AMS Guidelines - klimik.org.tr€¦ · Germany-Austria 1 Antimicrobial Stewardship, ESGAP October...

AMS Guidelines: USA

Germany-Austria

1

Antimicrobial Stewardship, ESGAP October 2017, Istanbul

Özlem Kurt Azap

Başkent University Faculty of Medicine

Infectious Diseases and Clinical Microbiology Dept.


2


3

• 2007, IDSA, Antimicrobial stewardship guideline

• 2014, CDC, Core elements of hospital antimicrobial stewardship programs

• 2015, White House, National Action Plan for Combating Antibiotic Resistant Bacteria

• 2016


4

In USA…


5


6

Total # recommendations: 28 # strong recommendations: 5 # weak recommendations: 18

# good practice recommendations: 5


7

Antimicrobial Stewardship, ESGAP October 2017, Istanbul 8

STRONG

WEAK


9


10


11

GOOD PRACTICE recommendation

Strong recommendations


12

Weak recommendations


https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjppoTVqdbWAhVGtBoKHctdDXAQjRwIBw&url=https%3A%2F%2Fleadinglearner.me%2F2013%2F12%2F01%2Fwhen-didactic-met-co-operative%2F&psig=AOvVaw3Tyw9KVeJLA_EQraDhD0Og&ust=1507184395527612

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjZhPbpqdbWAhVLVxoKHXrqCIUQjRwIBw&url=http%3A%2F%2Fwww.thecollectionshop.com%2Fxq%2FASP%2FWDCC-Disney-Classics-Ludwig-von-drake-didactic-duck%2FS.4006687%2FA.8%2Fqx%2FLimited_Edition_Art_Detail_Page.htm&psig=AOvVaw3Tyw9KVeJLA_EQraDhD0Og&ust=1507184395527612



https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjf-vuqvtbWAhVCOxoKHTPbC_AQjRwIBw&url=https%3A%2F%2Fwww.visitorpasssolutions.com%2FMarkets%2FHealthcare%2F&psig=AOvVaw0pkzxKyU495PQf_8FNPQlr&ust=1507189942407076

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjgrLT9vtbWAhVMExoKHdCvCIAQjRwIBw&url=https%3A%2F%2Fwww.coursera.org%2Flearn%2Falgorithms-on-graphs&psig=AOvVaw3zPNWRIxa9GOqyMopBjKd3&ust=1507190139004433

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjQw8nIv9bWAhWDCBoKHZWqC6IQjRwIBw&url=https%3A%2F%2Fwww.slideshare.net%2Fknowledgeseries%2Funderstanding-the-abcs-of-and-asp&psig=AOvVaw215kKetjdgHb1z0VHCDBDC&ust=1507190305816201



14

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiar_bKw9bWAhWMVRoKHU03C2EQjRwIBw&url=https%3A%2F%2Fmotherboard.vice.com%2Fen_us%2Ftopic%2Fcomputerized-clinical-decision-suppor&psig=AOvVaw1z_So6Bxfaz29D18KRrjRM&ust=1507191372034531

http://emibd.com/health-news/Altering+or+Cycling+of+Antibiotic+Use+Might+Help+Combat+Resistance?id=26

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjEqfunxNbWAhWCWRoKHUn9CgAQjRwIBw&url=http%3A%2F%2Fwww.webmd.com%2Fdrugs%2F2%2Fdrug-939%2Fvancomycin-intravenous%2Fdetails&psig=AOvVaw2U6ofwv9bvhy5J_1kAb9WX&ust=1507191573993778

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiizI3JxNbWAhWD5BoKHUAMASAQjRwIBQ&url=http%3A%2F%2Fsites.utexas.edu%2Fpharmacotherapy-rounds%2Ffiles%2F2017%2F03%2FHolly-Lien-ResRounds-Handout-UPDATED-030817-without-pic.pdf&psig=AOvVaw3bY0JZvhSUYNg4_zmhhtMp&ust=1507191639367522




15


http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwj5iLOjx9bWAhUJVhoKHa4CCUMQjRwIBw&url=http%3A%2F%2Fep.bmj.com%2Fcontent%2F96%2F6%2F228&psig=AOvVaw2U-zbqEY8hF4jE5nz22sSM&ust=1507191909679869

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiTq_ad59bWAhUPElAKHSX7AY0QjRwIBw&url=http%3A%2F%2Fjournal.frontiersin.org%2Farticle%2F10.3389%2Ffmicb.2011.00257&psig=AOvVaw1cFB6s1PthunqJCIIM1Wl0&ust=1507200950949147

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiGqMzu59bWAhWMiRoKHb2OApoQjRwIBw&url=https%3A%2F%2Fwww.slideshare.net%2Fvikaslakhanpal940%2Ffebrile-neutropenia-53793323&psig=AOvVaw3oXtIW3F0iHtOP6RVU8Gu-&ust=1507201114131207

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjv0_yg6NbWAhUoJ5oKHbC0BJcQjRwIBw&url=https%3A%2F%2Fwww.researchgate.net%2Ffigure%2F261029197_fig2_Figure-2-Multi-State-Model-of-Invasive-Aspergillosis-and-Antifungal-Therapy-in-febrile&psig=AOvVaw38lLuPnkpFbIPCCgoKWaAo&ust=1507201220427262


16


https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjL6M_V6dbWAhXHa1AKHZEaA38QjRwIBw&url=https%3A%2F%2Faimed.net.au%2Fcategory%2Fantibiograms%2F&psig=AOvVaw0_4ySN-4JBkpBevpdqhyWn&ust=1507201600623936

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjp18TR_tbWAhWId5oKHVYYBpUQjRwIBw&url=http%3A%2F%2Fallnurses.com%2Fgeneral-nursing-discussion%2Fhelp-reading-c-826846.html&psig=AOvVaw1XvCWKcceEMI5OlFgkIYL_&ust=1507207214254592

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjy5oCP_9bWAhXnDpoKHcRZAeEQjRwIBw&url=http%3A%2F%2Ftechnologyinscience.blogspot.com%2F2012%2F12%2Frapid-diagnostic-tests-types-strength.html&psig=AOvVaw3WFtH40iEkSEXZkjxgsxZj&ust=1507207351546406

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiTqefj_9bWAhVlLZoKHfCLAxQQjRwIBw&url=https%3A%2F%2Fwww.gov.uk%2Fgovernment%2Fpublications%2Fhealth-matters-antimicrobial-resistance%2Fhealth-matters-antimicrobial-resistance&psig=AOvVaw0C8ImKJj7rVnpk58t_-vkf&ust=1507207535408230

Good practice recommendations


17

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjun8GrgdfWAhVIDJoKHWscAEoQjRwIBw&url=https%3A%2F%2Fwww.news-medical.net%2Fnews%2F20151112%2FNew-research-uncovers-antibiotic-prescription-trends-across-England.aspx&psig=AOvVaw2x2meDUS9Akkzc-oTtWn-l&ust=1507207950380113

https://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiC7OblgdfWAhXFKJoKHSitAK8QjRwIBw&url=https%3A%2F%2Fwww.aap.org%2Fen-us%2Fadvocacy-and-policy%2Faap-health-initiatives%2Ffetal-alcohol-spectrum-disorders-toolkit%2FPages%2FAlgorithm-for-Evaluation.aspx&psig=AOvVaw0z3wSX13XZ1H3rVX1J4TuV&ust=1507208048889704

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiPp42jgtfWAhUjOpoKHWzwBTcQjRwIBw&url=http%3A%2F%2Fwww.nursinghomeabuseguide.org%2Fnews%2Fwhat-to-look-for-with-nursing-home-accessibility%2F&psig=AOvVaw1B2LXWc9gOisKj-f8_42pZ&ust=1507208159196502

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwiDwd3RgtfWAhWFHJoKHbEkBOIQjRwIBw&url=http%3A%2F%2Fwww.deccanchronicle.com%2Fnation%2Fin-other-news%2F180317%2Fbiometric-system-tried-at-neonatal-icu.html&psig=AOvVaw1hB2LPazubPVmVSSzxnc8B&ust=1507208253358701

http://www.google.com.tr/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&cad=rja&uact=8&ved=0ahUKEwjAl63Zg9fWAhWJNJoKHVaWDz0QjRwIBw&url=http%3A%2F%2Fwww.italymagazine.com%2Fitaly%2Fpolitics%2Fhunger-striker-s-death-spurs-campaign-living-will-law&psig=AOvVaw22WxzamW39h68BLTv-MKvI&ust=1507208509642243

Strong recommendations


18


19

Which method? Preauthorization? Prospective audit and feedback?

Implementing one of them is better than doing nothing!


20

Advantages…. Disadvantages….

Preauthorization

Faster reductions in inappropriate antibiotic use

Optimized empirical choices

Culture results are more commonly encountered while prescribing antibiotics

The cost of antibiotics are decreased

The direct “control” of antibiotics are obtained


Advantages

Prospective audit and feedback ASP becomes more visible, helps building collegial relationships

Prescribers face more clinical data

Flexibility in timing of recommendations

Can be done less than daily

Educational benefit

Prescriber autonomy

Preauthorization Only restricted agents

Loss of prescriber autonomy

Delay in treatment

Potential for manipulation

Shift to other antibiotics

...


22

Disadvantages

Prospective audit and feedback Compliance voluntary

Labour intensive

Method of feedback is important

Reluctance to change therapy

It takes longer to achieve reductions in antibiotic use

...

Treatment durations


23

The shortest effective duration is the best!


24

Shorter vs Longer duration of antibiotics

Oral treatment


25

Oral treatment Initial therapy

Sequential therapy after iv usage

Advantages Lower cost

Shorter hospital stay

PK monitoring and adjustment program


26

PK monitoring programs for aminoglycosides

C.difficile


27

Avoidance of antibiotics with high risk for C.difficile

Infection control measures



28

Implementing AMS for spesific infectious diesases syndromes


29

Community acquired pneumonia

Hospital acquired pneumonia

Cellulitis Asymptomatic bacteriuria ……

Which measures?


30

Process measures Excess days of therapy Duration of therapy Compliance with algorithms Treatment revision based on

microbiological data Switch to oral therapy

Outcome measures Length of hospital stay 30 day mortality Adverse events due to atbs: C.difficile inf ..etc Clinical failure, recurrent infection


31

Stratified antibiograms

Antimicrobial susceptibility data based on departments, samples….etc

Antibiotic cycling


32

Antibiotic cycling is NOT RECOMMENDED!

Rapid diagnosis: Procalcitonin, viral antigen tests, fungal biomarkers,

molecular methods


33

Monitoring antibiotic use: DDD or DOT ?


34

DOT: Days of Therapy Not impacted by dose adjustments; can be used both for adults and pediatric patients

CDC requires DOT

Patient-level antibiotic data is required; not feasible at every facility

DDD: Daily Defined Dose Recommended by WHO

Easier than DOT

Widely used and offers comparability

Limited use in pediatrics

Stop orders


35

Good practice recommendations


36

‘End of life antibiotic treatment’


37

In terminally ill patients, ASPs should support clinicians in the decision of antibiotic treatment

In Europe…

• 2001, European Comission

• 2010, European Community, Antimicrobial resistance surveillance and monitoring antibiotic consumption


38


39


40


41

Recommendations: # A: 31 # B: 11 # C: 2

The team should consist of…


42

0.5 FTE for 250 beds FTE: Full time equivalent

Infectious diseases specialist Clinical pharmacist

Microbiology specialist Epidemiyologist Infection control consultant

Surveillance


Resistance data should be accessible at least on yearly basis

Resistance data should be reported on department basis, sample basis..etc

Surveilance culture results should be reported seperately

Point prevelance surveys

Antibiotic consumption data: by AB class, top 5 or 10

Number of cultures per 1000 patient days: Blood, urine..


44

Quarterly use density (RDD/100patient days)

Targeted proactive audits of antiinfective use


Point prevalance surveys Antibiotic use for Surgical prophylaxis

Bacteremia

Pneumonia at the Emergency Department

Sequential therapy; PE to oral

Hospital formulary is important!


46

Treatment optimisation


47

Optimisation of treatment does not necessarily mean de-escalation; sometimes requires escalation

Evaluation at 48-72 hours of therapy

Prolonged infusion of beta lactams…etc

TDM of antibiotics

Computerised information technology


48

Treatment guidelines Hospital formulary Surveillance results ….

should be readily electronically accessible

Gram negatif bakteriler için

ANTİMİKROBİYAL YÖNETİM REHBERİ

Hazırlayan: KLİMİK DERNEĞİ


49

AMS Guidelines - klimik.org.tr€¦ · Germany-Austria 1 Antimicrobial Stewardship, ESGAP October...

Documents

Transcript of AMS Guidelines - klimik.org.tr€¦ · Germany-Austria 1 Antimicrobial Stewardship, ESGAP October...