1 Anti-microbial Resistance & Stewardship.pdf

Infection Prevention & Control Anti-microbial Resistance Anti-microbial Stewardship INFECTION PREVENTION & CONTROL 2  What are Antimicrobials?  Antimicrobials: including antibiotics, antivirals, antifungals and antiparasitics, are medicin...

Infection Prevention & Control Anti-microbial Resistance Anti-microbial Stewardship INFECTION PREVENTION & CONTROL 2  What are Antimicrobials?  Antimicrobials: including antibiotics, antivirals, antifungals and antiparasitics, are medicines used to prevent and treat infections in humans, animals and plants. INFECTION PREVENTION & CONTROL 3  What is Antimicrobial Resistance? Antimicrobial Resistance (AMR) occurs when bacteria, viruses, fungi and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, severe illness and death. As a result of drug resistance, antibiotics and other antimicrobial medicines become ineffective and infections become increasingly difficult or impossible to treat. INFECTION PREVENTION & CONTROL 4  Why we need Antibiotics?  Nearly one half of hospitalized patients receive antimicrobial agents. (ICU / NICU).  All current achievements in medicine are attributed to use of antibiotics, such as routine surgery.  Life saving in serious infection eg. sepsis. INFECTION PREVENTION & CONTROL 5  What is wrong with Usage (Antibiotic overuse/abuse)  Patient related factor: o Many use antibiotics without knowing the basic principles of Antibiotic therapy. o Many medical practitioners are under pressure of patient for short term solutions.  Physician related factor: oIn appropriate duration and prolongation of antibiotic use after surgery. oTreating viral infections with antibiotics has become routine affair. INFECTION PREVENTION & CONTROL 6 Keep the Matters in Order INFECTION PREVENTION & CONTROL 7  Education INFECTION PREVENTION & CONTROL 8  Role of Microbiology Lab.  Correct specimen testing.  Species identification.  Antimicrobial susceptibility testing (AST).  Correct reporting the results.  Correct interpretation of AST reports.  Advice on appropriate antimicrobial choice. INFECTION PREVENTION & CONTROL 9 Appropriate Antibiotic Treatment INFECTION PREVENTION & CONTROL 10  Spread of Antibiotic Resistance Inappropriate use of antibiotics in animals and medical practice (use antibiotics for growth promotion or to prevent diseases in healthy animal). R plasmids carrying gene of resistance which act as a vehicle for transferring antibiotic resistance among bacteria. Failure to implement infection control measures inside health care facility. INFECTION PREVENTION & CONTROL 11 Spread of Antibiotic Resistance INFECTION PREVENTION & CONTROL 12  Antibiotic Resistance Costs  Treatment failures.  Morbidity and mortality.  Risk of hospitalization.  Length of hospital stays.  Need for expensive and broad spectrum antibiotics. INFECTION PREVENTION & CONTROL 13  Antibiotic Resistance How Antibiotic Resistance occurs 1) Inactivation of the antibiotic outside a bacterium. 2) Reduction of the intracellular concentration of the antibiotic (reduce influx pumps). 3) Reduction of the intracellular concentration of the antibiotic (activate efflux pumps). 4) Target overproduction. 5) Target modification. 6) Target elimination. INFECTION PREVENTION & CONTROL INFECTION PREVENTION & CONTROL 14  Definitions of Antimicrobial Resistance  MDR (multidrug-resistant): The isolate is non susceptible to at least1 agent in ≥ 3 antimicrobial categories commonly used for treatment of this organism).  XDR (extensively drug-resistant): The isolate is non susceptible to at least 1 agent in all but 2 or fewer antimicrobial categories.  PDR (pan drug-resistant): Non susceptibility to all agents in all antimicrobial categories for each bacterium. INFECTION PREVENTION & CONTROL 15  Mechanisms of Antibiotic Resistance 1) Drug inactivation or modification: for example, enzymatic deactivation of penicillin G through the production of β-lactamases. 2) Alteration of target site: for example, a protective mechanism found among bacterial species is ribosomal protection proteins. These proteins protect the bacterial cell from antibiotics that target the cell’s ribosomes to inhibit protein synthesis. INFECTION PREVENTION & CONTROL 16  Mechanisms of Antibiotic Resistance 3) Alteration of metabolic pathway: for example, some bacteria do not require para-amino benzoic acid (PABA), an important precursor for the synthesis of folic acid and nucleic acids in bacteria. 4) Reduced drug accumulation: by decreasing drug permeability or increasing active efflux (pumping out) of the drugs across the cell surface. INFECTION PREVENTION & CONTROL 17  Spread of Antimicrobial Resistance  The misuse and over use of antimicrobials.  Lack of access to clean water, sanitation and hygiene (WASH) for both humans and animals.  Poor infection and disease prevention and control in health-care facilities and farms.  Poor access to quality, affordable medicines, vaccines and diagnostics.  Lack of awareness and knowledge; and lack of enforcement of legislation. INFECTION PREVENTION & CONTROL 18  Steps to Prevent Antimicrobial Resistance 12. Break the chain. Prevent Transmission 11. Isolate the pathogen. 10. Stop treatment when cured. 9. Know when to say “no” to vanco. 8. Treat infection, not colonization. Use Antimicrobial wisely 7. Treat infection, not contamination. 6. Use “local” data. 5. Practice antimicrobial control. 4. Access the experts. Diagnose & Treat 3. Target the pathogen. effectively 2. Get the catheters out. 1. Vaccinate. Prevent Infections INFECTION PREVENTION & CONTROL 19  Steps to Prevent Antimicrobial Resistance Step 1: Vaccinate  Fact: Pre-discharge influenza and pneumococcal vaccination of at-risk hospital patients and influenza vaccination of healthcare personnel will prevent infections.  Actions: oGive influenza / pneumo-coccal vaccine to at-risk patients before discharge. oGet influenza vaccine annually. INFECTION PREVENTION & CONTROL 20  Steps to Prevent Antimicrobial Resistance Step 2: Get the catheters out  Fact: Catheters and other invasive devices are the first exogenous cause of hospital infections.  Actions: o Use catheters only when essential. o Use proper insertion & catheter-care protocols. o Remove catheters when not essential. INFECTION PREVENTION & CONTROL 21  Steps to Prevent Antimicrobial Resistance Step 3:Target the pathogen  Fact: Appropriate antimicrobial therapy saves lives.  Actions: o Culture. o Target empiric therapy to likely pathogens and local antibiogram. o Target definitive therapy to known pathogens and antimicrobial susceptibility test results. INFECTION PREVENTION & CONTROL 22  Steps to Prevent Antimicrobial Resistance Step 4: Access the experts Fact: Infectious diseases expert input improves the outcome of serious infections. Action: o Consult infectious diseases experts about patients with serious infections. INFECTION PREVENTION & CONTROL 23  Steps to Prevent Antimicrobial Resistance Step 5: Practice antimicrobial control  Fact: Programs to improve antimicrobial use are effective.  Methods to Improve Antimicrobial Use: o Prescriber education. o Standardized antimicrobial order forms. o Formulary restrictions. o Prior approval to start/continue. o Pharmacy substitution or switch. o Multidisciplinary drug utilization evaluation (DUE). o Interactive prescriber education. o Provider/unit performance feedback. o Computerized decision support/on-line ordering. INFECTION PREVENTION & CONTROL 24  Steps to Prevent Antimicrobial Resistance Step 6: Use local data  Fact: The prevalence of resistance can vary by locale, patient population, hospital unit, and length of stay.  Actions: oKnow your local antibiogram. oKnow your patient population. INFECTION PREVENTION & CONTROL 25  Steps to Prevent Antimicrobial Resistance Step 7: Treat infection , not contamination  Fact: A major cause of antimicrobial overuse is “treatment” of contaminated cultures.  Actions: o Use proper antisepsis for blood & other cultures. o Culture the blood, not the skin or catheter hub. o Use proper methods to obtain & process all cultures. INFECTION PREVENTION & CONTROL 26  Steps to Prevent Antimicrobial Resistance Step 8: Treat infection, not colonization  Fact: A major cause of antimicrobial overuse is treatment of colonization.  Actions: oTreat pneumonia, not the tracheal aspirate. oTreat bacteremia, not the catheter tip or hub. oTreat urinary tract infection, not the indwelling catheter. INFECTION PREVENTION & CONTROL 27  Steps to Prevent Antimicrobial Resistance Step 9: Know when to say “no” to vanco  Fact: Vancomycin overuse promotes emergence, selection, and spread of resistant pathogens.  Actions: oTreat infection, not contaminants or colonization. oFever in a patient with an intravenous catheter is not a routine indication for vancomycin. INFECTION PREVENTION & CONTROL 28  Steps to Prevent Antimicrobial Resistance Step 10: Stop antimicrobial treatment  Fact: Failure to stop unnecessary antimicrobial treatment contributes to overuse and resistance.  Actions: oWhen infection is cured. oWhen cultures are negative and infection is unlikely. oWhen infection is not diagnosed. INFECTION PREVENTION & CONTROL 29  Steps to Prevent Antimicrobial Resistance Step 11: Isolate the pathogen  Fact: Patient-to-patient spread of pathogens can be prevented.  Actions: o Use standard infection control precautions. o Contain infectious body fluids (use approved airborne / droplet / contact isolation precautions). o When in doubt, consult infection control experts. INFECTION PREVENTION & CONTROL 30  Steps to Prevent Antimicrobial Resistance Step 12: Break the chain of infection  Fact: Healthcare personnel can spread antimicrobial-resistant pathogens from patient to patient.  Actions: oStay home when you are sick. oContain your contagion. oKeep your hands clean. INFECTION PREVENTION & CONTROL 31  Steps to Prevent Antimicrobial Resistance Step 12: Break the chain of infection Improved Patient Outcomes associated with Proper Hand Hygiene Ignaz Philipp Semmelweis (1818-65) Chlorinated lime hand antisepsis INFECTION PREVENTION & CONTROL 32  Steps to Prevent Antimicrobial Resistance  Fact: The prevalence of resistance can vary by locale, patient population, hospital unit & length of stay.  Actions: - Know the local ABGM. - Know the patient population. INFECTION PREVENTION & CONTROL 33  Antimicrobial Stewardship Program (ASP) in Hospital  ASP team (a multidisciplinary teamwork) oAn infectious disease physician. oAn infection control practitioner. oA microbiologist. oA clinical pharmacist. oA computer informational technologist. oA hospital epidemiologist. INFECTION PREVENTION & CONTROL 34  Supplemental Antimicrobial Stewardship Strategies 1) Education with active intervention to change prescribing practices. 2) Guidelines and clinical pathways incorporating local microbiology and resistance patterns to improve antimicrobial utilization. 3) Antimicrobial cycling and schedule antimicrobial switch. 4) Antimicrobial order forms with an automatic stop function. 5) Combination therapy which indicated only in certain clinical situation. INFECTION PREVENTION & CONTROL 35  Supplemental Antimicrobial Stewardship Strategies 7) Dose optimization depending on patient characteristics, causative organism, site of infection and pharmacokinetic and pharmaco- dynamics of the drug is an important part of antimicrobial stewardship. 8) Conversion from parenteral to oral therapy when the patient's condition allows can decrease length of hospital stay and health care cost. INFECTION PREVENTION & CONTROL 36 Components of Anti-microbial Stewardship Program (ASP) INFECTION PREVENTION & CONTROL 37  Process Measure Indicators  Compliance with current clinical treatment guidelines: Number of patients with an indication receiving empirical treatment with antibiotic(s) according to clinical guidelines Total number of patients with this indication. INFECTION PREVENTION & CONTROL 38  Process Measure Indicators  Stop/review date: Number of patients with a written stop/review date for antibiotic treatment Total number of patients treated with antibiotic(s) INFECTION PREVENTION & CONTROL 39  Process Measure Indicators  48-hour review: Number of patients where a 48-hour review is performed Total number of patients treated with antibiotic(s) hospitalized >48 hours using sample AMS review. INFECTION PREVENTION & CONTROL 40 Sample AMS Review Form INFECTION PREVENTION & CONTROL 41  Outcome Measure Indicator DOTs per 1000 patient-days: Days of therapy with an agent during a period of time ×1000 Total number of patient -days within days within that period of time to obtain data per 1000 patient patient-days. INFECTION PREVENTION & CONTROL 42  WHO INFECTION PREVENTION & CONTROL  Antibiotic Awareness Week  In 2015, the World Health Organization formally announced the first global Antibiotic Awareness Week.  Antibiotic Awareness Week is an annual, global event to raise awareness about the serious health issue of antibiotic resistance.  The event encourages people around the world to use antibiotics responsibly. The week arose from Antibiotic Awareness Day, which takes place globally on 18 November each year. INFECTION PREVENTION & CONTROL 44  Antibiotic Awareness Week  The campaign aims to create behavior change and drive down inappropriate antibiotic prescribing by delivering targeted education programs to health professionals, analyzing data on antibiotic prescribing and encouraging people to learn more and take the pledge to fight antibiotic resistance. INFECTION PREVENTION & CONTROL 45  Antibiotic Awareness Week The campaign reminds everyone that: o Misusing antibiotics can cause harm. o Antibiotic resistant bacteria could be passed on. o Antibiotics are a precious resource that should be handled with care. INFECTION PREVENTION & CONTROL 46 Antibiotic Awareness Week INFECTION PREVENTION & CONTROL 47 Methicillin-Resistant Staphylococcus Aureus (MRSA) INFECTION PREVENTION & CONTROL  Methicillin-Resistant Staphylococcus Aureus (MRSA)  Staphylococcus aureus is a species of bacterium commonly found on the skin and/or in the noses of healthy people.  Although it is usually harmless at these sites, it may occasionally get into the body (e.g. through breaks in the skin) and cause infections.  These infections may be mild (e.g. pimples or boils) or serious (e.g. infection of the bloodstream, bones or joints).  It is a type of Staphylococcus aureus that is resistant to the antibacterial activity of methicillin and other related antibiotics of the penicillin class (such as flucloxacillin). INFECTION PREVENTION & CONTROL 49  Methicillin-Resistant Staphylococcus Aureus (MRSA)  History of resistance of Staphylococcus aureus:  The treatment of infections due to Staphylococcus aureus was revolutionized in the 1940s by the introduction of penicillin.  However, most strains of Staphylococcus aureus are now resistant to penicillin. This is because Staphylococcus aureus produces ß-lactamase that degrades penicillin, destroying its antibacterial activity.  In the early 1960s, a new type of penicillin called methicillin was developed.  Methicillin was not degraded by ß-lactamase. INFECTION PREVENTION & CONTROL 50  Methicillin-Resistant Staphylococcus Aureus (MRSA)  History of resistance of Staphylococcus aureus:  Subsequently, methicillin was replaced by newer and better penicillin-type antibiotics (such as flucloxacillin) that were also not affected by ß-lactamase.  Shortly after the introduction of methicillin, certain strains of Staphylococcus aureus emerged that were resistant to methicillin (and also to the newer drugs such as flucloxacillin). INFECTION PREVENTION & CONTROL 51  Methicillin-Resistant Staphylococcus Aureus (MRSA)  Types of MRSA infections:  In hospital MRSA - (HA. MRSA).  In community MRSA - (CA. MRSA). INFECTION PREVENTION & CONTROL 52  Hospital Acquired MRSA (HA. MRSA)  Some patients harbor MRSA on their skin or nose (colonized).  However, these patients may develop infections if the MRSA spread to other parts of the body (endogenous infection).  Some patients are at increased risk of developing infection. They include those with breaks in their skin (due to wounds or indwelling catheters) which allow MRSA to enter the body. INFECTION PREVENTION & CONTROL 53  Hospital Acquired MRSA (HA. MRSA) The spread between patients is called cross-infection. In addition, MRSA may be spread via contaminated equipment or environment. Individuals colonized with MRSA may also serve as a 'reservoir‘ of MRSA that may spread to other patients. These strains are known as epidemic MRSA (or EMRSA for short). INFECTION PREVENTION & CONTROL 54  Prevention of MRSA Transmission Contact isolation for patients colonized or infected with MRSA. HH and PPE (gloves and disposable gowns) prior to having contact with MRSA patients. Visitors should wear disposable gloves, gowns and wash their hands before leaving the room. Environmental cleaning: MRSA can survive on inanimate objects or surfaces such as linen, sinks, floors and even mops used for cleaning. INFECTION PREVENTION & CONTROL 55  Diagnosis of MRSA  Swab of an infected wound or a blood sample are taken from the patient (This process may take several days).  Sometimes more rapid tests which detect the DNA typically found in MRSA may be undertaken( DNA probes).  Colonization with MRSA is detected similarly, using swabs from person's skin or from the inside of the nose. INFECTION PREVENTION & CONTROL 56 INFECTION PREVENTION & CONTROL 57