antimicrobial stewardship 101...antimicrobial stewardship program joe hessell, pharmd, bcps expert...
TRANSCRIPT
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How to Create a Successful Antimicrobial Stewardship
Program
Joe Hessell, PharmD, BCPSExpert Pharmacist
Diagnostic Microbiology Development Program (DMDP)
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Outline
• Overview: Core elements for AMS programs
• Challenges of resource-limited setting / LMIC
• Beginning with AMS situation analysis
• Establishing an AMS team and committee
• Assessing baseline antimicrobial prescribing
• Implementation of interventions
• Tracking / monitoring effectiveness
• Example of successful AMS implementation: Cambodian hospital experience
• Resources and e-learning for AMS
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Core Elements of Hospital AMS Programs
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
Core Elements of Hospital AMS Programs. Atlanta, GA: US Department of Health and Human Services, CDC; 2019.
CDC (USA) WHO (for LMICs)
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Challenges to developing AMS in LMICs
• Few infectious diseases-specific and pharmacy-specific training programs
• Gaps in the availability of appropriate policies and guidelines
• Limited diagnostic and laboratory capacity
• Gaps in data on antibiotic use or antibiotic resistance patterns
• Weak data management systems, inexperience with data analysis and program implementation
• Scarce human and material resources, including essential antimicrobials
The Core Elements of Human AMS Programs in Resource -Limited Settings: National and Hospital Levels. Atlanta, GA: US Department of Health and Human Services, CDC; 2018.
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Where to begin?
• Conduct hospital AMS situation analysis, identifying strengths, weaknesses, opportunities and barriers to AMS implementation
• Focus on:• Structures, policies and guidelines: Identify which are in place and which are
critically in need • Human resources: Identify the existing and required human resources
needed for a functioning AMS team• Antimicrobial use and resistance data: Review data on antimicrobial
consumption and AMR surveillance data, and identify challenges related to antibiotic prescribing practices
• AMS activities: Identify any existing AMS activities in the facility that can be built on and made sustainable.
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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WHO core elements checklist
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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Creating the AMS team
• Key points to creating an effective AMS team• Dedicated focal point to serve as AMS Champion
• Multidisciplinary membership
• Hospital leadership support
• May initially require local antimicrobial prescribing data to validate need for AMS in order to gain hospital leadership buy-in• In this case, baseline assessments can be done (by conducting a point
prevalence survey or antimicrobial consumption monitoring – coming up!) before creating formal AMS program
The Core Elements of Human AMS Programs in Resource -Limited Settings: National and Hospital Levels. Atlanta, GA: US Department of Health and Human Services, CDC; 2018.
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The AMS Team: Multidisciplinary membership
• Need to include different disciplines that will participate in AMS activities
• Key members:• Physicians (including surgeons)• Pharmacists • Pathologists / Microbiologists• Nurses (preferably involved in IPC)
• Appoint dedicated focal point to serve as AMS champion• Preferably physician with
experience and interest in ID, but others can also serve this role
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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Establishing an AMS Committee
• Coordinates activities of the AMS team
• Include relevant stakeholders and members from other relevant committees (e.g. IPC)
• Develop TOR, outlining clear objectives, members, and activities/interventions
• Progress of AMS activities to be reported at AMS committee meetings
• Don’t necessarily need to create new committee, can be included into existing one (e.g. D&T committee)
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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Baseline assessments on antimicrobial use
Available Methods:
• Point prevalence survey (PPS)• Qualitative and quantitative
data
• Antimicrobial consumption (AMC) monitoring• Quantitative data
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What is a PPS?
Antimicrobial Point Prevalence Survey (PPS):
Measures, at a particular point in time, the number of patients in a ward/hospital that are prescribed antimicrobials
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Purpose of antimicrobial PPS
• Monitor rates of antimicrobial prescribing• First PPS establishes ‘baseline’
• Identify targets areas to improve quality of antimicrobial prescribing• Specific indications, e.g. surgical prophylaxis
• Specific wards
• Assess effectiveness of interventions intended to address antimicrobial prescribing with a follow-up PPS
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What can be evaluated in PPS?
• % of patients prescribed antimicrobials
• Which antimicrobials prescribed most often
• Are antimicrobials being prescribed appropriately• Strength, route, frequency, duration
• Appropriateness for indication (according to local guidelines)
• Is diagnosis or indication of antimicrobial documented
• Are specimens for microbiology testing being ordered/collected
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Baseline PPS at Siem Reap Hospital, Cambodia
• 161 of 199 (81%) hospitalized patients prescribed antimicrobials
• 13% of patients prescribed antimicrobials had microbiology testing performed
• Indication for antimicrobial recorded in 2%of cases
• 45% of prescriptions written completely
• 100% of patients that underwent surgery had antibiotics prescribed post-operatively
81%
19%
Patients on antimicrobials
Patients not on antimicrobials
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Available PPS Methodologies
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Global PPS Ward form
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Global PPS Patient form
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How to conduct PPS
• Appoint PPS team members and focal point
• Select PPS protocol/methodology
• Train PPS team member
• Plan which wards to be surveyed and which dates
• Perform data collection (often on paper)
• Transfer data to electronic format
• Validate and analyze data, identifying areas for improvement
• Report results to relevant committees and hospital staff
• Consider plans for a follow-up PPS
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AMC Monitoring
• Necessary to evaluate trends in antibiotic use and monitor the progress of AMS initiatives
• The defined daily dose (DDD) of a medication is the assumed average maintenance dose per day for a drug used for its main indication in adults, as defined by WHO• Uniform unit of measure across different antimicrobials, which allows for comparison
and aggregation of consumption data• Example: Ceftriaxone 2 grams = 1 DDD
• Antibiotic use is often measured as DDDs per 1,000 patient days, which requires two sets of data for a selected period of time:• Number of units of an antimicrobial dispensed from pharmacy• Number of patient hospitalization days
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0
100
200
300
400
500D
DD
s /
1,0
00
pat
ien
t d
ays
AMC of Siem Reap PRH 2016(10 most common antimicrobials)
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1612
1260
944
0
200
400
600
800
1000
1200
1400
1600
1800
2016 2017 2018
DD
Ds/
1,0
00
pt.
day
s
Total AMC of Siem Reap PRH
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AWaRe Groups
• Classifies antibiotics into three categories:• Access
• Watch
• Reserve
• WHO’s goal of increasing the proportion of global consumption of antibiotics in the ACCESS group to ≥60%
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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How to perform AMC monitoring
AMC Tool, recommended by WHO:https://amu-tools.org/amctool/amctool.html
DMDP developed Excel tool(Can be modified to suit local needs, available upon request)
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Implementing an AMS intervention
“AMS interventions should be implemented in a stepwise approach, build on existing structures and reporting, maximize teamwork, and encourage champions and clinical staff – including prescribers – to participate. Start small and keep it simple and doable.”
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
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Implementing an AMS intervention
• Identify priority area to focus on – Start small, simple, achievable• Based on initial findings from situation analysis, PPS, AMC monitoring• Target ‘low hanging fruit’
• Ensure necessary policies/guidelines/resources in place• May need to be developed (collaborate with all relevant stakeholders)
• Identify quantitative measure to assess impact, and set goal• Educate staff and publicize AMS program initiative
• Must engage all relevant stakeholders to be successful!
• Implement intervention • Monitor and evaluate• Report / provide feedback
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Types of AMS interventions
• Surveillance (e.g. PPS, AMC monitoring)• Assess baseline, and follow-up for monitoring progress of interventions
• Treatment (or prophylaxis) guidelines• Surgical prophylaxis (‘low hanging fruit’)
• Restriction• Requires dedicated pharmacy involvement
• Audit and feedback• Prospective or retrospective
• Increase and improve microbiology testing, optimize reporting• Cascade reporting, antibiogram development
• Education and training necessary for all types of interventions
AMS programmes in health-care facilities in LMICs. A practical toolkit. Geneva: World Health Organization; 2019
The Core Elements of Human AMS Programs in Resource -Limited Settings: National and Hospital Levels. Atlanta, GA: US Department of Health and Human Services, CDC; 2018.
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Monitoring and evaluating AMS program
• Outcome measures to consider:• Total antimicrobial consumption
• Cost
• Appropriateness of antibiotic selection/dose/duration (according to local guidelines)
• Clinical outcomes
• Rates of AMR
• Proving the effectiveness of an AMS program validates the team's efforts and helps convince hospital leadership to continue and expand activities, as well as provide additional resources as needed
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AMS Success Story: Siem Reap Hospital, Cambodia
• 300 bed acute care government facility with 12 patient wards in Northwestern Cambodia
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AMS Program at Siem Reap Hospital
• Multidisciplinary team
• Dedicated focal point
• Hospital leadership supportAMS
Committee
Prescribers
Pharmacy
Nursing
Microbiology
Infection control
Administrative staff
QI staff
IT staff
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AMS Interventions
• Interventions implemented in stepwise manner, not all at once
• Baseline PPS results provided guidance where to focus interventions
ID Lab and
Ward Rounds
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Follow-up antimicrobials PPS results
*Statistically significant difference, based on confidence intervals calculated by modified Wald method.
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Key points for AMS implementation
1. Create a multidisciplinary team with a dedicated focal point• Engage with all relevant stakeholders
• Seek hospital leadership support, gain buy-in
2. Measure: assess baseline antimicrobial prescribing to identify targets for AMS interventions
3. Introduce interventions in strategic, stepwise manner• Prioritize activities, start small and build
• Monitor progress in a measurable way, and report back
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Resources
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Free E-learning AMS courses
• WHO: Antimicrobial Stewardship: A competency-based approach• https://openwho.org/courses/AMR-competency
• Stanford University: AMS: Improving Clinical Outcomes by Optimization of Antibiotic Practices• https://stanford.cloud-cme.com/default.aspx?P=0&EID=20868
• Future Learn: Antimicrobial Stewardship: Managing AMR• https://www.futurelearn.com/courses/antimicrobial-stewardship
• CDC: Antibiotic Stewardship Training Series• https://www.train.org/cdctrain/search?query=antimicrobial%20stewardship