Post on 29-Sep-2020
Επιμελητεία αντιβιοτικών(Antimicrobial Stewardship)
Διαμαντής Π Κοφτερίδης
Αναπληρωτής Καθηγητής Παθολογίας –Λοιμώξεων
Πανεπιστήμιο Κρήτης
Antimicrobial prescribing is a complex process determined by many factors
• Guidelines
• Individual health
professional factors
• Patients factors
• Professional interactions
• Incentives and resources
• Άλλα
The problemMisuse and over-use of antibiotics
The problem
• Approximately 40% of all hospitalised inpatients at any given
time receive antibiotics
• ~ 50% are inappropriate
• Antimicrobials account for 30% of hospital pharmacy budgets.
• Inappropriate and excessive use leads to resistance, C.
difficile, increased morbidity, mortality, increased cost, and
reduce quality of life.
• Insufficient knowledge of prescribing professionals
• Between 2000 and 2010, consumption of antibiotic drugs
increased by 36%.
• Brazil, Russia, India, China, and South Africa accounted for
76% of this increase.
• There was increased consumption of carbapenems (45%) and
polymixins (13%), two last-resort classes of antibiotic drugs.
NO ACTION TODAY
NO CURE TOMORROW
International crisis: Less antibiotics/more resistance
• Antimicrobial resistance has been identified as
a major threat by the World Health
Organisation due to the lack of new antibiotics
in the development pipeline and infections
caused by multi-drug resistant pathogens
becoming untreatable
Goossens et al., 2011; Carlet et al., 2011
https://ecdc.europa.eu/..........antimicrobial-resistance-europe-2015.pdf
E. faecium-VRE
E. faecalis-
high level
‘R’ to
gentamycin
MRSA in Europe(As percentage of S. aureus bacteriemia)
2001 2017
Data EARS-Net Atlas
Blood cultures carbapenem I and R
E. coli K. pneumoniae
EARS-NET interactive atlas, data 2017
ITALY 29,7%, GREECE 64.7%, BULGARIA 12.4%, ROMANIA 22.4
Pseudomonas aeruginosa(percentage of blood cultures)
Ceftazidime R Aminoglycosides R
EARS-Net Atlas, data 2017
Carbapenem R
The global pattern of resistance is high.In most European countries >10% of the P. aeruginosa isolates present a combined resistance to 3 or more antimicrobial groups tested (aminoglycosides, carbapenems, ceftazidime, fluoroquinolones, piperacilline tazobactam)
Acinetobacter baumannii
Carbapenem RAminoglycosides R
EARS-NET interactive atlas, data 2017
Acinetobacter represents a public health threat. Limited treatment options in countries of southern and south-eastern EuropeRates of carbapenem resistance: Croatia 96.2%, Greece 94.8%, Italy 78.7%
Lancet Infect Dis 2019; 19: 56–66
New antimicrobial agents(with a novel mechanism of action,research, development)
Actions to prevent and control antimicrobial resistance and nosocomial infections
Infection prevention and control(hand hygiene, screening, isolation)
Prudent use of antimicrobial agents(only when needed, correct dose, correct dose intervals, correct duration)
The solution
Very few new antibioticsSince 1998 only 10 new antibiotics have been approved. Only 2 (linezolid and daptomycin) have new targets of action.
Clin Infect Dis 2011;52(S5):S397–S428
New drugs
IDSAs 10 x ′20
initiative:
“Ten new
antibiotics
released before
2020”
Very few new antibiotics
What is Antimicrobial Stewardship?
The IDSA describes antimicrobial stewardship
• Interventions designed to improve and measure the appropriate
use of antimicrobials by promoting the selection of the optimal
antimicrobial drug regimen, dose, duration of therapy, and route of
administration.
• Antimicrobial stewardships seek to achieve optimal clinical
outcomes related to antimicrobial use, minimize toxicity and other
adverse events, reduce the costs of health care for infections, and
limit the selection for antimicrobial resistant strains.
Dellit et al. Clin Infect Dis 2007;44:159–77
AMS
✓The right antibiotic
✓For the right patient
✓At the right time
✓With the right dose and
✓The right route
✓Causing the least harm to the patient and
future patients
www/cdc.gov/getsmart/healthcare/inpatient-stewardship
Why is AMS important?
• Decreased use of antimicrobials
• Improve clinical outcomes
• Prevent-reduce resistance
Impact on clinical outcomesAntibiotic Stewardship Improves Clinical Outcomes
Ohl et al. Clin Infect Dis 2011;53(S1):S23–S28
RR 2.8 (2.1-3.8) RR 1.7 (1.3-2.1)
RR 0.2 (0.1-0.4)
AMP = Antibiotic Management ProgramUP = Usual Practice
Effective ASPs are
associated with
• Increased clinical and
microbiologic therapeutic
successes
• Reduced incidence of
bacteremia
• Gram-negative
infection
• Antimicrobial drug–
related advers events
• CDI
Impact of Stewardship on Safety? (critical care)
• The reductions in antimicrobial utilization
– Have not been associated with any worsening in nosocomial
infection rates, length of stay or mortality.”
– Stewardship interventions were associated with … fewer
antibiotic adverse events.
Kaki R, et al. J Antimicrob Chemother 2011; 66: 1223-1230
Rates of C. difficile AADRates of Resistant
Enterobacteriaceae
Carling P et al. Infect Control Hosp Epidemiol. 2003;24:699-706
Impact on C. difficile and Resistance
Antibiotic Stewardship Reduces C. difficile Infection and Gram Negative Resistance
• Restriction of
carbapenems is
associated with both
• lower use and
• lower incidence of
carbapenem resistance
P. aeruginosa.
Ohl et al. Clin Infect Dis 2011;53(S1):S23–S28
Projected cost savings if antimicrobial-resistant infection (ARI) rates were reduced from 13.5% to 10%.
Roberts et al. Clin Infect Dis. 2009;49:1175-84
The goals of AMS
Goals of Antimicrobial Stewardship Programs
The 6 Ds: Operational Goals of Antimicrobial Therapy and Stewardship
• Right Diagnosis What infection syndrome is being treated? – Is it responsive to antibiotics?
– Have appropriate diagnostic tests been collected?
• Right Drug(s) – Demonstrated effective Safest Narrowest spectrum
• Right Dose
• Right De-escalation: right Drug(s) redefined when: – Justified by culture results (positive or negative)
– Clinical improvement (e.g., IV to PO switch)
• Right Duration: – Minimum necessary
– Defined infections requiring prolonged therapy
• Right Debridement or source control
How to implement antimicrobial Stewardship Program?
ASP DIRECTORS
ID Physician
ID Pharm D
Microbiology Laboratory
Hospital Epidemiologist
Infection Control Practitioner
Clinical Pharmacy Specialist
Infectious Diseases Division
Specialist with interest in
antimicrobials
Hospital Administrator
Director, Outcomes Research
Medical Information
Systems
Assess the motivations
• Analyse your situation and what problems you want to address.
• Define where you are and where you want to go.
• For example, easier or less costly approaches can include:
– Simple clinical algorithms
– Prescribing guidance for treatment, surgical prophylaxis
– Intravenous (IV) to oral conversion
– Restricting availability of certain antibiotics (formulary restriction)
– Promoting education
Dellit et al. Clin Infect Dis 2007;44:159–77
Antimicrobial stewardship strategies
Περιορισμός συνταγολογίου και
προέγκριση
Προοπτικό audit με παρέμβαση και
feedback
Two core antimicrobial stewardship strategies
Chung GW et al. Virulence 2013; 4:1-7
Identify effective interventionsfor your setting
• When establishing a new stewardship program, it is
best to start with the core strategies and focus on
achieving and maintaining them before adding some
of the supplemental strategies
Front end strategiesPreauthorization and restriction
• Local guidelines
• List of restricted antimicrobial agents and criteria for their use
combined with
Approval system
– It is essential that all aspects of prescribing are supported
by expert advice 24 hours a day.
Back end strategyProspective audit and feedback
Johannsson B. et al. Inf. Control. Hosp. Epidemiol. 2011; 32:367-374
Antimicrobial
review methods
are employed
post-
prescription
Antibiotic “Time outs”All physicians should review of antibiotics 48 hours after antibiotics are
initiated to answer these key questions
• Does this patient have an infection that will respond to antibiotics?
• If so, is the patient on the right antibiotic(s), dose, and route of administration?
• Can a more targeted antibiotic be used to treat the infection (de-escalate)?
• How long should the patient receive the antibiotic(s)?
http://www.cdc.gov/getsmart/healthcare/ implementation/core-elements.html.
ASP Elements Potential Advantages and Disadvantages
Supplemental strategiesEducation
• Effective and useful component when combined with an active
intervention
• It should include health care professionals as well as patients and public
and convince them that is important.
• May include
– General principles of antimicrobial therapy
– Interpretation of antibiotic sudceptibility and antibiograms
– Diagnostic and treatment guidelines
– Discussion of penicillin allergy
Pulcini et al. Virulence. 2013;4:192-202.Dellit et al. Clin Infect Dis 2007;44:159–77
Combination therapy
• There are insufficient data to recommend the routine use of
combination therapy to prevent the emergence of resistance.
• Combination therapy does have a role
– for empirical therapy for critically ill patients at risk of
infection with multidrug- resistant pathogens.
Dellit et al. Clin Infect Dis 2007;44:159–77
Don’t expect too much from combination therapy
• Indications:– Prevent resistance in long-term treatment (tuberculosis)
– Additional killing in endocarditis
– Additional killing in biofilms / prosthetic joint infections
• P. aeruginosa infections– Generally beta-lactam + aminoglycoside
– To increase efficacy, broaden spectrum, limit resistance development
• Carbapenem-R enterobacterales (recommended)
Adequate evidence
Limited (if any) evidence
• There is insufficient evidence to recommend any combination therapy for
serious MRSA infections in actual patient care.
Guidelines and clinical pathways
• Development of evidence-based practice guidelines
incorporating local microbiology and resistance patterns can
improve antimicrobial utilization (A-I).
• Guideline implementation can be facilitated through provider
education and feedback on antimicrobial use and patient
outcomes (A-III)
Dellit et al. Clin Infect Dis 2007;44:159–77
Microbiology laboratory
• The microbiology laboratory plays a critical role in AMS by
1. Providing patient-specific culture and susceptibility data to
optimize individual antimicrobial management
2. Resistance surveillance
– Local antibiograms with pathogen-specific susceptibility data should
be updated at least annually
3. Assisting infection control efforts in molecular epidemiologic
investigation of outbreaks
Dellit et al. Clin Infect Dis 2007;44:159–77
Use of diagnostic tools
• The role of rapid diagnostics and biomarkers is recognized as a key
recommendation by the IDSA.
• Benefits of PCT among patients with RTI and sepsis
• Near-patient rapid tests, e.g. influenza, Strep A, can be useful to identify
patients with bacterial versus viral infections.
• Molecular diagnostics can improve antibiotic stewardship and clinical
outcomes.
Dellit et al. Clin Infect Dis 2007;44:159–77
De-Escalating therapy
• Empiric antimicrobial regimens are often broad spectrum
• Narrowing the spectrum based on
– Culture results
– Discontinue empiric therapy if no evidence of infection
Dellit et al. Clin Infect Dis 2007;44:159–77
Dose optimization
• Include strategies to improve rates of cure and minimize
toxicity
• Such strategies are
– Prolonged or continue dosing of beta-lactams
– Once daily dosing of aminoglycosides
– Appropriate dosing of vancomysin
– Weight based dosing of certain antimicrobials
– Dose adjustments for patients with renal dysfunction
Dellit et al. Clin Infect Dis 2007;44:159–77
Parenteral – oral conversion
• Changing from iv to oral
• Is commonly used for antimicrobial agents with similar oral
concentration achieved (fluroquinolones etc)
• May reduce length of hospital stay and costs and potentially
eliminate risks associated with vascular access.
Antimicrobial order forms
• Antimicrobial order forms decrease antimicrobial
consumption through the use of automatic stop orders and
the requirement of physician justification
Dellit et al. Clin Infect Dis 2007;44:159–77
Literature evaluating the impact of EHRs and CDSSs on patient outcomes is
lacking, although EHRs with integrated CDSSs have demonstrated
improvements in clinical and economic outcomes
Forrest et al. Clin Infect Dis 2014;59(S3):S122–33
Identify key measurementsfor improvement
• Outcome measurements
– Improved clinical outcome
– Reduced antimicrobial resistance
– Adverse drug events
– Cost
– Unintended consequences, such as rates of C. difficile infection
Dellit et al. Clin Infect Dis 2007;44:159–77
Dodds Ashley et al. Clin Infect Dis 2014;59(S3):S112–21
Conclusions
• ASPs, in all types and sizes of hospitals
– Reduce antimicrobial use
– Improve patient outcomes
– Prevent and/or control the emergence of antimicrobial-
resistant organisms
• With careful strategic planning and commitment from all
involved parties, ASPs can become a reality for all hospitals.
Ευχαριστώ