Who antibiotic policy by MBA 2nd year (Health and hospital) IIHMR Jaipur

2. WHO
ANTIBIOTIC POLICY
SUBMITTED BY:-
Dr. Anjali k. 384
Dr. Anshul Bhardwaj 390
Dr. Ashish Gupta 395
Dr. Jasleen Saluja 429
Guided by: Dr. Ruchi Garg

3. ANTI MICROBIAL RESISTANCE (AMR)
AMR has emerged as a major public health problem all over the world.
Infections caused by resistant microbes fail to respond to treatment,
resulting in prolonged illness and greater risk of death.
..What causes antibiotic resistance_ - Kevin Wu - YouTube (720p).mp4

4. Resistant microbes
fail to respond to
treatment
Treatment failures also
lead to longer periods
of infectivity
with increased numbers
of infected people
moving in the
community.
exposes the general
population to the risk
of contracting a
resistant strain
New people become
resistant to first-line
antimicrobials
virtually non-treatable
disease
Process
of AMR

5. STRATEGIC OBJECTIVES FOR HOSPITAL
ADMIN.To develop a system to recognize and report trends in AMR within the
institution.
To develop a system to rapidly detect and report resistant microorganisms in
individual patients and ensure prompt treatment.
To assure increased adherence to basic infection control policies and
procedures.
To incorporate the detection, prevention and control of AMR into institutional
strategic goals and provide the required resources.
To develop a plan for identifying, transferring, discharging and readmitting
patients colonized with specific anti microbial resistant pathogens.
To establish policy and practices for rational use of antimicrobials.
Strategies against AMR microorganisms in hospitals

6. STRATEGIC APPROACHES
To achieve these, a comprehensive approach through a hospital policy
on the rational use of antibiotics is essential.
Optimizing the duration of choice and dose of empiric therapy:
antimicrobial stewardship.
Optimizing antimicrobial prophylaxis for operative procedures.
Developing and implementing an antibiotic policy and standard treatment
guidelines (STG).
Monitoring and providing feedback regarding antibiotic resistance.
Improving antimicrobial prescribing by educational and administrative
means.

7. PROCESS FOR THE DEVELOPMENT OF
HOSPITAL ANTIBIOTIC POLICY
Antimicrobial Stewardship
Standard treatment guidelines
Antibiotic Policy
Cumulative antibiogram Hospital/Community
Hospital Associated infection Surveillance of Antimicrobial
Resistance/antibiotic consumption

8. GUIDELINE DEVELOPMENT PROCESS
• The objectives
• A tool to developing countries
• for establishing procedures and practices for formulating hospital
antibiotic policy and standard treatment guidelines
• WHO South East
Asia
• CMC, Vellore

9. ANTIBIOTIC POLICY

10. AIMS
• The primary aim of the hospital antimicrobial policy is to minimize
the morbidity and mortality due to AMR infection
• To preserve the effectiveness of antimicrobial agents in the treatment
and prevention of communicable diseases.

11. SCOPE OF HOSPITAL ANTIBIOTIC POLICY
The antibiotic policy is essentially for prophylaxis, empirical and
definitive therapy.
The policy shall incorporate specific recommendations for the treatment
of different high-risk/special groups such as immunocompromised
hosts; hospital-associated infections and community-associated
infections.

12. Hospital
antibiotic
policy shall
be based
upon
Spectrum
of
antibiotic
activity
Pharmaco
kinetics of
these
medicines
Pharmac
odynamic
s of these
medicine
sAdverse
effects
& cost of
treatment
Potential
to select
resistanc
e
Special
needs of
individual
patient
groups.
The hospital antibiotic policy shall be based upon

13. SCOPE OF HOSPITAL ANTIBIOTIC POLICY
CONT..
It should also set the levels for prescribing antibiotics -
First choice antibiotics can be prescribed by all doctors
Restricted choice antibiotics can only be prescribed after consulting the
head of the department or the antimicrobial team (AMT) representative.
Reserve antibiotics, on the other hand, are prescribed only by
designated experts.

14. ESTABLISH A MULTIDISCIPLINARY
ANTIBIOTIC MANAGEMENT TEAM (AMT) TO
DRAFT POLICY
• Total members: 6–10 members (multidisciplinary expertise and
experience)
(infectious diseases, internal medicine, surgery, pediatrics, clinical
Microbiology, pharmacology and hospital pharmacy)
• One member for Review (Literature and Systemic)
• Input from all stakeholders Should be there.

15. MAIN
FUNCTION
S OF AMT
Developing a hospital antimicrobial policy,Developing
Monitoring the implementation of the antibiotic
policy,
Monitoring
Receiving feedback,Feedback
Assessing outcome and discussing with clinicians,Assessing
Conducting a revision of the policy every year
based on the experience of prescribers and
antimicrobial susceptibility profiles, and setting
audit targets.
Review

16. Antimicrobial dose and regimen alteration;
Streamlining and sequential therapy;
Discontinuation of antimicrobials;
Advice on and as a result of therapeutic drug monitoring;
Automatic stop orders for antimicrobial prophylaxis;
Restricted antimicrobials; empirical antimicrobials;
Approval of restricted antibiotics;
THE OTHER FUNCTIONS ASSIGNED TO THE AMT TEAM
INCLUDE:

17. HOSPITAL VERSUS NATIONAL ANTIBIOTIC
POLICY
• Generally, the hospital antibiotic policy should concur or align with the
national antibiotic policy except for a few changes as warranted by the local
antimicrobial resistance profiles.
• If there is a wide variation from national to hospital, and hospital to hospital
then the desired purpose is defeated
i.e., to minimize the morbidity and mortality due to antimicrobial-resistant
infections; to preserve the effectiveness of antimicrobial agents in the
treatment and to prevent microbial infections.

18. SURVEILLANCE OF ANTIMICROBIAL
RESISTANCE

19. SURVEILLANCE OF ANTIMICROBIAL
RESISTANCE
Antibiotic policy mainly depend upon the surveillance of antimicrobial
resistance and antibiotic consumption in any settings. Hence, it is
mandatory to establish an efficient surveillance system.
• the following four features must be considered while establishing a
surveillance mechanism:
1.Use standards (for reporting quantitative resistance data)
2.Generate reliable numerator (only first +ve culture from the patient of each
disease)
3.Express resistance as incidence rate (within a defined human population
instead of using the number of isolates tested as denominators
4.Participate in external quality assessment schemes

20. THE ATTRIBUTES OF A “GOOD SURVEILLANCE
SYSTEM”
SIMPLICITY FLEXIBILITY REPRESENTATIVENESS
TIMELINESS USEFULNESS

21. CUMULATIVE ANTIBIOGRAM
 An antibiogram is an overall profile of antimicrobial susceptibility testing (AST)
results of a specific microorganism to a battery of antimicrobial drugs.
 This profile is generated by the laboratory using aggregate data from a hospital or
healthcare system; data are summarized periodically and presented showing
percentages (%) of organisms tested that are susceptible to a particular
antimicrobial drug.
 Only results for antimicrobial drugs that are routinely tested and clinically useful
should be presented to clinicians.

22. ATTRIBUTES TO CUMULATIVE ANTIBIOGRAM
Comparing
cumulative
antibiogram data
with the national
data
Avoid
potentially
misleading
data
Analyze data
using
statistical tool
Data stratification
to encourage
antimicrobial
therapy
CUMULATIVE
ANTIBIOGRAM
Ensuring quality of
cumulative
antibiogram
Reviewing
antibiogram data
if clinical failure
occurs

23. QUALITY INDICATORS OF CUMULATIVE
ANTIBIOGRAM
• Laboratory should be surveyed about their testing practices.
• Analysis of antibiograms may provide useful information when
deciding where to focus educational efforts.
• Increased compliance with standards should result in decreased
errors on antibiograms, and thus provide more reliable data to
clinicians to guide antibiotic choice and guidelines.
• Programmes that provide and explain the antimicrobial susceptibility
testing standards and guidelines may encourage compliance.

25. SOFTWARE: WHONET AND BACLINC
DEVELOPED BY
WHO collaborating centre for surveillance of antimicrobial resistance
based at the brigham and women's hospital in boston, (started since 1989)

26. WHONET SOFTWARE FOR THE
SURVEILLANCE OF ANTIMICROBIAL
SUSCEPTIBILITY
• WHONET is a free Windows-based database software developed for the
management and analysis of microbiology laboratory data with a special
focus on the analysis of antimicrobial susceptibility test results.
• WHONET is an effective tool which help not only in routine microbiology
laboratory data management but also generate valuable information about
antimicrobial susceptibility patterns
• The program facilitates sharing of data amongst different hospitals
by putting each laboratory data into a common code and file format, which
can be merged for national or global collaboration of antimicrobial resistance
surveillance.
Latest version: WHONET 5.6

28. BACLINK: FREE DATA CONVERSION
UTILITY FOR WHONET
• It avoid the need for double data entry.
• In most instances, Baclink can transfer data into WHONET from:
Common commercial database and spreadsheet software;
Commercial susceptibility test instruments for MIC broth microdilution and disk
diffusion readers
Hospital and laboratory information systems through text files.

29. DEVELOPMENT OF STANDARD
TREATMENT GUIDELINES
• Effective standard treatment guidelines (STG) improve patient care
while enhancing cost savings.
• The STG also reflect data on resistance, recognizing that local
patterns of resistance often differ across geographical regions.
• The use of the STG can be an effective means of changing behaviour;
hence the STG should be readily adaptable for local implementation.

30. PREREQUISITES & RECOMMENDATION OF
STG
Should involve treating physicians to bring ownership to the guidelines.
Should be based on local antibiograms.
Should be syndrome/diseased based.
Should specify type of clinical setting – Outpatient clinics, Inpatient units, ICU setting.
Should specify rationale of guidelines.
Should involve treating physicians to bring ownership to the guidelines.
Should provide evidence-based strength of recommendations.
The guideline developers should describe methods used to collect/select the evidence
such as search of electronic databases and the number of documents sourced.

31. STRATEGIES FOR PROMOTING RATIONAL
ANTIBIOTIC PRESCRIBING

32. STRATEGIES FOR PROMOTING RATIONAL
ANTIBIOTIC PRESCRIBING
conventional methods of communication,
BCC and education outreach for physician
Use of Information technology
Educational outreach for general public
Special methods
 Barrier-oriented interventions
 Using checklist as an effective tool
 Prescription auditing
Finally, the most generally effective strategy to consider is multifaceted
interventions. Multiple strategies are likely to be more successful than one.

33. BARRIER-ORIENTED INTERVENTIONS
Barrier Explanation
Lack of awareness Clinician unaware that the guidelines exist.
Lack of familiarity Clinician aware of guidelines but unfamiliar with specifics.
Lack of agreement Clinician does not agree with a specific recommendation made in
guidelines or is averse to the concept of guidelines in general.
Lack of self-efficacy Clinician doubts whether he or she can perform the behaviour.
Lack of outcome expectancy Clinician believes that the recommendations will be unsuccessful.
Lack of motivation Clinician is unable/unmotivated to change previous practices
Guideline-related barriers Guidelines are not easy or convenient to use.
Patient-related barriers Clinician may be unable to reconcile guidelines with patient preferences.
Environmental-related
barriers
Clinician may not have control over some changes (e.g., time, resources,
organizational constraints).

34. USING CHECKLIST AS AN EFFECTIVE
TOOL
• A checklist should be used to assure that
 The right thing is done at the right time in the right place.
• This check list is warranted because medical care has become
complicated enough that one physician cannot remember everything
that has to be done for a particular problem.
• A checklist for important interventions including use of antibiotics,
therefore, should be helpful.

35. PRESCRIPTION AUDITING STRUCTURE AND
PROCESS
Formulate antibiotic policy and implement the policy by creating awareness and training for
doctors
Critical review of patient records and policies in he organization , compilation and
analysis of data, Presentation of the to the hospital infection control committee and
treating physicians
Form prescription auditing team consisting of treating physicians , microbiologists,
infectious diseases specialists, pharmacologists as per resources in organization.
Identify indicator antimicrobials, which are general costlier antimicrobials or newer
antimicrobials
Design an auditing form, which include patient details , diagnosis, date of start and
discontinuation of antibiotic, doses and an indication to initiate the antimicrobial therapy

36. ANTIMICROBIAL
STEWARDSHIP

37. ANTIMICROBIAL STEWARDSHIP
With Minimizing toxicity and conditions for selection of resistant bacterial strains.
Optimizing its dose duration to cure an infection
Selecting an appropriate drug

38. PITFALLS OF PRACTICING ACCORDING TO THE
GUIDELINES
• The antibiotic stewardship achieves only “uniformity of prescribing” with
adherence to policies, guidelines and formularies.
Paradoxically this may actually be at times harmful, as the best defense
against resistance is probably “diversity of prescribing”.
• The earlier guidelines resulted in over-use of some drug.
The earlier guidelines from the British and American Thoracic Societies for treatment of
community-acquired pneumonia (CAP) resulted in over-use of cephalosporins,
quinolones and macrolides triggering MRSA outbreaks.
• Though the guidelines are evidence-based, the antibiotic recommendations are
definitely not and leaning heavily to combination therapy in trying to cover all etiological
agents.

39. WHO UPDATED ESSENTIAL MEDICINES LIST WITH NEW ADVICE ON USE OF
ANTIBIOTICS, AND ADDS MEDICINES FOR HEPATITIS C, HIV, TUBERCULOSIS
AND CANCER :
6 JUNE 2017 | GENEVA
• New advice on which antibiotics to use for common infections and which to preserve
for the most serious circumstances is among the additions to the WHO Model list of
essential medicines for 2017. Other additions include medicines for HIV, hepatitis C,
tuberculosis and leukaemia.
• The updated list adds 30 medicines for adults and 25 for children, and specifies new
uses for 9 already-listed products, bringing the total to 433 drugs deemed essential
for addressing the most important public health needs.
• The WHO Essential Medicines List (EML) is used by many countries to increase
access to medicines and guide decisions about which products they ensure are
available for their populations.

40. • "The new WHO list should help health system planners and
prescribers ensure people who need antibiotics have access to them,
and ensure they get the right one, so that the problem of resistance
doesn’t get worse.“

41. WHO REVISES ANTIBIOTICS PROTOCOL:
THE HINDU
JUNE 7, 2017
• In an effort to curb antibiotic resistance, the World Health Organization (WHO) has
divided the drugs into three categories — access, watch and reserve — specifying
which are to be used for common ailments and which are to be kept for complicated
diseases.
• WHO has put commonly used antibiotics under the ‘access’ category;
• The second line of antibiotics, slightly more potent, have been categorised under
‘watch’.
• Potent drugs to be used only as a “last resort” fall under the ‘reserve’ category.
Photo: Special Arrangement
This is the biggest revision of the antibiotics section in the 40-year history of the
essential medicines list (EML).

42. • Clinical samples for microbiologic culture and sensitivity must ALWAYS be sent, before starting
empiric therapy.
• Empiric treatment can be started as per policy guidelines and clinical judgment
• Step down or step up of treatment can be done based on the antibiotic sensitivity report. In case of
no clinical response, consult microbiologist and pharmacologist.
• Various factors associated with drug metabolism must be taken into account while prescribing
treatment
• Hypersensitivity(Patient MUST be questioned about drug allergies in past)
• Renal function
• Drug interactions
Antibiotic policy guidelines:
Safdarjung hospital, New Delhi

43. Antibiotic policy guidelines:
Safdarjung hospital, New Delhi cont..
• Irrational drug combinations must be avoided.
• Colistin, Carbapenems and linezolid are reserve drugs only and should be
prescribed only after culture sensitivity report demonstrating sensitivity exclusively to
these drugs.
• Therapy monitoring: Need of antibiotic must be reviewed on daily basis. Most
common infections usually need antibiotics for not more than 7 days. IV antibiotics
should be switched to oral within 24-48 hours, based on clinical improvement and
microbiology antibiotic sensitivity pattern.
• Antibiotics should not be used as a substitute for appropriate infection control
procedures.

44. ROLE OF HOSPITAL ADMINISTRATOR
• Creating awareness about antibiotic policy to the clinician and patient
• Proper implementation of antibiotic policy
• Aligning of hospital policy with national policy
• Formulation of antibiogram for high risk patient
• Checklist should be circulated among doctors
• Detection and flagging of AMR patients on HIS
• Integration and sharing the data of the hospital to WHONET

45. INFOTAINMENT BY WHO
• ..WHO_ ‘Antibiotics_ Handle with care’ campaign video - YouTube
(720p).mp4