Antimicrobial Stewardship Flashcards
List the aims and levels of antimicrobial stewardship program
Aims:
- Optimize clinical outcomes
- Minimize toxicities, selection pressure, resistance
- Reduce healthcare cost without adversely impacting quality of care
List the aims and levels of antimicrobial stewardship program
Levels:
- Micro (clinicians, pharmacists, patients etc.)
- Meso (institution, hospital, cluster)
- Macro (government, ministry)
What are the 5 core strategies employed by one health antimicrobial resistance workgroup to reduce the emergence and prevent the spread of drug-resistant organisms?
5 core strategies:
- Education
- Surveillance and risk assessment
- Research
- Prevention and Control of Infection
- Optimization of antimicrobial use - ASP
PROSE
List the core elements of an ASP in a healthcare institution
- Hospital leadership commitment
- Accountability
- Pharmacy expertise
- Action
- Tracking
- Reporting
- Education
Hospital Accountable Pharmacy Action Track Report Educate
List the core elements of an ASP in a healthcare institution
Discuss Hospital Leadership Commitment
Hospital leadership commitment
- Leadership buy-in is the KEY FIRST STEP to start ASP
- Dedicate necessary human, financial, and information technology resources
- Create a culture that advocates appropriate and safe use of antimicrobials
List the core elements of an ASP in a healthcare institution
Discuss Accountability
Accountability
- Appoint physician and pharmacist responsible for program management and outcomes
- Physician: ideally trained in ID, interest in abx use and pt safety, diplomatic and collegial
- Pharmacist: same, comfortable advising physicians and other providers, interventions
List the core elements of an ASP in a healthcare institution
Discuss Pharmacy Expertise
Pharmacy Expertise
- Pharmacist leader to drive implementation efforts to improve antibiotic use
- ID trained highly effective
- Specific training and/or experience in antibiotic stewardship
- Formal training, certificate programs in stewardship for pharmacists
List the core elements of an ASP in a healthcare institution
Discuss Action
What are the 3 priority interventions to improve antibiotic use?
Action
3 priority interventions:
- Formulary restrictions and preauthorization
- Prospecctive audit and feedback
- Facility-specific evidence-based treatment guidelines
Others:
- Infected-based interventions (e.g., pneumonia, UTI, SSTI)
- Provider/prescriber-based interventions (time-out, assess penicillin allergy)
Discuss the pros and cons of the three priority ASP interventions
- Formulary restrictions and preauthorization
- Gain approval before pharmacy can dispense Abx
- Pros: reduce unnecessary abx, optimize empiric choice, opportunity to discuss selection and send appropriate cultures/diagnostic tests
- Cons: impacts use of restricted agents only, resource intensive, delay in initiating treatment
- Prospective audit and feedback
- External review by expert at 48-72h after prescription
- Pros: more clinical data to enhance uptake recommendations, greater flexibility in timing of interventions, address duration of therapy
- Cons: impacts use of audited agents only, recommended action may not be followed
- Facility-specific evidence-based treatment guidelines
- Include diagnostics, choice, duration of Abx; based on local suceptibilities, formulary options, patient mix
- Pros: enhances the above 2 actions, influence prescribing habits and infection management, more engaging for clinicians
- Cons: uptake of guidelines, need to know how to identify cases and apply the guidelines
Other actions/strategies:
Pharmacy-based interventions
- Document indications for Abx
- Automatic changes from IV to oral
- Dose adjustment
- Duplicative therapy alerts
- Time sensitive automatic orders
- Detect and prevent DDI
Microbiology-based interventions
- Selective reporting of AST results
- Comments in microbiology reports - e.g., colonization or contaminant
Nursing-based interventions
- Optimizing microbiology cultures
- IV to oral
- Prompting antibiotic reviews, timeouts
List the core elements of an ASP in a healthcare institution
Discuss Tracking
Tracking
- Monitor Abx prescribing, impact of interventions, identify opportunities for improvement
- Process outcomes: % adhered to guidelines, number of preauthorization request received and approved, number of PAF carried out, interventions done and accepted
- Antibiotic use outcomes: drug consumption (DDD, DOT), average day of therapy
- Resistance: incidence density of MDROs (number of clinical isolates per 10,000 inpatient days), % of drug resistant isolates
- Clinical/patient outcomes: mortality, hospitalization, Abx-associated ADR including CDAD
- Global point prevalence survey
How is Defined Daily Dose (DDD) used to measure drug consumption?
DDD is the assumed average maintenance dose per day for a drug used for its main indication in adults
DDD allows an approximation of one average patient day of treatment across drugs with varying potencies and dosage intervals
DDD helps to adjust for activity and population size differences:
- Based on consumption in a geographical area: DDD per 1000 inhabitants
- Short course antibiotics: DDD per inhabitant per year
- Hospital drug consumption: DDD per 1000 bed days or DDD per 1000 discharges
*How to calculate: total grams given divide by DDD, then adjust for 1000 PD
Discuss the advantages and disadvantages of DDD
Advantages:
- Standardized comparison of aggregate antibiotic use b/w hospitals in diff locations and countries
- Estimate use in countries with limited access to computerized data
- Will change the estimate of drug use if the recommended daily dose is altered
Disadvantages:
- Will not accurately estimate DOT when the administered daily dose is not equal to the DDD, cannot compare between different antibiotic class
- Cannot be used in children, esp due to weight-based dosing
- Underestimate use for drugs that require reduced dosage (e.g., renally impaired patients)
- Approved DDD may change as new dosages are approved for existing drugs, might cause confusion when comparing use over time
Discuss the advantages and disadvantages of DOT
Advantages:
- Can be used to measure antimicrobial use in children
- Not influenced by changes in the recommended DDD
- Not influenced by discrepancies b/w DDD and the preferred daily dose
- Independent of age and weight
Disadvantages:
- Overestimate use for drugs that are given in multiple doses per day
- More difficult to measure without computerized pharmacy records
Explain the utility of point prevalence survey
Point prevalence surveys
- Provide quantifiable measures to assess and compare quantity and quality of antimicrobial prescribing and resistance in hospitalized adults, children, and neonates worldwide
- Can compare antimicrobial use between wards, compare between different countries
- Able to identify problems (see antibiotic prescription practices)
