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The antimicrobial management / stewardship teams: Global perspectives Philip Howard Consultant Antimicrobial Pharmacist [email protected] Twitter: @AntibioticLeeds

The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist [email protected] Twitter: @AntibioticLeeds . Draft WHO

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Page 1: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

The antimicrobial

management / stewardship

teams: Global perspectives Philip Howard

Consultant Antimicrobial Pharmacist

[email protected]

Twitter: @AntibioticLeeds

Page 2: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Draft WHO AMR Action Plan Dec-

14 1. Increasing AMR awareness through effective

communication, education and training

2. Strengthen the knowledge & evidence-base through surveillance & research

3. Reduce the incidence of infection through effective sanitation, hygiene & infection prevention measures

4. Optimise the use of antimicrobials medicines in human & animal health

5. Develop the economic case for sustainable investment that takes account of the needs of all countries, and increase investment in new medicines, diagnostic tools, vaccines and other interventions

Page 3: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Draft WHO AMR Action Plan Dec-

14 4. Optimise the use of antimicrobials medicines in human & animal health

• AMR driven by use & increasing due to OTC & internet sales, and food production

• Usage data lacking at patient level, or nationally in lower-income countries

• Antibiotics need to be seen as a public good to strengthen regulation

• Decisions to prescribe rarely based on definitive diagnoses. New “cheap” tools needed.

• Evidence-based prescribing & dispensing should be the standard.

Page 4: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO
Page 5: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO
Page 6: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Background & methodology

• Previous surveys of AMS looked at country or continental level only

• ESCMID-ESGAP & ISC-AMS Group project based around published standards, definitions & previous surveys

• Aim to measure the extent and components of global efforts in antimicrobial stewardship

• 43 questions survey was piloted in 11 countries in 6 continents then distributed through networks using on-line SurveyMonkey® software in Spring 2012

Page 7: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO
Page 8: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Do you have a hospital AMS

programme?

14%

53%

66%

67%

47%

46%

23%

29%

20%

22%

29%

25%

Africa

Asia

Europe

North America

Oceania

South America

58% have an ASP, 22% are planning one

Planned

Yes

Mean ASP duration: 3 years

(Europe 5yr to Africa 1yr)

Page 9: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO
Page 10: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

29% 29%

15% 20%

9%

14% 17%

12%

23% 16%

7% 9%

Current AMS programme(763)

Planned AMS programme(348)

Hospitals top 3 barriers to providing a functional and effective AMS

programme

No barriers

Lack of informationtechnology supportand/or ability to get dataOpposition from prescribers–

Administration not awareof AMS programme

Other higher priorityinitiatives

Lack of personnel orfunding

Page 11: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

AMS Governance AMS

Governance Africa Asia Europ

e

North

Americ

a

Oceani

a

South

Americ

a

Tota

l

Drug &

Therapeutics

26 39 333 61 30 53 542

60% 80% 96% 91% 88% 56% 85%

AMS

Committee

5 28 267 49 13 34 396

12% 57% 77% 73% 38% 36% 62%

AMS Policy

or Code of

Practice

3 25 182 23 19 41 293

7% 51% 52% 34% 56% 43% 46%

Published

AMS Strategy

3 21 169 21 13 28 255

7% 43% 49% 31% 38% 29% 40%

Published

AMS Annual

report

0 19 166 19 2 25 231

0% 39% 48% 28% 6% 26% 36%

Published

AMS Annual

plan

0 13 134 9 5 17 178

0% 27% 39% 13% 15% 18% 28%

Page 12: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

AMS policies and strategies

31%

58%

73%

38%

43%

56%

Africa (13)

Asia (31)

Europe (257)

North America (55)

Oceania (23)

South America (45)

Published AMS policy 61%

90% formulary; 93% specific treatment and 92% prophylaxis

guidance

Automatic stop / review policy: 33% Reserve antibiotics:

62%

Micro/ID advice: phone 77%; ward rounds 50%; bacteraemia

56%

Dose optimisation: by request 62%, pharmacy authorised 24%

Use procalcitonin: avoid starting 17%, early stopping 15%

Data warehousing: (link lab results to prescribed antibiotics):

13%

Page 13: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

6

13

18

32

18

9

18

3

8

8

15

6

12

10

8

6

11

5

1

8

9

9

9

8

6

8

8

8

7

3

4

14

6

4

6

2

6

2

7

4

5

2

3

9

2

5

4

8

3

2

7

9

4

5

3

3

5

8

4

4

5

5

2

1

8

3

4

2

2

8

3

7

3

1

2

7

3

4

5

1

1

3

2

AFRICA

ASIA

EUROPE

NORTH AMERICA

OCEANIA

SOUTH AMERICA

AVERAGE

Hours per week

Composition of AMS teams Antimicrobial or IDpharmacist

Infectious Diseases (ID)doctor

Medical Microbiologist

Infection control staff

Nurse

Admin support

Data analyst

Other pharmacist

Doctors in training

Other medical specialty

Pharmacy technician

Scientist or laboratorystaff

Surgeon

Pharmacy + Inf Dis: USA, Australia, Asia IPC Nurse: Africa

Pharmacy + Micro: UK

Infectious Diseases: Europe (non-UK) & South America (+ Nurse)

Page 14: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

AMS ward rounds

AMS Ward

Rounds Africa (13) Asia (31)

Europe

(247)

North

America

(54)

Oceania

(22)

South

Americ

a (41)

Medical

wards weekly daily weekly daily daily daily

Surgical

wards

daily =

weekly

daily =

<weekly weekly daily < weekly daily

Paediatrics

wards

daily =

weekly

daily =

<weekly <weekly daily n/a daily

ITU daily daily daily daily twice

weekly daily

Reported effect on antimicrobial consumption:

• surgical rounds decreased consumption

• others types of AMS rounds, consumption remained

stable

Page 15: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Antimicrobial restriction & reporting

• 80% restrict some antimicrobials – 73% restrict carbapenems, 63% fluoroquinolones

– 58% cephalosporins (mainly UK in Europe)

– Pharmacy follow up supply in 65%

• 25% practice diversity & 12% cycle antimicrobials

• 19% have electronic prescribing for all patients. (2% Africa to 39% North America).

• Antimicrobial usage reporting – 85% report antimicrobial usage (82%

expenditure, 73% DDD, 67% DDD/OBD) at hospital level.

– Less at speciality level

– 55% link these data to resistance rates

– 48% link to infection rates

Page 16: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Communication about AMS Most common

communication

method

Africa Asia Europe North

America

Oceani

a

South

America

Empiric guidelines booklet booklet intranet intranet intranet staff

meetings

Directed guidelines Booklet /

intranet intranet intranet intranet intranet

staff

meetings

Surgical

prophylaxis

guidelines

booklet intranet intranet intranet intranet booklet

Antibiograms

(hospital resistance

map)

staff

meetings intranet

staff

meetings intranet intranet

staff

meetings

Antimicrobial usage Booklet /

staff

meetings

staff

meetings

staff

meetings

staff

meetings

staff

meetings

staff

meetings

Learning points

from incidents

staff

meetings

staff

meetings

staff

meetings

staff

meetings

staff

meetings

staff

meetings

Formulary booklet intranet intranet intranet intranet Booklet

/newsletter

Marked differences between higher & lower-income

continents

Page 17: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Education of staff on AMS • 89% of hospitals educated their healthcare staff • 96% of hospitals educated their senior and trainee doctors

– face to face training (trainees 68% and seniors 46%)

– written information (45% and 35% respectively) at induction

– short courses were provided for trainees (31%) and seniors (27%)

• Small number of hospitals did not educate senior doctors (6%) or trainee doctors (2%).

• Less than 25% had mandatory updates every one or two years.

• Nurses received less education, 27% face to face and/or 16% given written information at induction, 21% provided short courses and 15% received no specific education. Only 12% had mandatory updates.

• 94% educated pharmacists (mainly at induction): 43% face to face and/or 25% written information, 22% short courses.

• Few centres (17% or less) used e-learning across the different staff groups.

Page 18: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Antimicrobial Audits

Audit % of

hospitals Most common freq

Any antimicrobial

audit 80%

Point prevalence 68% Yearly > never

Surgical prophylaxis 71% Monthly >> yearly =

never

Cultures before antibiotics 41% Never > yearly

Compliance to guidelines 74% Yearly > monthly > never

Outcome of day 3 review 43% Never >> monthly

Duration on Rx 64% Never > monthly

Indication on Rx 66% Never > monthly

Infection care bundles 56% Never > monthly

Audit own practice 42% Never >> yearly

Glycopeptide /

aminoglycoside monitoring 51%

Never >> monthly >

yearly

Time to 1st dose in sepsis 35% Never >> monthly =

yearly

Page 19: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

Formal review of ASP by 37%

80%

86%

65%

96%

71%

58%

20%

14%

35%

4%

29%

42%

0% 20% 40% 60% 80% 100%

direct expenditure (87)

usage of broad spectrum agents (96)

length of stay / mortality metrics (40)

inappropriate prescribing (80)

healthcare acquired infections (66)

antimicrobial resistance (67)

No benefit shown Positive benefit shown

Page 20: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

• Despite inherent limitations (e.g.

response bias, convenience

sampling), this survey suggests AMS

can reduce antimicrobial resistance

and expenditure

• This survey should encourage a

strategy to promote worldwide

Antimicrobial Stewardship

Programmes.

Conclusion

Page 21: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

• To all who took a time to complete the survey

• ESCMID-ESGAP, ISC-AMS & UKCPA Infection Management Group members who tested and refined the survey.

– Karin Thursky, Amani Alnimr, Wendy Lawson, Shaheen Mehtar, Wattal Chand, Jim Hutchinson, Barry Cookson & many more

• Wider distribution

– Jason Newlands, Tracey Guide, Chris Jay, Sean Egan, Antony Zorzi, Diane Jacobsen & many more

Thank you

Page 22: The antimicrobial management / stewardship teams: Global …€¦ · Philip Howard Consultant Antimicrobial Pharmacist philip.howard2@nhs.net Twitter: @AntibioticLeeds . Draft WHO

The antimicrobial

management / stewardship

teams: Global perspectives Philip Howard

Consultant Antimicrobial Pharmacist

[email protected]

Twitter: @AntibioticLeeds