Principles of Antibiotic Policies 1 Explain how antibiotic

Principles of Antibiotic Policies

1. Explain how antibiotic use can select resistant strains of bacteria 2. Identify important mechanisms used by antibiotic stewardship programmes to decrease bacterial resistance in hospitals 3. Describe the roles of the microbiology laboratory and IP&C staff in the containment of bacterial resistance in healthcare 4. Participate in the formation of an antibiotic stewardship programme December 1, 2013 Learning objectives 2

• 45 – 60 minutes December 1, 2013 Time involved 3

• Discovery of antibiotics – revolutionary event that saved millions of lives • Emergence of resistance – reduced effectiveness, increased toxicity, increased costs • To preserve susceptibility – or to postpone development of resistance – antibiotics should be used rationally December 1, 2013 Introduction 4

• Fleming changed the course of history • Mould contaminated an experiment – contained penicillin • Killed the Staphylococcus aureus that had been growing in the dish • Penicillin altered the treatment of bacterial infections December 1, 2013 Antibiotics Dr Alexander Fleming 5

• Antibiotic resistance develops • Through natural mutations of bacterial genes • Through transfer of resistance genes between different bacteria via plasmids, transposons, etc. • If a bacterial population with newly resistant bacteria are exposed to a specific antibiotic, they will be selected and develop a new resistant strain December 1, 2013 Antibiotic Resistance 6

Resistance can be mediated by: • Change in antibiotic target site - altered penicillin binding proteins, altered DNA gyrase: December 1, 2013 Mechanisms of resistance • Beta-lactams, Quinolones • Production of detoxifying enzymes: • Beta-lactams (Beta-lactamases) , Aminoglycosides, Chloramphenicol • Decreased uptake(reduced permeability, active efflux): • Erythromycin, Tetracyclines, Beta- lactams 7

• Antibiotics are used as treatment of infections • In veterinary medicine • In agriculture December 1, 2013 Antibiotic use outside human medicine • Antibiotics are also used as growth promotors 8

• Increased morbidity • Increased mortality • Extended hospital stay • Increased admission to intensive care • Loss of bed days December 1, 2013 Clinical Impact of Resistance 9

• Empirical therapy • Without the knowledge of pathogen • Pathogen-directed therapy December 1, 2013 Types of antibiotic uses • Knowing the pathogen and susceptibility to antibiotics • Prophylaxis • Surgical • Medical 10

Prevention of spread • Infection prevention & control in healthcare settings • Isolation • Hand Hygiene • Environmental hygiene Antibiotic stewardship • • Surveillance Antibiotic policies & guidelines Antibiotic management programmes Reduction • • December 1, 2013 Dealing with resistance Usage control Appropriate use • Human • Animal • Environmental 11

• Can modify prescribing practices • Should lead to reduced, rational use • Should be well designed, and implemented • Should be based on education • Ideally should be a mixture of measures that are: • Voluntary • Persuasive • Restrictive December 1, 2013 Antibiotic stewardship programmes - 1 12

Key to modifying prescribing practices, stewardship programmes must include: • • National policies Local hospital or health care policies Formularies and guidelines Education Effective microbiology laboratory support Audits Effective working relationship with IP&C* teams *IP&C: Infection Prevention and Control December 1, 2013 Antibiotic stewardship programmes - 2 13

• Legislation required to regulate production and import • Legislation to impose limitation of use in veterinary practices to treatment only December 1, 2013 Key Elements of National Antibiotic Policies • Not as growth promoters • Legislation to reduce over the counter use • Education of the general population • Reduce expectations • Avoid misuse and over demand 14

Important elements of an effective hospital programme: • • • Antibiotic Committee Antibiotic Management team Formularies, guidelines and protocols Education Audits December 1, 2013 Hospital stewardship programmes 15

• Can be a “stand alone” Committee, or part of Drugs and Therapeutics Committee • Membership should include: • Physicians and nurses who prescribe antibiotics • Pharmacists • Microbiologists • Members of Management/Administration • Members of Infection Control Committee • Others, as needed December 1, 2013 Antibiotic Committee 16

Team to advise on antibiotic use, audit of prescribing, introduction of new antibiotics • Larger hospitals: can include infectious disease (ID) physicians, clinical pharmacologists, pharmacists, clinical microbiologists, any doctor authorised to use reserve list • Smaller institutions: minimum requirement: antibiotic pharmacist (at least part-time), with support from ID or IP&C physician December 1, 2013 Antibiotic Management Team 17

Should include: • Protocols for the evaluation of parenteral antibiotics • Include stop orders after 3 -5 days and recommendations for sequential treatment December 1, 2013 Guidelines and Protocols • Protocol for list of reserve antibiotics • How to order • Who can authorise 18

Local hospital or health care policies should focus on using antibiotics that: • • Have narrowest possible spectrum Are inexpensive Have minimal toxicity Have least impact on development of resistance December 1, 2013 Hospital Guidelines/Policies 19

• Antibiotic formularies: no drug outside those listed should be used • Protocols for empiric and targeted treatment of common infections • Protocols for surgical prophylaxis • Protocols for de-escalation of parenteral use • Protocols for use of a reserve list December 1, 2013 Hospital formularies and protocols 20

Should include: • Formal meetings • Clinical rounds with antibiotic management team/committee members • Formal lectures December 1, 2013 Education programmes - 1 • Focus on: • New antibiotics • New methods of administration • Influence on bacterial ecology 21

• Should be provided by Senior member of Antibiotic Team, or independent expert • Should not be provided by individuals from pharmaceutical companies, unless a committee or antibiotic team member is present December 1, 2013 Education programmes - 2 22

• Regular reporting of changing resistance patterns – Newsletters – Specialty-specific data December 1, 2013 Stewardship: Role of the Microbiology Laboratory • Restricted antibiotic reporting ― Routinely only first line antibiotics ― Reserve antibiotics only if pathogen is resistant to first line antibiotics • Patient specific data (culture & sensitivity) to optimise treatment 23

• Provide leadership to Antimicrobial Team • Antibiotic ward rounds • Interpretation of patient-specific data (culture & sensitivity) to optimise treatment • Active surveillance/ awareness • Screening for carriage of resistant organisms • Molecular detection and typing December 1, 2013 Stewardship: role of Clinical Microbiologist/ID Specialist 24

1. Are antibiotics being used in accordance with approved protocols? • • Empirical vs. targeted treatments clearly specified? Stopped at the correct time? Based on clinical needs and microbiology results? Correct use of surgical prophylaxis guidelines? December 1, 2013 Audit: Monitoring compliance ü Antibiotic ü Timing ü Dosage 25

2. Are our policies & guidelines being followed? • Consumption data: Based on stock controls • Signed prescriptions • Usage data December 1, 2013 Audit: Monitoring effectiveness ü DDD*: based on patient bed days / length of stay *DDD = defined daily dose 26

3. Are the policies being used effectively? • Dosage: too much- too little? • Timeliness: start-stop dates? • Appropriateness: compliant with local policies? December 1, 2013 Audit: Monitoring Appropriateness 27

• Regular and timely feedback • Use as evidence for further teaching • Discuss in antibiotic ward rounds • Assess efficacy of guidelines and protocols before regular review December 1, 2013 Audit data 28

• Work in close collaboration with Microbiology laboratory • Have early warning system, based on regular surveillance • Act promptly to detect and manage outbreaks • Have effective isolation policies • Ensure effective cleaning and high compliance with hand hygiene December 1, 2013 Control and Prevention of Healthcare-associated Infections 29

• WHO Global Strategy for containment of antimicrobial resistance WHO, 2001. http: //whqlibdoc. who. int/hq/2001/WHO_CDS_DRS_2001. 2. pdf • Dellit TH, et al. Infectious Disease Society of America and Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159 -177. • Richards J. Emergence and spread of multiresistant organisms: can infection control measures help? Int J Infect Control 2009; v 5: i 2 doi: 10. 3396/ijic. V 5 i 2. 017. 09. December 1, 2013 Further reading 30

1. 2. 3. Methods to manage resistance are preventing spread of resistant pathogens, antibiotic stewardship, and reduction of antibiotic use. T/F Additional information from the microbiology laboratory, useful in prudent use of antibiotics, is reporting sensitivity testing to broad spectrum antibiotics as a first line antibiotics. T/F The topics usually included in antibiotic policies are: a. b. c. d. e. December 1, 2013 Quiz List of antibiotics in the formulary- with the possibility to use some antibiotics outside the formulary. Guidelines for empiric and targeted treatment not including dosage and duration of treatment. Protocols for reserve antibiotics including how to order and who authorises its use. Protocols for surgical prophylaxis including stop-orders after 48 hours. All of the above. 31

• IFIC’s mission is to facilitate international networking in order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe. • The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise. • For more information go to http: //theific. org/ December 1, 2013 International Federation of Infection Control 32