TAKLIMAT PELAKSANAAN

ANTIMICROBIAL STEWARDSHIP
(AMS)
DI KLINIK KESIHATAN

TARIKH: 5 APRIL 2019

WHAT IS ANTIMICROBIAL
STEWARDSHIP?
Coordinated program that promotes the
appropriate use of antimicrobials (including
antibiotics), improves patient outcomes,
reduces microbial resistance, and decreases the
spread of infections caused by multidrug-
resistant organisms.

Source: CDC
WHY ANTIMICROBIAL
STEWARDSHIP??
INCREASING AMR

i-newspaper (England) 11 March 2013

MORE USAGE, MORE
RESISTANCE!!
ANTIMICROBIAL STEWARDSHIP
(AMS) PROGRAM IN PRIMARY
HEALTH CARE (PHC)
Antibiotic Point Prevalence Survey in
Primary Care in 2015

• Overall antibiotic prescribing rate:

8.92%
• 48.7% URTI was prescibed with
antibiotics Why AMS is
important
in PHC?
ANTIBIOTICS FOR URTI AND UTI
PRESCRIBING IN MALAYSIAN PRIMARY CARE SETTINGS
- Teng CL et al. Australian Family Physician Vol. 40, No. 5, May 2011

URTI are primarily viral

(bacterial aetiology in
unselected URTI cases was
2.4%; pharyngitis
was 14%), these antibiotic
prescribing rates
are far too high

Hong CY, Lin RT, Tan ES, et al. Acute

respiratory
symptoms in adults in general
practice. Fam Pract
2004;21:317–23.
WHAT IS ANTIMICROBIAL
RESISTANCE?

1
Ability of microbes to resist the effects of
drugs – the germs are not killed and their
growth is not stopped.

2
Although some people are at greater risk than others, no
one can completely avoid the risk of antibiotic-resistant
infections.

Source: CDC
WHAT IS ANTIMICROBIAL
RESISTANCE?

3 Infections with resistant organisms are difficult to treat,

requiring costly and sometimes toxic alternatives.

4
Bacteria inevitably find ways of resisting the antibiotics
developed by humans - aggressive action is needed now
to keep new resistance from developing and to prevent
the resistance that already exists from spreading.

Source: CDC
HOW TO COMBAT AMR??
 WHO GLOBAL ACTION PLAN ON AMR

• Improve awareness and understanding of antimicrobial resistance

1
• Strengthen knowledge thru surveillance and research
2
• Reduce the incidence of infection
3
• Optimize the use of antimicrobial
4
• Increase investment in new medicines, diagnostic tools, vaccines and
5 other interventions
 MALAYSIAN ACTION PLAN ON
ANTIMICROBIAL RESISTANCE (2017-
2021)

• Introduced in PHC in 2014

• Revised Version 2018
ANTIMICROBIAL STEWARDSHIP (AMS) PROGRAM IN
PRIMARY HEALTH CARE (PHC)
(STRATEGIES & ACTIVITIES )

Reports the findings on

Implements the NAG, Tx antibiotic surveillance (DDD) &
guidelines & clinical proses audit (clinical, structure
pathways audit & PPS) & ensure actions
taken

Establishes formulary Selects & optimize the

restrictions & approval antimicrobial dose tailored
systems esp. for broad- to the patient’s
spectrum antimicrobials characteristics

Educates prescribers,
pharmacists and paramedics in
good antimicrobial prescribing
practice and AMR
ANTIMICROBIAL STEWARDSHIP
(AMS) PROGRAM IN PRIMARY
HEALTH CARE (PHC)

AMS POLICY
DATED 30/5/2018
AMS PROGRAM MEASUREMENT

• % of KK implementing structure
Process audits
• % of KK implementing clinical audits
indicator • % of KK implementing PPS

• % of KK with structure audit score of >

80%
• % of good practices in antibiotic
Outcome prescription (clinical audit score > 80 %)
• % of appropriate antibiotic prescription for
indicators URTI from PPS
• Pattern of total selected antibiotics
utilization using DDDs
DEVELOPMENT OF
AMS COMMITTEE
FUNCTIONAL STRUCTURE OF AMS AT
DISTRICT AND KLINIK KESIHATAN
LEVEL
District Infection
and Antibiotic
Control Committee

Klinik Kesihatan
Infection and
Antibiotic Control
TEAM
 KLINIK KESIHATAN INFECTION
AND ANTIBIOTIC CONTROL TEAM
(All KK with FMS or PPYM &
Pharmacist)
Link Nurse/Personnel
Infection PPP
Prevention & MLT (Optional)
Control Team
PAKAR IT Officer (Optional)
PERUBATAN
KELUARGA /
Pharmacist
PPYM (Secretariat)
Antimicrobial
Stewardship AMO
Team MLT (Optional)
IT Officer (Optional)
ROLES AND RESPONSIBILITIES OF
KLINIK KESIHATAN AMS TEAM
MEMBERS

Refer
Pg 15 - 16
AUDIT AMS DI KLINIK KESIHATAN

AUDIT STRUKTUR

AUDIT PROSES

POINT PREVALENCE SURVEY

 AUDIT STRUKTUR
• Menilai pelaksanaan elemen utama dan tahap
kemajuan aktiviti AMS di klinik kesihatan
• Audit silang ( cross audit ) – sekali setahun
• Senarai semak – AMSA-1
• Auditor – dilatih & ditetapkan oleh PKD
AUDIT STRUKTUR
Satu (1) skor bagi setiap jawapan yang betul dari setiap auditee
(keupayaan untuk menyampaikan sekurang-kurangnya 1 mesej mengenai preskripsi/
pengambilan antibiotik berdasarkan National Antibiotic Guidelines dan Clinical Pathway).
Seramai 5 orang auditee akan diaudit terdiri daripada pegawai perubatan, ahli farmasi dan
penolong pegawai perubatan

Mesej 1: Antibiotik tidak diperlukan untuk jangkitan virus.

• Contoh Senario: Jika pesakit datang dengan gejala jangkitan URTI ( viral URTI) dan meminta
antibiotik, bagaimanakah respon ada?

Mesej 2: Antibiotik hanya boleh diambil dengan preskripsi.

• Contoh Senario: Pesakit meminta pendapat untuk membeli antibiotik terkini yang boleh didapati
di farmasi swasta, bagaimanakah respon anda?

Mesej 3: Setiap kali dipreskripsi, antibiotik perlu diambil mengikut dos, kekerapan dan
tempoh yang ditetapkan.
• Contoh Senario: Pesakit bertanya sama ada boleh menghentikan antibiotik apabila gejala
bertambah baik, bagaimanakah respon anda?

Mesej 4: Jika antibiotik tidak diambil dengan betul/ sewajarnya, ia akan membawa kepada
kerintangan antibiotik.
• Contoh Senario: Bagaimanakah anda menasihati pesakit akibat daripada penggunaan antibiotik
yang tidak betul/ wajar.
 MARKAH 0 @ 1
• Reason for coming to the
clinic/ history taking*
• Vital sign*

• Physical examination*

• Relevant investigations
•Diagnosis* ( nama penyakit yg di tulis)

•Accurate Diagnosis*

•Notification if indicated

•Antibiotic is indicated*

•Statement on Drug Allergy*

•Prescription driven by C&S (if indicated)

•Correct antibiotic ps based on NAG/ clinical
pathway*

•Antibiotic Prescription using Pharmacological name*

•Correct Dosing and dose adjustment if indicated*

•Correct Frequency*

•Correct Duration*

•Health Education (compliance or side effect)

• Appropriate Referral if indicated
• Appropriate follow up / plan if indicated

• Phone call for outcome if indicated

• Identification of practitioner: Name/ Chop*
 Point prevalence Survey (PPS)
• Point Prevalence Survey is one of the audit process to evaluates the
antibiotic prescribing practices in Health Clinics.
• To be done once a year.
• Phases of Implementation:

• 2019: all health clinics with resident FMS

• 2020: all health clinics
 General Objective
To determine the pattern of antibiotic prescribing in Primary
Health Clinic In Malaysia

Specific Objectives
To determine the percentage of antibiotics prescribtion in
Primary Health Care
To determine the commonly prescribe antibiotic categories
based on MOH Drug Formulary
To determine the prescribing rate of antibiotics in URTI
To identify appropriateness of antibiotic usage for URTI

To identify total antibiotic prescribtions according to

prescriber categories
Criteria case selection

• All Prescriptions prescribed on the study

day (Universal Sampling) including:
• Prescriptions from all age categories
patients
• Prescriptions with oral & injectable
antibiotic received at pharmacy
• Prescriptions with URTI diagnosis
• Prescriptions during office hours and
extended hours
 Exclusion Criteria

• Prescriptions from other health facilities

• Prescriptions for “Sistem Pendispensan
Ubat Bersepadu” (SPUB)
• Partial prescriptions (refill prescription)
• Dental prescriptions
 Terima Priskribsi PF/PPF
CARTA ALIR PROSES KAJIAN PPS
Ya
“POINT PREVALENCE SURVEY” Tidak
preskribsi dengan PF/PPF
  antibiotik

PF/PPF
Isi borang PPS-PC 1

Tidak Ya
diagnosis
URTI Isi borang PPS-PC 2 dan serah kepada FMS PF/PPF

Carian kad pesakit/ care plan FMS

asingkan Kira Jumlah Justifikasi kesesuaian pengunaan FMS

antibiotik

Lengkapkan borang PPS-PC 2 dan serah FMS

kepada Peg Farmasi

Hantar kompilasi PPS-PC 1 dan PPS-PC 2 FP

kepada peg farmasi daerah
 
Hantar kompilasi PPS-PC 1 dan PPS-PC 2 PF
ke negeri Daerah
 

Hantar kompilasi PPS-PC 1 dan PF

PPS-PC 2 ke KKM Negeri
TERIMA KASIH
 ANTIBIOTIC USAGE
IN COMMON &
UNCOMMON INFECTION
IN PRIMARY CARE SETTING

Presenter: DR. MOHD BUSTAMANIZAN BIN BAKAR

Pakar Perubatan Keluarga
Klinik Kesihatan Kuala Rompin
1. RESPIRATORY
INFECTION
Comment?
 CASE 1
• MA, a 2 year old boy was diagnosed with URTI and was
treated as outpatient. Weight 10 kg.
• He was prescribed :
• Syrup Paracetamol 125mg tds
• Syrup Piriton 2.5 ml tds
• Syrup Benadryl 2.5 ml tds

• Comment?
 CASE 2
• AD, a 3 year old girl was diagnosed with URTI and treated as
outpatient. Weight 20 kg.
• She was prescribed :
• Syrup Paracetamol 250 mg tds
• Syrup Salbutamol 2mg tds
• Syrup Phenergan 5 ml tds
• Syrup Ampicillin 5 ml bd x 3 days

• Comment ?
 CASE 3
• DA, a 4 year old boy was diagnosed with URTI and treated as outpatient.
Weight 25 kg.
• He was prescribed :

• Syrup Paracetamol 500 mg tds

• Syrup Benadryl 5 ml tds
• Syrup Actifed 5 ml tds
• Syrup Bromhexine 5 ml tds x 3 days

• Comment?
 CASE 1
• MA, a 2 year old boy was diagnosed with URTI and was treated as
outpatient. Weight 10 kg.
• He was prescribed :
• Syrup Paracetamol 125mg tds
• Syrup Piriton 2.5 ml tds
• Syrup Benadryl 2.5 ml tds
Comment?
• Please AVOID using diagnosis of URTI- be more specific
• DO NOT used anti histamine (Piriton and Benadryl) in children < 6
years (unless 2 - 6 year old with urticaria/allergy, give
antihistamine with caution. CONTRAINDICATED in <2 years old)
• DO NOT used DOUBLE antihistamine
• Please use GENERIC name
 CASE 2
• AD, a 3 year old girl was diagnosed with URTI and treated as outpatient. Weight 20 kg.
• She was prescribed :
• Syrup Paracetamol 250 mg tds
• Syrup Salbutamol 2mg tds
• Syrup Phenergan 5 ml tds
• Syrup Ampicillin 5 ml bd x 3 days
Comment ?
• Please AVOID using diagnosis of URTI- be more specific
• DO NOT used anti histamine (Phenergen) in children < 6 years (unless 2 - 6 year old with
urticaria/allergy, give antihistamine with caution. CONTRAINDICATED in < 2 years old
• use Syr Salbutamol only in mild bronchospasm (minimal rhonchi on chest examination)
or parent insist of medication due to child’s having chesty cough especially at night ONLY
(no evidence based).
• Antibiotic should NOT be given in all URTI unless suspected bacteria in origin (use Mc
Issac criterias)
• If antibiotic is indicated, used recommended dose and duration
• Please use GENERIC name
 CASE 3
• DA, a 4 year old boy was diagnosed with URTI and treated as outpatient.
Weight 25 kg.
• He was prescribed :
• Syrup Paracetamol 500 mg tds
• Syrup Benadryl 5 ml tds
• Syrup Actifed 5 ml tds
• Syrup Bromhexine 5 ml tds x 3 days
Comment?
• Please AVOID using diagnosis of URTI- be more specific
• DO NOT used anti histamine (Benadryl & Actifed) in children < 6 years
(unless 2 - 6 year old with urticaria/allergy, give antihistamine with caution.
CONTRAINDICATED in < 2 years old
• DO NOT used DOUBLE antihistamine (Benadryl & Actifed)
• Bromhexine is NOT recommended in children < 5 years old – mucolytic
agent is DANGER in children who can not expectorate their sputum
• Please use GENERIC name
 Problems with antibiotic
• There is a very small risk of anaphylaxis but a much greater
risk of side effects eg. GI upset

• Although penicillin is a cheap drug, the financial cost to the

KKM when prescribed on a huge scale is considerable

• Widespread antibiotic prescribing encourages drug

resistance

• Prescribing fosters a patient’s dependence and reinforces

the sick role, teaching patient that he needs medical
treatment with his next illness episode
Chan GC, Tang SF. Parental knowledge, attitudes and antibiotic use for acute URTI in children
attending a primary healthcare clinic in Malaysia. Singapore Med J. 2006;47(4):266-70

• The majority of parents (68-76%) believed that antibiotic was helpful in

treating common cold, cough and fever.

• 29% thought that their child needed an antibiotic were not prescribed
with any Vs 17% believed that an antibiotic was unnecessary when
prescribed.

• 28% requested for an antibiotic and majority received what they asked
for Vs 31% of parents did not request any antibiotics but private GP
habitually prescribed them.

• The antibiotic compliance was poor ;

– only 74% completing the entire course
– 85% stopped once they improved symptomatically.
 RTI : aetiologic agents
• Acute pharyngitis is mostly viral in origin and self-limiting.

• Bacterial pharyngitis accounts for 15-30% of cases in children

and 10% of cases in adults.

• Most bacterial pharyngitis are secondary to Group A ß-

Haemolytic Streptococcus (GABS)
 PHARYNGITIS - assessment

MC ISAAC SCORE

Malaysian guidelines 2003

Features
• Rhinitis  Fever > 38 C +1
• Cough  Absence of cough +1
• Hoarseness  Tonsillar swelling or exudates +1
• Conjunctivitis  Tender anterior cervical LN +1
• Oral ulcer  Age < 15 +1
• Diarrhea  Age > 45 -1

< 2 2-3 > 3

Throat swab
Viral etiology likely - GAS pharyngitis likely
recommended -
Treat with antibiotic
Symptomatic treatment - Initiate antibiotic
if GAS detected
PHARYNGITIS - treatment
In our clinic
setting, we
consider to
give
antibiotic if
SCORE > 2
 ADVERSE EFFECT
CLASS ADVERSE EFFECT

Arrhythmia, blurred vision, dizziness, dry

mouth, hallucinations, heart block, paradoxic
ANTIHISTAMINES excitability, respiratory depression, sedation,
tachycardia, urinary retention

Agitation, anorexia, dysryhthmia, dystonia,

headache, hypertension, irritability, nausea,
DECONGESTANTS palpitations, seizure, sleeplessness,
tachycardia, vomiting

Montauk SL. Appropriate use of common OTC analgesics and cough and cold medications. Leawood, Kan.:
American Academy of Family Physicians, 2002. Accessed July 24, 2006
Kelly LF. Pediatric cough and cold preparations. Pediatr Rev 2004;25: 115-23
 HCW can safely recommended :

 Oral hydration (eg. teas, hot soups)

 Saline nose drops for relief of nasal congestion when it interferes

with feeding.

 Paracetamol for reduction of high fever when this distresses the

child and for relief of pain.

 Safe, soothing remedies for cough and sore throat.

Educate mothers that a child’s cough;

 performs a useful function in clearing

secretions from the airway and,

 is not an illness in itself, which must

be treated.
o Therapies containing atropine, codeine, or antihistamines
may sedate the child sufficiently to interfere with feeding and
the child ‘s ability to clear secretions from the lung.

o Over-the-counter (OTC) cough and cold medications are not

more effective than placebo in reducing acute cough and
other symptoms of URTI in children aged < 2 years.

Schroeder K, Fahey T. Over-the-counter medications for acute cough in children and adults in ambulatory
settings. Cochrane Database Syst Rev 2004(4):CD001831. Smith MB, Feldman W. Over-the-counter cold
medications. A critical review of clinical trials between 1950 and 1991. JAMA 1993;269: 2258—63
Rhinosinusitis - diagnosis
COMMUNITY AQCUIRED PNEUMONIA - assessment

CRB – 65 score

BTS 2004
 Confusion +1
 Respiratory rate > 30 /minute +1
 Blood pressure [ SBP < 90 or DBP < 60] +1
 Age > 65 +1

0 1 - 2 3 - 4

Likely suitable Urgent

Consider hospital
for home hospital
referral
treatment admission
Antibiotic therapy for pneumonia
in children under 5 (IMCI)
2. OTOLOGY
Acute Otitis Media - diagnosis
Differential diagnosis for ear condition
EAR INFECTION IN CHILDREN
(IMCI)
EAR INFECTION IN CHILDREN
(IMCI)
3. SKIN INFECTION
Impetigo (epidermis)
Ecthyma (dermis)
 Furunculosis

Carbuncle
4. OCULAR INFECTION
Internal hordeolum VS External hordeolum

• Staphylococcal abscess of
Caused by obstruction of duct
lash follicle and it’s of an oil gland within the
associated gland of Zeiss upper or lower eyelid
or Moll • Tender nodule within the
• Tender nodule in the lid tarsal plate
margin pointing through • May be associated cellulitis
the skin
 Case scenario
• 20 year old female, married, presents with 2/7
days history of dysuria, urgency and urinary
frequency. She just had her menses 2/52 ago.
There were no PV discharge.
• On examination, she is afebrile and vital signs
were normal.
• Per abdomen revealed suprapubic tenderness
but no guarding.
• What (1) investigation you want to do?
- Urine dipstick/UFEME.
- Her urine showed:
- nitrates –VE
- leucocytes +VE
- blood –VE
- protein trace
- glucose –VE
• What is your diagnosis?
- provisional diagnosis: UTI.
- you should still have to consider other
differential diagnosis.
• What aspect of her urine test must you ask
her?
- Technique and timing of urine collection
• She confirmed sending a mid stream urine, as
instructed to her, early that morning of
consultation
• How would you treat her now?
- Treat as UTI with severe symptoms
(patient has 3 or more symptoms)
THANK YOU