconsistent since the
programs do not generate revenue.
If hospital leadership is not publicly
committed to the program, recalcitrant
prescribers may thwart attempts to
improve antimicrobial use without fear of
sanction.
27. Methodological Issues
Outcome Measurements
The change in antimicrobial usage is the
most common outcome measured in
studies of stewardship programs.
Common outcome variables include
quantity of total antimicrobial use, quantity
of targeted antimicrobial use, duration of
therapy, percentage of oral versus
intravenous drug administration, and
antimicrobial drug expenditures.
1.
28. Methodological Issues-1.
Outcome measurements
Common clinical outcomes include allcause mortality, infection-related
mortality, duration of hospitalization, and
rates of readmission.
Microbiologic outcomes include the
percentage of organisms resistant to a
certain antimicrobial, percentage of
multidrug-resistant organisms, or
number of infections due to specific
organisms.
29. Methodological Issues
2. Study Design
Use of flawed methodologies may
overestimate or underestimate the effect of
interventions on outcomes.
In a review of 306 studies of interventions
to improve antimicrobial prescribing in
hospitals, 70% did not meet the minimum
criteria of the Cochrane Collaboration‟s
Effective Practice and Organization of Care
Group. (Ramsey et al 2003, J Antimicrob Chemother; 52).
30. Methodological Issues-2. Study
Design
The most commonly excluded studies were those
using uncontrolled before-and-after designs (46%) or
inadequate interrupted time series analysis (24%).
Analysis need to be done using interrupted time
series with segmented regression , a method of
analysis applied to before-and-after quasiexperimental study designs.
This methodology requires measurements at multiple
time points both before and after the intervention,
allowing evaluation of both the immediate change
due to the intervention (change in level) and the
sustained changes (change in slope).
32. Methodological Issues
3. Effect of Multiple Interventions
Analysis of the efficacy of interventions
to improve antimicrobial use is
complicated by the simultaneous
employment of multiple different
strategies by antimicrobial stewardship
programs.
It becomes difficult to compare the
effect of different strategies and
conclude which is most effective.
33. Methodological Issues
4. Publication Bias
There is a perception that positive results are more
noteworthy and manuscripts are more likely to be
submitted and accepted for publication if the report
demonstrates positive results
Thus, it is unclear whether antimicrobial stewardship
programs are generally effective in controlling
antimicrobial use (and sometimes in improving
resistance and clinical outcomes), or whether the
published literature only reflects the experience of
successful programs.
The careful study and publication of the results of
implementations of antimicrobial stewardship
strategies, successful or unsuccessful, should be
encouraged.
34. Antibiotic Stewardship
Programmes/Strategies
1.
2.
3.
4.
5.
Antimicrobial stewardship programs may be
generally classified according to the strategy
by which they seek to affect antimicrobial use.
However many programs use a combination
of such strategies.
Education and Guideline Implementation
Strategies
Formulary and Restriction Strategies
Review and Feedback Strategies
Computer-Assisted Strategies
Antibiotic Cycling Strategies.
35. 1. Education and Guideline
Implementation Strategies
A key foundation in encouraging appropriate
antimicrobial use in hospitals is defining what an
institution considers appropriate antimicrobial use.
Because of limited time to teach antimicrobial
pharmacology and infectious diseases in the medical
school curriculum, physicians often acquire their
antimicrobial prescribing habits from
the practice of their colleagues,
the recommendations of antibiotic handbooks, and
from information provided by representatives of the
pharmaceutical industry
36. 1. Education and Guideline
Implementation Strategies
Information from these sources may
vary widely and conflict with what is
considered best practice at an
institution.
Although the vast majority of physicians
recognize antimicrobial resistance as an
important problem, most underestimate
the true degree of antimicrobial
resistance in their own institutions
37. 1. Education and Guideline
Implementation Strategies
Physicians are primarily concerned with
the effects of antimicrobials in the
individual patients whose care they have
been charged with.
In a hypothetical case scenario, the risk
of contributing to antimicrobial
resistance was rated lowest among
seven factors influencing a physician‟s
choice of antimicrobial agent.
38. 1. Education and Guideline
Implementation Strategies
To counter these perceived conflicts in
knowledge and practice, institutions may
attempt to provide guidelines for
antimicrobial use and educate clinicians
regarding preferred antimicrobial
therapy.
This strategy attempts to influence
providers‟ prescribing during their
evaluation of the patient and selection of
antimicrobial therapy
39. 1. Education and Guideline
Implementation Strategies
Academic detailing refers to one-on-one
educational sessions between an
academic clinician educator (usually a
physician or pharmacist) and the clinician
targeted for education .
Also referred to as reverse detailing or
counterdetailing, this method co-opts the
strategy of individualized attention used by
pharmaceutical industry representatives
(detailers).
40. 1. Education and Guideline
Implementation Strategies
Prescriber feedback consists of providing
data to clinicians regarding their
prescribing habits, with comparisons to
expected norms (e.g.guidelines) or to other
prescribers in the same practice area.
In the hospital setting, passive
interventions involve measures such as
providing posters, handouts, or printed
guidebooks, or minimally interactive
educational sessions such as Grand
Rounds.
41. 1. Education and Guideline
Implementation Strategies
Reviews of studies of provider behaviour
change suggest that active,
personalized interventions such as
academic detailing are more effective
than passive dissemination of
information at eliciting desired changes.
Education- and guideline-based
strategies should be considered
primarily as a starting point for
antimicrobial stewardship programs.
42. 2. Formulary and Restriction
Strategies
Because of resistance to compliance
with guidelines for antimicrobial usage,
external control over clinicians‟
prescribing of these drugs may be
implemented.
This commonly takes the form of
establishment of an antimicrobial
formulary, such that only selected
antimicrobial agents are freely
dispensed by the pharmacy.
43. 2. Formulary and Restriction
Strategies
Other agents may only be available if certain criteria
for use are met (criterion-monitored strategies), if
approval for use is obtained from a specialist in
infectious diseases (prior-authorization strategies), or
may not be available at all (closed-formulary
strategies).
The goal of restriction-based policies may be a
reduction in drug costs to the hospital (through
restriction of more-expensive agents), a reduction in
the growth of antimicrobial resistance (through
restriction of agents considered to be more likely to
contribute to resistance), or both.
44. 2. Formulary and Restriction
Strategies
Restriction programs may also be based
on the potential of antimicrobials to
select for certain resistant organisms.
“Squeezing the balloon” phenomenon;
changing from the use of one agent to
another may reduce resistance to the
first drug, but increase resistance to the
second drug.
45. 2. Formulary and Restriction
Strategies
In response to an outbreak of an extended-spectrum
beta-lactamase-producing Klebsiella sp., a hospital
instituted strict restrictions on all cephalosporin use .
Subsequently, the incidence of resistant Klebsiella
infection decreased significantly. However, due to an
increase in use of imipenem/cilastatin, the incidence
of imipenem-resistant Pseudomonas aeruginosa
increased.
Heavy use of piperacillin-tazobactam was
associated with high rates of piperacillin-resistant
Pseudomonas infections in a medical-surgical
intensive care unit . Substitution of Pip-Taz with
imipenem led to a decrease in resistance piperacillin
resistance in Pseudomonas infections, but an
increase in imipenem resistance.
46. 3. Review and Feedback
Strategies
Restriction strategies may be effective at
channelling use of antimicrobials towards
preferable agents, but there are limitations
to the approach.
There may be inadequate personnel or
institutional commitment for a restrictive
approach.
Restriction strategies do not consider the
appropriateness of use of non-restricted
antimicrobials, which make up the vast
majority of antimicrobials used in the
hospital.
47. 3. Review and Feedback
Strategies
To optimize the use of non-restricted
antimicrobials, or to manage the use of
targeted antimicrobials in institutions where
restriction strategies are not in place,
programs built around antimicrobial review and
feedback may be instituted.
Such a program involves the retrospective
(hours to days) review of antimicrobial orders
If an order appears to be inappropriate, a
member of the antimicrobial management
team contacts the prescriber in an effort to
optimize therapy.
48. 3. Review and Feedback
Strategies
Review and feedback strategies may be especially
important in streamlining antimicrobial use.
This realization has led to the advocacy of early,
broad-spectrum empirical antimicrobial therapy for a
number of hospital infections.
For example, recent American Thoracic
Society/Infectious Diseases Society of America
guidelines for hospital-acquired pneumonia
recommend three-drug combination therapy (an
antipseudomonal beta-lactam, an aminoglycoside or
fluoroquinolone, and vancomycin or linezolid) for
empirical therapy in patients with late-onset
pneumonia.
49. 3. Review and Feedback
Strategies
This approach reduces the risk of a
patient‟s receiving inadequate therapy;
However, administration of multiple broadspectrum agents may increase the risk of
development of resistance in the patient‟s
(and the hospital‟s) bacterial flora.
Thus, it is crucial for clinicians to change to
the narrowest spectrum appropriate agent
to treat the infecting pathogen once it is
isolated and discontinue antimicrobials if
infection is unlikely.
50. 3. Review and Feedback
Strategies
Although adherence to these two
principles should be a fundamental tenet
of medical practice, in reality a formal
process (such as a guideline or critical
pathway) or the contribution of the
antimicrobial stewardship team
reviewing such orders may be required.
51. 4. Computer-Assisted
Strategies
The increasing computerization of the
hospital environment offers new
opportunities for programmes to optimize
antimicrobial use.
These opportunities have primarily been
associated with implementation of
computerized physician order-entry
systems in hospitals.
The order-entry encounter can be designed
to facilitate each of the antimicrobial
stewardship strategies .
52. 4. Computer-Assisted
Strategies
Educational strategies may be as simple as a link to
the institution‟s guidelines for therapy, or as
sophisticated as computerized expert systems that
integrate patient-specific laboratory and microbiology
data in devising a suggested therapeutic regimen.
If a prescriber enters an order for a restricted agent,
a list of formulary alternatives can be suggested,
along with the pager number needed to obtain
authorization.
When an agent targeted for review is ordered, the
data can be forwarded in real time or entered into a
queue for later review by antimicrobial stewardship
personnel.
53. 4. Computer-Assisted
Strategies
The most advanced programs integrate
patient-specific data extracted from hospital
information systems to provide tailored
recommendations for therapy using rulesbased criteria (expert systems).
The choice of antimicrobial is guided by the
results of the patient‟s cultures (for definitive
therapy) or by hospital-specific resistance
patterns (for empirical therapy).
Many softwares are commercially available
which can be integrated in hospital information
system.
54. 5. Antibiotic Cycling Strategies
In the 1980s, studies examining formulary
substitution of aminoglycosides (amikacin
for gentamicin and tobramycin) suggested
a strategy of rotating antimicrobials might
be effective in slowing the emergence of
resistance to any one agent.
These studies have led to the
development of strategies utilizing the
scheduled rotation of antimicrobials in
order to minimize the emergence of
bacterial resistance.
55. 5. Antibiotic Cycling Strategies
These programs typically target Gram-negative
resistance (the cycled antimicrobials are those
primarily active against Gram-negative organisms)
and are generally limited to the intensive care unit
setting.
Theoretically, during the periods when an
antimicrobial is out of rotation and its use is minimal,
resistance to that drug will decline.
The idea is to reduce selective pressure to any one
antimicrobial class by providing heterogeneity in drug
use –in the case of cycling, temporal heterogeneity
(by time period) rather than spatial (by patient)
heterogeneity.
56. 5. Antibiotic Cycling Strategies
However, compliance with the cycling
protocol may be low, for a number of
reasons: physicians may ignore the
protocol and prescribe off-cycle
antimicrobials to their patients, allergies
or toxicity may preclude administration
of the on-cycle drug, and the final
regimen may be tailored to culture
results.
57. Conclusions
Although resistance is a worldwide
concern, it is first and foremost a local
problem: selection for and amplification of
resistant members of a species are
occurring in individual hospitals (and
communities), which can then spread
worldwide.
Commitment to implementation of
antimicrobial stewardship programs must
come from the highest levels of hospital
administration.
58. Conclusions
Once a commitment to establishing an
antimicrobial stewardship program is
made, program personnel/committee
need to be put into place.
The committee then needs to decide
what strategies their program will use to
improve antimicrobial use.