1. Orientation to
Antimicrobial
Stewardship Program
HEBATALLAH MOHAMMED ABDALLATIF,BCPS

2. “
”
“Person playing with penicillin is morally
responsible for the death of the man who
finally succumbs to infection with the
penicillin- resistant organism. I hope this
evil can be averted.”
SIR ALEXANDER FLEMING NEW YORK TIMES JUNE 26, 1945

3. Antimicrobial use
 Antibiotics are one of the
miracles of modern Science
 Antibiotics saved millions of
lives.
 This has led to their misuse
through use without a
prescription and overuse for
self-limiting infections

4. Antibiotics continue to save lives every
day…..
 Neonatal care
 Transplantation
 Chemotherapy for
malignancy
 Immunosuppression
 Safe surgery
 Safe obstetric care
 Intensive care
interventions

5. Antimicrobial resistance

6. First discovery in
United States of
colistin resistance in
a human E. coli
infection E. coli bacteria carrying the MCR-
1 gene was found in a urine sample
from a Pennsylvania woman with
no recent travel outside of the U.S.
The mcr-1gene exists on a plasmid spreading
antibiotic resistance among bacterial species.

7. Resistance Consequences
Colistin Previously abandoned because
of its high rates of nephrotoxicity and
neurotoxicity
It Considered the last resort for Gram-negative
Resistant Strain Escherichia coli, Acinetobacter
baumanni,Pseudomonas aeruginosa, Klebsiella
pneumonia, and Enterobacter sp

8. Resistance Consequences
At least 2 million people acquire serious infections with
bacteria that are resistant
At least 14,000 people die each year in the United States
from C. difficile infections.

9. Collateral damage
 Term used to describe the
adverse ecological effects of
antibiotic therapy
 Cephalosporin use has been
linked to infection with
vancomycin-resistant
enterococci, extended-
spectrum β-lactamase—
producing Klebsiella
pneumoniae, β-lactam—
resistant Acinetobacter species,
and Clostridium difficile.

10. 30-50 % of
antibiotics
prescribed in
hospitals are
unnecessary or
inappropriate

11. Misuse Reasons
Use of antibiotics when
not needed
continued treatment when
no longer necessary
use of broad-spectrum agents to
treat very susceptible bacteria
wrong antibiotic to treat an
infection

12. Antimicrobial resistance has been identified as a
major threat by the Who

13. How does antibiotic resistance
occur?!

14. ANTIMICROBIAL
RESISTANT
STRATEGIES

15. Antimicrobial resistance
mechanisms

16. Intrinsic Resistance
• Innate ability of a bacterial species to resist
activity of a particular antimicrobial agent
through its inherent structure

17. Acquired resistance
Results from successful gene change and/or exchange that may
involve: mutation or horizontal gene transfer via transformation,
transduction or conjugation

18. Antimicrobial resistance
mechanisms

19. Biofilm Mechanism
Biofilms are communities of aggregated bacterial cells
embedded in a self-produced extracellular polymeric
matrix
‘Persister’ cells ,wild-type cells that neither grow
nor die in the presence of bactericidal agents
Indwelling devices are usually associated with microbial
biofilms and eventually lead to catheter-related bloodstream
infections (CLABSIs).

20. Biofilm Mechanism

21. Blood Stream Infection
0%
10%
20%
30%
40%
50%
60%
70%
VRE VSE
Blood Stream Infection
VRE
VSE
59% of the patients with VSE
bacteremia survived vs 24% with VRE
(P=.009), despite similar severity-of-
illness scores.
Stosor V1, Peterson LR, Postelnick
M, Noskin GA

22. Costs Associated with
Increased Bacterial
Resistance
↑Treatment failures
↑Morbidity and mortality
↑Risk of hospitalization
Need for expensive and broad spectrum
antibiotics

23. Antibiotic
Resistance
Threats

24. Bad bugs, no
drugs: no
ESKAPE!
The IDSA proposed
solutions in its 2004
policy report, "Bad Bugs,
No Drugs: As Antibiotic
R&D Stagnates, a Public
Health Crisis Brews

25. Bad bugs, no drugs: no ESKAPE!
Dramatically increasing rates of drug-
resistant bacterial infections
Regulatory approval of new Drugs
have declined
ESKAPE
2020Ten New Antibiotics BY

26. Combating Antibiotic resistance
Optimize the use of existing
antimicrobial agents
Prevent the transmission of drug-
resistant organisms through infection
control
Improve environmental
decontamination

27. CDC 12 Steps

28. Antimicrobial Stewardship
Program Definition
Coordinated Actions designed to improve
and measure the appropriate use of
antimicrobials
Optimal
antimicrobial Drug
Regimen
Optimal Dose
Optimal
Duration
Optimal Route

29. Antimicrobial Stewardship Goals
Minimizing unintended consequences of
antimicrobial use, including :
Improve infection cure rates
Reduce surgical infection rates
Reduce mortality and morbidity
Primary
Goal
Reduce health care costs without adversely
impacting quality of care.
Secondary
Goal

30. Antimicrobial Stewardship Goals
stewardship program with strict
implementation of infection control
measures leading to sustained
reduction in [CDI] cases

31. THE TEAM

32. Ideal ASP Team
Infection
Control
Support
Team
Microbiologist
Infectious
Disease Physician
Clinical
Pharmacy
Core
Team
Hospital,Pharmacy
Administration Collaborative

33. Clinical Pharmacy
 The clinical pharmacist
should be
knowledgeable on the
appropriate use of
antimicrobials, and
appropriate training
should be made
available to achieve and
maintain this expertise.

34. Infection Control
 The combination of
effective antimicrobial
stewardship with a
comprehensive infection
control program has
been shown to limit the
emergence and
transmission of
antimicrobial-resistant
bacteria

35. Getting Started
Starting an ASP requires
multiple steps.
An institution should assess its
current practices to understand
the prescribing environment and
scope of the antimicrobial
resistance issue

36. An institution should consider
the following elements
What is the prescribing climate
what are staff perceptions of the need for an
ASP?
What are the common clinical
infectious disease syndromes?

37. An institution should consider
the following elements

Aggregate antibiotic use [e.g., units
individual patients in defined daily dose
(DDD)
Pharmacy Data
Microbiology
Data
Rates of resistance in common
pathogens

38. PLANNING AND IMPLEMENTATION
It is recommended to identify 1 or 2 target areas for
intervention based on findings from the assessment of
current practices and on resource availability.
1. Common clinical infectious syndromes
treated at the facility (e.g., UTI, CAP,
“fever”)
2. Specific pathogens
3. Specific antimicrobial agents

39. Core Elements of ASP

40. Core Element 1: Leadership
Commitment
 Antibiotic stewardship
programs need clear
support from hospital
leadership
 Communicate regularly
the importance of
improving antibiotic use
and the hospital’s
commitment to antibiotic
stewardship.

41. Core Element 2: Accountability
 Appointing a leader or co-
leaders, who are responsible for
program outcomes and whose
effectiveness is assessed through
clear performance standards,
provides accountability for
antibiotic stewardship.

42. Core Element 3: Drug Expertise
 Dedicated staff with
demonstrated drug
expertise is critical to
the success of
antibiotic
stewardship

43. Core Element 4: Actions to
Support Optimal Antibiotic Use
 Implement a policy for review of
antibiotic orders
 Ensure that the prophylactic,
empirical, and therapeutic uses
of antimicrobial agents result in
optimal patient outcomes.

44. Core Element 5: Tracking
 Systematic collection of
antibiotic use and resistance
 Antibiotic Use Measures
 Adherence to documentation
policies

45. Core Element 7: Education
 Education about causes and
trends of antibiotic resistance
and guidance on approaches
 Education is provided on a
regular basis to all staff as well as
patients and families; education
is targeted where appropriate.

46. Core Element 6: Reporting Information on
Improving Antibiotic Use and Resistance
 Regular reporting of
information on antibiotic
use and resistance to
physicians, nurses
 Develop facility-specific
treatment
recommendations based
on national guidelines and
local susceptibility data

47. PLANNING AND
IMPLEMENTATION
.
Once the target area(s) have been
identified
Determine which evidence-based
strategies may be most effective
Begin planning the
implementation process

48. Unit Specific Lab Data

50. ASP in NICU

51. ASP In NICU
Neonate’s response to an infectious insult is
challenging to differentiate from other pathologic
Process
Infants hospitalized in the NICU have high rates of
health care associated infections and
subsequently high rates of antibiotic use
Neonates are at high risk of acquiring health care–
associated infections because of impaired host-defense
mechanisms

52. Broad spectrum
antibiotics exposure has
been associated with the
emergence of multi-drug
resistant gram-negative
bacilli and development
of invasive candidiasis

53. Prolonged duration of
empiric antibiotic therapy
for early onset sepsis in
extremely low birth
weight infants has been
associated with increased
risk of death and
necrotizing enterocolitis
(NEC)

54. Healthcare associated infections
in NICU
 CVCs are essential for
(VLBW) , (ELBW) infants
requiring parenteral
nutrition.
 The majority of
nosocomial infections
are due to CLABSI

55. Unique Challenges in Antibiotic
Prescribing in the NICU
Signs and symptoms of sepsis in infants are
non-specific
Adequate blood quantities may not be
feasible to obtain for culture
Treatment guidelines are often not
established for infants, particularly for
preterm neonates

56. ASP IDSA 2016 Updates
facility-specific guidelines for
selected common and
important infectious syndromes
Syndrome guidelines should
include a recommended
duration of therapy for each
specific infectious syndrome.

57. CLABSI
 Catheter-related bloodstream
infections are the most common
hospital-acquired infections in
NICUs
 A large proportion of these
infections may be preventable.

58. ASP in Nicu
 Requires significant
consideration of the special
needs of the neonatal
population.
 The pK and PD of neonates have
variability based on GA,weight,
and skin ,renal maturity
Colleen Nash, MD, et al,NeoReviews Vol.15 No.4 April 2014

59. ASP in NICU
Identifying
patients who
need antibiotic
therapy
Using local
epidemiology
Avoiding agents
with overlapping
activity
Adjusting
antibiotics when
cultures
results become
available
Monitoring for
toxicity, and
optimizing the
dose, route, and
duration of
therapy.

60. Cornerstone Tactics
Constant reevaluation
of the antimicrobial
regimen
Monitoring of
toxicity
Consideration of
shorter antimicrobial
courses

61. NICU Care Bundle
Small set of evidence-based actions for a defined population and
care setting implemented together in NICUs has been associated
with a reduction in CLABSI rates
This multifaceted approach has reduced the incidence of health
care–associated infection in each center or groups of centers where
it has been implemented.

62. Clabsi Prevention Care Bundle

63. Vap Prevention Care Bundle
• Head-of-bed elevation 300-450
• Re-enforcement of hand hygiene practice
• Sterile suction and handling of respiratory equipment
• Intubation, re-intubation and endotracheal tube (ETT) suction as strictly indicated by
unit protocol
• Change ventilator circuit if visibly soiled or mechanically malfunctioning
• Proper timed mouth care with normal saline and suction of oro-pharyngeal secretion.
• Daily evaluation for readiness for extubation to nasal continuous airway pressure
(NCPAP) at morning round, and sedation vacation for sedated patient

64. Success Keys
Establish a clear aim/vision
Stewardship should be a patient safety priority.
Seek management support
Assemble a strong multi-professional team
Start with core evidence-based stewardship actions
depending on local needs, plan measurement to
demonstrate their impact

65. Bibliography