Antimicrobial stewardship: a

competency based approach

Introduction

0
 " Antimicrobial resistance is a crisis that
must be managed with the utmost
Dr. Margaret Chan urgency. …We cannot allow hard-won
gains for health to be eroded by the
failure of our mainstay medicines.”
2015 WHO Global
Action Plan on
Antimicrobial
Resistance

1
Antimicrobials are life-saving drugs

2
Antimicrobial resistance requires a
global solution

3
1) Improve awareness and understanding of AMR through effective
communication, education and training
2) Strengthen knowledge through surveillance and research
3) Reduce the incidence of infection
4) Optimize the use of antimicrobial medicines in human and animal
health
5) Develop the economic case for sustainable investment (in AMR)

4
1) Improve awareness and understanding of AMR through
effective communication, education and training
2) Strengthen knowledge through surveillance and research
3) Reduce the incidence of infection
4) Optimize the use of antimicrobial medicines in human and animal
health
5) Develop the economic case for sustainable investment (in AMR)

5
1) Improve awareness and understanding of AMR through
effective communication, education and training
2) Strengthen knowledge through surveillance and research
3) Reduce the incidence of infection
4) Optimize the use of antimicrobial medicines in human and
animal health
5) Develop the economic case for sustainable investment (in AMR)

6
Antimicrobials are societal drugs
Antimicrobial
use

Antimicrobial resistance

7
Antimicrobials are societal drugs
Using antimicrobials
wisely
Antimicrobial
use

Antimicrobial resistance

8
We must all be antimicrobial stewards

Stewardship:
the careful and responsible
management of natural
resources

9
We must all be antimicrobial stewards
Drug

prescription
Dose .............
.............
Route
.............

Duration

10
We must all be antimicrobial stewards

Microbiology guides therapy wherever possible

Indications should be evidence based
Narrowest spectrum required
Dosage appropriate to the site and type of infection
Minimise duration of therapy
Ensure monotherapy in most cases

11
Adjusting the clinical approach

12
 Course content

Course roadmap
Basic concepts

Common infections

13
 Course framework:
the clinician-patient encounter
Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation

14
Course framework:
Initial evaluation
Diagnostic work-up
Clinical
Therapeutic decisions
assessment
Patient education

Initial evaluation

15
Course framework:
Initial evaluation
Diagnostic work-up
Clinical
Therapeutic decisions
assessment
Patient education

Initial evaluation

16
Course framework:
Initial evaluation
Diagnostic work-up
Clinical
Therapeutic decisions
assessment
Patient education

Initial evaluation

17
Course framework:
Initial evaluation
Diagnostic work-up
Clinical
Therapeutic decisions
assessment
Patient education

Initial evaluation

18
Course framework:
Initial evaluation
Diagnostic work-up
Clinical
Therapeutic decisions
assessment
Patient education

Initial evaluation

19
Course framework:
Subsequent evaluation

Data review Modify

Clinical re- antimicrobials
assessment

Subsequent evaluation

20
Course framework:
Subsequent evaluation

Data review Modify

Clinical re- antimicrobials
assessment

Subsequent evaluation

21
Course framework:
Subsequent evaluation

Data review Modify

Clinical re- antimicrobials
assessment

Subsequent evaluation

22
Course framework:
Subsequent evaluation

Data review Modify

Clinical re- antimicrobials
assessment

Subsequent evaluation

23
 Principles of optimal antimicrobial use

Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
Initial evaluation education
Initial evaluation Subsequent evaluation

24
 Core competencies for antimicrobial
prescribing
C1: Understands the patients and their clinical needs
C2: Understands treatment options and how they support the
patient’s clinical needs
C3: Works in partnership with the patient and other healthcare
professionals to develop and implement a treatment plan
C4: Communicates the treatment plan and its rationale clearly to
the patient and other health professionals
C5: Monitors and reviews the patient’s response to treatment

25
 Diagnostic
work-up
Clinical
Clinical Therapeutic re-assessment Modify
assessment decisions antimicrobials
Data
Patient review
education
Initial evaluation Subsequent evaluation
Initial evaluation Subsequent evaluation
Core competencies C1, C2, C3, C4, C5

26
Questions for front-line clinician

27
Questions for front-line clinician

Are antimicrobials indicated?

28
Questions for front-line clinician

Are antimicrobials indicated?

If yes, what drug is the best choice?

29
Questions for front-line clinician

Are antimicrobials indicated?

If yes, what drug is the best choice?

How can I limit the societal impact of this

antimicrobial use?

30
31
Course content developed by:
Marisa Holubar, MD MS
Clinical Assistant Professor, Infectious Diseases
Associate Director, Stanford Antimicrobial Safety
& Sustainability Program
Stanford University School of Medicine
Elizabeth Robilotti, MD MPH
Assistant Attending, Infectious Diseases
Associate Director, Infection Control
Memorial Sloan Kettering Cancer Center

Stan Deresinski, MD
Clinical Professor, Infectious Diseases
Director, Stanford Antimicrobial Safety
& Sustainability Program
Stanford University School of Medicine

32
 Course content reviewed by:
Tjalling Leenstra, MD PhD Hrachuhi Ghazaryan, MD
Head, WHO Collaborating Centre for Antimicrobial General Paediatrician
Resistance Epidemiology and Surveillance Head of General Paediatric department
Centre for Infectious Disease Control Arabkir Joint Medical centre
National Institute fro Public Health and the Environment Assistant Professor in Yerevan State Medical University
The Netherlands after M. Heratsi, chair of Paediatrics N2
Yerevan, Armenia
Muna ABU SIN, MD, MSc
Robert Koch-Institute
Department for Infectious Disease Epidemiology
Healthcare-associated Infections, Surveillance of
Antibiotic Resistance and Consumption
Germany

33
 WHO advisors:
Saskia Nahrgang, MD MPH
Technical Officer Programme Control of Antimicrobial Resistance
WHO Regional Office for Europe

Danilo Lo Fo Wong, PhD

Programme Manager, Programme Control of Antimicrobial Resistance
WHO Regional Office for Europe

34
References: General
• World Health Organization. Global Action Plan on Antimicrobial Resistance. Sixty-
eighth World Health Assembly (document WHA68/2015/REC/1, Annex 3.
http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf
• Fleming-Dutra KE, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among
US Ambulatory Care Visits, 2010 – 2011. JAMA 2016 May 3; 315(17):1864-73. doi:
10.1001/jama.2016.4151.
• The Review on Antimicrobial Resistance Chaired by Jim O’Neill. Tackling drug-
resistant infections globally: Final report and recommendations. May 2016.
http://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf
• Centers for Disease Control and Prevention. ANTIBIOTIC RESISTANCE THREATS
in the United States, 2013. http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-
508.pdf

35
 References: Core Competencies
https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20sta
ndards/Prescribing%20competency%20framework/prescribing-competency-framework.pdf

https://www.nps.org.au/__data/assets/pdf_file/0004/149719/Prescribing_Competencies_Framework.pdf

https://www.gov.uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies

http://apps.who.int/medicinedocs/pdf/whozip23e/whozip23e.pdf

http://www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf

http://www.euro.who.int/__data/assets/pdf_file/0010/288253/HWF-Competencies-Paper-160915-
final.pdf?ua=1

36