Antimicrobial stewardship

what is antimicrobial resistance

when bacteria, fungi and parasites no longer respond to antimicrobial medicines

microbes evolve mechanisms that protect them from the effects of antimicrobials

natural phenomenon accelerated by other factors

intrinsic resistance

cell can use genes it already possesses to survive antibiotics exposure

will always be resistant e.g. klebsiella and amoxicillin

acquired resistance

gain of new genetic material provides new capacities that allow survival

accelerators of antimicrobial resistance in healthcare

inappropriate use of antimicrobial drugs - main

poor infection prevention and control practices

poor diagnostics

lack of new antimicrobial drugs being developed

insufficient global surveillance of infection rates

what is the main driver of antimicrobial resistance

antibiotic use

-people consumed

-animal consumed

sources of environmental antibiotic resistance

human and animal waste - containing the antibiotics the person or animal has been treated with

pharmaceutical waste - active ingredients can release into the environment as part of the waste from the production of antibiotic treatments

pesticides for crop plants - antibiotics are sometimes used to treat and prevent crop-plant diseases, transport of plants and water runoff into the local waterways can both lead to contamination

antimicrobial stewardship

right drug, right dose, right time

shorter course is better

diagnostic stewardship

promote appropriate timely diagnostic testing

specimen collection

pathogen identification

accurate time report of results to guide patient treatment

you start antibiotics only if there is what?

only if there is clinical evidence of bacterial infection

timeframe for antibiotics to be given for severe sepsis or neutropenic sepsis

within 1 hour

at 24-48 hours after starting antibiotics, make..

an antimicrobial prescribing decision

• review clinical diagnosis

• review laboratory/radiology results

• choose one of five options

what are the 5 options after reviewing antibiotics

1. stop antibiotics - no evidence of bacterial infection or infection resolved

2. switch from intravenous to oral antibiotics - if patient meets criteria for oral switch

3. change antibiotics - narrower spectrum if possible, broader spectrum if indicated

4. continue current antibiotics - review again after further 24hrs

5. outpatient parenteral antibiotic therapy - consult with local OPAT team

following factors to prescribe the most appropriate antibiotics

history of drug allergy

recent culture results

recent antibiotic treatment

potential drug interactions

potential adverse effects

some antibiotics considered unsafe in pregnancy or young children

dose adjustment may be required for renal or hepatic failure

which set of antibiotics is c.difficile infection more likely

broad spectrum antibiotics

penicillin allergy STEP 1 approach

step 1 - is there a history suggestive of type 4 hypersensitivity reaction

• rash with blistering

• oral or genital ulceration or blistering

• rash associated by a severe systemic illness requiring admission to hospital

penicillin allergy STEP 2 approach

assess history of penicillin allergy to determine risk of type 1 hypersensitivity

were any of these features reported following a dose of penicillin antibiotic

• collapse

• facial/throat swelling

• breathing difficulties

• itchy rash