Lecture 24 - Antimicrobial Stewardship

Question 1

What is antimicrobial stewardship?

Answer 1

taking care of antibiotics

programme of activities to improve how we use antibiotics in hospitals and community settings

Question 2

What is a priority in healthcare?

Answer 2

reducing HAI

Question 3

What interventions are there to reduce HAI?

Answer 3

infection control, antimicrobial stewardship, maintenance of buildings, education of staff and the public

Question 4

What is antimicrobial stewardship part of?

Answer 4

the healthcare associated infection agenda

Question 5

What is a HAI?

Answer 5

infection starting after 48 hours in hospital and can affect any part of the body

infection resulting from medical care or treatment in hospital, care homes, patients own home

Question 6

What patients are at risk of HAI?

Answer 6

elderly

prolonged admission

recent prolonged admission

ICU/HDU

invasive procedures

broad spectrum antibiotics

co-morbidity

Question 7

What are the important HAIs?

Answer 7

MRSA/S aureus

multiresistant gram negative

C difficile

Question 8

When does the onset of C difficile occur?

Answer 8

after antibiotic therapy

Question 9

What are the drugs most implicated in C difficile infection?

Answer 9

clindamycin, cephalosporins, quinolones, co-amoxiclav

Question 10

What patients are most at risk of C difficile infection?

Answer 10

patients over 65

Question 11

Symptoms of C difficile infection?

Answer 11

mild watery to severe bloody diarrhoea

Question 12

How is C difficile transmitted?

Answer 12

patient, environment, staff contaminated by spores

spores ingested and produce toxins in lower GI tract which cause colitis

Question 13

What is the decrease in C difficile due to?

Answer 13

having different less virulent strains circulating

Question 14

What to broad spectrum antibiotics cause?

Answer 14

disrupt natural bowel flora allowing pathogenic organisms such as C difficile to flourish

Question 15

What are less likely to cause C difficile infection?

Answer 15

narrow spectrum antibiotics that cause little disruption to the bowel flora

Question 16

What are some patients with C difficile infection reported?

Answer 16

not been exposed to any antibiotics

Question 17

How to minimise C difficile infection when using antimicrobials?

Answer 17

restriction of antibiotics with a high risk of C difficile infection

local antibiotic policies may exclude them

Question 18

What does there need to be a balance between?

Answer 18

effectively treating the current infection and not causing harm in the future to both patient and wider population

Question 19

Prevention of C difficile infection?

Answer 19

standard infection control precautions

antimicrobial stewardship

Question 20

Management of C difficile infection?

Answer 20

isolation

medication review - antibiotics, PPIs

severity assessment

oral metronidazole or vanocymin

Question 21

Key elements of antimicrobial stewardship?

Answer 21

prescribing guidance

information about antibiotic use and antimicrobial resistance

audit of clinical practice

education of healthcare staff and patients/public

Question 22

What does a point prevalence survey provide?

Answer 22

a snapshot of antibiotic use at a given point in time

Question 23

Key information about antimicrobial use?

Answer 23

% of patients prescribed an antimicrobial

% IV vs oral

types of infections treated

which antimicrobials being used and in which wards

Question 24

What does a PPS involve?

Answer 24

staff collect data from patients medicines charts and notes

data collection tool - paper or online

analysis of data and comparison with previous PPS in same hospital or can compare between hospitals

identify areas for improvement e.g. use of policy antibiotics, use of IV route

Question 25

Compliance audits?

Answer 25

quality improvement methodology to review clinical practice in real time

Question 26

What do compliance audits involve?

Answer 26

collect and report data on a sample of patients every week or month and feed back data to staff involved in prescribing

Question 27

Key measures for compliance audit?

Answer 27

reason for antimicrobial therapy documented in notes choice of antibiotic compliant with local policy

Question 28

Public education?

Answer 28

patients and public have poor knowledge about antibiotics and AMR need to know about not using antibiotics for coughs, colds and how to manage themselves also need to know how to take antibiotics when they are prescribed them

Question 29

What does SAGP do?

Answer 29

aim is to improve use of antibiotics throughout all health and care settings in scotland

Question 30

How will SAGP do this?

Answer 30

reduce unnecessary antibiotic use ensure antibiotics are used correctly educate healthcare staff, patients, public about antibiotic use measure improvement in quantity and quality of antibiotic use and impact on clinical outcoes reduce harm from antibiotics

Question 31

Specific infection SAGP guidance?

Answer 31

neutropenic sepsis community acquired pneumonia UTI staph areus bacteraemia

Question 32

Where are antimicrobial management teams set up?

Answer 32

in each health board to oversee antimicrobial use

Question 33

People in antimicrobial management teams?

Answer 33

minimum of a doctor, a microbiologist and an antimicrobial pharmacist

Question 34

Where must antimicrobials be prescribed?

Answer 34

in hospitals documented on medicine chart or prescription form in primary care on GP10 prescription

Question 35

Who can prescribe antimicrobials?

Answer 35

usually doctors but also nurses, pharmacists etc

Question 36

Who usually administers antimicrobials?

Answer 36

nursing staff

Question 37

Who administers antimicrobials in primary care?

Answer 37

patients and carers

Question 38

Obstacles to antimicrobial stewardship?

Answer 38

physician loss of autonomy lack of resources poor IT infrastructure measure impact is difficult lack of evidence for some aspects of stewardship

Question 39

How does physician loss of autonomy affect this?

Answer 39

resistance of being told what to do fear of antagonising patients or more senior clinicians

Question 40

How can poor IT infrastructure affect this?

Answer 40

electronic prescribing electronic data capture - audit antibiotic usage data

Question 41

What does an antimicrobial pharmacist do?

Answer 41

develops, reviews and implements policies and guidance evaluates antimicrobial use data audits compliance with policy and use of antibiotics provides education for medical, pharmacy and nursing staff may have a clinical role

Question 42

Role of the pharmacist - hospital?

Answer 42

all medicine charts and prescriptions should be checked for compliance with antimicrobial policy for choice of antibiotic, route, frequency and duration clinical pharmacists can promote use of policies at ward level and educate other staff

Question 43

How many patients in hospital are prescribed an antibiotic?

Answer 43

up to 1/3

Question 44

What is common in hospital pratice?

Answer 44

inappropriate use, wrong dosage regimens, penicillin use in allergic patients, prolonged courses, broad spectrum rather than narrow

Question 45

Role of pharmacist - primary care?

Answer 45

monitor prescribing of all medicines identify problems with quantity and quality of antimicrobial prescribing feedback of prescribing info to prescribers is best way to influence and promote compliance with policy

Question 46

Role of the pharmacist - community?

Answer 46

awareness of local antimicrobial prescribing policy query use of non-policy antibiotics and inappropriate dosage or duration patient education on self management of minor infections pharmacy first initiative provide advice to care homes on antibiotic use in high risk patients