Antimicrobial Resistance and Stewardship PM-262

Vocabulary and key concepts based on the lecture on antimicrobial resistance and stewardship, including hospital and GP strategies, scoring systems, and the One Health approach.

Antimicrobial Stewardship

A healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness.

NICE Guideline August 2015

The source that defines antimicrobial stewardship as a system-wide approach to preserve antimicrobial effectiveness.

Main Principle of Antimicrobial Stewardship

Right Drug, Right Dose, Right Time, Right Duration, Every Time.

Lab Stewardship

The practice of reporting only appropriate antibiotic testing results that are in the local policy and suitable for the narrowest spectrum treatment.

Sensitivity Suppression

The laboratory practice of not showing results for broad-spectrum or irrelevant antibiotics on a report where narrow-spectrum agents are suitable.

Reporting of Resistant Results

Used to guide treatment and raise local awareness that antibiotic resistance is being found in the area.

Laboratory Influence on Prescribing

Phenomenon where a physician is $3 \times$ more likely to prescribe a specific antibiotic if it is shown on a laboratory report.

Microbiology Comment Nudge

A stewardship tactic such as calling out the absence of MRSA or Pseudomonas in respiratory specimens to improve de-escalation.

Start Smart Then Focus

The Antimicrobial Stewardship Toolkit for English Hospitals, updated March 2015 by Public Health England.

Start Smart: Promptness

A principle requiring the start of antibiotics promptly once they are clinically indicated.

Start Smart: Culture Collection

The practice of collecting cultures before the first dose of antibiotic wherever possible.

Start Smart: Documentation

The requirement to document the clinical indication and the stop or review date for antibiotics.

Start Smart: Empiric Treatment

The instruction to consult established guidelines when initiating antibiotic treatment without specific cultures.

Focus: 48-Hour Review

A critical step to stop, switch from IV to oral, de-escalate, or switch to narrower agents at the $48$-hour mark.

Focus: Stop Criteria

Stop antibiotics if the culture is negative, unless their use remains clinically indicated.

Focus: De-escalation

Switching to narrower spectrum agents to reduce the risk of Clostridioides difficile.

IV to Oral Switch: Medical Risks

Reduces the risk of bacteraemia from lines and the risk of thrombophlebitis.

IV to Oral Switch: Benefits

Saves medical and nursing time, increases patient comfort and mobility, and reduces administration errors.

IV to Oral Switch: Cost

Results in a significant cost reduction of approximately $x10$.

IV to Oral Switch: Clinical Timing

The switch should occur once the patient is clinically stable.

VAP Therapy Duration: Log-Rank P

A value of $P = .65$ was found when comparing probability of survival for $8$ vs $15$ days of therapy for ventilator-associated pneumonia.

Duration of Therapy Conclusion

Evidence suggests no significant difference in survival between an $8$-day and a $15$-day antibiotic regimen for ventilator-associated pneumonia.

Risky Behaviour Categories (NG 63)

Inappropriate demand and inappropriate use, as identified in primary care antimicrobial stewardship.

Primary Care Social Norm

The incorrect belief that it is "ok to take antibiotics just in case."

Primary Care Stewardship Strategies

Communication, clinical scoring systems, point of care tests, feedback to practices, and delayed prescriptions.

6Rs: Reassurance

Reassuring the patient about the nature of their infection.

6Rs: Reasons

Explaining why antimicrobials are not normally necessary and discussing potential side effects.

6Rs: Relief

Suggesting over-the-counter preparations such as paracetamol for pain management.

6Rs: Realistic

Providing a realistic timeframe for when the patient can expect to feel better.

6Rs: Reinforce

Providing written information and repeating the message not to take antibiotics unless symptoms fail to improve.

6Rs: Rescue

Providing safety netting advice regarding when to seek further professional help.

Centor Score: Age 3-14

Assigned a point value of $1$.

Centor Score: Age > 45

Assigned a point value of $-1$.

Centor Score: Tonsillar Exudate

Assigned a point value of $1$ if exudate or swelling is present.

Centor Score: Lymph Nodes

Assigned a point value of $1$ if cervical lymph nodes are tender.

Centor Score: Temperature

Assigned a point value of $1$ if the temperature is $> 38^\circ C$.

Centor Score: Absence of Cough

Assigned a point value of $1$ if no cough is reported.

Fever Pain Score

An alternative scoring system to the Centor Score used for assessing sore throats in primary care.

Acute Respiratory Infections: GP Workload

These infections account for $17\%$ of all GP consultations.

Community Acquired Pneumonia Prevalence

Accounts for $5 - 12\%$ of all lower respiratory tract infections (LRTI) managed by GPs.

C-Reactive Protein (CRP)

A blood test measuring levels of inflammation in the body; high levels are caused by infections and long-term diseases.

CRP POCT (Point of Care Test)

A tool used to aid diagnosis but not replace clinical judgement in lower respiratory tract infections.

CRP Management: < 20 mg/L

Clinicians should NOT routinely offer antibiotics.

CRP Management: 20 - 100 mg/L

Clinicians should consider a delayed antibiotic prescription.

CRP Management: > 100 mg/L

Clinicians should offer immediate antibiotics.

Back-up Prescribing

Recommended by NICE for minor self-limiting illnesses to change attitudes and beliefs about antibiotics.

Delayed Prescribing Strategy: Post-dated

Providing a prescription dated for $24 - 72$ hours in the future.

Delayed Prescribing Strategy: Re-contact

The patient must re-contact the clinician to obtain a prescription if symptoms do not improve.

One Health

An approach involving multiple sectors communicating and working together to design programmes and policies.

Zoonoses

Diseases that can spread between animals and humans.

UK Antibiotic Usage 2013: Humans

$531.2\,tonnes$ were dispensed through prescriptions.

UK Antibiotic Usage 2013: Animals

$418.7\,tonnes$ were sold for animal use.

Human share of UK Antibiotic Use (2013)

$56\%$ of total antimicrobial use was in humans.

Whole Herd Treatment

Prophylactic antibiotic use in agriculture when a few animals are sick or if animals are 'stressed'.

Growth Promotion (Agricultural Practice)

Giving food animals small doses of antibiotics to increase weight without requiring more feed.

Growth Promotion Weight Increase

Increases weights by only $1 - 3\%$ where advanced farming practices are used.

EU Growth Promoter Ban

The European Union banned the use of antibiotics as growth promoters in animals in $2006$.

Animal Antibiotic Sales Reduction (2013-2017)

Veterinary sales saw a $35\%$ reduction.

Human Antibiotic Usage Reduction (2013-2017)

Human usage saw a $6\%$ reduction.

Antibiotic Guardian

A pledge-based initiative developed by Public Health England in collaboration with various UK administrations.