Antimicrobial Stewardship Phase 2 2025 PDF

Antimicrobial Stewardship Phase 2 2025 Peter Daley MD MSc FRCPC DTM+H Associate Professor, MUN  Objectives 9070 Define appropriate antibiotic use Identify common clinical scenarios which promote 9071 inappropriate antibiotic use Recognize cons...

Antimicrobial Stewardship Phase 2 2025 Peter Daley MD MSc FRCPC DTM+H Associate Professor, MUN  Objectives 9070 Define appropriate antibiotic use Identify common clinical scenarios which promote 9071 inappropriate antibiotic use Recognize consequences of inappropriate antibiotic 9072 use Describe methods of antibiotic control within 9073 hospitals 9074 Identify methods of antibiotic use measurement Structure for Teaching in Antimicrobial Use Phase 2/3 Medical microbiology Antimicrobial pharmacology Antibacterials Antivirals, antifungals, antivirals, antimalarials, antihelminthics Phase 4 Antimicrobial use, simple syndromes Residency Antimicrobial use, complex syndromes  Canadian Medical Association 2019 “AMR represents an international public health challenge that will produce systemic level disruptions for health care by reversing over a century of efficacy in antimicrobial use. AMR is already producing significant impacts within the Canadian health care system. To date, Canada’s dedicated financial resources and leadership in AMR and antimicrobial stewardship fields (both federally and provincially), can only be viewed as wholly inadequate to address the scope of the problem, and the risks it poses for the health of Canadians.”  Antimicrobial Resistance, Why Worry? AMR infections have worse outcomes Failure of first line treatment Pharma is not producing new antimicrobials Low profit margin Short lifespan  What Causes AMR Globally? 1) increased global travel and medical tourism 2) the inappropriate, and high, use of antimicrobials in the agri-food sector 3) poor medical prescribing practices 4) inadequate implementation of infection prevention and control measures 5) the lack of knowledge, inappropriate expectations, and the misuse of antimicrobials on the part of the general public 6) the availability of poor quality antimicrobials 7) the lack of access to cheap rapid diagnostic tools and infrastructure 8) inadequate data and AMR surveillance systems 9) a lack of research, development, and introduction to market of new antimicrobials  Antimicrobial Resistance in Canada VRE Best our Drug. GE Eca/i  is a * Otitis media in Stupid to give to self-limiting bac. infection resp infections community acquired - children Appropriate Antibacterial Use Treat bacterial infections, not viral Pharyngitis, bronchitis, AECOPD, bronchiolitis Significant bacterial infections, not minor Otitis media, skin abscess Treat the organism the patient has, not the organism the patient doesn’t have (narrow spectrum) Anti-Pseudomonal Absolute minimum duration (stop at improvement) Control the source Drain it - - Dental infection, empyema, sinusitis - L-This problem - Not a medical one is a surgical  Consequence of Inappropriate Use (Goals of Antimicrobial Stewardship) Primary Reduce selection towards antibiotic resistance (AMR) Secondary Loss of healthy microbiome (Clostridium difficile diarrhea) Antibiotic toxicity Wasted drug cost Missed true diagnosis!  Reducing AMR Stop Creating AMR 30-50% of antimicrobial prescriptions in humans are UNNECESSARY Measure usage and appropriate usage > Measurement and - Reduce usage Quality Improvement Control Spread of AMR Isolation, handwashing Why do physicians over-prescribe? before. False beliefs (extension of indication) You've seen it work Diagnosis unknown Patient demand Prescription is faster Who is responsible? Male physicians Older physicians Higher volume practices International medical graduates Variability between physicians is based on physician, not patient population Antibiotic Prescribing for Non-bacterial Upper Respiratory Tract Infection in Elderly Persons. Silverman et al. Ann Intern Med 2017 Influences on the start, selection and duration of treatment with antibiotics in long-term care facilities. Daneman et al. CMAJ 2017  Responsibility - Antimicrobial Stewardship (AMS) Optimal selection, dose, route, duration of antimicrobial therapy Save lives without selecting for AMR Antimicrobials are “society” drugs  Antimicrobial Stewardship in Hospitals Monitor AMR (antibiogram) Monitor usage charts ID comments on Prospective audit and feedback - Day 3 “time-out” better was Clinical practice guidelines one Computerized decision support different They decided a Pharmacy auto-substitution - IV to PO stepdown No difference !!! Education  Antimicrobial Use Measurement (AMU) Pharmacy prescription data Defined Daily Doses (DDD)/1000 beds/year (hospital) Defined Daily Doses/1000 inhabitants/year (community) Prescription rate/population/year ⑳people/ year Choosing Wisely Canada Outpatient Otitis Media Don’t prescribe antibiotics in vaccinated children more than 6 months old and adults in whom you suspect acute otitis media, unless there is either: a perforated tympanic membrane with purulent discharge or a bulging tympanic membrane with one of the three following criteria: Fever (≥39°C) Moderately or severely ill Significant symptoms lasting > 48 hours  can't tell Y ou - by !' looking II SWAB Choosing Wisely Canada Outpatient Pharyngitis throat Sore Don’t routinely prescribe antibiotics unless the patient’s modified Centor score is > 2 AND throat swab culture (or rapid antigen test if available) confirms presence of Group A Streptococcus. Don’t perform throat swabs at all for patients with Centor score ≤ 1, OR if there are symptoms of a viral infection such as rhinorrhea, oral ulcers or hoarseness. ↓ I Indicates iral nose runny  with steroid , Drain ! Treat etc Steam , Saline ,... Choosing Wisely Canada Outpatient Sinusitis runny nose/sinus infection/Stufy nose Don’t prescribe antibiotics unless symptoms have persisted for greater than 7-10 days without improvement. Differentiating viral rhinosinusitis from acute bacterial rhinosinusitis can be challenging. Patients not meeting the below criteria are best managed with a viral prescription. Antibiotics should only be considered if the patient has at least 2 of the below PODS symptoms, one of those being O or D, AND the patient meets one of the following criteria: The symptoms are severe The symptoms are mild to moderate symptoms if there is no response after a 72 hours trial with nasal corticosteroids. P: Facial Pain/pressure/fullness; O: Nasal Obstruction; D: Purulent/discolored nasal or postnasal Discharge; Give nasal steroid < S: Hyposmia/anosmia (Smell) Choosing Wisely Canada Outpatient indicate Doesn't ! Bronchitis Cough green sputum - , pneumonia - > ↳ Don’t prescribe antibiotics for bronchitis/asthma/bronchiolitis exacerbations Not in alveoli /  * Viral prescription Rx for OTC aids Patient Name : Date : The symptoms you presented with today suggest a VIRAL infection. Upper Respiratory Tract Infection (Common Cold) : Lasts 7-14 days Flu : Lasts 7-14 days Acute Pharyngitis (“Sore Throat”) : Lasts 3-7 days, up to 10 days Acute Bronchitis/”Chest Cold” (Cough) : Lasts 7-21 days Acute Sinusitis (“Sinus Infection”) : Lasts 7-14 days You have not been prescribed antibiotics because antibiotics are not effective in treating viral infections. Antibiotics can cause side effects (e.g. diarrhea, yeast infections) and may cause serious harms such as severe diarrhea, allergic reactions, kidney or liver injury. When you have a viral infection, it is very important to get plenty of rest and give your body time to fight off the virus. If you follow these instructions, you should feel better soon : f Rest as much as possible f Drink plenty of fluids f Wash your hands frequently f Take over-the-counter medication, as advised : Acetaminophen (e.g. Tylenol®) for fever and aches Ibuprofen (e.g. Advil®) for fever and aches Naproxen (e.g. Aleve®) for fever and aches Lozenge (cough candy) for sore throat Nasal Saline (e.g. Salinex®) for nasal congestion Other : (e.g. Nasal decongestant if Salinex® does not work, for short-term use only!) Please return to your provider if : f Symptoms do not improve in day(s), or worsen at any time f You develop persistent fever (above 38°C, or as directed) f Other : Prescriber This “Viral Prescription Pad” has been adapted from the RQHR Antimicrobial Stewardship Program www.rqhealth.ca/antimicrobialstewardship , and is available in other languages. http://www.rxfiles.ca/rxfiles/uploads/documents/ABX-Viral-Prescription-Pad-Languanges.pdf Visit www.RxFiles.ca/ABX for more information.  Doesn't start later DELAYED until 2 days PRESCRIPTION About Your Delayed Prescription If you don’t feel better in _______ days, If you feel better, you do not need the antibiotic If things get worse To learn more, visit www.choosingwiselycanada.org/antibiotics Choosing Wisely Canada Acute Care Doesn't mean ! If asymptomatic have a - They Don’t use antimicrobials to treat bacteriuria in older adults unless UTI specific urinary tract symptoms are present. Don’t prescribe antibiotics after incision and drainage of uncomplicated skin abscesses unless extensive cellulitis exists. Don’t routinely prescribe intravenous forms of highly bioavailable antimicrobial agents for patients who can reliably take and absorb oral medications. Don’t prescribe alternate second-line antimicrobials to patients reporting non-severe reactions to penicillin when beta-lactams are the recommended first-line therapy. first ↳ Test the allergy Choosing Wisely Canada LTC Don’t use antimicrobials to treat bacteriuria in older adults unless specific urinary tract symptoms are present. Using the Microbiology Lab to Reduce AMU Collect the appropriate specimens Treat empirically if critically ill, by syndrome Narrow spectrum or discontinue antibiotics on day 3 based on susceptibility results Cascade reporting only provides narrow spectrum options Treatment recommendations based on local susceptibility trends AMS Interventions 1. Administrative Support. Develop Targets Percent reduction in inappropriate use Usage similar/lower than other provinces? Percent reduction in C.difficile Percent reduction in antibiotic costs Percent reduction in AMR the Antibiotics" to "Stop with Tell people  AMS Interventions 2. Measure Usage and Appropriateness Regularly Appropriateness assessment requires audit Appropriateness assessment requires indication information Green = unnecessary Why Are Antibiotics Used in Canada? NL is an Outlier in Antimicrobial Usage (0.95 prescriptions/person/year)  Canada AMU Pre/post COVID-19 AMS Interventions 3. Audit and Feedback is a good thing Changing physician behaviour involves understanding physician behaviour Physicians are independent professionals Without review of personal practice, how will physicians change?  does Quite doing to her AMS Interventions whatlative 4. Peer Comparison Oral antibiotics in patients 65+ yrs with NLPDP coverage for 2015−2016 FY (n = 42739) Number of Oral Antibiotic Prescriptions Oral Antibiotic Prescription Rates Per 1000 Prescriptions 800 500 Your Total Number of Antibiotic Prescriptions = 322 Your Crude Rate = 57 per 1000 Your Rate Adjusted for Comorbidity = 65 per 1000 400 600 300 Number 400 Rate 200 200 100 Top 20% Prescribers 0 0 High Volume Low Volume High Rate Low Rate Prescribers Prescribers Prescribers Prescribers General Practice Physicians (n = 485) General Practice Physicians (n = 485) Percentages of Your Most Frequently Prescribed Oral Antibiotics 40 34% 30 26% 20 12% 10 7% 6% 4% 3% 2% 2% 1% 0 AMOXICILLIN CIPROFLOXACIN CLARITHROMYCIN CLOXACILLIN AMOX−CLAV NITROFURANTOIN ERYTHROMYCIN CEFALEXIN AZITHROMYCIN DOXYCYCLINE AMS Interventions 5. Remove Penicillin “Allergy” 10% of inpatients have a penicillin “allergy” “Allergy” history leads to inappropriate second line antibiotics Stevens-Johnson, anaphylaxis, hives reactions: avoid penicillin Maculopapular rash, diarrhea, nausea: test penicillin dose in hospital Remove “allergy” label where possible  wound AMS Interventions afterclosed. 6. Surgical Prophylaxis Nis Antibiotics should be used during surgery, never after surgery > - Post - operative ABs not really necessary Objectives 9070 Define appropriate antibiotic use 9071 Identify common clinical scenarios which promote inappropriate antibiotic use 9072 Recognize consequences of inappropriate antibiotic use 9073 Describe methods of antibiotic control within hospitals 9074 Identify methods of antibiotic use measurement