Antimicrobial Stewardship

1. Antimicrobial Stewardship Dr.T.V.Rao MD Dr.T.V.Rao MD

2. 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. Why we Need Antibiotics Dr.T.V.Rao MD

3. 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. What went wrong with Antibiotic Usage Dr.T.V.Rao MD

4. Science magazine; July 18, 2008 • 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.'" Dr.T.V.Rao MD

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

6. What is Misuse of Antibiotics? 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. Dr.T.V.Rao MD

7. Costs Associated withIncreased BacterialResistance • ↑Treatment failures • ↑Morbidity and mortality • ↑Risk of hospitalization • ↑Length of hospital stays • ↑Need for expensive and broad spectrum antibiotics Dr.T.V.Rao MD

8. 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) Best way to keep the matters in Order Dr.T.V.Rao MD

9. “ what is Stewardship”???? • The office, duties, and obligations of a steward • The conducting, supervising, or managing of something especially:the careful and responsible management of somethingentrusted to one's care Dr.T.V.Rao MD

10. Therefore, Antibiotic Stewardship….. An activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy. Dr.T.V.Rao MD

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

12. Sobering Thoughts 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 Dr.T.V.Rao MD

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

14. 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 Goals of Ab Stewardship Dr.T.V.Rao MD

15. GUIDELINES FOR DEVELOPING AN INSTITUTIONAL PROGRAM TO ENHANCE ANTIMICROBIAL STEWARDSHIP Dr.T.V.Rao MD

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

17. ELEMENTS OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM Dr.T.V.Rao MD

18. Active Antimicrobial Stewardship Strategies • 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

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

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

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

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

23. A good clinical practice saves antibiotics • 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 Dr.T.V.Rao MD

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

25. Choosing the drugs • 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 Dr.T.V.Rao MD

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

27. Combination therapy • 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 Dr.T.V.Rao MD

28. Limitations of combination of antibiotics • 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. Dr.T.V.Rao MD

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 Review by pharmacist & an ID physician of 625 patients receiving combination antimicrobial therapy led to streamlining recommendations in 54% of antimicrobial courses over 7 months, resulting in a projected annual savings of $107,637 .

30. CDCvision 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

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. Conversion from parenteral to oral therapy 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 Dr.T.V.Rao MD

33. Computer Surveillance and Decision Support • 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 Dr.T.V.Rao MD

34. Our clinical Judgment carries many solutions… These guidelines are not a substitute for clinical judgment, and clinical discretion is required in the application of guidelines to individual patients. Dr.T.V.Rao MD

35. Multifaceted strategies can address and decrease antibiotic resistance in hospitals • 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 Dr.T.V.Rao MD

36. Prudent prescribing to reduce antimicrobial resistance • 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). Dr.T.V.Rao MD

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

38. Continuous Medical Education a Must .. • 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 Dr.T.V.Rao MD

39. Good hand washing practices still reduces antibiotic resistance and spread 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. 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 Dr.T.V.Rao MD