This document discusses antimicrobial stewardship and the importance of appropriate antibiotic usage. It notes that nearly half of hospitalized patients receive antimicrobial agents. However, there has been misuse of antibiotics through treating trivial infections, commercial pressures, and a lack of understanding of antibiotic principles. This has led to a rise in antibiotic-resistant bacteria. The document advocates for antimicrobial stewardship programs in hospitals to optimize clinical outcomes while reducing unintended consequences of antibiotic usage like toxicity, resistance, and costs. Such programs involve formulary restrictions, guidelines, education, and prospective audits to ensure appropriate antibiotic selection and usage.

1. Dr.T.V.Rao MD
ANTIMICROBIAL STEWARDSHIP
DR.T.V.RAO MD 1

2. WHY WE NEED ANTIBIOTICS
Nearly One half of the Hospitalized
patients receive antimicrobial
agents.
• Antibiotics are valuable Discoveries of the Modern
Medicine.
• All current achievements in Medicine are attributed to
use of Antibiotics
• Life saving in Serious infections.
DR.T.V.RAO MD 2

3. WHAT WENT WRONG WITH
ANTIBIOTIC USAGE
• Treating trivial infections / viral Infections with Antibiotics has
become routine affair.
• Many use Antibiotics without knowing the Basic principles of
Antibiotic therapy.
• Many Medical practioners are under pressure for short term
solutions.
• Commercial interests of Pharmaceutical industry pushing the
Antibiotics, more so Broad spectrum and Newer Generation
antibiotics. as every Industry has become profit oriented.
• Poverty encourages drug resistance due to under
utilization of appropriate Antibiotics.
DR.T.V.RAO MD 3

4. • The last decade has seen the inexorable proliferation of a
host of antibiotic resistant bacteria, or bad bugs, not just
MRSA, but other insidious players as well. ...For these
bacteria, the pipeline of new antibiotics is verging on
empty. 'What do you do when you're faced with an
infection, with a very sick patient, and you get a lab report
back and every single drug is listed as resistant?' asked
Dr. Fred Tenover of the Centers for Disease Control and
Prevention (CDC). 'This is a major blooming
public health crisis.'"
SCIENCE MAGAZINE; JULY 18, 2008
DR.T.V.RAO MD 4

5. SPREAD OF ANTIBIOTIC RESISTANCE
• Indiscrimate use of
Antibiotics in Animals and
Medical practice
• R plasmids spread among co-
inhabiting Bacterial flora in
Animals ( in gut )
• R plasmids may be mainly
evolved in Animals spread to
Human commensal, -
Escherichia coli followed by
spread to more important
human pathogens Eg Shigella
spp.
DR.T.V.RAO MD 5

6. Misuse of antibiotics can include any of the following
• When antibiotics are prescribed unnecessarily;
• When antibiotic administration is delayed in critically ill patients;
• When broad-spectrum antibiotics are used too generously, or when
narrow-spectrum antibiotics are used incorrectly;
• When the dose of antibiotics is lower or higher than appropriate for
the specific patient;
• When the duration of antibiotic treatment is too short or too long;
• When antibiotic treatment is not streamlined according to
microbiological culture data results.
WHAT IS MISUSE OF ANTIBIOTICS?
DR.T.V.RAO MD 6

7. COSTS ASSOCIATED WITH
INCREASED BACTERIAL
RESISTANCE
• ↑Treatment failures
• ↑Morbidity and mortality
• ↑Risk of hospitalization
• ↑Length of hospital stays
• ↑Need for expensive and broad spectrum
antibiotics
DR.T.V.RAO MD 7

8. BEST WAY TO KEEP THE MATTERS IN
ORDER
Every Hospital should have a policy which is
practicable to their circumstances.
Rigid guidelines without coordination will lead to
greater failures
The only way to keep Antimicrobial agents useful is
to use them appropriately and Judiciously
(Burke A.Cunha, MD,MACP Antimicrobial Therapy. Medical Clinics of
North America NOV 2006)
DR.T.V.RAO MD 8

9. • The office, duties, and
obligations of a steward
• The conducting,
supervising, or
managing of something
especially : the careful
and responsible
management of
something entrusted to
one's care
“ WHAT IS STEWARDSHIP”????
DR.T.V.RAO MD 9

10. An activity that
includes
appropriate
selection, dosing,
route, and
duration of
antimicrobial
therapy.
THEREFORE, ANTIBIOTIC
STEWARDSHIP…..
DR.T.V.RAO MD 10

11. WHAT IS ANTIBIOTIC STEWARDSHIP?
• A program that encourages judicious (vs injudicious)
use of antibiotics
• Antibiotics are relatively so effective, non-toxic and
inexpensive…so easy to use…that they are prone to abuse
• When the diagnosis is uncertain, antibiotics are often prescribed…
• Stewardship strives to fine tune antibiotic Rx in regards to
• Efficacy
• Toxicity
• Resistance-induction
• C. difficile-induction
• Cost
• Discontinuation
DR.T.V.RAO MD 11

12. The pipeline is drying up!
US FDA approval of new
antibacterials down 56% from
1983 to 2002
• Infectious diseases are still the
most common cause of death
worldwide.
• We are effectively living in the
post-antibiotic era
• Therefore, we must manage
carefully and responsibly what
we have
SOBERING THOUGHTS
DR.T.V.RAO MD 12

13. SHOULD RESTRICT AND
RATIONALIZE ANTIBIOTIC USE
Antimicrobial stewardship
+
Infection control program
Can limit the emergence and transmission of
antimicrobial-resistant bacteria
DR.T.V.RAO MD 13

14. GOALS OF AB STEWARDSHIP
• Optimizing clinical outcomes while minimizing unintended
consequences of antimicrobial uses.
•Toxicity
•Selection of Pathogenic
organisms
•Emergence of Resistance
• A secondary goal is also the reduction of health care costs
without adversely impacting quality of care
DR.T.V.RAO MD 14

15. GUIDELINES FOR DEVELOPING AN INSTITUTIONAL
PROGRAM TO ENHANCE ANTIMICROBIAL STEWARDSHIP
An institutional program to
enhance antimicrobial stewardship
Antimicrobial Stewardship Team
Antimicrobial Stewardship
Program
DR.T.V.RAO MD 15

16. ANTIBIOTIC STEWARDSHIP TEAM
• Infectious Disease Physician.
• Clinical Pharmacist with infectious disease training
• Clinical Microbiologist
• An information system specialist
• Infection control professional.
• Hospital epidemiologist (Optional)
Collaboration between the antimicrobial
stewardship team, the hospital infection control,
pharmacy and therapeutics committees is
essential
DR.T.V.RAO MD 16

17. ELEMENTS OF AN ANTIMICROBIAL
STEWARDSHIP PROGRAM
Active Antimicrobial Stewardship Strategies
Supplemental
Antimicrobial
Stewardship
Strategies
Computer Surveillance
and Decision Support
Microbiology Laboratory
Comprehensive
Multidisciplinary
Antimicrobial
Management Programs
Monitoring of Process and
Outcome Measurements
DR.T.V.RAO MD 17

18. ACTIVE ANTIMICROBIAL STEWARDSHIP
STRATEGIES
1. Prospective audit with intervention and
feedback.
• A medium-sized community hospital resulted in a
22% decrease in the use of parenteral broad-
spectrum antimicrobials.
• They also demonstrated a decrease in rates of
C. difficile infection & nosocomial infection
compared with the preintervention period.
DR.T.V.RAO MD 18

19. 2. FORMULARY RESTRICTION & PREAUTHORIZATION
REQUIREMENTS FOR SPECIFIC AGENTS
 Most hospitals have a pharmacy and therapeutics
committee or an equivalent group
 They evaluates drugs for inclusion on the hospital
formulary on the basis of
 therapeutic efficacy
 toxicity
 cost
 They also limit redundant new agents with no significant
additional benefit.
DR.T.V.RAO MD 19

20. SUPPLEMENTAL ANTIMICROBIAL STEWARDSHIP
STRATEGIES
• Education.
• Guidelines and clinical pathways.
• Antimicrobial cycling
• Antimicrobial order forms.
• Combination therapy.
• Streamlining or de-escalation of therapy.
• Dose optimization.
• Conversion from parenteral to oral therapy.
DR.T.V.RAO MD 20

21. EDUCATION
• Considered to be most essential part of
Stewardship Program:
• Antibiotics
• Resistance
• PK-PD
• Collateral damage ( unintended )
• Alignment of Ab to overcome anti-microbial resistance.
• Target Customers: Microbiologist and Clinicians.
DR.T.V.RAO MD 21

22. MOST FREQUENTLY EMPLOYED
INTERVENTION
• Educational efforts include passive activities
 conference/ presentations
 student and house staff teaching sessions
 provision of written guidelines
 e-mail alerts
However, education alone, without incorporation of active
intervention, is only marginally effective and has not
demonstrated a sustained impact
DR.T.V.RAO MD 22

23. • Treatment should be limited
to bacterial infections,
using antibiotics directed
against the causative
agent, given in optimal
dosage, interval and length
of treatment, with steps
taken to ensure maximum
patient compliance with the
treatment regimen and only
when the benefit of
treatment outweighs the
individual and global risks
A GOOD CLINICAL PRACTICE SAVES
ANTIBIOTICS
DR.T.V.RAO MD 23

24. ANTIMICROBIAL CYCLING AND SCHEDULED
ANTIMICROBIAL SWITCH.
“Antimicrobial cycling”
refers to
the removal and substitution of a specific antimicrobial or
antimicrobial class to prevent or reverse the development
of antimicrobial resistance within an institution or specific
unit.
DR.T.V.RAO MD 24

25. • Substituting one
antimicrobial for another
may transiently decrease
selection pressure reduce
resistance
• But, reintroduction of the
original antimicrobial is
again however known to
develop resistance
• There are insufficient
data to recommend the
routine use over a
prolonged period of time
CHOOSING THE DRUGS
DR.T.V.RAO MD 25

26. ANTIMICROBIAL ORDER FORMS.
• The use of automatic stop orders and the
requirement of physician justification for
continuation
• Decrease antimicrobial consumption in
longitudinal studies
Use of peri-operative prophylactic order forms with automatic
discontinuation at 2 days resulted in a decrease in the mean
duration of antimicrobial prophylaxis (from 4.9 to 2.4 days)
DR.T.V.RAO MD 26

27. • Has a role in certain clinical
contexts
• Including use for empirical
therapy for critically ill
patients at risk of infection
with multidrug resistant
pathogens
• To increase the breadth of
coverage and the likelihood
of adequate initial therapy
COMBINATION THERAPY
DR.T.V.RAO MD 27

28. • The role of combination
antimicrobial therapy for the
prevention of resistance is
limited to those situations in
which there is
 A high organism load
 A high frequency of mutational
resistance during therapy.
• Classic examples are
tuberculosis or HIV infection.
LIMITATIONS OF COMBINATION OF
ANTIBIOTICS
DR.T.V.RAO MD 28

29. 29
STREAMLINING OR DE-
ESCALATION OF THERAPY
• On the basis of culture and sensitivity reports
we can more effectively target the causative
pathogens, by elimination of redundant
combination therapy
• Resulting in decreased Ab exposure and
substantial cost savings
DR.T.V.RAO MD

30. CDC VISION FOR INPATIENT CARE
• Implementation of an antimicrobial stewardship
program in a healthcare facility – regardless of
inpatient setting – will help ensure that
hospitalized patients receive the right antibiotic,
at the right dose, at the right time, and for the
right duration. As a result, there is reduced
mortality, reduced risks of Clostridium difficile-
associated diarrhea, shorter hospital stays,
reduced overall antimicrobial resistance within
the facility, and cost savings
DR.T.V.RAO MD 30

31. DOSE OPTIMIZATION
Optimization of AB dosing based on
• Individual patient characteristics
• Causative organisms
• Site of infections
• PK-PD characteristics
• Systemic Plan from a broad spectrum to specific narrow
spectrum Ab, parenteral to oral Antibiotics.
DR.T.V.RAO MD

32. Enhanced oral bioavailability
among certain antimicrobials—
such as fluoroquinolones,
oxazolidinones, metronidazole,
clindamycin, trimethoprim-
sulfamethoxazole, fluconazole,
and voriconazole
Therefore, allows for
conversion to oral therapy
once a patient meets
defined clinical criteria
CONVERSION FROM PARENTERAL TO
ORAL THERAPY
DR.T.V.RAO MD 32

33. • Computer physician order
entry (CPOE) as 1 of the
most important “leaps” that
organizations can take to
substantially improve
patient safety.
• CPOE has the potential to
incorporate clinical decision
support and to facilitate
quality monitoring
COMPUTER SURVEILLANCE AND DECISION
SUPPORT
DR.T.V.RAO MD 33

34. These guidelines are
not a substitute for
clinical judgment,
and clinical
discretion is required
in the application of
guidelines to
individual patients.
OUR CLINICAL JUDGMENT CARRIES MANY
SOLUTIONS…
DR.T.V.RAO MD 34

35. • Antibiotic prescribing practices and decreasing antibiotic
resistance can be addressed through multifaceted strategies
including:
 Use of ongoing education
 Use of evidence-based hospital antibiotic
guidelines and policies
 Restrictive measures and consultations from
infectious disease physicians, microbiologists
and pharmacists
MULTIFACETED STRATEGIES CAN ADDRESS AND
DECREASE ANTIBIOTIC RESISTANCE IN HOSPITALS
DR.T.V.RAO MD 35

36. • Only use an antimicrobial
when clearly indicated.
• Select an appropriate agent
using local antimicrobial
prescribing policy.
• Prescribe correct dose,
frequency and duration.
• Limit use of broad
spectrum agents and de-
escalate or stop
treatment if appropriate
(Hospital).
PRUDENT PRESCRIBING TO REDUCE
ANTIMICROBIAL RESISTANCE
DR.T.V.RAO MD 36

37. PRACTICE RATIONALISM IN ANTIBIOTIC USE-
PROMOTE ANTIBIOTIC STEWARDSHIP
• 1 Antibiotic overuse contributes to the growing problems of
Clostridium difficile infection and antibiotic resistance in
healthcare facilities.
2 Improving antibiotic use through stewardship
interventions and programs improves patient outcomes,
reduces antimicrobial resistance, and saves money.
Interventions to improve antibiotic use can be implemented
in any healthcare setting—from the smallest to the largest.
3 Improving antibiotic use is a medication-safety and
patient-safety issue.
DR.T.V.RAO MD 37

38. • Training and educating health care
professionals on the appropriate
use of antibiotics must include
appropriate selection, dosing,
route, and duration of antibiotic
therapy. To ensure that training
and education is working, there
should be extensive collaboration
between the antibiotic stewardship
and hospital infection prevention
and control teams. Without
benchmarks, it is difficult to track
successes and weaknesses
CONTINUOUS MEDICAL EDUCATION A MUST ..
DR.T.V.RAO MD 38

39. GOOD HAND WASHING PRACTICES STILL REDUCES
ANTIBIOTIC RESISTANCE AND SPREAD
DR.T.V.RAO MD 39

40. DR.T.V.RAO MD 40
IMPLEMENTATION OF WHONET CAN HELP TO
MONITOR RESISTANCE
• Legacy computer systems,
quality improvement teams,
and strategies for
optimizing antibiotic use
have the potential to
stabilize resistance and
reduce costs by
encouraging
heterogeneous prescribing
patterns and use of local
susceptibility patterns to
inform empiric treatment.

41. DR.T.V.RAO MD 41
• Programme created by Dr. T.V.Rao MD for
Medical Professionals in the Developing
world
• Email
• doctortvrao@gmail.com