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