Antibiotic Stewardship Programme at the Kenyatta National Hospital , Nairobi , Kenya

Enoch Omonge University of Nairobi

Genesis of antibiotic stewardship initiatives at the Kenyatta National

Hospital • National Medicines and Therapeutic

Committee (Ministry of Health) - AMU• Kenyatta National Hospital (KNH)Medicines

and Therapeutic Committee• KNH Formulary Committee• KNH Infection Prevention and Control Unit• Kenya Antibiotic Consensus Group (Education)

Challenges of infection prevention and Antimicrobial resistance

• Referral hospital - large patient population, inadequate patient isolation space and protocol

• Liberal use of antimicrobials . No preauthorisation policy

• Delay microbiological sample collection and predominant empiric antibiotic therapy

• Absence of treatment protocols and guidelines• Inadequate local PK/PD data• Inappropriate OPAT and easy access to antibiotics

Antibiotic protocols as strategy to appropriate antimicrobial use

• Providing safe use of antimicrobial• Managing antimicrobial resistance • Improving quality of care by enhancing

appropriate antimicrobial selection• Ensuring cost effectiveness

Therapeutic options

EVIDENCE

STANDARDS

AUDITS GUIDELINES

INTERVENTION

•Clinical

•Laboratory

•Imaging

•Rational

•Cost effective

•Evolve

EBM

Omonge e

HOST

DRUGBUG

Composition of the multidisciplinary protocol development team

• Medical specialists• Microbiologists • Clinical pharmacists• Infection prevention and control team • Medicine and therapeutic committee• Representative of the hospital administration

Process of protocol development

• KNH antibiogram used to establish the antibiotic susceptibility pattern

• Similar protocols to be developed for other hospital units

• Periodic revision envisaged every two years • Modifications in special groups e.g

pregnant/lactating mother, renal/hepatic failure, recent antimicrobial therapy, hypersensitivity , drug interactions

Antimicrobial stewardship

• Selecting appropriate antibiotic• Optimising dose and duration of therapy• Minimising toxicity • Reducing resistance selection

Principles of AAU

Principles for appropriate prescribing and effective (locally compliant) guidelines:– TREAT bacterial infection only– OPTIMIZE diagnosis / severity assessment– MAXIMIZE bacterial eradication– RECOGNIZE (local) resistance prevalence– UTILIZE pharmacodynamics - for effective agents and

dosage– INTEGRATE local resistance, efficacy and cost-effectiveness

Appropriate prescribing conforms to these criteria

Ball et al. Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence. J Antimicrob Chemother 2002; 49:31–40

How to use the protocol

• Identify type of infection – bloodstream, respiratory, intra-abdominal, urinary tract, SSTI

• Identify location- CCU• Risk stratify the patient- category 1,2 or 3• Refer to the empiric therapy column• Send respective cultures before starting

antibiotics• De-escalate with culture reports

Incidence (%)

Pathogen n = 31,346

S.aureus 36.3Ps. aeruginosa 19.7Klebsiella spp 8.5

Enterobacter spp 6.5Acinetobacter spp 4.8

E. coli 4.6

Serratia spp 4.1

Stenotrophomonas maltophilia 3.1

S. pneumoniae 2.5

H. influenzae 2.5

Pathogen

Incidence (%)

n=197

K. pneumonia 22.3

Citrobacter spp. 16.2

Ps. aeruginosa 12.7

E. coli 9.6

Acinetobacter spp.

9.6

Enterococcus 9.6

S. pneumoniae 8.1

Proteus spp. 6.6

Enterobacter spp.

5.1

Incidence of pathogens isolated from patients hospitalised with pneumonia in the United States in the last 5 years of the SENTRY

Antimicrobial Surveillance Program

Data from Jones RN. Clin Infect Dis. 2010;51(S1):S81–7.

Incidence of pathogens isolated in aspirates of

patients hospitalised with pneumonia in 2012 at the

KNH CCU

Data from KNH

Algorithm for classifying patients with hospital-acquiredpneumonia according to the Consensus Statement of the American Thoracic

Society. Adapted with permission of the American Thoracic Society. Copyright 1996 American Thoracic Society. Hospital-acquired pneumoniain adults: diagnosis, assessment of severity, initial antimicrobialtherapy, and preventative strategies. A consensus statement.

Am J Respir Crit Care Med 1996; 153:1711–1725.

ATS/IDSA algorithm for initiating empirical antibiotic therapy for hospital-acquired pneumonia (HAP), ventilator-associated pneumonia (VAP),

and health care–associated pneumonia (HCAP) *Prior antimicrobial therapy (within 90 days), hospitalization for

5 days, high frequency of antibiotic resistance in the community or thehospital unit, immunosuppressive disease or therapy. Adapted with permission

of the American Thoracic Society. Copyright 2005 AmericanThoracic Society.

Am J Respir Crit Care Med. 2005; 171:388–416.

Potential Microorganisms in Each Group According to the 1996 Consensus Statement of the American Thoracic Society.

Group 1 Group 2 Group 3

Enteric gram-negative bacilliE. coliEnterobacter spp.Klebsiella spp.Proteus spp.Serratia marcescensH. influenzaeMSSAS. pneumoniae

AnaerobesMSSA and MRSALegionella spp.Ps. aeruginosa

Ps. aeruginosaAcinetobacter spp.MRSA

MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptibleStaphylococcus aureus.

Am J Respir Crit Care Med 1996; 153:1711–1725

Initial Empirical Antimicrobial Treatment for Patients with Hospital-Acquired, Ventilator-Associated, or Healthcare–Associated Pneumonia

ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible S. aureus.

Potential pathogen Recommended treatment

No risk factors for MDR, early onset and any disease severity Ceftriaxone; levofloxacin,

moxifloxacin, ciprofloxacin; ampicillin-sulbactam or ertapenem

S. pneumoniaeH. InfluenzaeMSSAAntibiotic susceptible, enteric gram-negative bacilli E. coli Klebsiella pneumoniae Enterobacter spp. Proteus spp. Serratia marcescens

Initial Empirical Antimicrobial Treatment for Patients with Hospital-Acquired, Ventilator-Associated, or Healthcare–Associated Pneumonia,

ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus aureus;

Potential pathogen Recommended treatment

Late onset disease or risk factors for MDR pathogens and all disease severity

Combination antibiotic therapy: antipseudomonal cephalosporin (cefepime or ceftazidime); antipseudomonal carbapenem (imipenem or meropenem) or b-lactam or b-lactamase inhibitor (piperacillin-tazobactam) plus antipseudomonal); fluoroquinolone (ciprofloxacin or levofloxacin) plus linezolid or vancomycin (if risk factors)

Ps. aeruginosaK. pneumoniae (ESBL)Acinetobacter spp.Legionella pneumophilaMRSA