Infection Prevention and Control

Video Transcript
Mechanisms of Antibiotic Resistance, Antibiotic Stewardship and Antibiogram
Antibiotic Stewardship and Antibiogram
Welcome to this learning session on antibiotic resistance, antibiotic stewardship, and antibiogram:
Antibiotic Stewardship and Antibiogram
Antibiotic Stewardship
Antibiotic Stewardship
• The use of antibiotics in clinical practice is influenced by the knowledge and expectations of
the clinician, interactions between the clinician and the patient, and the policies and
regulations of the healthcare system.
• Hospitals are the marketplace of antimicrobial misuse and antimicrobial resistance.
• Multi-drug resistant organisms are a common cause of healthcare-associated infections.
Cross infections with these agents can result in the spread of antimicrobial resistance to the
general community. Infection control measures should also be instrumental in preventing the
transmission of these infections. Therefore, hospital policies must integrate antimicrobial
stewardship programs. This process translates into a reduction of healthcare-associated
infections in the long run.
Antimicrobial Stewardship (AMS) is defined as the optimal selection, dosage, and duration of
antimicrobial treatment that results in the best treatment outcome and prevention of infection, with
minimal toxicity to the patient and subsequent development of resistance.
AMS refers to a set of coordinated strategies to improve the use of antimicrobials to enhance
patient health outcomes, reduce resistance to antibiotics, and decrease unnecessary costs.
The goals of antimicrobial stewardship are:
• To enable healthcare practitioners to help each patient receive the most appropriate
antimicrobial with the correct dose and duration
• To prevent antimicrobial overuse, misuse, and abuse
• To minimize the development of resistance
The Cycle of Antimicrobial Stewardship
The Cycle of Antimicrobial Stewardship
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The cycle of Antimicrobial Stewardship include:

• Diagnosis of infection
• Considering non-antibiotic alternatives
• Rational use of antimicrobial drugs
• Review of antimicrobial use
Rational Use of Antibiotics
Rational Use of Antibiotics
Resistance to bacteria is developed by both appropriate and inappropriate antibiotic usage.
Reportedly, the use of antibiotics has been extensive and inappropriate in most countries.
The rational use of antibiotics does not aim at reducing antibiotic use alone but also towards
ensuring that the use is appropriate. Misuse of antibiotics is usually done due to the lack of
awareness, lack of evidence-based practice guidelines, fear of secondary infections, fear of losing
patients, and a false sense of security.
W.H.O. strategies to promote rational antibiotic prescribing:
• To ensure appropriate ordering of therapeutic and preventive treatments, computer checks
can be programmed into hospital information systems (H.I.S.) for providing reminders,
warnings, and other suggestive strategies.
• Educational outreach could also be used as an effective strategy to facilitate appropriate
usage.
• Barriers like disagreement among experts, availability or alternative practices, patient
incompliance, institutional inertia, vested interests, ineffective medical education, the
inapplicability of guidelines to specific patient subgroups, and uncertainty about how and
when to apply evidence-based medicine measures can be carefully intervened by barrier-
oriented interventions.
• A checklist should be used to track the effective implementation of antibiotic usage.
• Monitoring of antimicrobial prescription practices can be done effectively with the help of
prescription auditing. This can help physicians improve their antimicrobial prescription skills
and help organizations adhere to, monitor, and improve compliance with the antibiotic
policy.
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Inappropriate Antibiotic Usage

Examples of inappropriate antibiotic usage
Antibiotics can be either overused or misused in the following instances:
• Apparent viral respiratory illnesses in children do not require antibiotic treatment unless a
bacterial infection has been diagnosed.
• When children or adults have ear infections, antibiotic eardrops could be preferable to oral
antibiotic administration.
• Treatment of viral conjunctivitis should not be done with antibiotics. Antibiotics should be
used only if a person is diagnosed with bacterial conjunctivitis.
• Skin conditions like eczema, which can be treated with topical creams or lotions, do not
require antibiotics.
• It is normal for older persons to have bacteria in their urine, which can be detected during
routine urine tests. This does not require prescribing antibiotics unless the person displays
symptoms of an infection in the urinary tract.
Antibiotic Treatment Strategies
Empiric Therapy
• Empiric therapy is an initial therapy that is guided by clinical presentation and the hospital
antibiotic policy. It is initiated after collecting the sample for culture before the
microbiological results and culture studies are available. The antibiotics are given during
empiric therapy usually cover multiple possible pathogens.
• It may consist of broad-spectrum antibiotics or a combination of different antibiotics which
are effective against the most likely cause of the infection. This therapy is used when the
organism causing the infection in an individual has not been identified.
Definitive Therapy
Definitive therapy involves a narrow-spectrum antibiotic to treat an infection after identifying the
causative organism. Definitive therapy is based on the patient's diagnostic results and the
subsequent identification of the organism responsible for the infection. This therapy involves
specific efficacy against particular organisms, unlike empiric therapy that works for a wide range of
bacteria.
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Antibiotic Treatment Strategies

Antibiotic Escalation and De-Escalation Strategies
Antibiotic escalation is a process of accelerating the antibiotic coverage in a patient according to
the results of microbiological investigations or when the patient does not respond to empiric
therapy.
A higher dose of the antibiotic is used for treatment, or the antibiotic is changed based on the type
of infection that has to be treated.
De-escalation is a mechanism where effective initial antibiotic treatment is achieved while avoiding
the unnecessary use of antibiotics. It is important for preventing the development of resistance. De-
escalation plays a significant role in antimicrobial stewardship and should be a part of routine
antimicrobial management. Once the culture and sensitivity reports are available, the empiric
antibiotics are stopped, reduced in number, or changed to a narrow spectrum.
Hospital Antibiotic Policy
An antibiotic policy is a set of strategies and activities undertaken in a hospital to optimize antibiotic
usage and promote antimicrobial stewardship to achieve patients' best possible health outcomes.
The infection prevention and control committee in a hospital function as the advisory board for the
hospital antibiotic policy. A hospital antibiotic policy must be formulated based on the following
principles:
• The policy must promote evidence-based practices considering the local epidemiology and
resistance patterns with adequate freedom for prescribing physicians.
• The policy must minimize the morbidity and mortality due to antibiotic-resistant infections
and preserve the effectiveness of the antibiotics.
• The policy must have specific recommendations for treating target groups like immuno-
compromised hosts, hospital-acquired infections, and community-acquired infections.
• The policy should also set the levels for prescribing antibiotics. All doctors can prescribe
First-choice antibiotics. Restricted antibiotics are to be prescribed after consultation with the
antimicrobial team (AMT) or the department head. Reserve antibiotics are to be prescribed by
designated experts alone.
Components of Antibiotic Policy
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An antibiotic policy must have three components:

• Direction: Involves tailoring a list of therapeutic antibiotic categories for a hospital and
developing protocols for prophylactic antibiotics. Strategies of implementation should also
be developed. Policies should be prepared at the clinical condition level, department level,
and hospital level.
• Education: The designed policy is to be introduced to the clinicians, and the subsequent
protocol is to be conveyed. Formal courses on antibiotic combinations, indications for
antibiotic therapy can be imparted.
• Monitoring and Evaluation: Surveys should be conducted to determine the inappropriate use
of antimicrobials through antimicrobial audits. Monitoring should be done at the hospital-
pharmacy level. The policy can be evaluated by understanding the impact on cost, bacterial
resistance, and patient care.
Key Players
Apart from the prescribing clinicians, the management, laboratory staff, and pharmacy must also be
trained and involved in implementing antibiotic policy.
Management: The responsibilities of the administration or the administerial staff includes the
following:
• Establish a comprehensive infection prevention and control program which is responsible for
the prevention and management of antimicrobial resistance in the hospital
• Institute a hospital therapeutics committee that oversees the antimicrobial practices in the
hospital
• Update the hospital drug formulary
• Create guidelines for the usage of antimicrobials and monitor the same with timely feedback
to the prescribers
Diagnostic Laboratories: The diagnostic laboratories in and associated with the hospital will be
concerned with the following:
• Provide adequate microbiology services according to the level of care provided by the
hospital
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• Maintain quality standards and performance of the diagnostic services, especially culture and
antimicrobial susceptibility testing results
• Record the resistance patterns and provide surveillance data of common pathogens to the
clinicians
Pharmacist: The role of a pharmacist in hospital antibiotic policy includes the following:
• Lead the stewardship program and ensure its implementation, maintenance, and promotions
• Ensure the availability of quality antimicrobial agents and their safe storage, dispensing, and
disposal
• Collaborate with infection control team, therapeutics committee, and the clinicians for
implementation of antimicrobial policy
Antibiogram
An antibiogram is a profile of the susceptibilities of specific microorganisms to a panel of
antimicrobial drugs. An antibiogram guides the clinicians and pharmacists in selecting empiric
antimicrobial treatment when the results of microbiology culture and susceptibility are pending.
Furthermore, they are helpful tools for the detection and monitoring of trends in antimicrobial
resistance.
Preparation of Antibiogram
• The laboratory generates an antibiogram profile by using the aggregate data from a hospital
or healthcare system. The collected data is summarized periodically and presented, showing
percentages of isolates susceptible to a particular antimicrobial drug.
• The Clinical and Laboratory Standards Institute (CLSI) published guidelines entitled “Analysis
and Presentation of Cumulative Antimicrobial Susceptibility Test Data” for creating an
antibiogram. Antibiograms are compiled by microbiology laboratory technologists in
collaboration with the pharmacist, clinicians, and infection prevention and control teams.
Making an antibiogram is the first step that should be done before framing the antibiotic
policy.
• An antibiogram has to be regularly updated. Most hospitals update their antibiogram on an
annual basis. If any, the profile should be shared on the organization’s intranet to make it
accessible to various departments.
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Conclusion
we have reached the end of this session. let us conclude:
• Intrinsic resistance and acquired resistance determine the antibiotic resistance
• Changes in cell permeability to the antibiotics, induction or activation of efflux pumps, target
modifications, and inactivating enzymes are the mechanisms by which the bacteria develop
resistance.
• Antimicrobial stewardship is the optimal selection, dosage, and duration of antimicrobial
treatment that results in the best treatment outcomes.