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Implementing AMS

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This presentation was presented at Apollo International Forum on Infection Control (AIFIC’ 2013), Chennai The presentation is solely meant for Academic purpose
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This presentation was presented at Apollo

International Forum on Infection Control

(AIFIC’ 2013), Chennai

The presentation is solely meant for Academic

purpose

Implementing Antimicrobial Stewardship

in a Hospital Setting

Guiding Document for Antimicrobial stewardship

Clinical Infectious Diseases 2007;44:159-77

Infectious Diseases Society of America and the

Society for Healthcare Epidemiology of America

Guidelines for Developing an Institutional Program to

Enhance Antimicrobial Stewardship

Primary:

Formulary restriction and preauthorization (BII)

Prospective audit with intervention and feedback.(AI)

Secondary:

Education.(AII)

Guidelines and clinical pathways (AI)

Streamlining or de-escalation of therapy.(AII)

Antimicrobial Stewardship Strategies

Can this be the

starting point in

India ?

AMS Simplified

4 D’s of Antibiotics

Glynn etal. Current Anaesthesia & Critical Care (2005) 16, 221–230

The Right Drug

The Right Dose

The Right Duration

De-escalation

Antimicrobial Stewardship – Indi(a)genous!

To Educate and Promote Evidence based usage of antibiotics by

making Customized treatment protocols based on the hospital’s

own Microbiology data

Prospective audit with intervention and feedback.

Formulary restriction and preauthorization

Education.(AII)

Guidelines and clinical pathways based on local data (AI)

Streamlining or de-escalation of therapy.(AII)

Principles for Making Antibiotic Protocols

Site of Infection

Risk stratification for MDRs

Local microbiology data

De-escalation

Step 1:

Compile Local Hospital data

Based on site of infection

– Geographic Variations

( ICUs / Wards / Surgical

Site Infections etc.)

1. % Distribution of Bugs

1. % Susceptibility of

antibiotics

Organism spectrum in general wards (Jan-Jun 2006)

Salmonela

6%

Burkhol

0.3%

Steno

0.3%Pneumoc

0.3%

Pseudo

19%

Candida

2%

Enteroc

5%

Acineto

1%

Proteus

4%Kleb

20%

Staph

7%

E.coli

35%

E.coli

Staph

Kleb

Proteus

Enteroc

Acineto

Pseudo

Candida

Pneumoc

Steno

Burkhol

Salmonela

Step 2: Putting data in Toolkit making antibiograms

Hospital surveillance data (Usually last 6 months) Validity of these data: Next one year (Max)

S. No Most common pathogens % prevalence S.

No.

Most sensitive antibiotics

pathogens in descending order.

1 1

2 2

3 3

4 4

5 5

- The data needed for last 6 months ( minimum 3 months)

- Ward and ICU isolates data for Blood Stream Infections, Pneumonias,

IAIs, SSTIs and UTIs.

- User Friendly Tool kit to put in data based on Site of Infection

- Tool kit will be separate for Ward and ICU isolates

-Tool kit contains 5 most common pathogens, and most antibiotics in

decreasing order of sensitivity

- Tool kit will also contain the Validity period

Example of Toolkit containing

Antibiogram for Blood culture Hospital surveillance data(Jan-10 till Dec 10) Validity of these data: Dec-2011

S.

No Most common

pathogens

%

prevalence

Most sensitive antibiotics

(% Sensitivity)

1 Pseudomonas

30% Colistin (98%) Imi (85%) Cef/Sul (79%) *Pip/Taz

(62%) *Amikacin (57%)

2 Klebsiella 25 % Imipenem (93%) Ertapenem (92%)

*Cef/Sul(76%) *Amikacin = Pip/Taz (65%)

3 Acinetobacter 14 % Colistin (98%) Cef/Sul (85%) Imipenem (82%)

*Pip/Taz(45%)

4 E.Coli 12 % Imipenem (95%) Ertapenem (94%) Cef/Sul (79%)

*Amikacin (70%) *Pip/Taz (67%)

5 Staph Aureus 9% Vancomycin (97%) *Ertapenem = Cef/Sul =

Pip/Tazo (70%)

Note: Cut off value to be used as empiric antibiotic is 80%

*Choices written in white have sensitivity less than 80%

Slide 18

Health Care Contact

Procedures

Antibiotic Rx History

Patients

Characteristics

No

No

No in last 90 days

Young – No co-

morbid conditions.

Yes

Minimum

Yes in last 90 days

Elderly

Few Co-morbid

conditions.

Prolonged

Major invasive

Procedures

Repeat multiple

antibiotics.

Immunocompromised,

or with many co-

morbid conditions.

Causative Pathogen

could be

Susceptible to

Common narrow

spectrum

antibiotics

ESBLs ESBLs /

Pseudomonas

/Acinetobacter

MRSA

Possible Antibiotic

recommendations

- No Need for

Broad spectrum

antibiotics

- Use Non-

Pseudomonal

broad spectrum

antibiotics

- Use Anti-

pseudomonal

Broad spectrum

antibiotics

Step -3. Patient types based on Risk stratification

Ref: Based on stratification criteria suggested by Dr Yehuda Carmelli

Type 1 Type 2 Type 3

Step 4: De-escalation

Discontinuate /Taper down antibiotics if negative

cultures and patient improving

Diminish the number of antibiotics.

Shorten length of duration of antibiotics.

Narrow spectrum of antibiotics.

Antimicrobial Stewardship brings hospital specific protocols

to the patient bedside to enable evidence based treatment

Options for Empiric

therapy and De-

escalation

Patient risk

stratification

Hospital specific

microbiology data

Specific

Indication

101 protocols (71hospitals) completed YTD

MSD India – the one representative from

pharmaceutical industry to highlight efforts on AMS

during the 1st Global forum on antibiotic resistance

organized by SHEA, the PHFI and the CDDEP in

New Delhi on Oct 3-5,2011

Indian society for critical care medicine

(ISCCM).

Workshops on AMS organized in annual

ISCCM meeting for last 4 years AMS

Update

2012

- Golden Peacock award for AMS

in 2012

-Expanding this AMS model in other

countries (Vietnam, Russia, S Africa)

AMS Update from India - 2013

The proposed national antibiotic policy

prepared by the Government of India

in 2011 also recommends a hospital

model of antimicrobial stewardship on

similar lines as this programme on

AMS

Next goals in AMS

Domain of Impact Indicator

Nosocomial infection Rate Incidence of nosocomial infections

Resistance pattern

- ESBL

- MRSA

- Pseudomonas/ carbapenem

Proportion (%) of resistant isolates

Average length of stay in ICU Reduction in LOS

Prescription practices Reduction in rate of inappropriate prescription

practices

Utilization / Consumption of antibiotics Defined daily dosages (DDD)

Duration of antibiotic therapy Reduction in duration of antibiotic therapy

Mortality rates Reduction in mortality rates before and after

intervention

Cost of treatment Reduction in per unit cost of therapy

Proposed Outcome measures for AMS

Drug Resistance Index (DRI)

DRI calculation

(Antibiogram +

DDD/100Bed days)

in progress

• Simple (yet not simplistic !)

• Evidence Based

• User friendly

• Democratic (OF the hospital, BY the hospital

and FOR the hospital)

Strengths of AMS Initiative


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