Antimicrobial Stewardship 101...Antimicrobial Stewardship Program Joe Hessell, PharmD, BCPS Expert Pharmacist [email protected] Diagnostic Microbiology Development Program (DMDP)

How to Create a Successful Antimicrobial Stewardship

Program

Joe Hessell, PharmD, BCPSExpert Pharmacist

[email protected]

Diagnostic Microbiology Development Program (DMDP)

Outline

• Overview: Core elements for AMS programs

• Challenges of resource-limited setting / LMIC

• Beginning with AMS situation analysis

• Establishing an AMS team and committee

• Assessing baseline antimicrobial prescribing

• Implementation of interventions

• Tracking / monitoring effectiveness

• Example of successful AMS implementation: Cambodian hospital experience

• Resources and e-learning for AMS

Core Elements of Hospital AMS Programs

AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019

Core Elements of Hospital AMS Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019.

CDC (USA) WHO (for LMICs)

Challenges to developing AMS in LMICs

• Few infectious diseases-specific and pharmacy-specific training programs

• Gaps in the availability of appropriate policies and guidelines

• Limited diagnostic and laboratory capacity

• Gaps in data on antibiotic use or antibiotic resistance patterns

• Weak data management systems, inexperience with data analysis and program implementation

• Scarce human and material resources, including essential antimicrobials

The Core Elements of Human AMS Programs in Resource -Limited Settings: National and Hospital Levels. Atlanta, GA: US Department of Health and Human Services, CDC; 2018.

Where to begin?

• Conduct hospital AMS situation analysis, identifying strengths, weaknesses, opportunities and barriers to AMS implementation

• Focus on:• Structures, policies and guidelines: Identify which are in place and which are

critically in need • Human resources: Identify the existing and required human resources

needed for a functioning AMS team• Antimicrobial use and resistance data: Review data on antimicrobial

consumption and AMR surveillance data, and identify challenges related to antibiotic prescribing practices

• AMS activities: Identify any existing AMS activities in the facility that can be built on and made sustainable.


WHO core elements checklist



Creating the AMS team

• Key points to creating an effective AMS team• Dedicated focal point to serve as AMS Champion

• Multidisciplinary membership

• Hospital leadership support

• May initially require local antimicrobial prescribing data to validate need for AMS in order to gain hospital leadership buy-in• In this case, baseline assessments can be done (by conducting a point

prevalence survey or antimicrobial consumption monitoring – coming up!) before creating formal AMS program


The AMS Team: Multidisciplinary membership

• Need to include different disciplines that will participate in AMS activities

• Key members:• Physicians (including surgeons)• Pharmacists • Pathologists / Microbiologists• Nurses (preferably involved in IPC)

• Appoint dedicated focal point to serve as AMS champion• Preferably physician with

experience and interest in ID, but others can also serve this role


Establishing an AMS Committee

• Coordinates activities of the AMS team

• Include relevant stakeholders and members from other relevant committees (e.g. IPC)

• Develop TOR, outlining clear objectives, members, and activities/interventions

• Progress of AMS activities to be reported at AMS committee meetings

• Don’t necessarily need to create new committee, can be included into existing one (e.g. D&T committee)


Baseline assessments on antimicrobial use

Available Methods:

• Point prevalence survey (PPS)• Qualitative and quantitative

data

• Antimicrobial consumption (AMC) monitoring• Quantitative data

What is a PPS?

Antimicrobial Point Prevalence Survey (PPS):

Measures, at a particular point in time, the number of patients in a ward/hospital that are prescribed antimicrobials

Purpose of antimicrobial PPS

• Monitor rates of antimicrobial prescribing• First PPS establishes ‘baseline’

• Identify targets areas to improve quality of antimicrobial prescribing• Specific indications, e.g. surgical prophylaxis

• Specific wards

• Assess effectiveness of interventions intended to address antimicrobial prescribing with a follow-up PPS

What can be evaluated in PPS?

• % of patients prescribed antimicrobials

• Which antimicrobials prescribed most often

• Are antimicrobials being prescribed appropriately• Strength, route, frequency, duration

• Appropriateness for indication (according to local guidelines)

• Is diagnosis or indication of antimicrobial documented

• Are specimens for microbiology testing being ordered/collected

Baseline PPS at Siem Reap Hospital, Cambodia

• 161 of 199 (81%) hospitalized patients prescribed antimicrobials

• 13% of patients prescribed antimicrobials had microbiology testing performed

• Indication for antimicrobial recorded in 2%of cases

• 45% of prescriptions written completely

• 100% of patients that underwent surgery had antibiotics prescribed post-operatively

81%

19%

Patients on antimicrobials

Patients not on antimicrobials

Available PPS Methodologies

17

Global PPS Ward form

18

Global PPS Patient form

How to conduct PPS

• Appoint PPS team members and focal point

• Select PPS protocol/methodology

• Train PPS team member

• Plan which wards to be surveyed and which dates

• Perform data collection (often on paper)

• Transfer data to electronic format

• Validate and analyze data, identifying areas for improvement

• Report results to relevant committees and hospital staff

• Consider plans for a follow-up PPS

AMC Monitoring

• Necessary to evaluate trends in antibiotic use and monitor the progress of AMS initiatives

• The defined daily dose (DDD) of a medication is the assumed average maintenance dose per day for a drug used for its main indication in adults, as defined by WHO• Uniform unit of measure across different antimicrobials, which allows for comparison

and aggregation of consumption data• Example: Ceftriaxone 2 grams = 1 DDD

• Antibiotic use is often measured as DDDs per 1,000 patient days, which requires two sets of data for a selected period of time:• Number of units of an antimicrobial dispensed from pharmacy• Number of patient hospitalization days

0

100

200

300

400

500D

DD

s /

1,0

00

pat

ien

t d

ays

AMC of Siem Reap PRH 2016(10 most common antimicrobials)

1612

1260

944

0

200

400

600

800

1000

1200

1400

1600

1800

2016 2017 2018

DD

Ds/

1,0

00

pt.

day

s

Total AMC of Siem Reap PRH

AWaRe Groups

• Classifies antibiotics into three categories:• Access

• Watch

• Reserve

• WHO’s goal of increasing the proportion of global consumption of antibiotics in the ACCESS group to ≥60%



How to perform AMC monitoring

AMC Tool, recommended by WHO:https://amu-tools.org/amctool/amctool.html

DMDP developed Excel tool(Can be modified to suit local needs, available upon request)

https://amu-tools.org/amctool/amctool.html

Implementing an AMS intervention

“AMS interventions should be implemented in a stepwise approach, build on existing structures and reporting, maximize teamwork, and encourage champions and clinical staff – including prescribers – to participate. Start small and keep it simple and doable.”





Implementing an AMS intervention

• Identify priority area to focus on – Start small, simple, achievable• Based on initial findings from situation analysis, PPS, AMC monitoring• Target ‘low hanging fruit’

• Ensure necessary policies/guidelines/resources in place• May need to be developed (collaborate with all relevant stakeholders)

• Identify quantitative measure to assess impact, and set goal• Educate staff and publicize AMS program initiative

• Must engage all relevant stakeholders to be successful!

• Implement intervention • Monitor and evaluate• Report / provide feedback

Types of AMS interventions

• Surveillance (e.g. PPS, AMC monitoring)• Assess baseline, and follow-up for monitoring progress of interventions

• Treatment (or prophylaxis) guidelines• Surgical prophylaxis (‘low hanging fruit’)

• Restriction• Requires dedicated pharmacy involvement

• Audit and feedback• Prospective or retrospective

• Increase and improve microbiology testing, optimize reporting• Cascade reporting, antibiogram development

• Education and training necessary for all types of interventions



Monitoring and evaluating AMS program

• Outcome measures to consider:• Total antimicrobial consumption

• Cost

• Appropriateness of antibiotic selection/dose/duration (according to local guidelines)

• Clinical outcomes

• Rates of AMR

• Proving the effectiveness of an AMS program validates the team's efforts and helps convince hospital leadership to continue and expand activities, as well as provide additional resources as needed

AMS Success Story: Siem Reap Hospital, Cambodia

• 300 bed acute care government facility with 12 patient wards in Northwestern Cambodia

AMS Program at Siem Reap Hospital

• Multidisciplinary team

• Dedicated focal point

• Hospital leadership supportAMS

Committee

Prescribers

Pharmacy

Nursing

Microbiology

Infection control

Administrative staff

QI staff

IT staff

AMS Interventions

• Interventions implemented in stepwise manner, not all at once

• Baseline PPS results provided guidance where to focus interventions

ID Lab and

Ward Rounds

Follow-up antimicrobials PPS results

*Statistically significant difference, based on confidence intervals calculated by modified Wald method.

Key points for AMS implementation

1. Create a multidisciplinary team with a dedicated focal point• Engage with all relevant stakeholders

• Seek hospital leadership support, gain buy-in

2. Measure: assess baseline antimicrobial prescribing to identify targets for AMS interventions

3. Introduce interventions in strategic, stepwise manner• Prioritize activities, start small and build

• Monitor progress in a measurable way, and report back

Resources

Free E-learning AMS courses

• WHO: Antimicrobial Stewardship: A competency-based approach• https://openwho.org/courses/AMR-competency

• Stanford University: AMS: Improving Clinical Outcomes by Optimization of Antibiotic Practices• https://stanford.cloud-cme.com/default.aspx?P=0&EID=20868

• Future Learn: Antimicrobial Stewardship: Managing AMR• https://www.futurelearn.com/courses/antimicrobial-stewardship

• CDC: Antibiotic Stewardship Training Series• https://www.train.org/cdctrain/search?query=antimicrobial%20stewardship

https://openwho.org/courses/AMR-competency

https://stanford.cloud-cme.com/default.aspx?P=0&EID=20868

https://www.futurelearn.com/courses/antimicrobial-stewardship

https://www.train.org/cdctrain/search?query=antimicrobial%20stewardship

Documents

Antimicrobial Stewardship 101...Antimicrobial Stewardship Program Joe Hessell, PharmD, BCPS Expert Pharmacist [email protected] Diagnostic Microbiology Development Program (DMDP)