of Microbiology Department Misr International University Microbiology Consultant and Head of Infection Prevention and Control Department IMC Antimicrobial stewardship Implementation of local ID: 744988
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Slide1
Mervat
I.EL-
Borhamy
Prof. & Head of Microbiology Department / Misr International UniversityMicrobiology Consultant and Head of Infection Prevention and Control Department / IMC
Antimicrobial stewardship:
Implementation of local
antibiotic
policySlide2
Antimicrobial stewardship
Multidisciplinary development of evidence-based practice guidelines incorporating local microbiology data and resistance patterns
Improve antimicrobial utilizationSlide3
Abuse of antibiotics and
mdrSlide4
The leading cause of MDR
Abuse of antibiotics: Unnecessary use or overuse
Increase in healthcare costs
Increase in hospital length of stayDevelopment of MDRSlide5
Abuse of
Antibiotics
Using multiple antibiotics when one would be sufficient
Unnecessarily long courses of antibiotic therapyUse antibiotics in self-limited infectionsOveruse antibiotics for prophylaxis before and after surgeryIn many countries, antibiotics are sold over the counter to the general publicAntibiotics are used in animal feed to prevent infection and promote growthSlide6
Why
is Antimicrobial Resistance important
in HAIs ??
PROGNOSIS for successful treatment of the patient is worse than with susceptible organismsSpecial efforts to control HOSPITAL SPREAD of resistant organisms may be requiredLIMITS TREATMENT choice, which is especially important with patients who have drug allergiesSlide7
MRSA
VRE
ESBL
PRP
KPCR
Multi – Drug Resistant BacteriaSlide8
Rational use of antibioticsSlide9
Rational use of antibiotics
Establishment of RAP is a key issue
Better care
of patientsDecrease antimicrobial resistance
Decrease in hospital length of stay
Decrease in healthcare costsSlide10
By maintaining sufficiently high level of the drug in tissues
Each hospital needs its own policy since the prevalence of resistant strains, plasmids, etc
… will vary to some extent from hospital to hospital
Limit the use of some drugsAvoidance of topical use of valuable antibiotics,e.g. GentamycinThe use of antibiotic prophylaxis only when strictly indicatedProper use of antibiotic combinations Rational Use of Antimicrobial TherapySlide11
General Principles of Antimicrobial UseSlide12
Empiric Therapy
Broad spectrum antibiotics
The clinical site of infection (UTI, LRTI,..) and host factors (HIV, organ transplant) give an indication of likely pathogens
No definitive information about the causative pathogenThe patient is sufficiently ill to warrant treatment before ABS test results are availableSlide13
Antibiotic Combinations
In empiric therapy to treat serious infections before I.D. of the organism
To achieve a synergistic inhibitory effect (e.g.Penicillin or vancomycin and Gentamycin for enterococcal endocarditis) To prevent the emergence of resistant organisms (treatment of M.tuberculosis) 1
2
3
Use a
single drug
unless it has been proven that combination therapy is required:Slide14
Guided “Directed”
Therapy
Therapy is selected: to the most effective, least toxic and narrow spectrum antibiotic Minimize the cost of therapy: when equivalent alternatives are available Duration of therapy: as short as possibleKnown infecting agentKnown ABS test
1
2
3Slide15
Questions for Treating Doctor
What is my rational in prescribing an antibiotic to this patient?
Does he/she really need it? Is it for empiric therapy or prophylaxis?If there is a confirmation of bacterial infections, what is the causative organism(s) and probable susceptibility?How quickly does treatment need to be given? What route is appropriate?Slide16
Implementation of local antibiotic policySlide17
Key components of antibiotic policy
Communication:
Improved communication between labs, treating clinicians, and pharmacy
Local sensitivity patterns: Laboratories should regularly make local sensitivity patterns widely known and routinely should only report on those agents which appear in the policyTime factor: Susceptibility and culture results should be reported to clinicians with the minimum of delay to allow them to continue or stop antibiotic therapy as appropriateEducation programme: Microbiology and Pharmacy departments should have adequate facilities to ensure that education programme can be carried outComputer facilities: Computer facilities should be available for auditSlide18
Team work
Information flow has to be rapid (phone and personal contact)
Microbiologist
ICPClinician & Clinical pharmacist
PATIENTSlide19
How do we get started ??Slide20
PLAN OF THE WORK
Collection of culture and antibiotic sensitivity results data for at least four months in a give time period
Site:
e.g ICUs or wordsSpecimens: all types of clinical specimens or select one of them20Slide21
21
Total number of tested bacteria is 290Slide22
22Slide23
Distribution of Gram negative bacteria in IMC
23Slide24
Distribution of Gram positive bacteria in IMC
24Slide25
25Slide26
Percentage of MDR
26
2011
20132015Slide27
Overall percentage of MDR - 2015
MDR (Gram -
ve
)/ total isolates/total GNB/same sppE.Coli (ESBL)Klebsiella (ESBL)Psudomonas (MDR)Acinetobacter(MDR)Enterobacter (MDR)11%37%6%15%2%13.5%45%7%
18.5%
3%
71%
99%
89%
100%
58%
MDR
(Gram +
ve
)
/total isolates
/total GPB
/
S.aureus
MRSA
2%
13%
88%
27Slide28
Distribution of gram negative MDR in different departments
28Slide29
Distribution of MRSA in different departments
29Slide30
30Slide31
31Slide32
32Slide33
33Slide34
34Slide35
35Slide36
36
ICU - DSlide37
Percentage of clinical sites of infection in ICU-D
37Slide38
38
All bacterial isolates in ICU-D are MDRSlide39
Percentage of bacteria causing BSI in ICU-D
39Slide40
Percentage of bacteria causing RTI in ICU-D
40Slide41
Percentage of bacteria causing UTI in ICU-D
41Slide42
Percentage of bacteria causing SSI in ICU-D
42Slide43
Antibiotic susceptibility percentage of gram negative bacteria (
mdr)in ICUD
AMP
AMP/SULBAUGPIP/TAZOCEFCXMCXM/AXCEFPODCTX
CAZ
CRO
CFP
AZT
ERT
IPM
MEM
GM
CIP
MOX
TET
TGC
SXT
KLEB
0
7
%
0
14%
0
0
0
00000016%14%14%23%20%20%17%73%6%Acineto0
0NT0NT0000000000027%00055%0PSEUDO00050%00000
25%00NTNT0067%000NT0EnterNTNTNT0NT00000NTNTNT00000
067%67%
67%43
All gram negative bacterial isolates in ICU-D are MDRSlide44
AB/ORG
P
AMP
OXGMCIPLEVMOXECLQUINOLZDVA
TET
TGC
RF
SXT
CNS
0
0
0
86
%
29
%
29
%
57
%
29
%
0
71
%
100%
100%86%100%43%43%Antibiotic susceptibility percentage of gram positive bacteria in ICUD44Slide45
Empiric antibiotic therapy of BSI in ICU-D
45Slide46
Empiric antibiotic therapy of BSI in ICU-D (CNS)
46Slide47
Empiric antibiotic therapy of RTI in ICU-D
47Slide48
Empiric antibiotic therapy of UTI in ICU-D
48Slide49
Emperic
antibiotic therapy of SSI in ICU-D
49Slide50
How does it work?
Restricted antibiotic
policy
50Slide51
Levels of Antibiotics (3)
First choice antibiotics:
- to be prescribed by all doctors
Restricted choice antibiotics: - for MDR, polymicrobial infections, patient conditions need special attention, more expensive antibioticsReserve antibiotics:- for life threatening infections, to be used after permission from a TC member51Slide52
Implementation of Restricted Antibiotic Policy
Restricted antibiotics can be ordered by the attending consultants or his registrar after permission
The drug will be automatically stopped unless approved by the clinical pharmacist
It is the responsibility of the treating consultant to arrange for approval of the prescription by the clinical pharmacistAfter approval from the pharmacy, the pharmacy will provide antibiotics for three working days52Slide53
Implementation of Restricted Antibiotic Policy-cont’d
In the third day culture and sensitivity result should be provided to the pharmacy to continue providing the antibiotics
Duration of therapy: either 10-14 days in total or until 3-5 days after clinical improvement
The antibiotic committee will review this policy regularly 53Slide54
Steps to prevent antibiotic resistance
54Slide55
STEPS: 1- 8
Break the chain of infection (prevent transmission/isolate the pathogen)
Stop treatment when cured (treat effectively)
Know when to say “no” to vancomycin (use antimicrobials wisely)Treat infection, not colonizationUse “local” dataAccess the expertsTarget the pathogenUse devices properly: IVD, Folley’s catheter, Ventilators)55Slide56
Dosage
appropriate to site and type of infection
MMinimize duration of therapy EEnsure
monotherapy
in most situations
Antimicrobial Creed: MIND ME
56Slide57
57
THANK
YOU