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ANTIMICROBIAL STEWARDSHIP

Dr.T.V.Rao MD

DR.T.V.RAO MD

WHY WE NEED ANTIBIOTICS


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.
DR.T.V.RAO MD

WHAT WENT WRONG WITH ANTIBIOTIC USAGE


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.


DR.T.V.RAO MD

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

SPREAD OF ANTIBIOTIC RESISTANCE


Indiscrimate use of Antibiotics in Animals and Medical practice R plasmids spread among coinhabiting 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

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

COSTS ASSOCIATED WITH INCREASED BACTERIAL RESISTANCE

Treatment failures

Morbidity and mortality


Risk of hospitalization Length of hospital stays Need for expensive and broad spectrum antibiotics
DR.T.V.RAO MD

BEST WAY TO KEEP THE MATTERS IN ORDER


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)

DR.T.V.RAO MD

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 something entrusted to one's care
DR.T.V.RAO MD

THEREFORE, ANTIBIOTIC STEWARDSHIP..


An activity that includes appropriate selection, dosing, route, and duration of antimicrobial therapy.
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WHAT IS ANTIBIOTIC STEWARDSHIP?


A program that encourages judicious (vs injudicious) use of antibiotics
Antibiotics are relatively so effective, non-toxic and inexpensiveso easy to usethat 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

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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

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SHOULD RESTRICT AND RATIONALIZE ANTIBIOTIC USE


Antimicrobial stewardship + Infection control program
Can limit the emergence and transmission of antimicrobial-resistant bacteria
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GOALS OF AB STEWARDSHIP
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
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GUIDELINES FOR DEVELOPING AN INSTITUTIONAL PROGRAM TO ENHANCE ANTIMICROBIAL STEWARDSHIP An institutional program to enhance antimicrobial stewardship

Antimicrobial Stewardship Team

Antimicrobial Stewardship Program

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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
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ELEMENTS OF AN ANTIMICROBIAL STEWARDSHIP PROGRAM


Active Antimicrobial Stewardship Strategies

Monitoring of Process and Outcome Measurements

Supplemental Antimicrobial Stewardship Strategies

Comprehensive Multidisciplinary Antimicrobial Management Programs

Computer Surveillance and Decision Support

Microbiology Laboratory
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ACTIVE ANTIMICROBIAL STEWARDSHIP STRATEGIES


1. Prospective audit with intervention and feedback.
A medium-sized community hospital resulted in a

22% decrease in the use of parenteral broadspectrum antimicrobials.


They also demonstrated a decrease in rates of C. difficile infection & nosocomial infection compared with the preintervention period.
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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.
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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.
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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.


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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
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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
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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.

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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
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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)
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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

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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.

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STREAMLINING OR DEESCALATION 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
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CDC VISION 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 difficileassociated diarrhea, shorter hospital stays, reduced overall antimicrobial resistance within the facility, and cost savings
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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

CONVERSION FROM PARENTERAL TO ORAL THERAPY


Enhanced oral bioavailability among certain antimicrobials such as fluoroquinolones, oxazolidinones, metronidazole, clindamycin, trimethoprimsulfamethoxazole, fluconazole, and voriconazole

Therefore, allows for conversion to oral therapy once a patient meets defined clinical criteria

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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

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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.
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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
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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 deescalate or stop treatment if appropriate (Hospital).
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PRACTICE RATIONALISM IN ANTIBIOTIC USEPROMOTE 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 settingfrom the smallest to the largest. 3 Improving antibiotic use is a medication-safety and patient-safety issue.

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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 weaknesse s

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GOOD HAND WASHING PRACTICES STILL REDUCES ANTIBIOTIC RESISTANCE AND SPREAD

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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 t reatment.
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Programme created by Dr. T.V.Rao MD for Medical Professionals in the Developing world
Email doctortvrao@gmail.com

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