ANTIMICROBIAL STEWARDSHIP

“Without action, by 2050

someone could die every three seconds as a result of AMR”

Without action, we are heading for a post-antibiotic era, in which

common infections and minor injuries can once again kill.

A multi-faceted approach is required to fight antimicrobial resistance through_

• strengthening antimicrobial stewardship

• enhance monitoring

• educate the public

• develop new treatments. 

Antimicrobial resistance poses a significant public health threat leading to

• increased morbidity and mortality from infections.

• It can also lead to longer hospital stays and higher medical costs given that there are limited treatment options.

ANTIMICROBIALS

• are medicines used to prevent and treat infections in humans, animals, and plants.

ANTIMICROBIALS include

• antibiotics

• antivirals

• antifungals

• antiparasitics.

ANTIMICROBIALS

• Agents derived from any source. It can be derived from

• microorganisms

• plants

• animals

• and can also be synthetic or semi-synthetic that can kill, prevent, or inhibit the growth of microorganisms.

Antibiotics

- targets bacteria (Penicillin, Tetracycline)

Antivirals

- targets virus (Oseltamivir, Acyclovir)

Antifungals

- combats fungal infections (Fluconazole, Amphotericin B)

Antiparisitics

- targets and treats parasitic infections (Metronidazole for protozoa, Ivermectin for worms)

ANTIMICROBIALS
Tend to be overused or abused which can lead to antimicrobial resistance.

Ongoing research determines new strategies or treatments to combat this developed resistance. 

ANTIMICROBIAL RESISTANCE

occurs when bacteria, viruses, fungi, and parasites change over time and no longer respond to medicines making infections harder to treat and increasing the risk of disease spread, and severe illness and death

PLANS AND PROGRAMS ON AMR

GLOBAL ACTION PLAN ON ANTIMICROBIAL RESISTANCE (AMR)

• To ensure, for as long as possible, continuity of successful treatment  and prevention of infectious diseases with effective and safe medicines that are quality-assured, used in a responsible way, and accessible to all who need them.

• we should also raise public awareness on the right use of antimicrobial medications and foster global collaboration. 

PLANS AND PROGRAMS ON AMR

PHILIPPINE ANTIBIOTIC AWARENESS WEEK (PAAW) 2016

• DOH and WHO unite to win the war against antimicrobial resistance

NATIONAL ANTIMICROBIAL STEWARDSHIP (AMS) PROGRAM

goal

Reducing the morbidity (illness) and mortality (death) due to AMR

NATIONAL ANTIMICROBIAL STEWARDSHIP (AMS) PROGRAM

Philippine Action Plan to Combat Antimicrobial Resistance:

One Health Approach

NATIONAL ANTIMICROBIAL STEWARDSHIP (AMS) PROGRAM

Philippine Action Plan to Combat Antimicrobial Resistance: One Health Approach

• Focuses on responsible human and animal antimicrobial use promotion

• Implementation of effective stewardship practices that seek to optimize treatment outcomes, reduce resistance, and improve public health and safety.

ANTIMICROBIAL STEWARDSHIP

goal

To optimize clinical outcomes while minimizing the adverse effects on microbiological ecology

ANTIMICROBIAL STEWARDSHIP

Set of coordinated strategies to ensure the patient receives optimal antimicrobial therapy when specifically indicated.

CORE ELEMENTS OF THE NATIONAL AMS PROGRAM

1. Leadership

2. Policies, Guidelines, Pathways

3. Surveillance AMU & AMR

4. Action

5. Education

6. Performance Evaluation

LEADERSHIP

A dedicated multi-disciplinary AMS Committee and Team supported by the hospital administration shall be responsible to successfully implement, perform, and monitor the AMS Program each hospital.

LEADERSHIP

• Emphasizes the

• importance of strong and committed leadership at all levels 

LEADERSHIP

• Essential to _

foster collaboration and ensure program success

Pharmacists play a crucial role in the leadership component 

• Expertise provision about antimicrobial agents

• Promotion of appropriate prescribing practices 

• Information provision about potential interactions that affect prescribers’ decision-making

• Development and implementation of different AMS strategies (e.g., protocol development, educational programs)

• Collaboration with  other healthcare professionals (e.g., physicians, nurses) to promote best AMS practices and ensure comprehensive patient care

THE AMS TEAM

• A team responsible for the effecting and monitoring of AMS strategies to promote appropriate antimicrobial use shall be created under the AMS Committee.

AMS should be spearheaded by

PHARMACISTS and physicians (especially Infectious Disease Specialists) 

AMS should be spearheaded by PHARMACISTS and physicians (especially Infectious Disease Specialists) 

• This helps in ensuring that the right drug is being prescribed at the right time for the right diagnosis or indication.

AMS Clinician

• 0.5 FTE (Full-Time Equivalent) per hospital

• Level II-III hospital IDS ()

• Level 1 hospital- AMS-trained physician

AMS Clinician

roles & responsibilities 

• Provides expert advice on inclusion of antimicrobials into the hospital formulary

• Leads in implementing and monitoring of AMS activities

• Establishes and maintains approval systems for restricted antimicrobials

• Educates staff on appropriate antimicrobial use, AMS activities and AMR

AMS Clinical Pharmacist

Level II & III hospital 1 FTE : 100 beds

Level I hospital 1 FTE per hospital

AMS Clinical Pharmacist

roles & responsibilities 

• Assists in coordinating and implementing AMS activities

• Assists in the development and dissemination of guidelines, monitoring of antimicrobial use and AMR, and in assessing the performance of AMS program

• Ensures/enforces compliance to all AMS policies, guidelines and procedures

• Performs point of care interventions to optimize the patient's antimicrobial therapy

• Educates pharmacy staff and students on AMS

• Coordinates with medical and nursing staff to ensure timely administration of appropriate antimicrobials

• Identifies cases that require review by ID specialists

• Provide drug information and advice on dosing, drug interactions and adverse drug reactions

• Evaluates antimicrobial prescribing behaviour and provide feedback to prescribers

Executive

1 FTE per hospital

Executive

roles & responsibilities 

• Provides administrative support to daily AMS activities

• Assists in monitoring of the performance of the AMS program

• Prepares AMS-related reports as requested by the AMS committee and DOH-PD

RESPONSIBILITIES OF THE AMS TEAM

1. Implementation of the AMS strategies and perform AMS interventions as needed;

2. Development and review of standard treatment guidelines and prescribing policies;

3. Regular collection, analysis and reporting on the progress of the AMS program to the hospital AMS committee, administrators and DOH;

4. Education of healthcare staff on appropriate antimicrobial prescribing and resistance;

5. Identification and designing of systems/processes to facilitate appropriate antimicrobial use; and,

6. Provision of expert advice on development of policies related to appropriate use of antimicrobials and control of A M in the hospital.

ROLES OF AN ANTIMICROBIAL STEWARDSHIP PHARMACIST

1. Surveillance

2. Optimizing Drug Therapy

3. Drug Therapy Monitoring and Adherence to CPG

4. Education/Training and Public Engagement

SURVEILLANCE / MONITORING

• Surveillance of antimicrobial consumption and resistance data are essential to understand the development and actions required to reduce antimicrobial resistance

Antibiotic consumption

Keep track of the quantity of antibiotics prescribed in a healthcare setting to identify patterns and areas for improvement

Defined Daily Doses

Use of standardized measurements to assess antibiotic dosage and allow for easier comparison Evaluate different prescribing practices at different times and locations

Correlation of resistance

Analyze antibiotic use and emergence of the resistant bacteria to help understand how prescribing practices contribute to resistance

OPTIMIZING DRUG THERAPY

Review for completeness and appropriateness of prescription 

OPTIMIZING DRUG THERAPY

Pharmacists should have access to patients’ chart

• which contains important details about their health to help determine the best drug therapy to be used, ensuring  safety and efficacy

• Check prescriptions for missing information or potential issues such as duration of treatment and correct antibiotic used for the disease

DRUG THERAPY MONITORING AND ADHERENCE TO CPG (CLINICAL PRACTICE GUIDELINES)

• this involves 

several important activities/tasks to ensure that the medication works well and that it's safe for our patients.

DRUG THERAPY MONITORING AND ADHERENCE TO CPG (CLINICAL PRACTICE GUIDELINES)

• Monitoring effectiveness/ineffectiveness of drug therapy and providing interventions

• Monitoring for adverse events / side effects / ADR

• Recommending dose adjustments 

• Adherence to guidelines 

Monitoring effectiveness/ineffectiveness of drug therapy and providing interventions

As a pharmacist we need to keep an eye on how the medication is working for the patient. If the drug does not exhibit the desired effect, we must suggest changes or other alternatives for the patient's medical condition.

Monitoring for adverse events / side effects / ADR

• To catch and address any problems early

Recommending dose adjustments 

Especially if the patient's response to the medication is not ideal. This is done to find the right amount of medication that works best for our patient.

Adherence to guidelines 

• 7th day antibiotic stop policy

• Antibiotic restrictions 

• Surgical prophylaxis

EDUCATION/TRAINING AND PUBLIC ENGAGEMENT

• We need to stay informed and Keeping up-to-date with the latest treatment guidelines, new evidences, research and studies to provide the best care for our patient

• Education for patients or the public (forums & leaflets with amr information) 

Education for patients or the public 

Offer information, guidance to our patients and the community about the proper use of antibiotics and the importance of preventing resistance.

Fora (Forums)

Organize events or discussions to engage with the public, answer their questions and share important information about antibiotic use.

Leaflets with antimicrobial resistance information 

Explain AMR in simple terms so that they can easily understand

AMS INTERVENTIONAL STRATEGIES

1. Persuasive Strategies

2. Restrictive Strategies

AMS INTERVENTIONAL STRATEGIES

goal 

• To safeguard and ensure the optimal use of antimicrobials 

• To optimize clinical outcomes of the patient 

PERSUASIVE STRATEGIES

Aims to persuade health professionals to prescribe appropriately by addressing underlying knowledge deficiencies, attitudes and/or behaviour through active interaction and discussion

Types of Persuasive Strategies

• audit and feedback 

• point of care interventions 

AUDIT AND FEEDBACK 

• Prospective Audit of Antimicrobial Prescribing and Direct Intervention and Feedback

AUDIT AND FEEDBACK 

involves 

• Clinical evaluation and close reviewing of individual prescriptions of antimicrobials for appropriateness 

• Followed by the immediate and direct communication with prescribers to optimize treatment for each patient

POINT OF CARE INTERVENTIONS

• IV to PO switch, De-escalation (reducing the strength of the antibiotics), Dose optimization

• Occur routinely (directly) at the ward level 

• With direct feedback to the prescriber/attending physician at the time of prescription or laboratory diagnosis.

POINT OF CARE INTERVENTIONS

adv

• improves patient management and outcomes

• an excellent opportunity to educate clinical staff on appropriate prescribing 

RESTRICTIVE STRATEGIES

• Control the use of antimicrobials by instituting “barriers” to

• prescribing of certain antimicrobials

• administration of certain antimicrobials or

• after a duration of time

RESTRICTIVE STRATEGIES

• It includes the following strategies:

• Formulary Restriction and Pre-authorization

• 7th Day Automatic Stop Policy

Formulary Restriction and Pre-authorization

• Wherein certain antibiotics will only be available through a specific list  of approved medications, doctors need special permission when prescribing  restricted drugs

• It also needs pre-authorization. Before a doctor prescribes a restricted antibiotic, they need to get approval from a pharmacist or an antimicrobial stewardship team (infectious disease team) to ensure that the medication is necessary and appropriate

7th Day Automatic Stop Policy

• Some antibiotics are set to automatically stop after 7 days  unless the  healthcare team decides that more treatment is needed

FORMULARY RESTRICTION (ANTIMICROBIAL RESTRICTION) AND PRE-AUTHORIZATION

• Antimicrobial restriction and pre-authorization requires clinicians to obtain approval for use of selected antimicrobials before prescribing.

FORMULARY RESTRICTION (ANTIMICROBIAL RESTRICTION) AND PRE-AUTHORIZATION

objective 

• to preserve last-line antimicrobials to use for conditions where they are truly indicated.

• to help minimise unnecessary patient exposure to toxicities and costs associated with inappropriate therapy.

FORMULARY RESTRICTION (ANTIMICROBIAL RESTRICTION) AND PRE-AUTHORIZATION

scope 

Use of restricted antimicrobials administered orally and intravenously to all patients (inpatient and outpatient settings).

FORMULARY RESTRICTION (ANTIMICROBIAL RESTRICTION) AND PRE-AUTHORIZATION

exception 

• Use for treatment of MDR  (multidrug-resistant) tuberculosis under the Programmatic Management of Drug Resistant Tuberculosis (PMDT); and

• Antimicrobial prescribed/order by an IDS (infectious disease specialist) or AMS Clinician.

IDSA/ SHEA ANTIMICROBIAL STEWARDSHIP  GUIDELINES 2016

• Preauthorization of broad-spectrum antibiotics and prospective review after two or three days of treatment should form the cornerstone of antibiotic stewardship programs to ensure the right drug is prescribed at the right time for the right diagnosis.

INCLUSION CONSIDERATION OF WHICH ANTIMICROBIALS ARE IN PREAUTHORIZATION

• Potential to promote resistance

• Potential for/documented overuse or misuse

• Need to reserve for treatment of multi-drug-resistant organisms

• Broad spectrum

• High cost

• Risk for serious adverse effects

DOH MANUAL (RESTRICTED ANTIMICROBIALS)

• IV Antifungals (All except Fluconazole)

• Aztreonam

• Carbapenems (All)

• 4th Generation Cephalosporins (All)

• Colistin

• Linezolid

• Vancomycin

 FORMULARY RESTRICTION (ANTIMICROBIAL RESTRICTION) AND PRE-AUTHORIZATION

process flow 

1. Physician writes the medication order

2. Physician/Resident on Duty (ROD) accomplishes Restricted Antimicrobial Order Form (RAOF) and seeks approval from AMS Officer

3. Physician/ROD documents the resolution and forwards the RAOF to Pharmacy

4. Pharmacist dispenses the medication

5. Nurse administers the medication

6. AMS Officer validates and countersigns the RAOF the next working day

for sepsis and bacterial meningitis, medication will be given within

30 minutes to 1 hour without the need for pre-approval

In case the AMS Officer cannot be contacted, it is documented on the form

and Pharmacy may dispense the first dose; but the succeeding dose will require approval already

 7TH DAY AUTOMATIC STOP POLICY

• This policy shall govern the duration of antimicrobial use by requiring prescriptions to be regularly reviewed, specifically in the need to continue therapy beyond seven (7) days.

 7TH DAY AUTOMATIC STOP POLICY

rationale 

• Infections should be treated with the shortest effective treatment duration. 

• Unnecessarily prolonged antimicrobial exposure predisposes patients to: 

  • adverse effects 

  • emergence of drug-resistant organisms 

  • increased costs

 7TH DAY AUTOMATIC STOP POLICY

scope

This standard operating procedure shall cover the use of all antimicrobials administered orally and intravenously to all patients admitted in the hospital (inpatient setting only)

 7TH DAY AUTOMATIC STOP POLICY

exception 

• Use in HIV/AIDS or cancer patients as antimicrobial prophylaxis according to guidelines; and 

• Use as anti-tuberculosis antibiotics.

 7TH DAY AUTOMATIC STOP POLICY

process flow 

1. CP monitors duration/antimicrobial days

2. RN and/or CP notifies MD on 6th day of antimicrobial use

3. Physician/ROD accomplishes SDAF and seeks approval from AMS Officer

4. Physician/ROD documents the resolution and forwards the SDAF to Pharmacy

5. Pharmacist dispenses the medication

6. Nurse administers the medication

7. AMS Officer validates and countersigns the SDAF the next working day/earliest time possible

Administration, the nurse or pharmacist in charge of the patient shall alert the attending physician

no later than on the 6th day of antimicrobial therapy

As a general rule:

• Day 1 is the

first day of treatment and counting is continuous (once a day, divided dose, transfer, missed dose, loading dose)

Counting is reset if

discontinued or put on hold for more than 24 hours

ANTIMICROBIAL DAYS COUNTING GUIDELINES

• Antimicrobials administered once daily:

day of first dose (day 1) + 6 days = 7 days

ANTIMICROBIAL DAYS COUNTING GUIDELINES

• Antimicrobials administered in divided doses or spaced more than 24 hours apart (e.g. Q48H):

• day of first dose (day 1) + 7 days = 8 days

ANTIMICROBIAL DAYS COUNTING GUIDELINES

• For patients transferred to the hospital with antimicrobials started from an outside healthcare facility,

the initial/original start date shall be used for calculation of treatment duration

ANTIMICROBIAL DAYS COUNTING GUIDELINES

• Loading and missed doses

are to be included in the treatment period

ANTIMICROBIAL DAYS COUNTING GUIDELINES

• When there is a change in routes of administration or change antimicrobial agent (escalation or de-escalation), 

the counting of days continues to apply

There is NO NEED to fill out the SDAS form if:

• Total treatment duration is intended to be less than or equal to 7 days 

• Use of the antimicrobial beyond 7 days has been recommended by the AMS clinician, IDS or IPC Chairperson

There is NO NEED to fill out the SDAS form if

• Use of the antimicrobial beyond 7 days has been recommended by the AMS clinician, IDS or IPC Chairperson 

• Recommendation must be made in writing as evidence for pharmacy to dispense and nurse to administer)