Principles of Antibiotic Policies

Learning objectives1. Explain how antibiotic use can select resistant

strains of bacteria 2. Identify important mechanisms used by

antibiotic stewardship programmes to decrease bacterial resistance in hospitals

3. Describe the roles of the microbiology laboratory and IP&C staff in the containment of bacterial resistance in healthcare

4. Participate in the formation of an antibiotic stewardship programme

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Time involved

• 45 – 60 minutes

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Introduction

• Discovery of antibiotics – revolutionary event that saved millions of lives

• Emergence of resistance – reduced effectiveness, increased toxicity, increased costs

• To preserve susceptibility – or to postpone development of resistance – antibiotics should be used rationally

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Antibiotics

• Fleming changed the course of history

• Mould contaminated an experiment – contained penicillin

• Killed the Staphylococcus aureus that had been growing in the dish

• Penicillin altered the treatment of bacterial infections

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Dr Alexander Fleming

Antibiotic Resistance• Antibiotic resistance develops

• Through natural mutations of bacterial genes

• Through transfer of resistance genes between different bacteria via plasmids, transposons, etc.

• If a bacterial population with newly resistant bacteria are exposed to a specific antibiotic, they will be selected and develop a new resistant strain

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Mechanisms of resistance

Resistance can be mediated by:• Change in antibiotic target site - altered

penicillin binding proteins, altered DNA gyrase:

• Beta-lactams, Quinolones

• Production of detoxifying enzymes: • Beta-lactams (Beta-lactamases) ,

Aminoglycosides, Chloramphenicol

• Decreased uptake(reduced permeability, active efflux):

• Erythromycin, Tetracyclines, Beta- lactams

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Antibiotic use outside human medicine• Antibiotics are used as treatment of infections

• In veterinary medicine• In agriculture

• Antibiotics are also used as growth promotors

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Clinical Impact of Resistance

• Increased morbidity• Increased mortality• Extended hospital stay• Increased admission to

intensive care• Loss of bed days

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Types of antibiotic uses

• Empirical therapy• Without the knowledge of pathogen

• Pathogen-directed therapy• Knowing the pathogen and susceptibility to antibiotics

• Prophylaxis• Surgical• Medical

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Dealing with resistance

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Antibiotic stewardship• Surveillance• Antibiotic policies

& guidelines• Antibiotic management• programmes

Prevention of spread• Infection prevention &

control in healthcare settings

• Isolation• Hand Hygiene• Environmental

hygiene

Reduction• Usage control• Appropriate use

• Human• Animal• Environmental

Antibiotic stewardship programmes - 1

• Can modify prescribing practices• Should lead to reduced, rational use• Should be well designed, and implemented• Should be based on education• Ideally should be a mixture of measures that are:

• Voluntary• Persuasive • Restrictive

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Antibiotic stewardship programmes - 2Key to modifying prescribing practices, stewardship programmes must include:

• National policies• Local hospital or health care policies• Formularies and guidelines• Education• Effective microbiology laboratory support• Audits• Effective working relationship with IP&C* teams

*IP&C: Infection Prevention and Control

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Key Elements of National Antibiotic Policies• Legislation required to regulate production

and import• Legislation to impose limitation of use in

veterinary practices to treatment only• Not as growth promoters

• Legislation to reduce over the counter use• Education of the general population

• Reduce expectations• Avoid misuse and over demand

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Hospital stewardship programmesImportant elements of an effective hospital programme:

• Antibiotic Committee• Antibiotic Management team• Formularies, guidelines and protocols• Education• Audits

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Antibiotic Committee• Can be a “stand alone” Committee,

or part of Drugs and Therapeutics Committee

• Membership should include:• Physicians and nurses who prescribe

antibiotics• Pharmacists• Microbiologists• Members of

Management/Administration• Members of Infection Control

Committee• Others, as needed

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Antibiotic Management Team

Team to advise on antibiotic use, audit of prescribing, introduction of new antibiotics

• Larger hospitals: can include infectious disease (ID) physicians, clinical pharmacologists, pharmacists, clinical microbiologists, any doctor authorised to use reserve list

• Smaller institutions: minimum requirement: antibiotic pharmacist (at least part-time), with support from ID or IP&C physician

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Guidelines and Protocols

Should include: • Protocols for the evaluation of parenteral

antibiotics• Include stop orders after 3-5 days and

recommendations for sequential treatment

• Protocol for list of reserve antibiotics• How to order• Who can authorise

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Hospital Guidelines/Policies

Local hospital or health care policies should focus on using antibiotics that:

• Have narrowest possible spectrum• Are inexpensive• Have minimal toxicity• Have least impact on development of resistance

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Hospital formularies and protocols• Antibiotic formularies: no drug outside

those listed should be used• Protocols for empiric and targeted

treatment of common infections• Protocols for surgical prophylaxis• Protocols for de-escalation of parenteral

use• Protocols for use of a reserve list

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Education programmes - 1

Should include:• Formal meetings• Clinical rounds with antibiotic

management team/committee members• Formal lectures

• Focus on:• New antibiotics• New methods of administration• Influence on bacterial ecology

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Education programmes - 2

• Should be provided by Senior member of Antibiotic Team, or independent expert

• Should not be provided by individuals from pharmaceutical companies, unless a committee or antibiotic team member is present

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Stewardship: Role of the Microbiology Laboratory• Regular reporting of changing resistance

patterns– Newsletters– Specialty-specific data

• Restricted antibiotic reporting― Routinely only first line antibiotics― Reserve antibiotics only if pathogen is

resistant to first line antibiotics

• Patient specific data (culture & sensitivity) to optimise treatment

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Stewardship: role of Clinical Microbiologist/ID Specialist• Provide leadership to Antimicrobial

Team• Antibiotic ward rounds• Interpretation of patient-specific data

(culture & sensitivity) to optimise treatment

• Active surveillance/ awareness• Screening for carriage of resistant organisms• Molecular detection and typing

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Audit: Monitoring compliance

1. Are antibiotics being used in accordance with approved protocols?• Empirical vs. targeted treatments clearly specified?• Stopped at the correct time?• Based on clinical needs and microbiology results?• Correct use of surgical prophylaxis guidelines?

AntibioticTimingDosage

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Audit: Monitoring effectiveness

2. Are our policies & guidelines being followed?• Consumption data: Based on stock controls• Signed prescriptions• Usage data

DDD*: based on patient bed days / length of stay

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26*DDD = defined daily dose

Audit: Monitoring Appropriateness

3. Are the policies being used effectively?

• Dosage: too much- too little?• Timeliness: start-stop dates?• Appropriateness: compliant with local

policies?

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Audit data

• Regular and timely feedback• Use as evidence for further teaching• Discuss in antibiotic ward rounds• Assess efficacy of guidelines and

protocols before regular review

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Control and Prevention of Healthcare-associated Infections• Work in close collaboration with Microbiology

laboratory• Have early warning system, based on regular

surveillance• Act promptly to detect and manage outbreaks• Have effective isolation policies• Ensure effective cleaning and high compliance

with hand hygiene

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Further reading• WHO Global Strategy for containment of antimicrobial

resistance WHO, 2001. http://whqlibdoc.who.int/hq/2001/WHO_CDS_DRS_2001.2.pdf

• Dellit TH, et al. Infectious Disease Society of America and Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007;44:159-177.

• Richards J. Emergence and spread of multiresistant organisms: can infection control measures help? Int J Infect Control 2009;v5:i2 doi:10.3396/ijic.V5i2.017.09.

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Quiz1. Methods to manage resistance are preventing spread of

resistant pathogens, antibiotic stewardship, and reduction of antibiotic use. T/F

2. Additional information from the microbiology laboratory, useful in prudent use of antibiotics, is reporting sensitivity testing to broad spectrum antibiotics as a first line antibiotics. T/F

3. The topics usually included in antibiotic policies are:a. List of antibiotics in the formulary- with the possibility to use some

antibiotics outside the formulary.b. Guidelines for empiric and targeted treatment not including dosage

and duration of treatment.c. Protocols for reserve antibiotics including how to order and who

authorises its use.d. Protocols for surgical prophylaxis including stop-orders after 48 hours.e. All of the above.

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International Federation of Infection Control• IFIC’s mission is to facilitate international networking in

order to improve the prevention and control of healthcare associated infections worldwide. It is an umbrella organisation of societies and associations of healthcare professionals in infection control and related fields across the globe .

• The goal of IFIC is to minimise the risk of infection within healthcare settings through development of a network of infection control organisations for communication, consensus building, education and sharing expertise.

• For more information go to http://theific.org/

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