Antimicrobial Stewardship PDF

Antimicrobial Stewardship Understanding Antimicrobial Stewardship By Marwa Mohamed Khalifa Lecturer of Microbiology & Immunology Faculty of Pharmacy Assiut University Objectives Describe the role of resistance Analyzed the scope of the problem wit...

Antimicrobial Stewardship Understanding Antimicrobial Stewardship By Marwa Mohamed Khalifa Lecturer of Microbiology & Immunology Faculty of Pharmacy Assiut University Objectives Describe the role of resistance Analyzed the scope of the problem with resistance Discuss the elements and activities of antimicrobial stewardship program (ASP) Understanding the rationale for ASP Evaluate components lead to a successful ASP 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. WHAT WENT WRONG WITH ANTIBIOTIC USE -Treating viral Infections with Antibiotics has become routine affair. -Many use Antibiotics without the Basic principles of Antibiotic therapy. -Many Medical practioners are under pressure of short term solutions. -Commercial interests of Pharmaceutical industry pushing the Antibiotics, more so Broad spectrum. WHAT IS MISUSE OF ANTIBIOTICS? 1) When antibiotics are prescribed unnecessarily. 2) When antibiotic administration is delayed in critically ill patients. 3) When broad-spectrum antibiotics are used too commonly, or 4) When narrow-spectrum antibiotics are used incorrectly. 5) When the dose of antibiotics is lower or higher than appropriate for the specific patient. 6) When the duration of antibiotic treatment is too short or too long. 7) When antibiotic treatment is not streamlined according to microbiological culture data results. Antibiotic Use Drives Resistance ❑ For an individual, getting an antibiotic increases a patient’s chance of becoming colonized or infected with a resistant organism. ❑ Increasing use of antibiotics in healthcare settings increases the prevalence of resistant bacteria in hospitals. ↑Treatment failures ↑Morbidity and Mortality ↑Risk of hospitalization ↑Length of hospital stays ↑Need for expensive and broad spectrum antibiotics How Antibiotic Resistance Happen? http://www.cdc.gov/drugresistance/threat-report-2013/ Selection for Antimicrobial-Resistant Strains Resistant Strains Rare Antimicrobial Exposure Resistant Strains Dominant CDC Campaign to Prevent Antimicrobial Resistance in Healthcare Settings. Accessed January 25, 2008 http://www.cdc.gov/drugresistance/healthcare/ha/HASlideSet_clean.ppt#3 Antibiotic Use Drives Resistance Penicillin Methicillin 1942 1961 vanA genetic transfer 2002 Examples of How Antibiotic Resistance Spreads http://www.cdc.gov/drugresistance/threat-report-2013/ Inappropriate Antimicrobial Therapy Impact Mortality 600 17.7% mortality 500 Relative Risk = 2.37 400 (95% C.I. 1.83-3.08; p <.001) No. Infected Patients 300 42.0% mortality 200 # Survivors 100 # Deaths 0 Inappropriate Appropriate Therapy Therapy Kollef M et al. Chest 1999;115:462-74 Tomorrow’s Antibiotics: The Drug Pipeline http://www.cdc.gov/drugresistance/threat-report-2013/  WHO Report Reveals Global Antimicrobial Resistance Warning United States population 300m >23,000 deaths, >2.0m illnesses Overall societal costs Up to $20 billion direct Up to $35 billion indirect European Union population 500m 25,000 deaths per year, 2.5m extra hospital days Overall societal costs (€900 million, hosp. days) Approx. €1.5 billion per year Thailand population 70m >38,000 deaths, >3.2m hospital days Overall societal costs US$ 84.6–202.8 mill. direct >US$1.3 billion indirect  The solution The CDC has recommended four necessary actions to prevent antimicrobial resistance 1. Prevent infections, prevent the spread of resistance 2. Tracking 3. Developing new drugs and diagnostic tests 4. IMPROVING ANTIBIOTIC PRESCRIBTION/ STEWARDSHIP  Antibiotic Stewardship What is it? Definition: A system of informatics, data collection, personnel, and policy/procedures which promotes the optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use. Using the right antibiotic at the right time at the right dose for the right duration 2014: CDC recommended that all acute care hospitals implement antibiotic stewardship programs Goals of Antimicrobial Stewardship Healthcare Goals 1) Optimizing clinical outcomes while minimizing unintended consequences of antimicrobial uses. Toxicity Selection of Pathogenic organisms Emergence of Resistance 2) Reduction of health care costs Without adversely impacting quality of care Antibiotic Stewardship Where does it apply? Is pertinent to inpatient, outpatient, and long-term care settings Is practiced at the – Level of the patient – Level of a health-care facility or system, or network Should be a core function of the medical staff (i.e. doctors and other healthcare providers) Utilizes the expertise and experience of clinical pharmacists, microbiologists, infection control practitioners and information technologists Five Ds of the AMS 1) Diagnosis ❑ Correct Identification of Infection: Essential to distinguish between bacterial, viral, fungal, or other causes. ❑ Use of Diagnostic Tools: Cultures, imaging, and biomarkers (e.g., procalcitonin) aid in determining the need for antibiotics. 2) Drug Selection Once an infection is diagnosed, selecting the correct antimicrobial agent is crucial. ❑ The choice is often guided by: The type of infection (site, severity) The most likely pathogens Local antimicrobial resistance patterns Patient-specific factors (allergies, age, renal function) - Initial use of broad-spectrum agents, but narrow-spectrum therapy after pathogen identification Five Ds of the AMS 3) Dose ❑ Dosage must balance effectiveness and minimize toxicity. ❑ Adjustments may be required for renal or hepatic impairment. ❑ Consideration of pharmacokinetics and pharmacodynamics properties (e.g., time-dependent killing vs. concentration-dependent killing). 4) Duration ❑ Limiting Treatment Duration: Antibiotics should be prescribed for the shortest effective duration to minimize resistance and side effects. Prolonged use increases the risk of adverse events and resistance. ❑ Clinical guidelines based on current evidence often recommend shorter durations than traditionally used, as they are equally effective in many cases (e.g., community-acquired pneumonia, uncomplicated urinary tract infections). Five Ds of the AMS 5) De-escalation ❑ Narrowing the Spectrum of Therapy: After culture results identify the pathogen, the therapy should be de-escalated from broad-spectrum antibiotics to narrower, more targeted agents. This reduces unnecessary exposure to broad-spectrum drugs, preserving their efficacy for future use. ❑ Stopping Antibiotics: In cases where antibiotics are found to be unnecessary (e.g., viral infections or non-infectious causes of inflammation), therapy should be discontinued promptly.  1) Antimicrobial An stewardship team institutional program to enhance the Antimicrobial stewardship 2) Antimicrobial stewardship Program  1) ANTIBIOTIC STEWARDSHIP TEAM 1. Infectious Disease Physician. 2. Clinical Pharmacist with infectious disease training 3. Clinical Microbiologist 4. An information system specialist 5. Infection control professional. 6. Hospital epidemiologist (Optional) Co-operation between the antimicrobial stewardship team, the hospital infection control, pharmacy and therapeutics committees is Essential 2)Antimicrobial Stewardship Program Roles ❑ Develop guidelines, policies, and protocols that support optimal prescribing ❑ Priority efforts regarding ▪ Specific conditions ▪ Particular units or groups ▪ Specific antimicrobial drugs ❑ Educate ❑ Monitor and Report What are the Core elements of the Antimicrobial Stewardship Program (ASP)????  1) Leadership Commitment Institutional Commitment: Effective antimicrobial stewardship (AMS) programs require strong backing from healthcare institutions, with support from senior leadership (e.g., hospital administrators, directors). This involves allocating the necessary resources such as funding, staffing, and time. Dedicated Funding: Financial investment ensures sustainability, allowing for the hiring of specialized personnel, acquisition of diagnostic tools, and funding for educational initiatives. Organizational Policies: Leadership can establish formal policies and procedures to ensure consistent antimicrobial use across the institution. 2) Accountability Designated Stewardship Leader: A single leader, typically an infectious disease (ID) physician or a clinical pharmacist with infectious disease expertise, should be responsible for implementing and maintaining the stewardship program. This individual is accountable for achieving the program’s goals. Role of Clinicians: All prescribers, pharmacists, and healthcare professionals involved in patient care have a responsibility to follow stewardship guidelines to reduce inappropriate antimicrobial use. 3) Drug Expertise Infectious Disease Pharmacists: These experts are central to AMS programs, helping to select the most appropriate antimicrobial therapy based on clinical evidence, patient factors, and pathogen susceptibility data. Multidisciplinary Teams: The AMS team often includes infectious disease physicians, clinical microbiologists, infection control practitioners, and nurses. Together, they assess antibiotic regimens and adjust them as needed to optimize patient care.  4)Action Formulary Management: The AMS team can control access to certain broad- spectrum antibiotics by implementing preauthorization requirements or restricting usage to specific indications. This reduces inappropriate prescriptions and conserves powerful antibiotics. Prospective Audit and Feedback: Regular audits of antibiotic prescriptions with feedback to prescribers, typically within 48-72 hours of initiating therapy, ensure that treatments are appropriate. For example, when culture results are available, clinicians may switch from empirical broad-spectrum agents to narrower, targeted therapies. Guideline Adherence: AMS teams develop and update clinical guidelines to support evidence-based prescribing for common infections (e.g., pneumonia, sepsis). Following these guidelines leads to better patient outcomes and reduced antimicrobial use. 5) Tracking and Reporting Antimicrobial Use Metrics: Monitoring the quantity and quality of antibiotic prescriptions, including which agents are used and for how long. Tracking is done through Defined Daily Dose (DDD) metrics or Days of Therapy (DOT) per 1000 patient- days. Antimicrobial Resistance (AMR) Surveillance: Routine microbiological surveillance is essential for tracking local resistance patterns. This helps in modifying empirical therapies and providing timely updates on resistance trends in hospitals and communities. Regular Feedback: Healthcare providers should receive feedback on their antibiotic prescribing patterns and outcomes, with recommendations for improvement when necessary. 6) Education and Training Continuous Professional Development: Regular education for healthcare professionals is essential to update them on the latest guidelines, treatment protocols, and emerging resistance patterns. This includes training prescribers on diagnostic tools, de-escalation practices, and pharmacodynamics. Patient Education: Educating patients is equally critical. Patients often expect antibiotics for viral infections. AMS programs should include strategies to inform patients about when antibiotics are or aren’t necessary, along with the risks of overuse (e.g., resistance, side effects). Case-Based Learning: Utilizing case studies where physicians can review real-world scenarios helps to reinforce the appropriate use of antimicrobials in different clinical settings.  Summary Antimicrobial resistance is at a critical threaten Optimize antimicrobial therapy with a goal to improve patient safety Collaboration is the key to a successful program Identify and measure where improvement is needed to be implemented Implementation and intervention is vital in the overall success of the program in addition to patient outcome and stepwise implementation Data, collection is the key to measuring sucess