Antimicrobial stewardship: a

competency based approach

Introduction

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" Antimicrobial resistance is a crisis that

must be managed with the utmost

urgency. …We cannot allow hard-won

gains for health to be eroded by the

failure of our mainstay medicines.”

Dr. Margaret Chan

2015 WHO Global

Action Plan on

Antimicrobial

Resistance

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Antimicrobials are life-saving drugs

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Antimicrobial resistance requires a

global solution

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1) Improve awareness and understanding of AMR through effective

communication, education and training

2) Strengthen knowledge through surveillance and research

3) Reduce the incidence of infection

4) Optimize the use of antimicrobial medicines in human and animal

health

5) Develop the economic case for sustainable investment (in AMR)

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1) Improve awareness and understanding of AMR through

effective communication, education and training

2) Strengthen knowledge through surveillance and research

3) Reduce the incidence of infection

4) Optimize the use of antimicrobial medicines in human and animal

health

5) Develop the economic case for sustainable investment (in AMR)

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1) Improve awareness and understanding of AMR through

effective communication, education and training

2) Strengthen knowledge through surveillance and research

3) Reduce the incidence of infection

4) Optimize the use of antimicrobial medicines in human and

animal health

5) Develop the economic case for sustainable investment (in AMR)

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Antimicrobials are societal drugs

Antimicrobial resistance

An

tim

icro

bia

l

use

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Antimicrobials are societal drugs

Antimicrobial resistance

An

tim

icro

bia

l

use

Using antimicrobials wisely

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We must all be antimicrobial stewards

Stewardship:

the careful and responsible

management of natural

resources

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We must all be antimicrobial stewards

Drug

Dose

Duration

Routeprescription

.............

.............

.............

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Microbiology guides therapy wherever possible

Indications should be evidence based

Narrowest spectrum required

Dosage appropriate to the site and type of infection

Minimise duration of therapy

Ensure monotherapy in most cases

We must all be antimicrobial stewards

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Adjusting the clinical approach

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Course content

Cou

rse

road

map

Basic concepts

Common infections

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Course framework:

the clinician-patient encounter

Subsequent evaluationInitial evaluation

Clinical

assessment

Diagnostic

work-up

Patient

education

Therapeutic

decisions

Modify

antimicrobialsData

review

Clinical

re-assessment

14

Initial evaluation

Clinical

assessment

Diagnostic work-up

Patient education

Therapeutic decisions

Course framework:

Initial evaluation

15

Initial evaluation

Clinical

assessment

Diagnostic work-up

Patient education

Therapeutic decisions

Course framework:

Initial evaluation

16

Initial evaluation

Clinical

assessment

Diagnostic work-up

Patient education

Therapeutic decisions

Course framework:

Initial evaluation

17

Initial evaluation

Clinical

assessment

Diagnostic work-up

Patient education

Therapeutic decisions

Course framework:

Initial evaluation

18

Initial evaluation

Clinical

assessment

Diagnostic work-up

Patient education

Therapeutic decisions

Course framework:

Initial evaluation

19

Subsequent evaluation

Modify

antimicrobials

Data review

Course framework:

Subsequent evaluation

Clinical re-

assessment

20

Subsequent evaluation

Modify

antimicrobials

Data review

Course framework:

Subsequent evaluation

Clinical re-

assessment

21

Subsequent evaluation

Modify

antimicrobials

Data review

Course framework:

Subsequent evaluation

Clinical re-

assessment

22

Subsequent evaluation

Modify

antimicrobials

Data review

Course framework:

Subsequent evaluation

Clinical re-

assessment

23

Principles of optimal antimicrobial use

Initial evaluation

Subsequent evaluationInitial evaluation

Clinical

assessment

Diagnostic

work-up

Patient

education

Therapeutic

decisions

Modify

antimicrobialsData

review

Clinical

re-assessment

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Core competencies for antimicrobial

prescribing

C1: Understands the patients and their clinical needs

C2: Understands treatment options and how they support the

patient’s clinical needs

C3: Works in partnership with the patient and other healthcare

professionals to develop and implement a treatment plan

C4: Communicates the treatment plan and its rationale clearly to

the patient and other health professionals

C5: Monitors and reviews the patient’s response to treatment

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Core competencies C1, C2, C3, C4, C5

Subsequent evaluationInitial evaluationSubsequent evaluationInitial evaluation

Clinical

assessment

Diagnostic

work-up

Patient

education

Therapeutic

decisions

Modify

antimicrobialsData

review

Clinical

re-assessment

26

Questions for front-line clinician

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Questions for front-line clinician

Are antimicrobials indicated?

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Questions for front-line clinician

If yes, what drug is the best choice?

Are antimicrobials indicated?

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Questions for front-line clinician

How can I limit the societal impact of this antimicrobial use?

If yes, what drug is the best choice?

Are antimicrobials indicated?

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Marisa Holubar, MD MS Elizabeth Robilotti, MD MPHClinical Assistant Professor, Infectious Diseases Assistant Attending, Infectious DiseasesAssociate Director, Stanford Antimicrobial Safety Associate Director, Infection Control

& Sustainability Program Memorial Sloan Kettering Cancer CenterStanford University School of Medicine

Stan Deresinski, MDClinical Professor, Infectious DiseasesDirector, Stanford Antimicrobial Safety

& Sustainability ProgramStanford University School of Medicine

Course content developed by:

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Tjalling Leenstra, MD PhD Head, WHO Collaborating Centre for Antimicrobial Resistance Epidemiology and Surveillance Centre for Infectious Disease Control National Institute fro Public Health and the EnvironmentThe Netherlands

Muna ABU SIN, MD, MScRobert Koch-InstituteDepartment for Infectious Disease Epidemiology Healthcare-associated Infections, Surveillance of Antibiotic Resistance and ConsumptionGermany

Hrachuhi Ghazaryan, MDGeneral PaediatricianHead of General Paediatric departmentArabkir Joint Medical centreAssistant Professor in Yerevan State Medical University after M. Heratsi, chair of Paediatrics N2Yerevan, Armenia

Course content reviewed by:

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Saskia Nahrgang, MD MPH

Technical Officer Programme Control of Antimicrobial Resistance

WHO Regional Office for Europe

Danilo Lo Fo Wong, PhD

Programme Manager, Programme Control of Antimicrobial Resistance

WHO Regional Office for Europe

WHO advisors:

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References: General

• World Health Organization. Global Action Plan on Antimicrobial Resistance. Sixty-

eighth World Health Assembly (document WHA68/2015/REC/1, Annex 3.

http://www.wpro.who.int/entity/drug_resistance/resources/global_action_plan_eng.pdf

• Fleming-Dutra KE, et al. Prevalence of Inappropriate Antibiotic Prescriptions Among

US Ambulatory Care Visits, 2010 – 2011. JAMA 2016 May 3; 315(17):1864-73. doi:

10.1001/jama.2016.4151.

• The Review on Antimicrobial Resistance Chaired by Jim O’Neill. Tackling drug-

resistant infections globally: Final report and recommendations. May 2016.

http://amr-review.org/sites/default/files/160525_Final%20paper_with%20cover.pdf

• Centers for Disease Control and Prevention. ANTIBIOTIC RESISTANCE THREATS

in the United States, 2013. http://www.cdc.gov/drugresistance/pdf/ar-threats-2013-

508.pdf

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References: Core Competencies

https://www.rpharms.com/Portals/0/RPS%20document%20library/Open%20access/Professional%20sta

ndards/Prescribing%20competency%20framework/prescribing-competency-framework.pdf

https://www.nps.org.au/__data/assets/pdf_file/0004/149719/Prescribing_Competencies_Framework.pdf

https://www.gov.uk/government/publications/antimicrobial-prescribing-and-stewardship-competencies

http://apps.who.int/medicinedocs/pdf/whozip23e/whozip23e.pdf

http://www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf

http://www.euro.who.int/__data/assets/pdf_file/0010/288253/HWF-Competencies-Paper-160915-final.pdf?ua=1

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