Formulating Institutional Antibiotic Policy

Formulating Institutional Antibiotic

PolicyMARY ANN D. LANSANG, MD, FPCP, FPSMID

PHICS 23RD ANNUAL CONVENTION

MAY 19, 2017

OutlineContext: global and local actions; the infection control unit and the

antimicrobial stewardship program of an institution

Why: the need for an institutional antibiotic policy

How: evidence-guided recommendations, best practices, and

experiences in the formulation of antibiotic policies in an

institution

Who: stewards of rational antibiotic use and stakeholders

The Development of Antimicrobial ResistanceFrom: Faces of Antimicrobial Resistance, IDSA, 2017

2020 Targets of the Action Plan (5-year time frame)

- Reduce by 30% carbapenem-resistant Enterobacteriaceae infections acquired during hospitalization

-Maintain the prevalence of ceftriaxone-resistant N. gonorrhoeae to zero

-Reduce by at least 30% MRSA bloodstream infections compared to 2014 rates

-Reduce by 30% MDR Pseudomonas spp. Infections acquired during hospitalization compared to 2014 rates

- Reduce by 25% ciprofloxacin-resistant non-typhoidalSalmonella infections compared to 2014

November 14 – 20, 2016

WHO Global Priority Pathogens Listfor R&D of New Antibiotics (released 27 Feb 2017)

# Mycobacteria not included – already established as a global priority.

WHO Global Priority Pathogens Listfor R&D of New Antibiotics

WHO Global Priority Pathogens Listfor R&D of New Antibiotics

Yearly resistance rates of E. coli to ceftriaxone, gentamicin and imipenem

ARSP, 2006 - 2015

2015 carbapenem resistance rates: Ertapenem: 4.2% (n=3,036); Imipenem: 3.5% (n=6,132);

Meropenem: 3.4% (n=5,794)

Yearly resistance rates of K. pneumoniae to carbapenems

ARSP, 2006 - 2015

Imipenem: 2014 = 6.9%; 2015 = 11.1%; Meropenem: 2014 = 7.6%; 2015 = 11.9%;

Ertapenem: 2014 = 10%; 2015 = 15.3%

Yearly resistance rates of S. aureusARSP, 2006-2015

MRSA rate for bloodstream infections, 2015: 60.25% (n=570)

From: Philippine Action Plan to Combat Antimicrobial Resistance, 2015

“… the concerted implementation of systematic,

multi-disciplinary, multi-pronged interventions

in both public and private hospitals in the

Philippines to improve appropriate use of

antimicrobials…”

Strategies for controlling AMR:inter-related approaches

Antibiotic

stewardship

• Surveillance

• Antibiotic policies &

guidelines

• Antibiotic manage-

ment programs

Prevention of spread

• Infection prevention &

control in healthcare settings

• Isolation when needed

• Hand hygiene

• Environmental hygiene

Reduction

• Usage control

• Appropriate use

• Human

• Animal

• Environmental

Core elements of the DOH AMS Program

Strategies for controlling AMR:inter-related approaches

Antibiotic

stewardship

• Surveillance

• Antibiotic policies

& guidelines

• Antibiotic manage-

ment programs

Prevention of spread

• Infection prevention &

control in healthcare settings

• Isolation when needed

• Hand hygiene

• Environmental hygiene

Reduction

• Usage control

• Appropriate use

• Human

• Animal

• Environmental




How: evidence-guided recommendations, best practices, and

experiences in the formulation of antibiotic policies in an

institution


Why do we need a hospital antibiotic policy? (1)• High level of antibiotic use in hospitals. CDC report (MMWR, 7Mar2017):

• 56% of patients discharged from 323 US hospitals received antibiotics• 37% of antibiotic prescribing could be improved

• Patients with multiple pathogens are concentrated in hospitals

• Close proximity of patients with multiple healthcare worker contacts

• Sicker, more vulnerable patients in the hospitals

• Transfer of patients with MDR organisms into the hospital from the

community, another facility, or another country

From: Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing within HospitalsClin Infect Dis. 2006;42(Supplement_2):S90-S95. doi:10.1086/499407

Why do we need a hospital antibiotic policy? (2)• To improve patient outcomes through appropriate antibiotic use: the RIGHT indication, choice, dose, route of administration, timing, duration

• To minimize harm to the patients (and future patients)

• To reduce health care-related costs: shorter hospital stay, use of less costly antibiotics, less ADRs

• To prevent or control the emergence of AMR




How: evidence-guided recommendations, best

practices, and experiences in the formulation of

antibiotic policies in an institution


Hospital antibiotic policy

development cycle

Ideal organizational structure for the AMS program

From:

From:

All hospitals should have a hospital antibiotic

policy to promote rational antimicrotial

prescribing and dispensing practices.

From:

From:

All hospitals should adopt or adapt to their local

context the National Antibiotic Guidelines to

guide clinicians in the management of infectious

diseases and in the selection of the most

appropriate antimicrobial agent.

From:

Simple and clear clinical pathways

should be created to guide and

standardize treatment for timely

and appropriate management of

infections.

Example of clinical pathway: Severe sepsis(from The Medical City)

Summary of strategies to improve antibiotic use (1)Pulcini & Gryssens. Virulence 2013; 4:192-202

Passive educational measures Developing/updating local antibiotic guidelines

Educational sessions, workshops, local conferences

Clinical rounds discussing cases

Active interventions Prospective audit with intervention & feedback

Reassessment of abtic prescriptions, with streamlining &

de-escalation of therapy

Academic detailing, educational outreach visits

Restrictive measures Limiting no. of abtics on the hosp. formulary

Antibiotic order form (compulsory)

Automatic stop order

Formulary restriction & pre-authorization

Limiting reporting of susceptibilities by the micro lab

Regulating contacts with the pharma industry

Summary of strategies to improve antibiotic use (2)Pulcini & Gryssens. Virulence 2013; 4:192-202

Supportive/supplemental measures Multidisciplinary AMS team

Consultancy service (infectious diseases, pharmacy,

microbiology)

Computer-assisted management program

Parenteral to oral conversion

Therapeutic drug monitoring service

Carrot or stick approach toimproving antibiotic use?

Carrot or stick approach toimproving antibiotic use?

Positive

Clinical

Impact

Positive

Financial

Impact

Political

Expediency

Resource

Requirements

Ease of

Implementation

0 = None

5 = High

0 = None

5 = High

0 = Impossible

5 = Win/Win

0 = Impossible

5 = None

0 = Impossible

5 = Easy

Prioritize potential interventions




How: evidence-guided recommendations, best

practices, and experiences in the formulation of

antibiotic policies in an institution

Who: stewards of rational antibiotic use and

stakeholders

Ideal organizational structure for the AMS program

Clinicians/

Prescribers

Patients

Patient’s

relatives

Public? PhilHealth?

DOH timelines for selected core elements of the AMS Program

2015 WHO WPRO and Philippines partnership: Pilot AMS Program implementation in Hospitals

TRAINING OF TRAINORS

WORKSHOP ON THE

ANTIMICROBIAL STEWARDSHIP

ADVOCACY PACKAGE

(March and September 2015)

Baguio General Hospital and Medical

Center

CAR

Jose B. Lingad Memorial Regional

Hospital

Region III

Rizal Medical Center NCR

Research Institute for Tropical Medicine NCR

Corazon Locsin Montelibano Memorial

Regional Hospital

Region VI

Vicente Sotto Memorial Medical Center Region VII

Northern Mindanao Medical Center Region X

Southern Philippines Medical Center Region XI

Health & Medicine

Formulating Institutional Antibiotic Policy