Orientation to Antimicrobial Stewardship ProgramHEBATALLAH MOHAMMED ABDALLATIF,BCPS

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“Person playing with penicillin is morally responsible for the death of the man who finally succumbs to infection with the penicillin- resistant organism. I hope this evil can be averted.”

SIR ALEXANDER FLEMING NEW YORK TIMES JUNE 26, 1945

Antimicrobial use

Antibiotics are one of the miracles of modern Science

Antibiotics saved millions of lives.

This has led to their misuse through use without a prescription and overuse for self-limiting infections

Antibiotics continue to save lives every day…..

Neonatal care Transplantation Chemotherapy for

malignancy Immunosuppression Safe surgery Safe obstetric care Intensive care

interventions

Antimicrobial resistance

First discovery in United States of colistin resistance in a human E. coli infection

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E. coli bacteria carrying the MCR-1 gene was found in a urine sample from a Pennsylvania woman with no recent travel outside of the U.S.

The mcr-1gene exists on a plasmid spreading antibiotic resistance among bacterial species.

Resistance Consequences

Colistin Previously abandoned because of its high rates of nephrotoxicity and neurotoxicity

It Considered the last resort for Gram-negative Resistant Strain Escherichia coli, Acinetobacter baumanni,Pseudomonas aeruginosa, Klebsiella pneumonia, and Enterobacter sp

Resistance Consequences

At least 2 million people acquire serious infections with bacteria that are resistant

At least 14,000 people die each year in the United States from C. difficile infections.

Collateral damage

Term used to describe the adverse ecological effects of antibiotic therapy

Cephalosporin use has been linked to infection with vancomycin-resistant enterococci, extended-spectrum β-lactamase—producing Klebsiella pneumoniae, β-lactam—resistant Acinetobacter species, and Clostridium difficile.

30-50 % of antibiotics prescribed in hospitals are unnecessary or inappropriate

Misuse Reasons

Use of antibiotics when not neededcontinued treatment

when no longer necessary

use of broad-spectrum agents to treat very susceptible bacteria

wrong antibiotic to treat an infection

Antimicrobial resistance has been identified as a major threat by the Who

How does antibiotic resistance occur?!

ANTIMICROBIAL RESISTANT STRATEGIES

Antimicrobial resistance mechanisms

Intrinsic Resistance

• Innate ability of a bacterial species to resist activity of a particular antimicrobial agent through its inherent structure

Acquired resistance

Results from successful gene change and/or exchange that may involve: mutation or horizontal gene transfer via transformation, transduction or conjugation

Antimicrobial resistance mechanisms

Biofilm Mechanism

Biofilms are communities of aggregated bacterial cells embedded in a self-produced extracellular polymeric matrix

‘Persister’ cells ,wild-type cells that neither grow nor die in the presence of bactericidal agents

Indwelling devices are usually associated with microbial biofilms and eventually lead to catheter-related bloodstream infections (CLABSIs).

Biofilm Mechanism

Blood Stream Infection

VRE VSE0%

10%20%30%40%50%60%70%

Blood Stream Infection

Survival Rate

59% of the patients with VSE bacteremia survived vs 24% with VRE (P=.009), despite similar severity-of-illness scores.

Stosor V1, Peterson LR, Postelnick M, Noskin GA

Costs Associated withIncreased BacterialResistance

↑Treatment failures

↑Morbidity and mortality

↑Risk of hospitalization

Need for expensive and broad spectrum antibiotics

Antibiotic Resistance Threats

Bad bugs, no drugs: no ESKAPE!

The IDSA proposed solutions in its 2004 policy report, "Bad Bugs, No Drugs: As Antibiotic R&D Stagnates, a Public Health Crisis Brews

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Bad bugs, no drugs: no ESKAPE!

Dramatically increasing rates of drug-resistant bacterial infections

Regulatory approval of new Drugs have declined

ESKAPE

2020Ten New Antibiotics BY

Combating Antibiotic resistance

Optimize the use of existing antimicrobial agents

Prevent the transmission of drug-resistant organisms through infection control

Improve environmental decontamination

CDC 12 Steps

Antimicrobial Stewardship Program Definition

Coordinated Actions designed to improve and measure the appropriate use of antimicrobials

Optimal antimicrobial Drug Regimen

Optimal DoseOptimal DurationOptimal Route

Antimicrobial Stewardship Goals

Minimizing unintended consequences of antimicrobial use, including :Improve infection cure rates Reduce surgical infection rates Reduce mortality and morbidity

Primary Goal

Reduce health care costs without adversely impacting quality of care.

Secondary Goal

Antimicrobial Stewardship Goals

stewardship program with strictimplementation of infection control measures leading to sustainedreduction in [CDI] cases

THE TEAM

Ideal ASP Team

Infection Control

Support Team

Microbiologist

Infectious Disease Physician

Clinical Pharmacy

Core Team

Hospital,Pharmacy Administration Collaborative

Clinical Pharmacy

The clinical pharmacist should be knowledgeable on the appropriate use of antimicrobials, and appropriate training should be made available to achieve and maintain this expertise.

Infection Control

The combination of effective antimicrobial stewardship with a comprehensive infection control program has been shown to limit the emergence and transmission of antimicrobial-resistant bacteria

Getting Started

Starting an ASP requires multiple steps.

An institution should assess its current practices to understand the prescribing environment and scope of the antimicrobial resistance issue

An institution should consider the following elements

What is the prescribing climate what are staff perceptions of the need for an ASP?

What are the common clinical infectious disease syndromes?

An institution should consider the following elements

Aggregate antibiotic use [e.g., units individual patients in defined daily dose (DDD)

Pharmacy Data

Microbiology Data

Rates of resistance in common pathogens

PLANNING AND IMPLEMENTATION

It is recommended to identify 1 or 2 target areas for intervention based on findings from the assessment of current practices and on resource availability.

1. Common clinical infectious syndromes treated at the facility (e.g., UTI, CAP, “fever”) 2. Specific pathogens 3. Specific antimicrobial agents

Core Elements of ASP

Core Element 1: Leadership Commitment

Antibiotic stewardship programs need clear support from hospital leadership

Communicate regularly the importance of improving antibiotic use and the hospital’s commitment to antibiotic stewardship.

Core Element 2: Accountability

Appointing a leader or co-leaders, who are responsible for program outcomes and whose effectiveness is assessed through clear performance standards, provides accountability for antibiotic stewardship.

Core Element 3: Drug Expertise

Dedicated staff with demonstrated drug expertise is critical to the success of antibiotic stewardship

Core Element 4: Actions to Support Optimal Antibiotic Use

Implement a policy for review of antibiotic orders

Ensure that the prophylactic, empirical, and therapeutic uses of antimicrobial agents result in optimal patient outcomes.

Core Element 5: Tracking

Systematic collection of antibiotic use and resistance

Antibiotic Use Measures Adherence to documentation

policies

Core Element 7: Education

Education about causes and trends of antibiotic resistance and guidance on approaches

Education is provided on a regular basis to all staff as well as patients and families; education is targeted where appropriate.

Core Element 6: Reporting Information on Improving Antibiotic Use and Resistance

Regular reporting of information on antibiotic use and resistance to physicians, nurses

Develop facility-specific treatment recommendations based on national guidelines and local susceptibility data

PLANNING AND IMPLEMENTATION

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Once the target area(s) have been identified

Determine which evidence-based strategies may be most effective

Begin planning the implementation process

Unit Specific Lab Data

ASP in NICU

ASP In NICU

Neonate’s response to an infectious insult is challenging to differentiate from other pathologic Process

Infants hospitalized in the NICU have high rates of health care associated infections and subsequently high rates of antibiotic use

Neonates are at high risk of acquiring health care–associated infections because of impaired host-defense mechanisms

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Broad spectrum antibiotics exposure has been associated with the emergence of multi-drug resistant gram-negative bacilli and development of invasive candidiasis

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Prolonged duration of empiric antibiotic therapy for early onset sepsis in extremely low birth weight infants has been associated with increased risk of death and necrotizing enterocolitis (NEC)

Healthcare associated infections in NICU

CVCs are essential for (VLBW) , (ELBW) infants requiring parenteral nutrition.

The majority of nosocomial infections are due to CLABSI

Unique Challenges in Antibiotic Prescribing in the NICU

Signs and symptoms of sepsis in infants are non-specific

Treatment guidelines are often not established for infants, particularly for preterm neonates

ASP IDSA 2016 Updates

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facility-specific guidelines for selected common and important infectious syndromes

Syndrome guidelines should include a recommended duration of therapy for each specific infectious syndrome.

CLABSI

Catheter-related bloodstream infections are the most common hospital-acquired infections in NICUs

A large proportion of these infections may be preventable.

ASP in Nicu

Requires significant consideration of the special needs of the neonatal population.

The pK and PD of neonates have variability based on GA,weight, and skin ,renal maturity

Colleen Nash, MD, et al,NeoReviews Vol.15 No.4 April 2014

ASP in NICU

Identifying patients who need antibiotic therapyUsing local epidemiology

Avoiding agents with overlapping activityAdjusting antibiotics when culturesresults become available

Monitoring for toxicity, and optimizing the dose, route, and duration of therapy.

Cornerstone Tactics

Constant reevaluation of the antimicrobial regimen

Monitoring of toxicity

Consideration of shorter antimicrobial courses

NICU Care Bundle

Small set of evidence-based actions for a defined population and care setting implemented together in NICUs has been associated with a reduction in CLABSI rates

This multifaceted approach has reduced the incidence of health care–associated infection in each center or groups of centers where it has been implemented.

Clabsi Prevention Care Bundle

Vap Prevention Care Bundle

•Head-of-bed elevation 300-450

•Re-enforcement of hand hygiene practice

•Sterile suction and handling of respiratory equipment•Intubation, re-intubation and endotracheal tube (ETT) suction as strictly indicated by unit protocol

•Change ventilator circuit if visibly soiled or mechanically malfunctioning•Proper timed mouth care with normal saline and suction of oro-pharyngeal secretion.•Daily evaluation for readiness for extubation to nasal continuous airway pressure (NCPAP) at morning round, and sedation vacation for sedated patient

Success Keys

Establish a clear aim/visionStewardship should be a patient safety priority.Seek management support

Assemble a strong multi-professional teamStart with core evidence-based stewardship actions depending on local needs, plan measurement to demonstrate their impact

Bibliography

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