AMS Indian Persceptive

The presentation is solely meant for Academic purpose

500 beds.

Tertiary care centre with DNB training in 19 specialties .

AMS program initiated in January 2010

1. Education & Awareness

2. Evolving local Antibiogram

3. Management support – talking to the “consultants”

4. Prioritisation – areas/drugs

5. Feedback – management & consultants

6. Surveillance

Initial period of 1 year (2009) – monthly CMEs on Resistance / Basics of Antibiotics and Common mistakes in antibiotic prescriptions.

The Hospital staff was sensitized to the issues – 1. Antibiotics are important.

2. There is a trained person in charge.

3. Management is serious about this.

1. Full time Microbiologist employed.

2. Reporting standardized as per CLSI guidelines.

3. New indigenous software designed and integrated into the LIS/HIS – captures reports from the LIS and gives output as “Antibiogram” Location/Duration/Drugs/Bugs.

Monthly Meeting with Consultants and CMD

Compliance measures of AMS and Outcome Measures to be presented every 3 months

Direct involvement and “pressure” from top management crucial in keeping the momentum.

Focus of – ICUs, Surgical Prophylaxis and common infections with abuse potential (ARI/AGE)

Focus on select antibiotics.

Risk stratification of patients and local data (marriage between clinical category & microbiology) – KIMS manual for empirical therapy in sepsis/infection

• ICUs – 6 monthly audit – Retrospective analysis of case records of all culture positive cases for choice of initial empiric therapy, whether de-escalated after reports and total duration of therapy.

• Surgical Prophylaxis – quarterly audit of choice, timing and duration of antibiotic use for prophylaxis in only clean surgeries.

1. Resistance to sentinel antibiotics

2. MDRO isolation rates

3. Consumption of sentinel antibiotics

4. De-escalation rates

2010 – 400 beds – 119820 patient days

2011 – 450 beds – 131424 patient days

2012 – 500 beds – 154692 patient days

Overall “sales” might have increased!!!

3 months prospective study

All admissions in the MD -ICU

Non-sepsis syndromes excluded

N = 187 (of sepsis syndrome)

Classified as Type 1/2/3/4 as per criteria

De-escalation defined as withdrawal of MDR-GNB cover (Carb/Tige/Colistin)

Type 1 – Ceftriaxone/Doxycycline/ Azithromycin

Type 2 –BL/BLI, Amikacin, Ertapenem, Clarithromycin (Lung/Unknown), Teicoplanin (Unknown) Linezolid (Lung, SSTI)

Type 3 – Imipenem/Meropenem , Teicoplanin (Unknown) , Linezolid (Lung, SSTI), Clarithromycin (lung)

Type 4 - Tigecycline, Colistin, Flucanozole/ Caspofungin

Site of Infection Type 1 Type 2 Type 3 Type 4

SSTI (10) 5 2 3 0

Lung (45) 13 4 10 18

Intraabdominal (25) 2 4 17 2

Urinary tract (52) 0 16 26 10

CNS (1) 1 0 0 0

Unknown (20) 0 2 14 4

Patient Type

Total Number

Total culture positivity

Initial Antibiotic Appropriate antibiotic

1 21 8 7 (87.5%)

2 49 18 16 (88.88%)

3 83 41 37 (90.24%)

4 34 29 28 (96.55%)

Patient Class Total culture

positivity De-escalation done

Type 1 8 1 (12.5%)

Type 2 18 6 (33.33%)

Type 3 41 11 (26.83%))

Type 4 29 7 (24.14%)

Patient Class Average APACHE-II

Mortality %

Expected mortality as per APACHE-2 scores (international standards)

Type 1 13.8 10 15

Type 2 24.4 39 40

Type 3 29 44 55

Type 4 28 59 55

3.7

3.8

3.9

4

4.1

4.2

4.3

4.4

4.5

Pre-AMS (2008) Study period

Average LOS in ICU

Average LOS

Protocol based , patient risk stratification - derived from history, physical examination & simple labs –achieves high degree of appropriateness, with comparable mortality!

(37% of patients were spared from empiric use of carbapenems in ICU)

1. Protocol based antibiotic use in MD-ICU

2. Top Management Support INCLUDES IT.

3. Closed ICU system – Intensivist Managed

4. Willingness among “most” of the clinicians to “trust” the ID advice.

1. Protocol based Antibiotic policy is safe.

2. Antibiotic Policy can be implemented.

3. Improvement in surgical prophylaxis use - > 90% compliance except for duration.

1. Scope limited to Medical ICUs & Surgical prophylaxis & Few antibiotics only.

2. Implementation in ICU monitored and outcome surveillance done only twice in this 2 years.

3. Cost analysis not done

1. Actions not taken based on surveillance reports from wards - SHORTAGE OF MANPOWER

2. Unable to demonstrate gain in resistance profile nor significant reduction in AUR/AUD

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