Antimicrobial Stewardship Program in Saudi Arabia;

Experiences and Vision Future

Yousef A. Alomi, Bsc., Msc, BCPS, BCNSP, DiBAGeneral Manager of General Administration of Pharmaceutical Care

November 2015

yalomi@moh.gov.sayalomi@gmail.com

Pharma Middle East 2015Dubai, UAE

Yousef A. Alomi Reports No Relevant Financial Relationship

Disclosure

Pharma Middle East 2015Dubai, UAE

Understand Antimicrobial Stewardship Program at MOH Saudi Arabia

Know the Assessment Plan of Antimicrobial Stewardship Program

How to Implement Antimicrobial Stewardship Program to all Middle East countries

Learning Objectives

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“an ongoing effortby a health care institution to optimize antimicrobial use among hospitalized patientsin order to improve patient outcomes, ensure cost-effective therapy, and reduce adversesequelae of antimicrobial use (including antimicrobial resistance)

Allerberger, F. and H. Mittermayer (2008). “Antimicrobial stewardship.”Clinical Microbiology and Infection 14(3): 197-199.

Antimicrobial Stewardship Program

Three levels of demand were used sequentially until an antibiotic was dispensed or denied [4]: 1) Can I have something to relieve my symptoms?: 2) Can I have something stronger? 3) I would like to have antibiotic.

Saudi Pharmaceutical Journal (2014) 22, 550–554

Saudi Pharmaceutical Journal (2014) 22, 550–554

Saudi Pharmaceutical Journal (2014) 22, 550–554

Alumran et al. Health and Quality of Life Outcomes 2013, 11:39

The antimicrobial stewardship program in Gulf Cooperation Council (GCC) states: insights from a regional survey

Journal of Infection Prevention October 8, 2015

• Objectives: The purpose of the current study is to describe the prevalence and characteristics of antimicrobial stewardship programs (ASP) in Gulf Cooperation Council (GCC) states to explore opportunities and overcome barriers to effective ASP implementation.

• Methods: A cross-sectional questionnaire survey was used to evaluate the current status of ASP: major stewardship components, barriers of implementation and program impact in acute care hospitals of GCC states.

• Results: Forty-seven healthcare professionals responded from four GCC states, the majority from Saudi Arabia (81%). Twenty-nine (62%) participating hospitals had ASP in place. Of these established programs, 35 (75%) reported lack of funding and personnel as major barriers to program implementation. The top three objectives cited for the hospital ASP were to reduce resistance (72.3%), improve clinical outcomes (70.2%) and reduce costs (44.7%). The reported impact of existing ASP was reduction of inappropriate prescribing (68%), reduction of broad spectrum antibiotic use (63.8%), reduction of healthcare-associated infections (61.7%), reduction of length of stay or mortality metrics (59.6%), reduction in direct antibiotic cost (57.4%) and reduction of reported antibiotic resistance (55.3%).

• Conclusion: Survey participants from GCC states who have implemented ASP report significant impacts in the reduction of broad spectrum antibiotic use, hospital-acquired infection, inappropriate prescribing and antimicrobial resistance. These findings suggest a promising opportunity to enhance existing ASP through sharing of best practices and support the development of regional guidelines across GCC states.

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi

Arabia.Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS1.

BACKGROUND AND OBJECTIVES: Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics.DESIGN AND SETTINGS: This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh.

Ann Saudi Med. 2013 Nov-Dec;33(6):547-54 .

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi

Arabia.Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS1.

METHODS: Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback.RESULTS: A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm.CONCLUSION: A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region.

Ann Saudi Med. 2013 Nov-Dec;33(6):547-54 .

Skeleton of Committees  

Central antibiotics committee

Regional antibiotic committee

Hospital Antibiotic committee

Primary Care Centres Antibiotic committee

Pharma Middle East 2015Dubai, UAE

• 2014• Stage 1• Antibiotic Committee Central • Antibiotic Committee Region 20• Antibiotic Committee Peripheral 90 Hospital • Antibiotic adults Manual booklet and electronic • Antibiotic Training Courses Central • Antibiotic training courses region 20

Antimicrobial Stewardship Program Plan

Pharma Middle East 2015Dubai, UAE

• 2015• Stage 2 • Antibiotic Committee Peripheral additional 90 Hospital • Antibiogram Central • Antibiogram 20 Region• Antibiogram 90 Hospital • Antibiotic pediatrics Manual booklet and electronic • Review Antibiotic Adults Manual base on antibiogram • Antibiotic utilization • Antibiotic consumption • Antibiotic Training Courses Central • Antibiotic training courses region 20• Stewardship Antibiotics Residency Program (ASHP)

Antimicrobial Stewardship Program Plan

• 2016• Stage 3 • Antibiotic Committee Peripheral additional 60 Hospital • Antibiogram Central • Antibiogram 20 Region• Antibiogram 180 Hospital • Antibiotic pediatrics Manual booklet and electronic • Review Antibiotic Adults Manual base on antibiogram • Antibiotic utilization adults and pediatrics • Antibiotic consumption adults and pediatrics • Antibiotic Training Courses Central • Antibiotic training courses region 20• Follow Up Stewardship Antibiotics Residency Program (ASHP)

Antimicrobial Stewardship Program Plan

• 2017• Stage 4 • Antibiotic Committee 90 Private Hospital • Antibiogram Central • Antibiogram 20 Region adults and pediatrics • Antibiogram 250 Hospital adults and pediatrics • Review Antibiotic pediatrics Manual booklet and electronic • Review Antibiotic Adults Manual base on antibiogram • Antibiotic utilization adults and pediatrics• Antibiotic consumption adults and pediatrics • Antibiotic Training Courses Central • Antibiotic training courses region 20 • Follow Up Stewardship Antibiotics Residency Program (ASHP)

Antimicrobial Stewardship Program Plan

• 2018• Stage 5• Antibiotic Committee additional 90 Private Hospital• Antibiogram Central • Antibiogram 20 Region adults and pediatrics • Antibiogram 250 Hospital adults and pediatrics • Antibiogram in 90 Private Hospital • Review Antibiotic pediatrics Manual booklet and electronic • Review Antibiotic Adults Manual base on antibiogram • Antibiotic utilization adults and pediatrics in MOH and Private • Antibiotic consumption adults and pediatrics in MOH and Private• Antibiotic Training Courses Central in MOH and Private• Antibiotic training courses region 20 in MOH and Private• Follow Up Stewardship Antibiotics Residency Program (ASHP)

Antimicrobial Stewardship Program Plan

Guideline for Establish Antimicrobial Stewardship at MOH hospitals • Section I: Policy and procedure • Section II: National antimicrobial guideline: Group A streptococcal Pharyngitis

Acute Bacterial Rhinosinusitis Community Acquired Pneumonia Bacterial Meningitis Brain Abscess Infective endocarditis Urinary Tract Infection Osteomyelitis Diabetic Foot Infection Skin and Soft Tissue Infection Peritonitis Sexually Transmitted Disease Pelvic Inflammatory Disease Intra-abdominal Infection Brucellosis Tuberculosis Antiviral Infection Antifungal Infection Parasitic Infection Surgical Prophylaxis

• Appendix A: Guideline for blood culture collection • Appendix B: Infection Control • Appendix C: Skin test kits, Anaphylactic kits , Skin test procedure and anaphylaxis

algorithm • Appendix D: Antibiotics dosing monitoring • Appendix E: Practical Approaches for Conversion IV antibiotics to Oral therapy

Appendix F: Antibiogram • Appendix G: Antimicrobial Consumption • Appendix H: Formulary/ Pre-Authorization Restricted Forms • Appendix I: Abbreviation • Appendix J: Dose Adjustment for Renal Impairment

Guideline for Establish Antimicrobial Stewardship at MOH hospitals

The antimicrobial stewardship team and administrative support Core members of antimicrobial stewardship: • Infectious diseases physician ( Leader ) • Clinical pharmacist with infectious diseases training (Coordinator) • Clinical microbiologist • An information system specialist • An infection control professional • hospital epidemiologist

Administrative support: • Hospital administration (necessary infrastructure) • Medical staff leadership • local providers ( e.g: nurses)

Collaborated providers: • Hospital infection control • Pharmacy and therapeutics committees

Guideline for Establish Antimicrobial Stewardship at MOH hospitals

Core strategies: • Prospective audit with intervention and feedback• Formulary restriction and preauthorization:

Supplemental Antimicrobial Stewardship Strategies:• Education• Guidelines and clinical pathways• Antimicrobial order forms• Combination empirical therapy and de-escalation antimicrobial• Conversion from parenteral to oral therapy• Antimicrobial dosing

Surveillance of antimicrobial resistance Computer Surveillance and Decision Support Monitoring of Process and Outcome Measurements

Policy

• This guideline only for adult • Antibiotics order form is controlled and guided

method to all health provider(physician, pharmacist, clinical pharmacist and nurse during prescribing the antibiotics

• It is formatting as physician order • Using of this order form only for community

acquired infection.

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Antimicrobial Stewardship

• Antibiotic Committees• Infectious Diseases Team• Antibiotics Physician order Form• Antibiotics dosing monitoring Aminogylcoside,

Vancomycin• Switching IV antimicrobial to oral • Dose adjustment for Renal Impairment • Antibiotics Consumption• Antibiogram

Monthly antibiotics consumption

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No

1 1 0 1 Antibiotics Committee (Central)

15 0 0 20 Antibiotics Committee (Region)

20 0 0 250 Antibiotics Committee (Peripheral)

0 0 80-100 Antibiotics Committee (PCC)

1 0 0 1 Antibiotics ManualBooklet

1 0 0 1 Antibiotics Manual Electronic

0 0 0 1 Antibiogram (Central)

0 0 0 20 Antibiogram (Region)

0 0 0 250 Antibiogram (Peripheral)

Antimicrobial Stewardship Program Indicators

2014 2013 2012 No

0 0 0 1 Antibiotics Consumption (Central)

0 0 0 20 Antibiotics Consumption (Region)

0 0 0 250 Antibiotics Consumption (Peripheral)

0 0 0 80-100 Antibiotics Consumption (PCC)

0 0 0 1 Antibiotics Utilization Review(Central)

0 0 0 20 Antibiotics Utilization Review(Region)

0 0 0 250 Antibiotics Utilization Review(Peripheral)

0 0 0 1 Antibiotic Conference

Antimicrobial Stewardship Program Indicators

2014 2013 2012 No

1 0 0 2 Antibiotics Course (Central)

0 0 0 2-4 Antibiotics Course (Region)

0 0 0 250 Antibiotics Course (Peripheral)

0 0 0 80-100 Antibiotics Course (PCC)

0 0 0 1 Therapeutic Drug Monitoring (Central)

0 0 0 20 Therapeutic Drug Monitoring (Region)

0 0 0 250 Therapeutic Drug Monitoring (Peripheral)

Antimicrobial Stewardship Program Indicators

2014 2013 2012 No

1 0 0 Decrease 20%

Resistance Bugs(Central)

0 0 0 Decrease 20%

Resistance Bugs(Region)

0 0 0 Decrease 20%

Resistance Bugs(Peripheral)

0 0 0 Will not increase

Infection Rate(Central)

0 0 0 Will not increase

Infection Rate(Region)

0 0 0 Will not increase

Infection Rate(Peripheral)

Stewardship Antibiotics Program Indicators

2014 2013 2012 No

1 0 0 Decrease 20-50%

Antibiotics Cost Reduction (Central)

0 0 0 Decrease 20-50%

Antibiotics Cost Reduction (Region)

0 0 0 Decrease 20-50%

Antibiotics Cost Reduction (Peripheral)

0 0 0 Decrease 20-50%

Antibiotics Cost Reduction (PCC)

0 0 0 50% Privilege of Antibiotics Prescribing (Central)

0 0 0 50% Privilege of Antibiotics Prescribing (Region)

0 0 0 50% Privilege of Antibiotics Prescribing (Peripheral)

Stewardship Antibiotics Program Indicators

2014 2013 2012 No

1 0 0 50% Antibiotics Policy Adherence(Central)

0 0 0 50% Antibiotics Policy Adherence(Region)

0 0 0 50% Antibiotics Policy Adherence(Peripheral)

0 0 0 50% Antibiotics Policy Adherence(PCC)

0 0 0 50% Antibiotics Automatic Stop order(Central)

0 0 0 50% Antibiotics Automatic Stop order(Region)

0 0 0 50% Antibiotics Automatic Stop order(Peripheral)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No

1 0 0 0 Days of Therapy (DOT)(Central)

0 0 0 0 Days of Therapy (DOT)(Region)

0 0 0 0 Days of Therapy (DOT)(Peripheral)

0 0 0 0 Days of Therapy (DOT)(PCC)

0 0 0 0 Defined Daily Dose (DDD)(Central)

0 0 0 0 Defined Daily Dose (DDD)(Region)

0 0 0 0 Defined Daily Dose (DDD)(Peripheral)

0 0 0 0 Defined Daily Dose (DDD)(PCC)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No

1 0 0 0 Post Marketing Surveillance (Central)

0 0 0 0 Post Marketing Surveillance (Region)

0 0 0 0 Post Marketing Surveillance (Peripheral)

0 0 0 0 Post Marketing Surveillance (PCC)

0 0 0 0 Drug Quality Reporting System(Central)

0 0 0 0 Drug Quality Reporting System(Region)

0 0 0 0 Drug Quality Reporting System(Peripheral)

0 0 0 0 Drug Quality Reporting System(PCC)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No

1 0 0 0 Antibiotic Medication Errors(Central)

0 0 0 0 Antibiotic Medication Errors(Region)

0 0 0 0 Antibiotic Medication Errors (Peripheral)

0 0 0 0 Antibiotic Medication Errors (PCC)

0 0 0 0 Antibiotic Adverse Drug Reaction (Central)

0 0 0 0 Antibiotic Adverse Drug Reaction (Region)

0 0 0 0 Antibiotic Adverse Drug Reaction (Peripheral)

0 0 0 0 Antibiotic Adverse Drug Reaction (PCC)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No

1 0 0 0 No of Mortality due to Infections(Central)

0 0 0 0 No of Mortality due to Infections(Region)

0 0 0 0 No of Mortality due to Infections(Peripheral)

0 0 0 0 No of Parenteral Antibiotic (Central)

0 0 0 0 No of Parenteral Antibiotic (Region)

0 0 0 0 No of Parenteral Antibiotic (Peripheral)

0 0 0 0 No of Parenteral Antibiotic (PCC)

Conclusion

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