antimicrobial stewardship: start SMART then FOCUS

what is antimicrobial stewardship

an organisational and system-wide approach to promoting and monitoring the use of antimicrobials by

• optimising therapy for individual patients

• preventing the overuse and misuse of antimicrobials

• minimising the development of resistance at patient and community levels

what is the antimicrobial stewardship clinical management algorithm

• evidence-based guidance for secondary care clinicians and leaders (inpatient care settings)

• designed to reduce the risk of antimicrobial resistance whilst safeguarding the quality of care for patients with infection 

in start SMART, what is Assess

is the antimicrobial needed? is there evidence of infection? → DO NOT START ANTIMICROBIAL THERAPY UNLESS THERE IS CLEAR EVIDENCE OF INFECTION

• Assess patient for clear evidence of infection 

• Perform a comprehensive patient assessment to guide selection of
  proportionate treatment and determine the appropriate care environment.

• This includes considering disease severity, immunocompromised
  patients, likelihood of resistant pathogen, prior exposure to antimicrobials, and patients with factors commonly associated with health inequalities where appropriate

what is the importance of clinicians ensuring that patients clinically require an antimicrobial prior to starting therapy 

• preserves the effectiveness of antimicrobials by keeping antimicrobial resistance in check 

• the unnecessary use of antimicrobials produce strong selective pressure, which drives the evolutionary response in microbes 

how does antimicrobial therapy disrupt the gut microbiota

• reduction in their microbial diversity → alters the function and formation of antimicrobial resistant strains → patients more susceptible to infection with opportunistic pathogens 

• example: C. dificil

what is the importance of patient and infection specific factors when reviewing patients with infection

includes considering patient vulnerability e.g.

• if a patient is immunocompromised

• if their using immunosuppressant medications

• their vaccination status 

• infection severity 

• risk of mortality 

in start SMART, what is investigate

• Obtain appropriate specimens for culture prior to commencing therapy where possible, including blood cultures before starting IV treatment if appropriate (but do not delay treatment in cases of severe sepsis)

  • helps identify the infection source and organism susceptibility → clinicians can treat resistant pathogens effectively in the event of subsequent deterioration

  • cultures and sensitivities help support de-escalation from broad to narrow spectrum antibiotics

  • helps decide whether we can stop therapy when cultures are negative 

• Follow local guidelines for ordering appropriate laboratory investigations

  • biochemistry (C-reactive protein), haematology (WBC count), immunology

  • organ function

  • medical imaging where available to find out location and severity of infection

• implement any required source control interventions as soon as medically/surgically practical → reduces risk of treatment failure

  • for example an infected abscess on the chest would need to be drained and removed before antibiotics can actively treat the infection, or removing an infected catheter

how are cultures obtained 

Any body tissue or fluid evaluated in the laboratory using culture techniques to detect and identify infectious processes. Culture techniques can be used to determine sensitivity to antibiotics.

• A sensitivity test checks to see what kind of medicine, such as an antibiotic, will work best to treat the illness or infection.

• Links with “FOCUS” as sensitivities usually take 48 to 72 hours to come back

• Due to advances in rapid diagnostics it may be possible to review prior to 48 hours after first dose.

what is the CRP (C-reactive protein) test

• measures level of CRP in the blood 

• CRP plays a key role in the body’s immune response by acting as a signal for inflammation, as well as

  • assess the risk of heart disease

  • track inflammatory conditions like rheumatoid arthritis or lupus 

  • evaluate how well the body responds to treatment 

• viral infections can increase CRP levels 

in start SMART, what is prescribe

1. Initiate prompt antimicrobial treatment for patients with severe sepsis or life-threatening infections based on local guidelines/scores → reduces avoidable morbidity and mortality.

2. Comply with local antimicrobial prescribing guidance e.g. formularies

3. Take a thorough drug allergy history, make sure it is a true allergy

4. Avoid inappropriate use of broad-spectrum antibiotics

in start SMART, what is document

1. Document evidence of infection, working diagnosis (clinical indication) and disease severity, drug name, dose, formulation, and route on the prescription chart and in the clinical notes → in accordance with
   good clinical record-keeping.

2. Include treatment duration where possible or specify a review date → avoids unnecessarily prolonged treatment as colleagues know when to change or stop therapy

3. Record a clear clinical plan for patient management to ensure safe handover of care between clinical teams.

4. Provide exact indication on the drug chart for medical prophylaxis

what is allergy status 

• On paper charts the allergy status of a patient has to be written on the front of the drug card.

• Some hospital policies prohibit the nurse from administering any medication, unless the allergy status of the patient is documented on the front of the drug chart.

• In the EPMA system the allergy status has to be entered into the system, which can prove difficult at times.

• if the allergy status of the patient is not done properly, warning signs to alert the prescriber about an allergy do not necessarily appear and cause patient safety issues.

how do we avoid inappropriate use of broad-spectrum antibiotics

should only be used when indicated by the person's clinical condition,  however you MUST consider sepsis or life-threatening conditions.

• Need to be reserved to treat resistant disease.

• They should generally be used only when narrow-spectrum antibiotics are ineffective because they increase the risk of MRSA, Clostridium difficile and resistant UTIs

what is empirical therapy 

• Treatment given without knowledge of the cause or nature of the disorder and based on experience rather than logic

•  Sometimes urgency dictates empirical treatment, as when a dangerous infection by an unknown organism is treated with a broad- spectrum antibiotic while the results of bacterial culture and other tests are awaited

how is the prescribing decision documented

Document on drug chart and in clinical notes

• Evidence of infection

• Clinical indication /working diagnosis (and disease severity)

• drug name

• Dose

• formulation

• route

• include review/stop date or duration

hospital A recording of clinical indication and documentation error 

• In Hospital A, the EPMA system used mandatory fields to force the prescriber to
  document the clinical indication of the stipulated medications, by not allowing
  them to continue with the prescribing process unless the information was
  completed.

• Mandatory field, can lead to “workarounds” where prescribers enter a full stop
  or “not known” to navigate past and complete the prescription. Drop down lists can
  facilitate but they must be user friendly

hospital B recording of clinical indication and documentation error 

• In Hospital B, the clinical indication of stipulated medications was done by
  completing a “note” within the electronic prescription, this was not compulsory
  and therefore the system did not enforce the prescriber to provide this
  information.

• A note to be completed, not mandatory, but must specifically click on “note” to
  enter the detail

hospital C recording of clinical indication and documentation error 

• In Hospital C, on the paper drug chart there was a specific box requiring the
  clinical indication to be completed, like the rest of the prescription, manually

• Paper prescription chart – prescriber can complete at any time quite quickly. Colleagues can also update the CI on the prescription

documenting antibiotic course length

• A three day antibiotic course length can be automatically populated within the EPMA system or can be pre-printed for three days of administration on the paper chart.

• These design features of the prescribing systems are in place to facilitate antibiotic review and discontinuation in a timely fashion.

• Both paper and EPMA systems have their difficulties regarding this area → Ultimately it comes down to the prescriber putting in the right information in the first place, showing an area of prescribing more susceptible to human error

stop dates in the EPMA system 

• It was considered how EPMA might change the discontinuation of antibiotics, possibly leading to the prescription never being stopped.

• The EPMA systems are able to counteract the potential problem of antibiotics never being stopped, by utilising automatic stop dates within the system.

• However, the EPMA system may overcompensate, if the stop date is inappropriate, leading to patient safety issues.

what is ‘then FOCUS’ the antimicrobial stewardship clinical management algorithm

reviewing the clinical diagnosis and the continuing need for antibiotics at 48-72 hours and documenting a clear plan of action, which is called the ‘antimicrobial review outcome’. the five ‘antimicrobial review outcomes’ options are to (CARES):

1. CEASE antimicrobial treatment if there is no evidence of infection

2. AMEND antibiotics → ideally to a narrower spectrum, or broader if required

3. REFER to non-ward-based services → Outpatient Parenteral Antibiotic Therapy (OPAT)

4. EXTEND antimicrobial treatment and document next review date or stop date

5. SWITCH antibiotics from intravenous to oral (IVOS)

example of a culture and sensitivity report

what is REFER ( ‘antimicrobial review outcomes’)

Refer appropriate patients to non-ward antimicrobial therapy services when available. Options include

• OPAT (Outpatient Parenteral Antimicrobial Therapy)

• COPAT (Complex Outpatient Antimicrobial Therapy)

• virtual wards if available.

These services enable timely discharge, reduce healthcare-associated infection risk, and maintain safe, monitored treatment outside hospital settings

what is EXTEND (‘antimicrobial review outcomes’)

• Extend antimicrobial prescription and document next review date or
  stop date for IV and oral antimicrobials → avoids inappropriately prolonged treatment.

• Balance risk versus benefit

what is Intravenous-to-oral SWITCH (IVOS)  (‘antimicrobial review outcomes’)

The national antimicrobial IVOS criteria for prompt switch contains 24 IVOS criteria in 5 sections. There are different guidelines for adults and paediatrics see canvas.
The 5 sections are

1. Timing of intravenous antimicrobial review (within 48 hrs 1st dose)

2. Clinical signs and symptoms of infection improving

3. Infection Markers

4. Enteral route

5. Special considerations

what infection markers need to be considered

• Temperature has been between 36 to 38°C for the past 24 hours.

• Early Warning Score is decreasing.

• White Cell Count is trending towards the normal range.*

• C-Reactive Protein is decreasing.*

these infection markers could also indicate inflammation or be affected by, for example, steroid treatment; ‘Prompt for switch’ or ‘Assess for switch’ may still occur if they are the only markers not met.

what are the considerations for enteral route

• Gastrointestinal tract must be functioning with no evidence of
  malabsorption.

• is itsSafe to swallow or is there enteral tube administration.

• availability of suitable oral switch option available, considering oral bioavailability, any clinically significant drug interactions or patient allergies.

• No significant concerns over patient adherence to oral treatment.

• No vomiting within the last 24 hours

summary of oral bioavailability of different antibiotics 

what are special considerations

• deep-seated infection

• infection requiring high tissue concentration of antimicrobial

• infection requiring prolonged intravenous antimicrobial therapy

• critical infection with high risk of mortality

 what are specific infections for special consideration

• bloodstream infection

• empyema

• endocarditis

• meningitis

• osteomyelitis

• severe or necrotising soft tissue infections

• septic arthritis

• undrained abscess