1. OVERVIEW OF
ANTIMICROBIAL STEWARDSHIP
DR TANVEER REHMAN
SCIENTIST – B (MEDICAL)
PUBLIC HEALTH DIVISION

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3. Background
• Global Action Plan on Antimicrobial Resistance (AMR)
• Overuse and misuse of antimicrobials as a main driver for development of AMR
• Optimize the use of antimicrobial medicines in human and animal health
• Practical guidance on how to implement antimicrobial stewardship (AMS)
programmes in the human health sector at health-care facility
• Improve patient outcomes, reduce AMR and health-care-associated infections,
and save health-care costs amongst others
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4. Antimicrobial stewardship
• Careful and responsible management of something entrusted to one’s care
• Applied in the health-care setting as a tool for optimizing antimicrobial use
• One of three “pillars” of an integrated approach to health system strengthening
• Infection prevention and control (IPC) and medicine and patient safety
• WHO essential medicines list (EML) AWaRe classification
• Promotes equitable and quality health care towards the goal of achieving
universal health coverage (UHC)
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5. ‘Access’ Group – WHO ‘AWaRe’
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6. ‘WAtch’ Group – WHO ‘AWaRe’
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7. ‘REserve’ Group – WHO ‘AWaRe’
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9. Aim of AMS
• Optimize the use of antibiotics
• Promote behaviour change in antibiotic prescribing and dispensing practices
• Improve quality of care and patient outcomes
• Save on unnecessary health-care costs
• Reduce further emergence, selection and spread of AMR
• Prolong the lifespan of existing antibiotics
• Build the best-practices capacity of health-care professionals
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12. Antimicrobial prescribing facts
• 30% of all hospitalised in-patient at any given time receive antibiotics
• About 50% of antimicrobial use has been found to be inappropriate
• Up to 30% of all surgical prophylaxis is inappropriate
• URTI – reason for the 75% of the antibiotic prescriptions each year; in most
cases of URTIs, antibiotic confers little or no benefit
• 10-30% of antimicrobial cost can be saved by AMS
• Globally, dentists were reported to prescribe up to 11.3 % of all antibiotics.
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14. Prospective (real-time) audit with feedback
• Prospective audit with feedback (e.g. on ward rounds) involves the assessment
of antibiotic therapy by AMS team, who make recommendations to prescribers
in real time when therapy is considered suboptimal.
• It may be performed alongside clinical personnel on ward rounds, providing
oral recommendations for changes in antibiotic treatment in real time.
• Alternatively, AMS team may perform ward rounds on their own, providing
written recommendations for changes in antibiotic treatment
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15. Formulary restriction/preauthorization
• Use of restricted antibiotics may be limited to certain indications, prescribers,
services, patient populations or a combination of these.
• Selection of restricted antibiotics is done by facility authorities, the AMS team
and heads of units based on spectrum, cost or toxicities.
• Antibiotics are restricted before use; ensures expert approval before initiation
• Practical approach that allows attending physician to use the drug pending
approval by physician or AMS team after +/− 48 hours
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16. Didactic education
• Formal or informal teaching to engage prescribers in improving antibiotic
prescribing, dispensing and administration practices
• Clinical case discussions, classes, reminders, conference presentations, student
and house staff teaching sessions, provision of written guidelines,
informational pamphlets, posters or e-mail alert – STG/ updates
• Education alone, without incorporation of active intervention is only
marginally effective
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17. Streamlining/de-escalation
• All clinicians should perform a review of antibiotics 48 hours after prescription
• When microbiological results become available, antibiotic treatment should be
streamlined accordingly: choose the most active antibiotic(s) with least
toxicity, narrowest spectrum and lowest cost
• De-escalation is safe for sepsis and septic shock, and is associated with
decreased mortality
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19. Outcome measures
• Outcome measures/indicators related to antimicrobial use
DDD or DOTS per 100(0) patient-days: Defined Daily Dose of an agent from
pharmacy dispensing or health-care facility purchasing data or Days of Therapy
from nursing chart administrative data (paper) in a period of time
• Outcome measures/ indicators related to patients and microbiology
In-hospital mortality, Length of stay, Readmission within 30 days after discharge
Clostridium difficile: Number of health-care-associated C. difficile infections
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20. Common areas for improving antibiotic prescribing
• Overprescribing: when not needed, e.g. fever without evidence of infection,
viral infections, malaria, asymptomatic urinary tract colonization
• Overly broad spectrum: More broad-spectrum antibiotics (WATCH and
RESERVE) are prescribed than are necessary (e.g. surgical prophylaxis)
• Unnecessary combination therapy, including certain FDC: Multiple antibiotics
are used, particularly with overlapping spectra and in combinations that have
not been shown to improve clinical outcomes.
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21. Common areas for improving antibiotic prescribing
• Wrong antibiotic choice: Wrong antibiotic(s) are prescribed for particular
indications/infections.
• Wrong dose: Over- or under dosing
• Wrong dose interval: Antibiotics are prescribed with the wrong dose interval
(too much time between doses).
• Wrong route: Antibiotics are prescribed by the wrong route (e.g. IV instead of
oral).
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22. What can the individual physicians do
• Obtain appropriate cultures before starting antibiotic
• Review antibiotic use after 48 – 72 hours : does it need to be continued?
• Stop antibiotic in patient with alternative non-infectious diagnosis
• Optimize dosing and duration of antibiotic therapy
• Avoid unnecessary use, especially in viral upper respiratory tract infections
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23. Health-care facility AMS team
• Implements day-to-day AMS activities like conducting regular ward rounds
• Undertakes audits or PPSs to assess the appropriateness of antibiotic prescription
• Monitors, analyses and interprets the quantity and types of antibiotic use at the
unit and/or facility-wide level
• Monitors antibiotic susceptibility and resistance rates for a range of key indicator
bacteria at the facility-wide level or uses the data from existing groups
• Facilitates education and training on AMS in the facility.
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24. Health-care facility AMS team
Option 1: >2 : physician, a pharmacist, a nurse with expertise in infections or IPC,
and in facilities with a microbiology laboratory, a microbiologist
Option 2: a physician and a nurse or pharmacist, with access to expert advice
Option 3: an AMS champion, e.g. a physician, nurse or pharmacist leading the
stewardship programme, with access to expert advice (e.g. secondary or small
facilities with limited resources).
• Frequency of meetings: Weekly to two times a month
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25. THANK YOU
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References
1. ICMR. Antimicrobial Stewardship Program Guideline
2. Antimicrobial stewardship programmes in health-care facilities in low-and middle-income
countries: a WHO practical toolkit
3. Vijay S, Ramasubramanian V, Bansal N, Ohri VC, Walia K. Hospital-based antimicrobial
stewardship, India. Bulletin of the World Health Organization. 2023