Antimicrobial Stewardship

Antimicrobial Stewardship 

Why is antibiotic resistance important? 

• Poses a big threat to global health. 

• All germs can develop resistance to antibiotics 

• The number of new antimicrobials being developed has decreased over time so patients are more likely to be resistant to the ones that have been developed and it is important to manage the use of antibiotics more wisely. 

• Can increase mortality of patients and the amount of time patients spend in hospital. 

• There is an increase in antimicrobial resistant organisms globally. 

Examples of gram positive and gram negative bacteria that require antibiotic treatment -  

How do bacteria become resistant to antibiotics? 

Antibiotic resistance happens when bacteria change and become resistant to the antibiotics which used to treat the infections that they cause. Antibiotic resistance can occur in humans and animals.  

• It is predicted that by 2050, 10 million people will die due to antimicrobial resistance. 

• Antibiotic consumption correlates with antibiotic resistance  

Healthcare Associated multidrug resistant infections 

All require patient isolation in side room to prevent infection spreading.  

Solutions to antimicrobial resistance 

1. Infection, prevention and control  

2. Develop new antimicrobials  

3. Preserve the antibiotics we have got! 

Antimicrobial Stewardship  

The primary goals of antimicrobial stewardship are to -  

1. Optimise Clinical Outcomes  

2. Minimise consequences of antimicrobial use – toxicity, selection of opportunistic pathogens and emergence of resistance (individual and population) 

• Culture First – microscopy, culture and sensitivity  

• Empirical treatment – start immediately if the condition is serious or if a treatable infection is likely.  

• The choice of antibiotic is based on – the likely infecting organism, the local antimicrobial resistance rates and the severity of disease. 

• It is important to know which patients are tagged for MRSA/ESBL as they need isolating in side rooms.  

• Follow up sensitivities from microbiologists and aim to narrow the spectrum if an organism is identified to decrease the risk of resistance and the risk of clostridioides difficil which is associated diarrhoea.  

Clostridioides Difficile (c.diff) 

• An opportunistic infection that occurs through the overuse of antibiotics which disrupt the gut flora  

Risk Factors =  

• Older than 65 

• Extended healthcare stays in hospitals and care homes  

• Broad spectrum antibiotics  

• Gastric acid suppressents e.g PPIS (protein pump inhibitors) 

• Weakened immune system due to steroids, chemo and diabetes  

• Previous infection  

• GI surgery  

• Underlying conditions e.g IBD, cancer, CKD (chronic kidney damage) 

Management of C.Diff  

• Reduce risk by reviewing and stopping antibiotics when appropriate following guidelines  

• Review PPIs and H2 antagonists and stop if needed or reduce dose. 

• Avoid antidiarrhoeals 

• Minimise duration of antibiotics  

• 40-60% risk of further reoccurrence 

• Treatment of C.diff is usually 10-14 days and treatment is stopped at 10 days if the patient is asymptomatic  

• Oral Vancomycin is only used to treat C.Diff as it is not systemically absorbed.  

• If the C-diff is not responding of is worsening refer to microbiologists for testing. 

Missed Doses  

Patients must not miss their doses of antibiotics because it can lead to resistance, lack of response to treatment which means broader spectrum antimicrobials are used which can lead to resistance. 

IV to oral switch  

• All IV antibiotics should be reviewed after 48 hours of initiation and daily thereafter if appropriate 

• Some deep-seated infections will require long durations of IV antibiotics E.g. endocarditis, osteomyelitis 

• May require a micro review for the most suitable oral step down i.e. meropenem 

• Ensure documentation of indication and review date on drug chart 
  When to prompt switch? 
  ★ Inflammatory marks improving - Reducing WCC and Reducing CRP (There can be a 48 hr lag on CRP) 
  ★ Stable observations - BP + RR stable and No unexplained tachycardia 
  ★ Apyrexial (absence of fever) for ≥24 hours 
  ★ Able to take oral meds i.e. no GIT dysfunction 

CQUINs (Commissioning for quality and innovation) 

• A framework within the NHS that supports improvements in the quality of services and creation of new, improved patterns of care.  

• Covers a wide range of areas with the intention to drive transformational change in the NHS.  

Infection, Prevention and Control  

Responsibilities -  

• Abide by the Health and Social Care Act 2008 (updated 2015)  

• Compliance is assessed by the Care Quality Commission (CQC) and the National Health Service improvements (NHSI) 

• Everyone's Responsibility! 

Transmission of infection -  

• Direct Contact – physical contact with the infected person 

• Indirect Contact – on the hands/ contact with contaminated objects and equipment 

• Faecal-oral – from gut to the mouth of susceptible individual 

• Airborne/Droplet - respiratory droplets through the air 

• Inoculation/Splashes - via needle stick injuries and splashes to eyes and mouths 

• Vectors – insects and rodents 

• Vertical – via the placenta 

HAND HYGIENE EXTREMELY IMPORTANT  
 

• Follow uniform policy  

• Change into uniform when arriving and before leaving work  

• Bare below elbow  

• Hair tied back  

• Wash hands regularly  

• PPE (personal protective equipment)