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What is it, Why is it Important and What is
Your Role?
Aug 16, 2017
Paul Bonnar (MD, FRCPC) & Andrea Kent PharmD
http://www.cdha.nshealth.ca/nsha-antimicrobial-stewardship
What is Antimicrobial Stewardship?
• Coordinated interventions designed to
improve and measure the appropriate use of
antibiotics
Barlam. CID. 2016;62(10):e51–e77
Tamma CID 2017;64(5):537–43
Right drug
Right dose
Right duration
Right route
WHY IS AMS IMPORTANT?
What Does a ‘Post Antibiotic Era’ mean?
It means we are heading back to a time where
common illnesses like pneumonia and minor surgical
procedures will once again be feared killers because we
do not have antibiotics to combat them due to
developing resistance.
Fluoroquinolones which were introduced in 1980 with
zero resistance now have as much as 50% resistance to
E. coli in some countries
MRSA counts for almost 90% of Staph infections in
parts of the USA
People with MRSA infections have a 64%
increase risk of death
Why is AMS Important?
O’Neill. 2014. Antimicrobial Resistance:
Tackling a crisis for the health and wealth
of nations
Why is AMS Important?
• Increasing MDR organisms
• Side-effects / costs of antimicrobials
• Accreditation Canada ROP
O’Neill. Antimicrobial Resistance: Tackling
a crisis for the health and wealth of nations
Tamma. JAMA Intern Med. 2017 Jun 12
VISION
• Safe and effective use of antimicrobial
agents in patients cared for in the NSHA
TENETS
• Promote a culture of optimal antibiotic use
• Respect and promote regional strengths
• Act in collaborative and engaging manner
• Make evidence-based recommendations
• Maintain an open/transparent program
• Start small, build on success
Team members
Andrea Kent
Paul Bonnar
Ian Davis
Jason Reynolds
Kim Abbass
Valerie MurphyStephen Smith
WHAT IS NURSING’S ROLE?
CID 2016;62(1):84–9
CID 2016;62(1):84–9
Situation
• 30 – 40% of patients will receive an
antibiotic while in hospital
• Growing number of resistant bacteria
• Most nursing staff will come face to face
with the consequences of our antimicrobial
resistance crisis
Survey of nursing staff in Australia
• 65% knew or had heard of the term Antimicrobial
Stewardship or AMS
• 57% rated their knowledge of antimicrobials as
minimal or limited
• Hand hygiene, infection control, and knowledge of
antimicrobials were most commonly seen as nursing
role
• Prompting switch from IV to oral, therapeutic drug
monitoring and checking restriction status were less
frequently thought of as nursing roles
Infection, Disease & Health (2017) 22, 57e64
Why has nursing not been a focus?
• Prescribing emphasized over
MANAGING antibiotics
• Hierarchy & Tradition
• Time constraints
• Knowledge
What is Nursing’s Role in AMS?
• AMS is multidisciplinary
• Nurses are the operational and
communication hub
• Trusted by patients and families
• Many existing roles of nursing already
fit well with AMS roles
Nursing benefits
• Better patient outcomes
• Less resistance: less isolation
• Less C. difficile
• Less abx administration
CID 2016;62(1):84–9
CID 2016;62(1):84–9
Triage
- Early recognition of sepsis
Early cultures and Abx
Clarification of allergies
Daily nursing care
- Monitor abx (duration, dose, IV)
-Early C diff / sepsis
- Correct culturing
- Culture reports
-Educating families
- Prevention (catheter removal)
Discharge
- Duration
-OPAT
- Follow-ups
Allergies
• Penicillin most commonly reported allergy
• 95% are not truly allergic reactions
• Minor adverse reactions or intolerances (eg
nausea or diarrhea)
• Non severe delayed type hypersensitivity
reactions (eg. maculopapular rashes)
Allergies
• Over reporting of allergies is NOT benign
• Alternative antibiotics may be less effective or
have more adverse effects
• Increased selection of resistant bacteria
• More often on more than one antibiotic
• Increased risk of ICU admission
• Longer lengths of stay
• Increased risk of death
What can Nursing Do?
• Ask what the reaction was
• If on old charts – question further
Catheters and CAUTI
• In one centre a nurse directed catheter
removal protocol reduced catheter use by
50% and CAUTI by 70%.
• ICU nurse reminders to physicians for
catheter removal reduced both CAUTI and
costs
https://www.ammi.ca/?ID=127
https://choosingwiselycanada.org/nursing/
Managing the Patient with a possible UTI:
Facts !!
Malodorous /cloudy urine alone is NOT a sign /symptom of a UTI
Changes in cognitive function or ADL’s require a clinical assessment first before assuming this is due to a UTI
Urine should always be collected as a midstream or in/out catheterization
Managing the Patient with a possible UTI:
Facts!!
Positive urine cultures in asymptomatic patients should
NOT be automatically treated (except in pregnancy or prior to urological/gynecological procedures
UTI is a clinical diagnosis…not a lab diagnosis!!
Delirium is not considered a typical symptom of a UTI for non-catheterized patients.
Questions?
