P olicies Learning objectives Explain how antibiotic use can select resistant strains of bacteria Identify important mechanisms used by antibiotic stewardship programmes to decrease bacterial resistance in hospitals ID: 1036813
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1. Principles of Antibiotic Policies
2. Learning objectivesExplain how antibiotic use can select resistant strains of bacteria Identify important mechanisms used by antibiotic stewardship programmes to decrease bacterial resistance in hospitalsDescribe the roles of the microbiology laboratory and IP&C staff in the containment of bacterial resistance in healthcare Participate in the formation of an antibiotic stewardship programmeDecember 1, 20132
3. Time involved45 – 60 minutesDecember 1, 20133
4. IntroductionDiscovery of antibiotics – revolutionary event that saved millions of livesEmergence of resistance – reduced effectiveness, increased toxicity, increased costsTo preserve susceptibility – or to postpone development of resistance – antibiotics should be used rationallyDecember 1, 20134
5. AntibioticsFleming changed the course of historyMould contaminated an experiment – contained penicillinKilled the Staphylococcus aureus that had been growing in the dishPenicillin altered the treatment of bacterial infectionsDecember 1, 20135Dr Alexander Fleming
6. Antibiotic ResistanceAntibiotic resistance developsThrough natural mutations of bacterial genesThrough transfer of resistance genes between different bacteria via plasmids, transposons, etc.If a bacterial population with newly resistant bacteria are exposed to a specific antibiotic, they will be selected and develop a new resistant strainDecember 1, 20136
7. Mechanisms of resistanceResistance can be mediated by:Change in antibiotic target site - altered penicillin binding proteins, altered DNA gyrase:Beta-lactams, QuinolonesProduction of detoxifying enzymes: Beta-lactams (Beta-lactamases) , Aminoglycosides, ChloramphenicolDecreased uptake(reduced permeability, active efflux): Erythromycin, Tetracyclines, Beta- lactamsDecember 1, 20137
8. Antibiotic use outside human medicineAntibiotics are used as treatment of infectionsIn veterinary medicineIn agricultureAntibiotics are also used as growth promotorsDecember 1, 20138
9. Clinical Impact of ResistanceIncreased morbidityIncreased mortalityExtended hospital stayIncreased admission to intensive careLoss of bed daysDecember 1, 20139
10. Types of antibiotic usesEmpirical therapyWithout the knowledge of pathogenPathogen-directed therapyKnowing the pathogen and susceptibility to antibioticsProphylaxisSurgicalMedical December 1, 201310
11. Dealing with resistanceDecember 1, 201311Antibiotic stewardship Surveillance Antibiotic policies & guidelines Antibiotic management programmesPrevention of spreadInfection prevention & control in healthcare settingsIsolationHand HygieneEnvironmental hygieneReductionUsage controlAppropriate useHumanAnimalEnvironmental
12. Antibiotic stewardship programmes - 1 Can modify prescribing practicesShould lead to reduced, rational useShould be well designed, and implementedShould be based on educationIdeally should be a mixture of measures that are: VoluntaryPersuasive RestrictiveDecember 1, 201312
13. Antibiotic stewardship programmes - 2Key to modifying prescribing practices, stewardship programmes must include:National policiesLocal hospital or health care policiesFormularies and guidelinesEducationEffective microbiology laboratory supportAuditsEffective working relationship with IP&C* teams*IP&C: Infection Prevention and ControlDecember 1, 201313
14. Key Elements of National Antibiotic PoliciesLegislation required to regulate production and importLegislation to impose limitation of use in veterinary practices to treatment onlyNot as growth promotersLegislation to reduce over the counter useEducation of the general populationReduce expectationsAvoid misuse and over demandDecember 1, 201314
15. Hospital stewardship programmesImportant elements of an effective hospital programme:Antibiotic CommitteeAntibiotic Management teamFormularies, guidelines and protocolsEducationAudits December 1, 201315
16. Antibiotic CommitteeCan be a “stand alone” Committee, or part of Drugs and Therapeutics CommitteeMembership should include:Physicians and nurses who prescribe antibioticsPharmacistsMicrobiologistsMembers of Management/AdministrationMembers of Infection Control CommitteeOthers, as neededDecember 1, 201316
17. Antibiotic Management TeamTeam to advise on antibiotic use, audit of prescribing, introduction of new antibioticsLarger hospitals: can include infectious disease (ID) physicians, clinical pharmacologists, pharmacists, clinical microbiologists, any doctor authorised to use reserve listSmaller institutions: minimum requirement: antibiotic pharmacist (at least part-time), with support from ID or IP&C physicianDecember 1, 201317
18. Guidelines and ProtocolsShould include: Protocols for the evaluation of parenteral antibioticsInclude stop orders after 3-5 days and recommendations for sequential treatmentProtocol for list of reserve antibioticsHow to orderWho can authoriseDecember 1, 201318
19. Hospital Guidelines/PoliciesLocal hospital or health care policies should focus on using antibiotics that:Have narrowest possible spectrumAre inexpensiveHave minimal toxicityHave least impact on development of resistanceDecember 1, 201319
20. Hospital formularies and protocolsAntibiotic formularies: no drug outside those listed should be usedProtocols for empiric and targeted treatment of common infectionsProtocols for surgical prophylaxisProtocols for de-escalation of parenteral useProtocols for use of a reserve listDecember 1, 201320
21. Education programmes - 1Should include:Formal meetingsClinical rounds with antibiotic management team/committee membersFormal lecturesFocus on:New antibioticsNew methods of administrationInfluence on bacterial ecologyDecember 1, 201321
22. Education programmes - 2Should be provided by Senior member of Antibiotic Team, or independent expertShould not be provided by individuals from pharmaceutical companies, unless a committee or antibiotic team member is presentDecember 1, 201322
23. Stewardship: Role of the Microbiology LaboratoryRegular reporting of changing resistance patternsNewslettersSpecialty-specific dataRestricted antibiotic reporting Routinely only first line antibiotics Reserve antibiotics only if pathogen is resistant to first line antibioticsPatient specific data (culture & sensitivity) to optimise treatmentDecember 1, 201323
24. Stewardship: role of Clinical Microbiologist/ID SpecialistProvide leadership to Antimicrobial TeamAntibiotic ward roundsInterpretation of patient-specific data (culture & sensitivity) to optimise treatmentActive surveillance/ awarenessScreening for carriage of resistant organismsMolecular detection and typingDecember 1, 201324
25. Audit: Monitoring compliance1. Are antibiotics being used in accordance with approved protocols?Empirical vs. targeted treatments clearly specified?Stopped at the correct time?Based on clinical needs and microbiology results?Correct use of surgical prophylaxis guidelines?AntibioticTimingDosageDecember 1, 201325
26. Audit: Monitoring effectiveness2. Are our policies & guidelines being followed?Consumption data: Based on stock controlsSigned prescriptionsUsage data DDD*: based on patient bed days / length of stayDecember 1, 201326*DDD = defined daily dose
27. Audit: Monitoring Appropriateness3. Are the policies being used effectively?Dosage: too much- too little?Timeliness: start-stop dates?Appropriateness: compliant with local policies?December 1, 201327
28. Audit dataRegular and timely feedbackUse as evidence for further teachingDiscuss in antibiotic ward roundsAssess efficacy of guidelines and protocols before regular reviewDecember 1, 201328
29. Control and Prevention of Healthcare-associated InfectionsWork in close collaboration with Microbiology laboratoryHave early warning system, based on regular surveillanceAct promptly to detect and manage outbreaksHave effective isolation policiesEnsure effective cleaning and high compliance with hand hygieneDecember 1, 201329
30. Further readingWHO Global Strategy for containment of antimicrobial resistance WHO, 2001. http://whqlibdoc.who.int/hq/2001/WHO_CDS_DRS_2001.2.pdf Dellit TH, et al. Infectious Disease Society of America and Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-177.Richards J. Emergence and spread of multiresistant organisms: can infection control measures help? Int J Infect Control 2009;v5:i2 doi:10.3396/ijic.V5i2.017.09.December 1, 201330
31. QuizMethods to manage resistance are preventing spread of resistant pathogens, antibiotic stewardship, and reduction of antibiotic use. T/FAdditional information from the microbiology laboratory, useful in prudent use of antibiotics, is reporting sensitivity testing to broad spectrum antibiotics as a first line antibiotics. T/FThe topics usually included in antibiotic policies are:List of antibiotics in the formulary- with the possibility to use some antibiotics outside the formulary.Guidelines for empiric and targeted treatment not including dosage and duration of treatment.Protocols for reserve antibiotics including how to order and who authorises its use.Protocols for surgical prophylaxis including stop-orders after 48 hours.All of the above.December 1, 201331
32. International Federation of Infection ControlIFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe . The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. For more information go to http://theific.org/December 1, 201332