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Mushira Enani, MBBS, FRCPE, FACP,CIC
Head- Infectious Disease Section
King Fahad Medical City
Stewardship: Challenges & Opportunities
in the Gulf Region
• Background of Healthcare system
• Antimicrobial resistance in GCC states
• GCC Antimicrobial Stewardship survey
• KFMC Experience
• Conclusion
Outline
Gulf Cooperation Council (GCC) States
Demographic Indicators C
ou
ntr
y
Are
a (K
m2)
Population
Nat
ion
als
No
n-
Nat
ion
als
Tota
l
Year
UAE 83,600 892,000 3,873,000 4,765,000 08
Bahrain 760.5 537,700 568,800 1,106,500 08
KSA 2000,000 18,543,246 6,830,266 25,373,512 09
Oman 309,500 2,018,000 1,156,000 3,174,000 09
Qatar 11,580 - - 1638,6 09
Kuwait 17,820 1,102,485 2,340,460 3,442,945 09
Human and Material Resources Indicators C
ou
ntr
y
Ph
ysic
ian
s
Ph
arm
acis
ts
He
alth
-re
late
d
pe
rso
nn
el
Ho
spit
al
be
ds
PH
C U
nit
s an
d C
en
ters
#
Ho
spit
als
# H
eal
th c
en
ters
Yr
All per 10,0000 population
MO
H
Oth
er
Go
v P
riv.
se
ct
Yr
Rat
e
Yr
Rat
e
Yr
Rat
e
Yr
Rat
e
Yr
Rat
e
Yr
UAE 27.9 08 6.1 08 12.9 08 19.3
08 0.5 08 14 18 59 08 64 08
BAH 21.1 08 6.0 08 14.2 08 19 08 0.2 08 9 1 13 09 24 09
KSA 21.8 09 5.9 09 23.5 09 22.04 09 0.8 09 244 39 125 09 2037 09
OMAN 17.5 09 3.4 09 39.5 08 17.7 09 0.7 09 50 5 5 09 217 09
QATAR 26.8 09 8.64 09 22.04 09 12.3 09 1.4 09 5 1 4 09 30 09
KUW 19 09 1.6 09 22 09 20 09 0.2 09 15 - 9 09 85 09
Projected increase in treatment demand in GCC by 2025
Projected demand for hospital beds in GCC by 2025 (percent)
Resistant pathogens in clinical isolates GCC countries (Jan 1990 - April 2011)
37,295 bacterial isolates studied for antimicrobial resistance
• E.coli 44%
• K. pneumoniae 20%
• P. aeruginosa 18.7%
• MRSA 5.4%
• Acinetobacter 5%
• C. difficile & Enterococcus reported less than 1%
Prevalence of resistant pathogens in clinical isolates from GCC countries
The percentage of CRE (+MHT) compared to total Enterobacteriaceae
Pseudomonas aeruginosa antibiotic susceptibility (%) KFMC 2009 -2012
71
74
78
85
84
91
78
72
CAZ
CPE
CIP
TZP
GM
AN
MER
IMP
An
tib
ioti
c t
este
d
2012
2011
2010
2009
Cost of Antibiotic Resistance in KFMC
0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000
Vanc
Merop
Imip
Pip-Taz
Cipro
Colistin
2012
2011
2010
Cumulative
Antimicrobial Stewardship Survey GCC Countries
GCC Survey
Participants Job Title
0
5
10
15
20
25
Specialist AssistantConsultant
consultant Consultant Others pharmacist
Fre
qu
ecn
y
GCC States
Bahrain
KSA
Oman
UAE
0
2
4
6
8
10
12
14
16
Type of Hospital
Community hospital
District or general hospital
Non-teaching tertiary hospital
Other
Private hospital
200-400 43%
500-700 23%
>800 34%
Number of Inpatient Beds
0
5
10
15
20
25
30
Don't know No Yes
3
15
29
Having Antimicrobial Stewardship program
Barriers
0
5
10
15
20
25
Dedicated funding 17%
Don't know 37%
Funded from savings on antimicrobials
7%
Not applicable 39%
Funding
49%
51%
Having AMS ward Rounds
No Yes
Wards Having AMS Rounds
Both
ICU
NonICU
Having Animicrobial Guidelines
Don't know
No
Yes
Having Restricted Antimicrobial List
Don't know
No
Yes
Having Antimicrobial Audit
Don’t Know
No
Yes
28%
72%
Having Electronic Prescription No
Yes
Reduction in Direct cost Expenditure
Don'tknow
No
Yes
Reduction in Broad Specturm Agents Usage
Don'tknow
No
Yes
Reduction of Inapropriate Prescription
Don't know
No
Yes
Reduction of Health Care Aquired Infection
Don't know
No
Yes
Reduction Of Antmicrobial Resistance
Don'tknow
No
Yes
Therapy for specific infectious syndromes (CMG) 10
Individual drugs? 5
Dosage? 12
Others 1
Dosage for special populations (e.g. renal or liver impairment? 8
Individual drugs?\nDrug class? 1
Surgical prophylaxis guidelines? 9
Antifungal guidelines? 6
Drug Class 7
First choice antibiotic (empirical therapy guidelines) 12
Alternative choice (e.g. if allergic) 3
Route of Administration 9
Duration of prescription 4
Antiviral guidelines 4
Microorganisms covered by antibiotic tested? 5
Side effects 6
Dosage for obese patinets 1
KFMC Experience
Multidisciplinary team approach
OBJECTIVES 1. Improving patients outcome by optimizing the
antimicrobial use, 2. Minimizing irrational use, 3. Reducing adverse events including healthcare-
associated infections such as clostridium difficile infection, MDROs
4. Minimizing healthcare cost.
KFMC Antimicrobial Stewardship
Core Strategies of Successful Antimicrobial Stewardship Program
Prospective audit with intervention and feedback (AI)
Formulary restriction and pre-authorization (AII)
IDSA/SHEA Guidelines for developing an Institutional Program to Enhance Antimicrobial Stewardship, 2007
n= 377
Patients in Medical Wards
on I.V Antibiotics
March – July 2013
Antimicrobial Prescribing
n= 377
69 68
51 49 47
40
13 10 9 6 6 5 4
0
10
20
30
40
50
60
70
80
13%
Indications
n= 377
51%
24%
3% 3%
5%
7%
7% Tazocin
Ceftriaxone
Carbapenem
Ceftazidim
Ciprofloxacin
Vancomycin
Metronidazole
Broad spectrum Antibiotic prescribing with no
evidence of bacterial infection through five months
n=49
122
151
104
planned notdocumented
Not plannednot
documented
planned anddocumented
No.of Rx
Documentation of Duration of Therapy
n= 377
32%
40%
28%
60%
7%
21%
12%
Stop
IV/Po
Deescalate/ change
spescify duration
n = 195/377 (52%)
*Recommendation made by stewardship team
Type of Stewardship Intervention*
73
122
Yes NoIntervention Feedback
37.4%
Intervention Implementation*
*Compliance with Stewardship team Recommendations
62.6%
Pipracillin-Tazobactam Carbapenem Ceftriaxone
Total Rx No. 69 22 26
Total Intervention 35 14 12
Discontinue 28 12 10
Descalation 7 2 2
No
.of
Rx
Top Three Prescribed Antibiotics vs. Interventions Before
After
Projected Cost
Saving
Avoided
direct cost
of the top 3
antibiotics over 5
months
150,000SR
Average Savings 30,000 SR/month
360,000 SR/year
0 50000 100000 150000 200000 250000 300000 350000 400000 450000 500000
Jan
Feb
Mar
Apr
May
June
July
Aug
Sep
Oct
Cost of Some Antibiotics 2013
VANCOMYCIN 500MG INJECTION
CIPROFLOXACIN 200MG/100ML (CIPRO) INJECTION
CIPROFLOXACIN 250MG (CIPRO) TABLET
CIPROFLOXACIN 500MG (CIPRO) TABLET
COLISTIMETHATE SODIUM 1000.000 UNIT/VIAL (COLOMYCIN)
PIPERACILLIN 4GM + TAZOBACTAM 500MG (AS PIPERACILLIN) (TAZOCIN) INJECTION
MEROPENEM 1GM (MERONEM) INJECTION
IMIPENEM/CILASTATIN 500MG (AS IMIPENEM) INJECTION
Hospital-acquired Clostridium difficile Medical wards - 2012-2013*
0
3.28
7.1
0
1.62 1.64
0 0 0
1
2
3
4
5
6
7
8
1st 2nd 3rd 4th
Quarterly rate (#cases per 10000 patient-days)
Infection rate/10000patient-days2012
Infection rate/10000patient-days2013
*2013 quarter 1-3
Manpower
-Infectious diseases Clinical Pharmacists trained in
antimicrobial stewardship
-Coordinator/ data manager Education of healthcare providers, CMG
Integrated electronic system: CPOE, decision
support, automated approval of restricted
antibiotics
Informatics based monitoring:
Antibiotic consumption
Antimicrobial resistance Rapid diagnostics in Microbiology lab
Compensation/ incentives for stewardship
members
Requirements for Project Sustainability
Conclusion
• The global spread of antibiotic resistance among clinically important Gram-negative bacilli is a growing problem in the GCC states.
• Health care demand and spending are rising sharply in the GCC.
• GCC governments must make major regulatory and policy changes to regulate antibiotic use in the community and hospitals.
Recommendations
• Antimicrobial Stewardship should be implemented across GCC in healthcare facilities
• Prohibiting antibiotic use without prescription
• Educational campaigns about antibiotic use, antimicrobial resistance, & infection prevention for prescribers and consumers.
• Developing regional surveillance system on antibiotic resistance and antibiotic consumption for benchmarking .
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