EAAD 2017 – Toolkit for professionals in hospitals and other healthcare settings

What is EAAD?European Antibiotic Awareness Day (EAAD) is a European health initiative coordinated by ECDC, which aims to provide a platform and support for national campaigns on the prudent use of antibiotics. Each year across Europe, EAAD is marked by national campaigns on the prudent use of antibiotics on or around 18 November.

What are the key messages and how they will be used?To support communication activities at national level, ECDC has produced several communication toolkits containing template materials and evidence-based key messages which may be adapted for use at national level.

Key messages are the cornerstone of any communication campaign. The key messages for the new toolkit:

- Aim at creating a sense of individual responsibility in tackling antibiotic resistance and at empowering professionals to take action.

- Provide a set of water-tight statements, each of which is accompanied by a reference, that should be used as a basis for the content of the template materials;

- Cover a number of professionals working at hospitals and other healthcare settings: managers/administrators, infectious disease specialists, infection prevention and control professionals, epidemiologists, prescribers, junior doctors and students, pharmacists, nurses, clinical microbiologists, and professionals in emergency departments, in intensive care units, and in long-term care facilities.

The issues surrounding antibiotic resistance may differ in each EU/EEA country. It is important to stress that the template materials developed by ECDC provide core information and common messages, but will be most effective if adapted to respond to the needs and situations in each country, and even each hospital or healthcare setting. Countries could consider leveraging the national antibiotic resistance and antibiotic consumption data available from EARS-Net and ESAC-Net respectively, and consulting with national professional associations on the most appropriate tools to be used in their country.

What is “expert consensus”?When, in this document, a reference to a message is indicated as “expert consensus”, ECDC is referring to the agreement reached in the outlined decision-making process, including ECDC experts’ internal agreement, EAAD TAC members’ opinion, and consultation with external experts and stakeholders.

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1. General key messages for healthcare professionals in hospitals and other healthcare settings

What is the problem? 1. Antibiotic1 resistance threatens the health and safety of patients in all healthcare settings in Europe [1].

2. The emergence of bacteria resistant to multiple classes of antibiotics is particularly concerning. Such multidrug-resistant bacteria are a real and constant threat to clinical practice in all healthcare settings in Europe [1].

3. Infections with multidrug-resistant bacteria can be severe, fatal and costly and can directly lead to [2-11] [expert consensus]:a) Delayed access to effective antibiotic therapy for individual patients, causing

treatment failures, longer illnesses, prolonged stays in hospital and increased morbidity and mortality;

b) More adverse events, because alternative antibiotic therapies, that are more toxic, must often be used;

c) Fewer effective antibiotic treatments for immunosuppressed patients and those undergoing surgical operations;

d) Reduced quality of patient stay due to anxiety because of the need for rigorous infection control measures;

e) Higher direct and indirect hospital costs.

Examples - Patients with bloodstream infections have a threefold higher mortality rate, prolonged hospital stays, and higher costs if their infection is due to third-generation cephalosporin-resistant Escherichia coli, compared with third-generation cephalosporin-susceptible isolates [12].- Patients have a 24% increased risk of mortality with any antibiotic-resistant Pseudomonas aeruginosa infection [13].- Patients are up to three times more likely to die if their infections is caused by carbapenem-resistant Klebsiella pneumoniae, compared with carbapenem-susceptible isolates [14].

4. Misusing antibiotics increases the risk of infections with multidrug-resistant bacteria [15].

ExampleGram-negative bacteria, such as Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp., are becoming resistant to most available antibiotics [16,17].

1 With the word “antibiotics”, ECDC means antibacterial agents or antibacterials. However, the key messages proposed for antibiotics could be extended to other antimicrobial agents based on the specific needs of countries and of hospitals and other healthcare settings.

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5. Antibiotics are misused when they are prescribed unnecessarily (i.e. antibiotic treatment is not clinically needed) or when they are prescribed inappropriately, i.e. one of the following [18]:a) Delayed administration of antibiotics in critically ill patients; b) The spectrum of antibiotic therapy is either too narrow or too broad; c) The dose of antibiotic is either too low or too high; d) The duration of antibiotic therapy is either too short or too long;e) Antibiotic therapy is not reviewed after 48-72 hours, or the choice of

antibiotic is not streamlined when microbiological culture data become available.

6. Misusing antibiotics increases the incidence of Clostridium difficile infections [19-22].

Example In European hospitals, Clostridium difficile infections can lead to up to a 42% increase in mortality, 19 extra days of hospital stay, and more than EUR 14,000 of additional costs per patient [23,24].

7. Many prescribers do not know antibiotic resistance prevalence rates in their local setting [25,26], and recognise lacks in their training regarding antibiotic use [27]. Availability of guidelines, consultation with infectious diseases specialist, and trainings represent the most helpful interventions to promote better use of antibiotics [25,27].

8. Only a few antibiotics in the research and development pipeline may be effective against existing multidrug-resistant bacteria [28-30].

9. Losing effective options for the treatment and prevention of infections is a global health security threat [31].

How is our use of antibiotics contributing to the problem10. Misuse of antibiotics accelerates the emergence and dissemination of antibiotic resistance [8,31-34].

11. Antibiotics are given to many hospital inpatients [35,36].

12. Up to a half of all antibiotic use in European hospitals is unnecessary or inappropriate [6,37,38].

13. Antibiotic resistance is more likely to develop and spread when [39] [expert consensus]:

Broad-spectrum antibiotics are used; Long durations of antibiotics are used; Too low doses of antibiotics are used.

Example

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Cephalosporins, carbapenems, fluoroquinolones and anti-anaerobe antibiotics have a high risk of selecting for multidrug-resistant Gram-negative bacteria [40].

14. Antibiotics have long-term effects on the development and persistence of antibiotic resistance in the microbiota. This resistance may be transferred to other bacteria [41].

15. Antibiotics are often prescribed to patients in hospitals without explaining the importance of prudent antibiotic use [expert consensus].

Why hospitals should be promoting antibiotic stewardship?16. Promoting prudent antibiotic use is both a patient safety and a public health priority [31,42].

Example Increasingly, many European countries have national guidance on antimicrobial stewardship programmes for hospital prescribers. The ECDC directory (link) contains online resources for developing guidelines.

17. Antimicrobial management initiatives that promote prudent antibiotic use are called antibiotic stewardship programmes [19,42-45].

18. Antibiotic stewardship programmes, can contribute to [42,45,46] [expert consensus]:

a) Optimising how infections are treated;b) Increasing infection cure rates and reduce treatment failures; c) Reducing adverse events from antibiotic use; andd) Preventing and reducing antibiotic resistance, together with infection prevention and control measures.

Examples2

In a recent survey of hospitals that had implemented an antibiotic stewardship programme [47]: 96% hospitals reported reduced inappropriate prescribing; 86% reported reduced use of broad-spectrum antibiotics; 80% reported reduced expenditures; 71% reported reduced healthcare-associated infections; 65% reported reduced length of stay or mortality; 58% reported reductions in antibiotic resistance.

19. Antibiotic stewardship programmes can successfully reduce Clostridium difficile infection rates [19,22,43,44,48].

2 Some examples refer to antimicrobial stewardship programmes. The objectives of antimicrobial and antibiotic stewardship programmes, including the appropriate indication, selection, dosing, route of administration, and duration of antimicrobial therapy, are the same.

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ExampleThe incidence of Clostridium difficile infections decreased in the medical and surgical wards of an acute general hospital in the United Kingdom in response to revised empirical antibiotic treatment guidelines for common infections and restrictive measures for fluoroquinolone and cephalosporin usage [48].

20. Antibiotic stewardship programmes can reduce patient care costs [42,45,46].

Example In a pooled analysis of antibiotic stewardship programmes, total consumption fell (by 19% hospital-wide and by 40% in intensive care units), overall antibiotic costs were reduced (by about one third), and the hospital length of stay shortened (by 9%). These improvements did not cause any increase in adverse patient outcomes [46].

How do antibiotic stewardship programmes work?21. Antibiotic stewardship programmes consist of multifaceted actions, such as [19,42,43,44,48-57]:a) Leadership commitment: ensuring the necessary resources in terms of staff, technology and budget are available. b) Appointing leaders that are responsible for the overall programme and for antibiotic use. c) Hospital-based teams, which include infectious disease specialists, clinical pharmacists and microbiologists, providing support to prescribers; d) Proactive auditing of antibiotic prescriptions with feedback to team members; e) Training and education for medical, pharmacy, laboratory, nursing, and non-clinical staff, as well as patients and their families;f) Using evidence-based antibiotic guidelines and policies;g) Using restrictive measures for antibiotic prescriptions (e.g., pre-approval and post-authorization requirements for specific antibiotics);h) Monitoring antibiotic resistance and use, and making this information available to prescribers.

Examples of antibiotic stewardship strategies, actions and outcomes in European countries include:22. France - Restricting use of fluoroquinolones reduced consumption of this class of antibiotics and decreased the rate of meticillin-resistant Staphylococcus aureus in a teaching hospital [58].

23. France – Using information technology support for antibiotic prescriptions decreased antibiotic consumption in many hospitals [59].

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24. Germany - Implementing a computerised decision support system led to higher adherence to locally adapted guidelines, increased antibiotic-free days and reduced mortality over a five-year period in five intensive care units [60].

25. Hungary - Infectious disease specialist consultation in a surgical intensive care unit, together with a restricted prescribing policy, led to lower use of all antibiotics and a marked reduction in use of broad-spectrum antibiotics [61].

26. Italy – A four-year infection control programme decreased the incidence of infections and colonisation caused by carbapenem-resistant bacteria in a teaching hospital. The programme included antibiotic stewardship measures targeting carbapenem use [62].

27. Netherlands – Implementing rapid processing of microbiology tests increased the proportion of patients receiving appropriate treatment within the first 48 hours in a teaching hospital [63].

28. Netherlands - Case audits for the reassessment of antibiotic use after 48 hours reduced antibiotic consumption and length of stay in a urology ward of an academic hospital, and also had a positive direct return on investment [64,65].

29. Poland - Developing guidelines for antibiotic prescriptions and pre-authorisation approval for restricted antibiotics decreased total antibiotic consumption in a general paediatric ward [66].

30. Spain – After only one year, education on guidelines combined with regular feedback led to a 26% improvement in the rate of appropriate treatments, and a 42% reduction of antibiotic consumption at a tertiary teaching hospital [67].

31. Sweden – Twice weekly audit and feedback in an internal medicine department led to an absolute 27% reduction of antibiotic use , especially of broad-spectrum antibiotics (cephalosporins and fluoroquinolones), as well as shorter antibiotic treatment durations and earlier switching to oral therapy [68].

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2. Key messages relevant for all prescribersThings you can do 32. Learn and apply all antibiotic use and infection prevention and control recommendations that are relevant to your area of specialisation [expert consensus].

33. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

34. Remain aware of local antibiotic resistance patterns in your department, your hospital and in the community [31] [expert consensus].

35. If in doubt before you prescribe an antibiotic, you should [25,26,53,70] [expert consensus]: Check local, regional and national epidemiological data; Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team.

36. Ensure that cultures are appropriately taken and send to the microbiology laboratory, before starting antibiotics [31,42,70,71].

37. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31,72].

38. Avoid unnecessary antibiotic prophylaxis [31,73].

39. For patients with severe infections, initiate effective antibiotic treatment as soon as possible [31,74].

40. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart [31,42,70,71].

41. Regularly participate in training courses and in meetings that support the implementation in the hospital of: a) prudent antibiotic use, b) evidence-based, local antibiotic guidelines, and c) infection prevention and control measures [52,53].

42. Answer the following key questions when reassessing antibiotic therapy after 48-72 hours (or as soon as microbiological results are available) [42,70]: Does the patient have an infection that will respond to antibiotics?If yes:

i. Is the patient on the correct antibiotic(s), correct dose, and correct route of administration?

ii. Could an antibiotic with a narrower spectrum be used to treat the infection?

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iii. For how long should the patient receive the antibiotic(s)?

3. Key messages for hospital managers / administrators

Tasks 43. Your tasks related to improving antibiotic use include [31,42,56,71,75]:a) Establishing a multidisciplinary team for your hospital antibiotic stewardship programme. This team should include infectious disease specialists, clinical microbiologists and pharmacists, and should receive dedicated funding and resources;b) Supporting implementation of antibiotic guidelines and infection prevention and control measures;c) Implementing targeted educational activities and training that:

i. optimise the diagnostic and therapeutic management of patients;ii. ensure that antibiotic stewardship recommendations are followed;iii. address behavioural factors shaping misuse of antibiotics;iv. enhance prevention and control of healthcare-associated infections and

the spread of antibiotic-resistant bacteria. d) Promoting prescribers and antibiotic stewardship team leaders to collaborate and conduct proactive audit and feedback.e) Setting quality indicators and quantity metrics to measure the progress and outcomes of the antibiotic stewardship programme;f) Ensuring that antibiotics listed in hospital formulary are always available; andg) Ensuring that prudent antibiotic use and prevention of antibiotic resistance are “priority action areas” in your hospital’s annual plan.

Things you should know44. Antibiotic stewardship programmes, together with infection prevention and control practices, can increase patient safety and quality of care and reduce hospital costs across all services by improving how antibiotics are used, as well as by decreasing C. difficile infections and other adverse events [19,42].

Example Implementing antibiotic stewardship programmes has resulted in [46]: Reducing antibiotic consumption by 20%, Reducing the incidence of hospital-acquired infections, Shortening the length of hospital stays, and Reducing antibiotic costs by 33%.

45. Infectious disease specialists, clinical microbiologists, and clinical pharmacists are all key leaders in the antibiotic stewardship team [56,76].

46. Many prescribers and other healthcare professionals believe their training in prudent antibiotic use is insufficient. They are asking for local antibiotic guidelines, specific education and antibiotic stewardship teams [25,27].

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47. Clinicians are responsible for prescribing and they must be fully engaged in shared decision-making with the antibiotic stewardship team [42].

48. For antibiotic stewardship teams to be successful, they need the active support of other key professionals in hospitals, such as infection prevention and control professionals, emergency department practitioners, hospital epidemiologists, nurses and IT staff [42,77].

49. Improving antibiotic use in the emergency department can lead to better antibiotic use across the entire organisation, because the emergency department is a common point of entry to the inpatient setting [77].

50. Both restrictive measures and persuasive measures can decrease antibiotic use [19,43,54,56]:

Restrictive measures include pre-approval and post-authorization decisions for specific antibiotics; Persuasive measures include proactive audit and feedback by infectious diseases physicians, microbiologists and pharmacists.

51. Antibiotic guidelines and regular educational sessions and rounds improve how physicians manage infections [78].

52. Certain structural strategies can improve antibiotic prescribing and patient outcomes. These include [54,79-81]:

computer-supported decisions, which link clinical indication, microbiological data and prescribing data together, and use of rapid and point-of-care diagnostic tests.

Things you can do in your hospital or institution53. Support your multidisciplinary antibiotic stewardship team by designating the specific leaders for accountability and drug expertise, and by stating the supportive roles of other key groups [42,71].

54. Prioritise antibiotic stewardship and infection prevention and control policies, as well as strategies and activities that support prudent antibiotic use and prevent the spread of antibiotic-resistant bacteria [31,71].

55. Provide funds and resources for an antibiotic stewardship programme (including e.g., salaries for dedicated staff, IT capabilities, rapid and point-of-care diagnostic tests) [31].

56. Fund and promote educational activities, training, and meetings about antibiotic stewardship and antibiotic resistance for all healthcare professionals (physicians, infectious disease specialists, pharmacists, microbiologists and nursing staff) [19,53,56].

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57. Strengthen surveillance activities for antibiotic use and antibiotic resistance [56].

58. Promote compliance with evidence-based guidelines for diagnosing and managing common infections, and for perioperative antibiotic prophylaxis. If these guidelines do not exist in your hospital, then support their development [31,54,56].

59. Promote using local microbiology and antibiotic resistance patterns to inform guidelines and empirical antibiotic choices [31].

60. Promote compliance with evidence-based guidelines for infection control measures, to reduce transmission of antibiotic-resistant bacteria [82].

61. Promote proactive audits and ensure that individual prescribers receive feedback [54,56].

62. Promote peer-review of antibiotic prescriptions and infection management, and encourage communication among healthcare professionals [71].

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4. Key messages for hospital infectious disease specialists

Tasks63. Your tasks related to improving antibiotic use include [31,56,68,71,83]:

a) Participating in the antibiotic stewardship team, as a key member of the team;

b) Collaborating with the hospital pharmacist and the clinical microbiologist to implement the antibiotic stewardship programme;

c) Consulting with hospital prescribers and providing them with feedback to ensure the quality of antibiotic prescribing;

d) Educating hospital prescribers on how to diagnose and treat common infections, and on the antibiotic stewardship principles;

e) Implementing evidence-based hospital antibiotic guidelines for common infections and for surgical prophylaxis;

f) Sharing information on local microbiology and antibiotic resistance patterns; and,

g) Managing your hospital’s antibiotic formulary (i.e., list of drugs available for prescribers).

Things you can do, or collaborate on64. Support the development and implementation of an antibiotic stewardship programme within your organisation [69].

65. Promote local guidelines on managing infections and using antibiotics. These should be readily and reliably accessible to all healthcare providers [56,69].

66. Check that antibiotic prescriptions follow antibiotic treatment protocols, based on evidence-based guidelines. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

67. Provide feedback and advice to prescribers on diagnostic evaluation and treatment of infectious diseases [83].

68. Regularly train hospital prescribers on prudent antibiotic use and participate in meetings on implementing evidence-based hospital antibiotic guidelines [31,53].

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5. Key messages for hospital infection prevention and control professionals and hospital epidemiologists

Tasks69. Your task is to ensure that the fundamental elements of the hospital infection prevention and control programme are carried out [82,84,85] [expert consensus]. These include:

a) education and training, b) policies and procedures, c) aseptic techniques and clinical interventions,d) hand hygiene, e) decontamination of instruments and equipment, f) decontamination of the environment, g) water safety, h) vaccination of healthcare workers alongside occupational health, i) liaising with public health organisations,j) embedding infection prevention and control in all policies, and k) ensuring, from the board level to the ward, that all staff understand

their role in preventing infections.

70. Other tasks include [31,42,56,82,85-87]:a) Coordinating hospital surveillance and prevention and control programmes

of healthcare-associated infections; b) Ensuring infection prevention and control guidelines, protocols and

checklists are available for preventing both healthcare-associated infections and transmission of microorganisms

c) Sharing information on local microbiology and antibiotic resistance patterns;

d) Monitoring compliance with infection prevention and control guidelines;e) Auditing and reporting healthcare-associated infections surveillance data;f) Ensuring antibiotic stewardship programmes are integrated with policies

andprogrammes for infection prevention and control;

g) Educating all relevant healthcare professionals on infection prevention and control interventions to reduce the transmission of both antibiotic-resistant and antibiotic-susceptible bacteria.

Example71. Greece – A three-year multifaceted infection control programme to control the spread of carbapenem-resistant bacteria in a haematology unit of a tertiary care hospital led to fewer infections caused by these bacteria [88].

72. Italy – A four-year infection control programme decreased the incidence of infections and colonisation caused by carbapenem-resistant bacteria in a teaching hospital. The programme included antibiotic stewardship measures targeting carbapenem use [62].

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73. The ECDC directory (link) contains online resources for prevention and control of healthcare-associated infections.

Thinks you can do74. Make guidance for infection prevention and control measures to reduce healthcare-associated infections and transmission of microorganisms readily and reliably accessible. This guidance can include guidelines, protocols and checklists [expert consensus].

75. Organise and promote educational events, courses and meetings together with hospital administrators to strengthen infection prevention and control activities among all healthcare professionals (e.g. hand hygiene, contact precautions, active screening cultures, and environmental cleaning) [89].

76. If you see staff members at the hospital or healthcare setting who breaches guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

77. Coordinate hospital surveillance of healthcare-associated infection through using both [82,85] [expert consensus]:

Point prevalence surveys, which give a snapshot picture of the number of patients with healthcare-associated infection in hospital at a particular point in time, and

Long-term surveillance of the incidence of healthcare-associated infections (e.g. in intensive care units, or for specific infection types).

78. Use local data on healthcare-associated infections, set local targets and find areas where additional infection prevention and control support is needed [82,85] [expert consensus].

79. Monitor how effective targeted preventive measures are at reducing transmission of antibiotic-resistant bacteria [82,85] [expert consensus].

80. Train healthcare professionals regularly on how to implement effective prevention and control strategies [82,85] [expert consensus].

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6. Key messages for hospital prescribers

Tasks81. As hospital prescribers your tasks related to improving antibiotic use include [31,42,43,52-54,56,70,71,90]:

a) Prescribing according to evidence-based hospital antibiotic guidelines for common infections and for surgical prophylaxis;

b) Identifying relevant individual patient background when evaluating the need for an antibiotic prescription, including recent antibiotic use, drug allergies, use of immunosuppressive therapy, recent hospitalisation or institutionalisation, recent travel outside of Europe, and microbiology results for the previous 3 months;

c) Documenting the indication for antibiotic treatment, drug choice, dose, route of administration and duration of treatment, in the patient chart, when you prescribe an antibiotic;

d) Follow infection prevention and control guidance;e) Ensuring that relevant cultures are taken before starting antibiotics;f) Re-evaluating treatment after 48-72 hours, or when results from

microbiological samples are available;g) Initiating antibiotic treatment as soon as possible in patients with severe

infection; h) Considering local microbiology and antibiotic resistance patterns when

prescribing empirical antibiotic treatments; i) Informing your patients of any antibiotics prescribed, and their potential

adverse effects; and,j) Participating in annual training courses on prudent antibiotic use.

Things you should know82. Using antibiotic guidance and attending educational rounds improve antibiotic prescribing [78].

83. Documenting indication, drug choice, dose, route of administration and duration of treatment in the patient chart leads to better use of antibiotics [71].

84. Prescribing the shortest evidence-based duration of antibiotic treatment reduces emergence of antibiotic-resistant bacteria [54,56,71,91].

85. Correct timing and optimal duration of antibiotic prophylaxis for surgery leads to fewer surgical site infections, and decreases the emergence of antibiotic-resistant bacteria [73].

86. Taking microbiology samples before starting empirical antibiotic therapy and streamlining antibiotic treatment based on culture results help improve antibiotic use [31,70,71].

87. Reviewing initial antibiotic treatment after 48–72 hours and switching from

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parenteral to oral administration (when possible), reduces antibiotic resistance rates and improves clinical outcomes [37,54,57,71,92,93].

88. Consulting the antibiotic stewardship team increases the quality of drug prescribing and improves patient outcome [56,83].

Example89. A pharmacist-led parenteral-to-oral switch resulted in shortened parenteral therapy durations without negatively impacting on clinical outcomes [56].90. Infectious disease specialist interventions have been associated with a significant improvement in the quality of antibiotic prescribing and leading a reduction in antibiotic use [83].

Things you can do91. Follow antibiotic treatment protocols, based on evidence-based guidelines, and apply infection prevention and control measures that are established in your setting [31] [expert consensus].

92. Consult the antibiotic stewardship team when needed, for examples when you prescribe an antibiotic outside of normal guidelines [31,56] [expert consensus].

93. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31,72].

94. Avoid unnecessary antibiotic prophylaxis [31,73].

95. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [expert consensus].

96. Answer the following key questions to optimise antibiotic therapy. If in doubt, consult with antibiotic stewardship team [31,42,53,70,71]: a) Is there a high probability of a bacterial infection, rather than colonisation or a viral infection?b) Have the appropriate cultures been taken before starting antibiotic therapy?c) Have you checked for recent antibiotic use, drug allergies, use of immunosuppressive therapy, recent hospitalisation or institutionalisation, recent travel outside of Europe, and microbiology results for the previous 3 months?d) Does the patient have an infection that will respond to antibiotics?If yes:

i. Is the patient on the correct antibiotic(s), correct dose, and correct route of administration?

ii. Could an antibiotic with a narrower spectrum be used to treat the infection?

iii. For how long should the patient receive the antibiotic(s)?

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97. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart [31,42,70,71].

98. Be a good source of information for your patients and help them understand the importance of prudent antibiotic use. Ensure that patients (and their families) understand the reasons for antibiotic therapy, and key points related to antibiotic use, including to [expert consensus]:

a) Take antibiotics exactly as prescribed;b) Never save antibiotics for later use;c) Never use leftover antibiotics from previous treatments;d) Never share leftover antibiotics with other people.

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7. Key messages for junior doctors and students Consider these messages in addition to those for the specific target groups that relate to your area of specialisation.

Things you can do99. Learn and apply all antibiotic use and infection prevention and control recommendations that are relevant to your area of specialisation [expert consensus].

100. When you see an antibiotic prescribed, ask the prescriber about the indication, choice, dose, route of administration and duration of treatment, to understand if this is follows antibiotic guidelines [69].

101. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

102. Before you prescribe an antibiotic, you should [25,26,53,70] [expert consensus]: Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team; Check local, regional and national epidemiological data. 103. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart [31,42,70,71].

104. Answer the following key questions to optimise antibiotic therapy. If in doubt, consult with antibiotic stewardship team [31,42,53,70,71]:

a) Is there a high probability of a bacterial infection, rather than colonisation or a viral infection?

b) Have the appropriate cultures been taken before starting antibiotic therapy?

c) Have you checked for recent antibiotic use, drug allergies, use of immunosuppressive therapy, recent hospitalisation or institutionalisation, recent travel outside of Europe, and microbiology results for the previous 3 months?

d) Does the patient have an infection that will respond to antibiotics?If yes:i. Is the patient on the correct antibiotic(s), correct dose, and correct route of

administration?ii. Could an antibiotic with a narrower spectrum be used to treat the

infection?iii. For how long should the patient receive the antibiotic(s)?

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105. Ensure that patients (and their families) understand the reason for antibiotic therapy, and key points related to antibiotic use, including to [31,69] [expert consensus]: a) Take antibiotics exactly as prescribed; b) Never save antibiotics for later use;c) Never use leftover antibiotics from previous treatments; andd) Never share leftover antibiotics with other people.

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8. Key messages for hospital pharmacists

Tasks106. Your tasks related to improving antibiotic use include [42,56,76,94,95]:

a) Participating in the antibiotic stewardship team, as a key member of the team;

b) Collaborating with the infectious disease specialist and the clinical microbiologist to implement the antibiotic stewardship programme;

c) Improving the quality of antibiotic prescribing (e.g. checking for drug interactions, optimising dosage and route of administration, preventing adverse events);

d) Consulting with hospital prescribers and providing them with feedback to ensure the quality of antibiotic prescribing;

e) Implementing interventions on formulary restrictions, such as pre-approval and post-authorisation requirements, and assessing compliance with these restrictions;

f) Analysing data on antibiotic use and costs for the purpose of surveillance and benchmarking;

g) Supporting evidence-based hospital antibiotic guidelines for common infections and for surgical prophylaxis;

h) Managing your hospital’s antimicrobial formulary (i.e., list of drugs available for prescribers).

Things you should know107. Compliance with formulary restrictions as well as pre-approval and post-authorisation requirements for specific antibiotics decreases the use of these antibiotics in intensive care unit settings [43].

108. Pharmacist-led parenteral-to-oral switches improve clinical outcomes (e.g. shortening the duration of parenteral therapy without negatively impacting on clinical outcomes) [56].

109. Special order forms limit the duration of perioperative antibiotic prophylaxis and reduce the incidence of surgical site infections, antibiotic use and costs [56].

110. Pharmacists can have multiple roles in the emergency department, including giving real-time feedback and consultation regarding prescribing practices, and identifying drug interactions. These reduce treatment durations and lower the overall cost of care [77].

Things you can do, or collaborate on111. Support the development and implementation of an antibiotic stewardship programme within your organisation [69,94].

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112. Provide feedback and advice to prescribers on antibiotic choice, dose, duration optimisation and route of administration [31,94].

113. Encourage clinicians to perform appropriately timed parenteral-to-oral switches [56].

114. Check that antibiotic prescriptions follow antibiotic treatment protocols, based on evidence-based guidelines. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

115. Collect and share data on antibiotic use and costs at ward level and hospital level [56,76].

116. Together with prescribers, provide patients who have to continue antibiotic therapy after discharge with information on use of antibiotics at home [31].

117. Train hospital prescribers regularly on prudent antibiotic use and participate in meetings on implementing evidence-based hospital antibiotic guidelines [31,53,94,95].

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9. Key messages for nurses

Tasks118. You are in a key position to improve antibiotic use by collaborating with the antibiotic stewardship team [96].

119. Your tasks related to improving antibiotic use include [31,96,97] [expert consensus]:a) Administering antibiotics to patients according to the prescription;b) Coordinating the taking and sending of microbiological specimens, and their reporting back to physicians;c) Reporting adverse effects of antibiotic therapy to physicians and appropriate review committees;d) Facilitating communication between physicians, the pharmacy, the laboratory, discharge planners, consultants and patients;e) Providing information on treatments to patients and families; f) Monitoring patient status on a 24 hour basis; andg) Managing antibiotic stocks on your ward, and ensuring the traceability of antibiotic use [expert consensus].

Things you can do, or collaborate on120. Improve antibiotic administration practices in collaboration with doctors and pharmacists [96,97].

121. Follow infection prevention and control measures that are established in your setting [expert consensus].

122. Ensure that patients (and their families) understand the reason for antibiotic therapy, and key points related to antibiotic use, including to [31,69] [expert consensus]: e) Take antibiotics exactly as prescribed; f) Never save antibiotics for later use;g) Never use leftover antibiotics from previous treatments; andh) Never share leftover antibiotics with other people.

123. Ensure that cultures are appropriately taken and send to the microbiology laboratory, before starting antibiotics [31,42,70].

124. Ensure that laboratory results are promptly communicated to the treating physician [expert consensus].

125. Prompt prescribers to document their reviewing decision for all patients on antibiotics after 48-72 hours [31,42,69].

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126. Inform the prescriber or pharmacist if you see a patient has an antibiotic prescription which has continued beyond seven days without specified duration [69].

127. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

128. Participate regularly in training courses and meetings on prudent antibiotic use, specimen collection, and infection prevention and control [53,96].

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10. Key messages for clinical microbiologists

Tasks129. Your tasks related to improving antibiotic use include [31,98-100] [expert consensus]:

a) Participating in the antibiotic stewardship team, as a key member of the team;

b) Collaborating with the infectious disease specialist and the hospital pharmacist to implement the antibiotic stewardship programme;

c) Supporting evidence-based hospital antibiotic guidelines for common infections and for surgical prophylaxis;

d) Timely identification and reporting of microorganisms (e.g. in blood cultures) and antimicrobial susceptibility testing;

e) Communicating critical results promptly to the treating physician;f) Presenting data in a way that supports prudent antibiotic use, for example

by selectively reporting to physicians a limited number of antimicrobial susceptibility results;

g) Providing guidelines for appropriate specimen collection, enforcing rejection criteria for specimens submitted inappropriately, and establishing procedures to limit the work-up of contaminants (e.g. blood cultures);

h) Guiding empirical antibiotic therapy by providing hospital and ward specific (e.g. intensive care unit or emergency department) cumulative antimicrobial susceptibility data;

i) Identifying critical trends in antibiotic resistance in the hospital and promptly communicating observations to the antibiotic stewardship team and the infection control team.

j) Managing your hospital’s antimicrobial formulary (i.e., list of drugs available for prescribers).

Things you can do, or collaborate on130. Provide guidelines for specimen collection, storage and transport [98,99].

131. Ensure that laboratory testing and antimicrobial susceptibility reporting follow treatment guidelines (including selective reporting), and include relevant comments on interpretation if needed [31].

132. Ensure that identification and antimicrobial susceptibility testing results are communicated to prescribers, nurses and the antibiotic stewardship team, especially for critical results (e.g. blood cultures) [98-100].

133. Ensure that testing and reporting of microbiology results follow European and national standards (i.e. European Committee on Antimicrobial Susceptibility Testing - EUCAST) [31].

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134. Provide data on antibiotic resistance at hospital level and ward level, and communicate trends to the antibiotic stewardship team and the infection prevention and control team [101].

135. Train hospital prescribers regularly on antibiotic resistance, and on use of rapid and point-of-care diagnostic tests [31,53].

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11. Key messages for emergency departments [physicians and managers]

136. You are in an important position to improve antibiotic prescribing in both inpatients and outpatients, since your facility sits at the interface of the hospital and the community [77].

137. Antibiotic regimens started in your department strongly influence what therapy is continued in the hospital and community settings [77].

Tasks138. Clinical tasks related to improving antibiotic use include [102] [expert consensus]:a) Following local evidence-based antibiotic guidelines for common infections; b) Deciding on the first antibiotic dose for inpatients;c) Taking relevant cultures, before starting antibiotic therapy, which will allow antibiotic therapy to be tailored or stopped during hospitalisation;d) Communicating all relevant patient background and treatment decisions to in- or out-patient follow-up practitioners.e) Informing patients (and their families) about the indication for an antibiotic prescription, possible side effects, and their proper use.

139. Departmental tasks include [77] [expert consensus]:a) Making available evidence-based hospital antibiotic guidelines and clinical pathways for diagnosing, treating and managing the most common infections encountered in your department (i.e. respiratory tract infections, skin and soft tissue infections, urinary tract infections and sepsis). This should include the indication, drug choice, dose, route of administration and duration of treatment.b) Ensuring guidelines incorporate local microbiology and antibiotic resistance patterns, and reflect existing hospital formulary.c) Strengthening real-time follow-up and interpretation of microbiological culture data, by coordinating with the microbiology laboratory to efficiently share results to prescribers.d) Educating staff on infectious diseases and prudent use of antibiotics.

Things you can do140. Follow antibiotic treatment protocols, based on evidence-based guidelines (e.g. for sepsis [74], urinary tract infections [103], skin and soft tissue infections [104]), and apply infection prevention and control measures that are established in your setting [31] [expert consensus].

141. Take a thorough patient history when you prescribe an antibiotic, including recent antibiotic use, drug allergies, use of immunosuppressive therapy, and risk factors for antibiotic resistance (for example, recent hospitalisation, recent procedure or recent travel outside of Europe) [31].

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142. Remain aware of local antibiotic resistance patterns in the community, hospital and department [31] [expert consensus].

143. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31,72].

144. Avoid unnecessary antibiotic prophylaxis [31,73].

145. For patients with a severe infection, initiate effective antibiotic treatment as soon as possible [31,74].

146. Ensure that cultures are taken before starting antibiotics [31,42,70,71].

147. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart [31,42,70,71].

148. If in doubt before you prescribe an antibiotic, you should [25,26,53,70] [expert consensus]: Check local, regional and national epidemiological data; Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team.

149. Regularly participate in training courses and in meetings that support the implementation in the hospital of: a) prudent antibiotic use, b) evidence-based, local antibiotic guidelines, and c) infection prevention and control measures [52,53].

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12. Key messages for intensive care unit [physicians and managers]

TasksCore tasks to improve the use of antibiotics in your department include:

150. Following antibiotic treatment protocols, based on evidence-based guidelines (e.g. for sepsis) [90].

151. Remain aware of local antibiotic resistance patterns in your department, your hospital and in the community [31,72].

152. Organising regular multidisciplinary staff rounds and case discussions to improve the quality of antibiotic treatment [72].

153. Reassessing antibiotic treatments in light of clinical conditions at 48–72 hours, or as soon as microbiological results are available, to [31,42,70-72]:

change to a narrow-spectrum antibiotic; continue or stop antibiotic therapy; switch to oral antibiotic therapy.

154. Implementing infection prevention and control strategies, including [86,87,105]:

staff education, hand hygiene, environmental cleaning, active screening, contact precautions, evidence-based practices, establishing surveillance systems for healthcare-associated infections.

155. Participating in education activities regularly, as well as proactive audits and feedback together with the antibiotic stewardship team [54,56].

Things you should know156. Narrowing or streamlining antibiotic therapy leads to better patient outcomes [106].

157. Following infection prevention and control measures reduces the incidence of healthcare-associated infections. For example:

a) Complying with a central-line care protocol (for insertion and maintenance), reduces central-line-associated bloodstream infections in all types of intensive care units (adults and neonatal) [107].

b) Care bundles can prevent ventilator-associated pneumonia in adult intensive care units [108].

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Things you can do158. Implement guidance (guidelines, protocols and checklists) for infection prevention and control measures, together with the infection prevention and control team [86,87] [expert consensus].

159. Follow antibiotic treatment protocols, based on evidence-based guidelines that are established in your setting [31] [expert consensus].

160. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31].

161. Avoid unnecessary antibiotic prophylaxis [31].

162. Take a thorough patient history when you prescribe an antibiotic, including recent antibiotic use, drug allergies, use of immunosuppressive therapy, and risk factors for antibiotic resistance (for example, recent hospitalisation, recent procedure or recent travel outside of Europe) [31].

163. If in doubt before you prescribe an antibiotic, you should [25,26,53,70] [expert consensus]: Check local, regional and national epidemiological data; Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team.

164. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart[31,42,70,71].

165. For patients with sepsis, initiate effective antibiotic treatment via the intravenous route as soon as possible [90].

166. Ensure that cultures are appropriately taken and send to the microbiology laboratory, before starting antibiotics [31,42,70,71].

167. Answer the following key questions when reassessing antibiotic therapy after 48-72 hours (or as soon as microbiological results are available) [42,70]: Does the patient have an infection that will respond to antibiotics?If yes:

i. Is the patient on the correct antibiotic(s), correct dose, and correct route of administration?

ii. Could an antibiotic with a narrower spectrum be used to treat the infection?

iii. For how long should the patient receive the antibiotic(s)?

168. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

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169. Regularly participate in training courses and in meetings that support the implementation in the hospital of: a) prudent antibiotic use, b) evidence-based, local antibiotic guidelines, and c) infection prevention and control measures [52,53].

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13. Key messages for long-term care facilities [physician and managers]

TasksCore tasks to improve antibiotic use in your facility include: 170. Education of medical and nursing staff, targeting areas where antibiotic

misuse is common [109,110]: antibiotic prophylaxis; antibiotic use in asymptomatic patients with positive cultures

(colonisation); topical antibiotics; and excessively long durations of treatment.

171. Education of patients and their families on the risks of selecting for antibiotic-resistant bacteria when using antibiotics unnecessarily (e.g. asymptomatic bacteriuria, viral respiratory tract infections) [109,110].

172. Using clinical pathways and evidence-based guidelines for diagnosing, treating and managing the most common infections (e.g. pneumonia, upper respiratory tract infections, skin and soft tissue infections, and urinary tract infections), and taking into account local antimicrobial susceptibility data [109].

173. Reassessing antibiotic treatments in light of clinical conditions at 48–72 hours, or as soon as microbiological results are available, to [31,42,70-72]:

change to a narrow-spectrum antibiotic; continue or stop antibiotic therapy; switch to oral antibiotic therapy.

174. Avoiding diagnostic tests and cultures in asymptomatic patients [56,111].

Things you can do175. Implement infection prevention and control measures together with

infection prevention and control professionals [expert consensus].

176. Take a thorough patient history when you prescribe an antibiotic, including recent antibiotic use, drug allergies, use of immunosuppressive therapy, and risk factors for antibiotic resistance (for example, recent hospitalisation, recent procedure or recent travel outside of Europe) [31].

177. Always perform a clinical examination of the patient before prescribing an antibiotic [31].

170. If in doubt before you prescribe an antibiotic, you should [25,26,53,70] [expert consensus]: Check local, regional and national epidemiological data;

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Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team.

178. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31].

179. Avoid unnecessary antibiotic prophylaxis (e.g. urinary tract infection prophylaxis) [111].

180. Ensure that cultures are taken before starting antibiotics [31,42,70,71].

181. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart [31,42,70,71].

182. Answer the following key questions when reassessing antibiotic therapy after 48-72 hours (or as soon as microbiological results are available) [42,70]:

Does the patient have an infection that will respond to antibiotics?If yes:

i. Is the patient on the correct antibiotic(s), correct dose, and correct route of administration?

ii. Could an antibiotic with a narrower spectrum be used to treat the infection?

iii. For how long should the patient receive the antibiotic(s)?

183. Promote vaccination programmes for residents and staff [expert consensus].

184. Follow infection prevention and control measures that are already established in your setting. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].

185. Regularly participate in training courses and in meetings that support the implementation in the hospital of: a) prudent antibiotic use, b) evidence-based, local antibiotic guidelines, and c) infection prevention and control measures [52,53].

186. Organise educational events and campaigns that provide residents with information on prudent antibiotic use.

187. Ensure that residents (and their families) understand the reasons for

antibiotic therapy, and key points related to antibiotic use, including to [expert consensus]:

a) Take antibiotics exactly as prescribed;b) Never save antibiotics for later use;

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c) Never use leftover antibiotics from previous treatments;d) Never share leftover antibiotics with other residents or other people.

188. Regularly organise audits/surveys of antibiotic prescribing practices and of healthcare-associated infections [93].

References

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