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Transcript
Principles of
Antibiotic Policies
1. Explain how antibiotic use can select resistant
strains of bacteria
2. Identify important mechanisms used by
antibiotic stewardship programmes to decrease
bacterial resistance in hospitals
3. Describe the roles of the microbiology
laboratory and IP&C staff in the containment of
bacterial resistance in healthcare
4. Participate in the formation of an antibiotic
stewardship programme
December 1, 2013
Learning objectives
2
• 45 – 60 minutes
December 1, 2013
Time involved
3
• Discovery of antibiotics – revolutionary
event that saved millions of lives
• Emergence of resistance – reduced
effectiveness, increased toxicity, increased
costs
• To preserve susceptibility – or to
postpone development of resistance –
antibiotics should be used rationally
December 1, 2013
Introduction
4
• Fleming changed the course of
history
• Mould contaminated an
experiment – contained
penicillin
• Killed the Staphylococcus
aureus that had been growing
in the dish
• Penicillin altered the treatment
of bacterial infections
December 1, 2013
Antibiotics
Dr Alexander Fleming
5
• Antibiotic resistance develops
• Through natural mutations of
bacterial genes
• Through transfer of resistance genes
between different bacteria via
plasmids, transposons, etc.
• If a bacterial population with
newly resistant bacteria are
exposed to a specific antibiotic,
they will be selected and develop a
new resistant strain
December 1, 2013
Antibiotic Resistance
6
Resistance can be mediated by:
• Change in antibiotic target site - altered
penicillin binding proteins, altered DNA
gyrase:
December 1, 2013
Mechanisms of resistance
• Beta-lactams, Quinolones
• Production of detoxifying enzymes:
• Beta-lactams (Beta-lactamases) ,
Aminoglycosides, Chloramphenicol
• Decreased uptake(reduced
permeability, active efflux):
• Erythromycin, Tetracyclines, Beta- lactams
7
• Antibiotics are used as treatment of infections
• In veterinary medicine
• In agriculture
December 1, 2013
Antibiotic use outside human
medicine
• Antibiotics are also used as growth promotors
8
• Increased morbidity
• Increased mortality
• Extended hospital stay
• Increased admission to
intensive care
• Loss of bed days
December 1, 2013
Clinical Impact of Resistance
9
• Empirical therapy
• Without the knowledge of pathogen
• Pathogen-directed therapy
December 1, 2013
Types of antibiotic uses
• Knowing the pathogen and susceptibility to antibiotics
• Prophylaxis
• Surgical
• Medical
10
Prevention of spread
•
•
•
•
Infection prevention &
control in
healthcare settings
Isolation
Hand Hygiene
Environmental hygiene
Antibiotic stewardship
•
•
•
•
Surveillance
Antibiotic policies
& guidelines
Antibiotic management
programmes
Reduction
•
•
December 1, 2013
Dealing with resistance
Usage control
Appropriate use
•
Human
•
Animal
•
Environmental
11
• Can modify prescribing practices
• Should lead to reduced, rational use
• Should be well designed, and implemented
• Should be based on education
• Ideally should be a mixture of measures that are:
• Voluntary
• Persuasive
• Restrictive
December 1, 2013
Antibiotic stewardship
programmes - 1
12
Key to modifying prescribing practices,
stewardship programmes must include:
•
•
•
•
•
•
•
National policies
Local hospital or health care policies
Formularies and guidelines
Education
Effective microbiology laboratory support
Audits
Effective working relationship with IP&C* teams
*IP&C: Infection Prevention and Control
December 1, 2013
Antibiotic stewardship
programmes - 2
13
• Legislation required to regulate production
and import
• Legislation to impose limitation of use in
veterinary practices to treatment only
December 1, 2013
Key Elements of National
Antibiotic Policies
• Not as growth promoters
• Legislation to reduce over the counter use
• Education of the general population
• Reduce expectations
• Avoid misuse and over demand
14
Important elements of an effective
hospital programme:
•
•
•
•
•
Antibiotic Committee
Antibiotic Management team
Formularies, guidelines and protocols
Education
Audits
December 1, 2013
Hospital stewardship
programmes
15
• Can be a “stand alone” Committee,
or part of Drugs and Therapeutics
Committee
• Membership should include:
• Physicians and nurses who prescribe
antibiotics
• Pharmacists
• Microbiologists
• Members of
Management/Administration
• Members of Infection Control
Committee
• Others, as needed
December 1, 2013
Antibiotic Committee
16
Team to advise on antibiotic use, audit of
prescribing, introduction of new antibiotics
• Larger hospitals: can include infectious
disease (ID) physicians, clinical
pharmacologists, pharmacists, clinical
microbiologists, any doctor authorised to use
reserve list
• Smaller institutions: minimum requirement:
antibiotic pharmacist (at least part-time), with
support from ID or IP&C physician
December 1, 2013
Antibiotic Management Team
17
Should include:
• Protocols for the evaluation of parenteral
antibiotics
• Include stop orders after 3-5 days and
recommendations for sequential treatment
December 1, 2013
Guidelines and Protocols
• Protocol for list of reserve antibiotics
• How to order
• Who can authorise
18
Local hospital or health care policies should
focus on using antibiotics that:
•
•
•
•
Have narrowest possible spectrum
Are inexpensive
Have minimal toxicity
Have least impact on development of resistance
December 1, 2013
Hospital Guidelines/Policies
19
• Antibiotic formularies: no drug outside
those listed should be used
• Protocols for empiric and targeted
treatment of common infections
• Protocols for surgical prophylaxis
• Protocols for de-escalation of parenteral
use
• Protocols for use of a reserve list
December 1, 2013
Hospital formularies and
protocols
20
Should include:
• Formal meetings
• Clinical rounds with antibiotic
management team/committee members
• Formal lectures
December 1, 2013
Education programmes - 1
• Focus on:
• New antibiotics
• New methods of administration
• Influence on bacterial ecology
21
• Should be provided by Senior member
of Antibiotic Team, or independent
expert
• Should not be provided by individuals
from pharmaceutical companies, unless
a committee or antibiotic team
member is present
December 1, 2013
Education programmes - 2
22
• Regular reporting of changing resistance
patterns
– Newsletters
– Specialty-specific data
December 1, 2013
Stewardship: Role of the
Microbiology Laboratory
• Restricted antibiotic reporting
― Routinely only first line antibiotics
― Reserve antibiotics only if pathogen is
resistant to first line antibiotics
• Patient specific data (culture &
sensitivity) to optimise treatment
23
• Provide leadership to Antimicrobial
Team
• Antibiotic ward rounds
• Interpretation of patient-specific data
(culture & sensitivity) to optimise
treatment
• Active surveillance/ awareness
• Screening for carriage of resistant organisms
• Molecular detection and typing
December 1, 2013
Stewardship: role of Clinical
Microbiologist/ID Specialist
24
1. Are antibiotics being used in accordance with
approved protocols?
•
•
•
•
Empirical vs. targeted treatments clearly specified?
Stopped at the correct time?
Based on clinical needs and microbiology results?
Correct use of surgical prophylaxis guidelines?
December 1, 2013
Audit: Monitoring compliance
 Antibiotic
 Timing
 Dosage
25
2. Are our policies & guidelines being followed?
• Consumption data: Based on stock controls
• Signed prescriptions
• Usage data
December 1, 2013
Audit: Monitoring effectiveness
 DDD*: based on patient bed days / length of stay
*DDD = defined daily dose
26
3. Are the policies being used
effectively?
• Dosage: too much- too little?
• Timeliness: start-stop dates?
• Appropriateness: compliant with local
policies?
December 1, 2013
Audit: Monitoring Appropriateness
27
• Regular and timely feedback
• Use as evidence for further teaching
• Discuss in antibiotic ward rounds
• Assess efficacy of guidelines and
protocols before regular review
December 1, 2013
Audit data
28
• Work in close collaboration with Microbiology
laboratory
• Have early warning system, based on regular
surveillance
• Act promptly to detect and manage outbreaks
• Have effective isolation policies
• Ensure effective cleaning and high compliance
with hand hygiene
December 1, 2013
Control and Prevention of
Healthcare-associated Infections
29
• WHO Global Strategy for containment of antimicrobial
resistance WHO, 2001.
http://whqlibdoc.who.int/hq/2001/WHO_CDS_DRS_2001.2.
pdf
• Dellit TH, et al. Infectious Disease Society of America and
Healthcare Epidemiology of America guidelines for
developing an institutional program to enhance
antimicrobial stewardship. Clin Infect Dis 2007;44:159-177.
• Richards J. Emergence and spread of multiresistant
organisms: can infection control measures help? Int J Infect
Control 2009;v5:i2 doi:10.3396/ijic.V5i2.017.09.
December 1, 2013
Further reading
30
1.
2.
3.
Methods to manage resistance are preventing spread of resistant
pathogens, antibiotic stewardship, and reduction of antibiotic use.
T/F
Additional information from the microbiology laboratory, useful in
prudent use of antibiotics, is reporting sensitivity testing to broad
spectrum antibiotics as a first line antibiotics. T/F
The topics usually included in antibiotic policies are:
a.
b.
c.
d.
e.
December 1, 2013
Quiz
List of antibiotics in the formulary- with the possibility to use some
antibiotics outside the formulary.
Guidelines for empiric and targeted treatment not including dosage
and duration of treatment.
Protocols for reserve antibiotics including how to order and who
authorises its use.
Protocols for surgical prophylaxis including stop-orders after 48 hours.
All of the above.
31
• IFIC’s mission is to facilitate international networking in
order to improve the prevention and control of
healthcare associated infections worldwide. It is an
umbrella organisation of societies and associations of
healthcare professionals in infection control and related
fields across the globe .
• The goal of IFIC is to minimise the risk of infection within
healthcare settings through development of a network of
infection control organisations for communication,
consensus building, education and sharing expertise.
• For more information go to http://theific.org/
December 1, 2013
International Federation of
Infection Control
32