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Mervat I.EL- Borhamy Prof. & Head

of . Microbiology Department / . Misr. . International University. Microbiology Consultant and Head . of Infection Prevention and Control . Department / . IMC. Antimicrobial stewardship:. Implementation of local.

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Mervat I.EL- Borhamy Prof. & Head






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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