4/17/2013 antimicrobial stewardship: pengalaman di belanda...pengalaman di belanda henri a. verbrugh...

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Antimicrobial Stewardship: pengalaman di Belanda

Henri A. Verbrugh

MD PhD

KE Jones et al., Nature 2008

EID is disease caused by a pathogen that has recently evolved or entered the human

population for the first time, or which has occurred previously, but is increasing in

incidence or expanding into an area in which it has not previously been reported, or

which has significantly changed its pathological or clinical presentation.


number of emerging infectious diseases events per decade

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exposure selection expansion

sensitive population resistant clones/genes outbreak, epidemic, pandemic

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sensitive population resistant clones outbreak, epidemic, pandemic

Antibiotic control Infection control


sensitive population resistant clones outbreak, epidemic, pandemic

Antimicrobial Stewardship program

Infection control

Stewardship:

Steward comes from old English language:

“Stig” and “weard”

=

“Hall” and “keeper”

:

a person who manages another person’s affairs or property

MacDougall & Polk, Clin Microbiol Rev 2005;18:638

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Antimicrobial Stewardship:

An ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to improve patient outcomes, ensure cost-effective therapy, and reduce adverse sequelae of antimicrobial use including antimicrobial resistance……………… ...

MacDougall & Polk, Clin Microbiol Rev 2005;18:638

Goals of antimicrobial stewardship programs:

• optimize favorable clinical outcomes

• reduce health care costs

• minimize toxicity

• minimize emergence & spread resistance

IDSA & SHEA Guideline 2007, CID 44;159-77







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antimicrobial stewardship core team:

• infectious diseases physician (internist/pediatrician)

• infectious diseases trained clinical pharmacist

• clinical/medical microbiologist

• information technology specialist

• infection control professional

• hospital epidemiologist


Antimicrobial stewardship program: basic requirements

• organize a formal mandate from medical staff and hospital administration leadership

• collaborate with infection control team,

• policy by pharmaceutical therapeutics committee, execution by A-team

• surveillance antimicrobial use & resistance


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Antimicrobial stewardship program core activities:

• prospective audit & intervention (A-I)

• formulary restriction (A-II)

• pre-authorization (B-II)


Antimicrobial stewardship program ‘supplementary’ activities:

• education (A-III)

• guidelines on use (A-I)

• antimicrobial cycling (C-II)

• antimicrobial order forms (B-II)

• combination empiric therapy (A-II)

• streamlining (A-I, A-II)

• dose optimization (A-II)


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170 hospitals in 32 European countries survey 2001

Key indicators for stewardship:

1] drugs and therapeutics committee?

2] written antibiotic formulary?

3] formulary with list of restricted antibiotics?

4] written antibiotic policy?

5] antibiotic committee?

6] strategic goal to improve drug use?



1] drugs and therapeutics committee?.........................86%

2] written antibiotic formulary?....................................77%

3] formulary with list of restricted antibiotics?.......66%

4] written antibiotic policy?.............................................57%

5] antibiotic committee?..................................................52%

6] strategic goal to improve drug use?..........................51%

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1] drugs and therapeutics committee?.........................86%

2] written antibiotic formulary?....................................77%

3] formulary with list of restricted antibiotics?.......66%

4] written antibiotic policy?.............................................57%

5] antibiotic committee?..................................................52%

6] strategic goal to improve drug use?..........................51%

22% did not have antibiotic committee nor a written antibiotic policy !

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Casus Belanda

low levels of antibiotic use and resistance:

how come ???

Critical success factors Netherlands: summary:

• reliable clinical microbiological services for id/ast & surveillance pathogens & resistance (typing)

• clinical microbiologists & ID clinicians ‘in the lead’ locally, provide expert advice to fellow clinicians on a daily basis

• evidence and consensus based local guidelines for antibiotic use and infection control (committees)

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Critical success factors Netherlands: summary:

• empowerment of guidelines by local & national authorities

• national professional societies ‘in the lead’ in providing framework for control of antibiotic use (SWAB) and infection prevention (WIP)

• competence to collaborate accross disciplinary boundaries

recent development in the Netherlands: the A-team

• 2010-2011 large outbreak K.pneumoniae OXA-48 in ‘Maasstad’

hospital in Rotterdam

• 2011 Health inspectorate asked SWAB to come up with a

strategy to combat emergence of resistance better

• SWAB position paper 2012:

– regard antimicrobial agents as separate class of medicines:

they have profound ecological effects, should be strictly

controlled (like narcotics, cytostatic agents)

– every hospital needs an antibiotic control team (A-team) and

an antibiotic stewardship program

if we do have:

traffic control

gun control

narcotics control

fire control

environment control

infection control……..

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we certainly should also have

many roadblocks remain, but

many roadblocks remain, but

you can always call me !!!

4/17/2013 antimicrobial stewardship: pengalaman di belanda...pengalaman di belanda henri a. verbrugh...

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