Antimicrobial stewardship involves prudent use of antibiotics and infection control.

1. Antimicrobial Stewardship
1. Antibiotic Policy
2. Infection Control Manual
Dr. Ashok Rattan,
Chairman : Laboratory Medicine

2. Discovery & Development of
Anti-bacterials is one of the most
important discovery of the
20th Century
2

3. Power of antibiotics
Disease Pre Antibiotic era Deaths with Change in deaths due
deaths antibiotics to antibiotics
CAP (1) 35% 10% - 25%
HAP (2) 60% 30% - 30%
Heart Infection (3) 100% 25% - 75%
Brain Infections (4) > 80% < 20% - 60%
Skin Infection (5) 11% < 0.5% -10%
By comparison…. Treatment of heart attacks with aspirin or clot busting drugs (6) - 3%
Ref.: (1) IDSA Position Paper. Clin Infect Dis 2008; 47 (S3): S 249 – 65
(2) IDSA/ACCP/ATS/SCCM position paper. CID 2010; 51 (S1): 51 – 3
(3) Kerr AJ. SABE Lancet 1935; 226: 383 – 4
(4) Waring et al. Am J Med 1948; 5: 402 – 18
(5) Spellberg et al CID 2009; 49: 383 – 91
(6) Lancet 1998; 351 : 233 – 41.
3

4. Introductions of New Antibiotic Classes
1940 1950 1960 1970 1980 1990 2000 2002 2004 2006 2007 2008 2010
Ceftaroline 2010
Doripenem 2007
Tigecycline 2006
Telithromycin 2004
Quinolones 1962
Daptomycin 2003
Streptogramin 1962 Ertapenem 2001
Oxazolidinone 2000
Glycopeptides 1958
Macrolides 1952
Aminoglycosides 1950
Tetracycline 1949 Me too drugs
Different Generations
Penicillin 1940
Sulfas 1936 4

5. Mankind has always had
the benefit of “good” advice
“By the year 2000, nearly all
experts agree that bacterial and
viral diseases will have been
virtually wiped out…”
The futurists: looking toward year 2000
(Time magazine, february 25, 1966)
US surgeon general William Stewart:
“ The time has come to close the book on
infectious diseases” (1969)
5

6. Increasing Incidence of Resistance in the US
MRSE, MRSA, VRE, PRSP, GISA
1980-2006
100
Percentage
MRSE
of 80
Pathogens
Resistant to
Antibiotics 60 MRSA
PRSP
40
VRE
20
VRSA
VISA
0
1975 1980 1985 1990 1995 2000 2006
1997
6

7. Bad bugs, no drugs: No ESKAPE
CID 2009; 48: 1 - 12
E nterococcus faecium
S taphylococcus aureus
K lebseilla pneumoniae
A cinetobacter baumanii
P seudomonas aeruginosa
E nterobacter species
Clostridium difficile & E. coli
7

8. We have a basic problem
We must make the best use of what we have
8

9. Consequences of antibiotic use
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects
•Clinical cure
9

10. Antimicrobial Stewardship
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects
Clinical cure
10

11. Antimicrobial Stewardship
Effective antimicrobial stewardship Comprehensive infection control
Audit & feedback Managing data and information
Guidelines & algorithms Policies & procedures
Antibiotic order form Regulatory requirements
Combination Employee health
De escalation Prevent transmission,
investigate outbreaks
Dose optimization
Education & training
Parentral  oral
Mobilize resources: human &
Cycling
financial
11

12. Empiric treatment
Broad spectrum antibiotic
No sample collected
Prolonged
treatment
Selection of MDR
Mutant bacteria
12

13. Empiric treatment
Broad spectrum antibiotic
No sample collected
Prolonged
treatment
Reward
Selection of MDR
Mutant bacteria
13

14. Knowledge of local ecology
OPD
IPD
ICU
14

15. PK/PD terminology
32 C max/ MIC
16
AUC / MIC
t > MIC
8
Serum
Conc. 4 C max
(ug/ml)
2
1
0.5
MIC
0.25
0.12 Time > MIC
0.06
0 15

16. PK/PD correlation with efficacy
T > MIC AUC or Cmax/MIC
Target: >40 % of dosing 100 10
Penicillin Aminoglycosides
Cephalosporins Fluoroquinolones
Carbapenems Metronidazole
Daptomycin
Monobactam
Ketolides
Macrolides
Azithromycin
Clindamycin
Streptogramin
Oxazolidinones
Glycopeptides
Glycylcyclines
Amphotericin
Flucytosine
Fluconazole 16

17. De Escalation strategy
17

18. Short duration of therapy
Automatic stop orders
18

19. Antibiotic Use Bundle
Initiation bundle:
1. 1. Clinical rationale for antibiotic initiation documented
2. 2. Appropriate samples for smear & culture collected &
submitted to the laboratory
3. 3. Antibiotic selected according to local policy & risk group
4. 4. Antibiotic ordered as per plan
1. (name, dose, route, frequency & tentative duration)
5. 5. Removal of foreign body or ID, as appropriate,
considered
19

20. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle
[Complete this section for all Community or Hospital Acquired Infections]
Care Bundle Element Evident Comments
Yes / No
1 Clinical signs of infection
documented in medical notes
2 Appropriate clinical specimens sent
to microbiology / blood samples
requested
3 Antimicrobial prescription in
accordance with local guidelines and
appropriate for individual patient
4 Antibiotic plan documented ?
5 Foreign body removed or pus
drained, as appropriate
Total no. care bundle elements evident % Compliance
20

21. 21

22. Day 3 bundle:
1. 1. Was an antibiotic plan documented
1. (name, dose, route, frequency & planned duration ?)
2. 2. Review of diagnosis after lab reports ?
3. 3. If positive microbiology results, was there any adaptation
: streamlining or discontinuation
4. 4. Was IV -> oral switch considered & implemented
5. 5. Were all four above mentioned steps followed ?
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23. Lewisham Empirical Antimicrobial Prescribing (LEAP) Initiation Care Bundle
[Complete this section for all Community or Hospital Acquired Infections]
Care Bundle Element Evident Comments
Yes / No
1 Was an antibiotic plan documented (name, dose,
route, frequency & planned duration ?)
2 Review of diagnosis after lab reports ?
3 If positive microbiology results, was there any
adaptation : streamlining or discontinuation
4 Was IV -> oral switch considered &
implemented
5 Were all four above mentioned steps followed ?
Total no. care bundle elements evident % Compliance
23

24. Gram +ve problem
Nailed down
Vancomycin &
Teicoplanin Tigecycline
& Colistin
Linezolid
Daptomycin
Ceftaroline
Gram –ve infections may leave us exposed
24

25. Hand washing is an important strategy to
control MRSA
25

26. Surveillance culture is an important strategy to
control MDR GNB
26

27. Rapid diagnostic tests would help
TAT 20 min to 4 hours
Procalcitonin for initiation of antibacterial
therapy
POCT for infectious markers
Lateral flow Immunological tests
Real time PCR; Multiplex PCR for Sepsis
MALDI TOF MS
Emergent indications for antibiotic use
Sever sepsis or septic shock
Infections known to have fulminant course
27

28. Extinction of MDR Bacteria is
not an achievable Goal
Bacteria have inhabited the Earth longer than humans
and in far greater number
Humans have capability of causing extinction of other
species, mostly unintentional (Dodo, ? Tiger)
However, Extinction of MDR bacteria is not an
achievable goal by Man Kind
28

29. Our innovations must stay ahead of
bacterial adaptation
New strategies may include
Discovery & Development of new antimicrobials
Antimicrobial stewardship and appropriate
guidelines for use of older drugs
Rapid point of care diagnostic tests
Biomarkers for diagnostic & prognostic accuracy
Strict Infection control
29

30. Current Crisis of MDR Infections
Act of GOD (nature) Act of Man Kind
Spread of resistant gene Selection of resistant
from antibiotic mutants by use & over
producing bacteria to use of antibiotics
pathogens Spread of MDR strains
Acquisition of resistance from one patient to
to available drugs by another by non
mutation application of
Infection Control
policies 30

31. but we
CAN
31

32. Dennis Maki, IDSA Meeting 1998
Developing new antibiotics without having mechanisms
to insure their appropriate use is much like supplying
your alcoholic patients with a finer brandy.
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