OVERVIEW OF ANTIMICROBIAL STEWARDSHIP

Practical guidance on how to implement antimicrobial stewardship (AMS) programmes in the human health sector at health-care facility

1. OVERVIEW OF ANTIMICROBIAL STEWARDSHIP DR TANVEER REHMAN SCIENTIST – B (MEDICAL) PUBLIC HEALTH DIVISION

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3. Background Global Action Plan on Antimicrobial Resistance (AMR ) Overuse and misuse of antimicrobials as a main driver for development of AMR Optimize the use of antimicrobial medicines in human and animal health Practical guidance on how to implement antimicrobial stewardship ( AMS) programmes in the human health sector at health-care facility Improve patient outcomes, reduce AMR and health-care-associated infections, and save health-care costs amongst others 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 3

4. Antimicrobial stewardship Careful and responsible management of something entrusted to one’s care Applied in the health-care setting as a tool for optimizing antimicrobial use One of three “pillars” of an integrated approach to health system strengthening Infection prevention and control (IPC) and medicine and patient safety WHO essential medicines list (EML) AWaRe classification Promotes equitable and quality health care towards the goal of achieving universal health coverage (UHC) 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 4

5. ‘Access ’ Group – WHO ‘ AWaRe ’ 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 5

6. ‘ WAtch ’ Group – WHO ‘ AWaRe ’ 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 6

7. ‘ REserve ’ Group – WHO ‘ AWaRe ’ 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 7

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9. Aim of AMS Optimize the use of antibiotics Promote behaviour change in antibiotic prescribing and dispensing practices Improve quality of care and patient outcomes S ave on unnecessary health-care costs Reduce further emergence, selection and spread of AMR Prolong the lifespan of existing antibiotics Build the best-practices capacity of health-care professionals 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 9

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12. Antimicrobial prescribing facts 30% of all hospitalised in-patient at any given time receive antibiotics About 50% of antimicrobial use has been found to be inappropriate Up to 30% of all surgical prophylaxis is inappropriate URTI – reason for the 75% of the antibiotic prescriptions each year; in most cases of URTIs, antibiotic confers little or no benefit 10-30 % of antimicrobial cost can be saved by AMS Globally, dentists were reported to prescribe up to 11.3 % of all antibiotics. 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 12

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14. Prospective (real-time) audit with feedback Prospective audit with feedback (e.g. on ward rounds) involves the assessment of antibiotic therapy by AMS team, who make recommendations to prescribers in real time when therapy is considered suboptimal. It may be performed alongside clinical personnel on ward rounds, providing oral recommendations for changes in antibiotic treatment in real time. Alternatively, AMS team may perform ward rounds on their own, providing written recommendations for changes in antibiotic treatment 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 14

15. Formulary restriction/preauthorization Use of restricted antibiotics may be limited to certain indications , prescribers, services , patient populations or a combination of these. Selection of restricted antibiotics is done by facility authorities, the AMS team and heads of units based on spectrum , cost or toxicities. Antibiotics are restricted before use ; ensures expert approval before initiation Practical approach that allows attending physician to use the drug pending approval by physician or AMS team after +/− 48 hours 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 15

16. Didactic education Formal or informal teaching to engage prescribers in improving antibiotic prescribing , dispensing and administration practices Clinical case discussions , classes, reminders, conference presentations, student and house staff teaching sessions , provision of written guidelines, informational pamphlets, posters or e-mail alert – STG/ updates Education alone, without incorporation of active intervention is only marginally effective 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 16

17. Streamlining/de-escalation All clinicians should perform a review of antibiotics 48 hours after prescription When microbiological results become available, antibiotic treatment should be streamlined accordingly: choose the most active antibiotic(s ) with least toxicity, narrowest spectrum and lowest cost De-escalation is safe for sepsis and septic shock, and is associated with decreased mortality 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 17

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19. Outcome measures Outcome measures/indicators related to antimicrobial use DDD or DOTS per 100(0) patient-days: D efined D aily D ose of an agent from pharmacy dispensing or health-care facility purchasing data or Days of Therapy from nursing chart administrative data (paper) in a period of time Outcome measures/ indicators related to patients and microbiology In-hospital mortality, Length of stay, Readmission within 30 days after discharge Clostridium difficile : Number of health-care-associated C. difficile infections 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 19

20. Common areas for improving antibiotic prescribing Overprescribing: when not needed, e.g. fever without evidence of infection, viral infections, malaria, asymptomatic urinary tract colonization Overly broad spectrum: More broad-spectrum antibiotics (WATCH and RESERVE) are prescribed than are necessary ( e.g. surgical prophylaxis ) Unnecessary combination therapy, including certain FDC: Multiple antibiotics are used, particularly with overlapping spectra and in combinations that have not been shown to improve clinical outcomes . 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 20

21. Common areas for improving antibiotic prescribing Wrong antibiotic choice: Wrong antibiotic(s) are prescribed for particular indications/infections. Wrong dose: Over- or under dosing Wrong dose interval: Antibiotics are prescribed with the wrong dose interval (too much time between doses ). Wrong route: Antibiotics are prescribed by the wrong route (e.g. IV instead of oral). 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 21

22. What can the individual physicians do Obtain appropriate cultures before starting antibiotic Review antibiotic use after 48 – 72 hours : does it need to be continued? Stop antibiotic in patient with alternative non-infectious diagnosis Optimize dosing and duration of antibiotic therapy Avoid unnecessary use, especially in viral upper respiratory tract infections 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 22

23. Health-care facility AMS team Implements day-to-day AMS activities like conducting regular ward rounds Undertakes audits or PPSs to assess the appropriateness of antibiotic prescription M onitors , analyses and interprets the quantity and types of antibiotic use at the unit and/or facility-wide level Monitors antibiotic susceptibility and resistance rates for a range of key indicator bacteria at the facility-wide level or uses the data from existing groups Facilitates education and training on AMS in the facility. 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 23

24. Health-care facility AMS team Option 1: >2 : physician , a pharmacist, a nurse with expertise in infections or IPC, and in facilities with a microbiology laboratory, a microbiologist Option 2: a physician and a nurse or pharmacist, with access to expert advice Option 3: an AMS champion, e.g. a physician, nurse or pharmacist leading the stewardship programme , with access to expert advice (e.g. secondary or small facilities with limited resources). Frequency of meetings: Weekly to two times a month 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 24

25. THANK YOU 25/09/2023 AMS Dr Tanveer Rehman RMRCBB 25 References 1. ICMR. Antimicrobial Stewardship Program Guideline 2. Antimicrobial stewardship programmes in health-care facilities in low-and middle-income countries: a WHO practical toolkit 3. Vijay S, Ramasubramanian V, Bansal N, Ohri VC, Walia K. Hospital-based antimicrobial stewardship, India. Bulletin of the World Health Organization. 2023