antimicrobial stewardship from principles to practice

347 Pages·2017·40.91 MB·English

E-BOOK
E-BOOK
E-BOOK
ANTIMICROBIAL
STEWARDSHIP
FROM PRINCIPLES
TO PRACTICE
THIS E-BOOK HAS BEEN
DEVELOPED BY BSAC

IN COLLABORATION
WITH ESGAP/ESCMID
PLEASE NOTE THAT THE AUTHORS' CHAPTERS DO NOT REFLECT THE OPINION
OF ANY ORGANISATIONS THEY MAY BE ALIGNED WITH
GLOSSARY OF TERMS
ACKNOWLEDGEMENT
No venture into creating such an ambitious project can be done without support of a good team. It has been said
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the diligent, persistent and patient support of BSAC colleagues – Tracey Guise, CEO; Sally Bradley, eLearning manager
and Neil Watson without whom the transformation of the written word into a visually engaging eBook could not
have been accomplished. Thank you all.
BSAC is grateful to the following companies who provided, as part of a consortia sponsorship pool, unrestricted grants
to support the cost of developing this e-book: Alere now Abbott, Accelerate Diagnostics, MSD, Pfizer Inc
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ISBN: 978-1-78926-984-0
CONTENTS
PREFACE 10 CHAPTER 2 - ANTIBIOTIC 27
USE AND MISUSE ACROSS
THE RANGE OF HEALTHCARE
CHAPTER 1 - 12
COMMUNITIES AND THE
OVERVIEW OF AMR
DRIVERS/DETERMINANTS
OF MISUSE
Define antimicrobial and antibiotic resistance
in the human population ...................................................... 13
Antibiotic consumption and prevalence
What is antimicrobial resistance? ....................................... 13 of use-in primary and secondary care .............................. 27
What is the difference between antibiotic Global consumption of antibiotics ..................................... 28
and antimicrobial resistance? .............................................. 13
Antibiotic use in the community setting .......................... 29
Antibiotic resistance is a natural and
acquired problem ................................................................... 13 Antibiotic use in the hospital setting ................................. 31
How do antibiotics work? ..................................................... 14 Long term care ...................................................................... 34
Where does resistance occur and how Misuse of antibiotics ............................................................. 35
does resistance happen? ..................................................... 15
Non-prescription use of antibiotics ................................... 37
What are the drivers for resistance and potential
Determinants of antibiotic prescribing and use ............. 37
approaches to tackle resistance? ....................................... 15
What are the drivers for the use and CHAPTER 3 - WHAT IS 40
misuse of antibiotics? ............................................................ 17
ANTIMICROBIAL
The global epidemiology of antibiotic
STEWARDSHIP?
resistance and consumption in humans ........................... 19
What are the clinical and economic impact What is Antimicrobial Stewardship
of drug resistant infections and impact and why is it Important? ....................................................... 40
on health care acquired infections? ................................... 19
Impact of Antimicrobial Stewardship
What is the economic impact of AMR? ............................. 21 (AMS) programs ...................................................................... 41
Stewardship as a solution to Combat AMR ..................... 23 Key principles of prudent
antimicrobial prescribing ..................................................... 42
What is antimicrobial stewardship and
what are its goals? ................................................................ 24 Antimicrobial Stewardship Goals:
Improve Patient Outcomes ................................................. 43
How does this look in practice? ......................................... 26
LEARNING OUTCOME:
Reduce collateral damage .................................................. 43
Reduce antibiotic consumption CHAPTER 6 - EXPERTISE, 67
and costs without increasing mortality
STRUCTURES AND
or infection-related re-admissions .................................... 46
ORGANISATION
Optimise healthcare costs .................................................. 46
Defining your organisation
LEARNING OUTCOME: Evaluate core
and healthcare sector .......................................................... 67
elements of antimicrobial stewardship
and discuss opportunities to implement
Situating antimicrobial stewardship
core elements in your practice setting ............................. 47
within the organisation ........................................................ 68
LEARNING OUTCOME: Patient Cases:
National action plans ............................................................ 70
Apply key principles of prudent
antimicronial prescribing to the Examining workforce engagement
following scenarios ............................................................... 47 across professional groups ................................................. 70
Towards integrated models of ams ................................... 70
CHAPTER 4 - KEY STEPS 49
IN DEVELOPING AN
CHAPTER 7 - THE ROLE 72
ANTIMICROBIAL STEWARDSHIP
OF LABORATORY AND RAPID
PROGRAMME
DIAGNOSTICS/BIO-MARKERS
IN STEWARDSHIP
Introduction ............................................................................ 49
Business case ......................................................................... 51 Introduction to empirical prescribing ............................... 72
Antimicrobial stewardship committee ............................... 51 The use of currently available diagnostic
tests to inform the optimal use of antibiotics ................. 74
Developing antimicrobial prescribing guidelines .......... 55
The role of the laboratory in stewardship ....................... 75
Educate and train .................................................................. 55
Role of the clinician in laboratory testing ........................ 76
CHAPTER 5 - ASSESSING 59
Acute phase proteins and other biomarkers .................. 77
THE NEED AND MOTIVATION
CHAPTER 8 - OPTIMISING 78
Introduction ............................................................................ 59
STEWARDSHIP THROUGH
Resources ............................................................................... 60
BETTER PK-PD
Leadership Structure and Accountability ......................... 61
Pharmacokinetics and
Process .................................................................................... 62
pharmacodynamics (PK-PD) ............................................... 78
Outcomes ............................................................................... 63
Pharmacodynamic parameters
Motivation ............................................................................... 64 predictive of outcome .......................................................... 79
Conclusion .............................................................................. 64 Commonly used antimicrobial
pharmacodynamic parameters .......................................... 79
Summary of Learning Outcomes ....................................... 66
When is PK/PD clinically relevant? .................................... 80
Clinical application of PK/PD
in special circumstances ...................................................... 81
Interactive Case study ......................................................... 86
Continuous infusions of CHAPTER 11 - METHODS 119
beta-lactam antibiotics ......................................................... 87
FOR IMPROVING THE QUALITY
Therapeutic Drug monitoring (TDM) ................................. 88 OF ANTIMICROBIAL PRESCRIBING
USING LOCAL DATA
Combination Therapy .......................................................... 88
Resistance suppression ....................................................... 88 Introduction ........................................................................... 119
Getting started with improving
Toxicodynamics ..................................................................... 88
antimicrobial prescribing ................................................... 120
Optimising PK/PD for
Quality improvement (QI) approach ................................ 121
Antimicrobial stewardship .................................................. 89
How to get started with improving
antimicrobial prescribing .................................................... 127
CHAPTER 9 - 91
THE STEWARDSHIP TOOLKIT
CHAPTER 12 - 128
How to implement a successful ANTIMICROBIALSTEWARDSHIP
antimicrobial stewardship programme ............................. 91 AND BEHAVIOUR CHANGE
Proposed members of antimicrobial
The need to optimise antibiotic prescribing ................. 128
stewardship groups .............................................................. 93
The role of behaviour and culture in
Position of antimicrobial stewardship
antibiotic prescribing .......................................................... 129
groups within the organisation .......................................... 94
Hierarchies ........................................................................... 130
How to identify priority areas in
which to focus ASP ............................................................... 95
Behaviour change as quality improvement ................... 131
The ASP toolkit ...................................................................... 96
Examples of successful application
of behaviour change theory to
Core interventions ................................................................ 97
antimicrobial stewardship research ................................ 132
Guideline development ..................................................... 100
Additional Interventions .................................................... 102 CHAPTER 13 - KNOWLEDGE 133
AND PRACTICE IN
How do I assess the effectiveness of
an antimicrobial stewardship programme? ................... 106 STEWARDSHIP: EDUCATIONAL
COMPETENCIES FOR PRUDENT
Communication ................................................................... 108
PRESCRIBING
CHAPTER 10 - WHAT IS 110
Introduction ........................................................................... 133
MEASUREMENT AND WHY
Current landscape: National strategies
IS IT IMPORTANT?
to improve AMS knowledge and practice ..................... 134
Quantity of antimicrobial use ............................................ 112 Examples of how countries have
implemented objective 1 of the global
Quality of antimicrobial use ............................................... 114
AMR action plan .................................................................. 136
Using data to improve antimicrobial stewardship ........ 116
Free worldwide access to AMS training ......................... 137
What about data visualisation? .......................................... 117
Summary ............................................................................... 140
What are competences for antimicrobial
prescribing and stewardship ............................................ 140
Who should the competences CHAPTER 16 - 167
be intended for? .................................................................. 140
STEWARDSHIP IN THE
Developing competences .................................................. 141 RESOURCE LIMITED SETTINGS -
Current Landscape: Developed EXAMPLES OF GLOBAL
competences across the world:
SUCCESS STORIES
UK - National competences ............................................... 141
Expert professional curriculum Introduction .......................................................................... 168
for antimicrobial pharmacists in the UK ......................... 142
South Africa .......................................................................... 168
Guidance for the Knowledge and Skills
Global success story: antimicrobial stewardship
Required for Antimicrobial Stewardship
model to reduce excessive prescribing ............... 168
Leaders (USA) ...................................................................... 143
Process measures involving
An Antibiotic Stewardship Curriculum
“low-hanging fruit” for pharmacist
for Medical Students .......................................................... 143
audit during dedicated antibiotic
Europe ................................................................................... 143 rounds (all patients on antibiotics) ......................... 168
Educational Resources ...................................................... 143 AMS “breakthrough series collaborative”
model for implementation and
A GP guide to antimicrobial resistance .......................... 146 monitoring process ................................................... 169
The importance of collaborative learning
CHAPTER 14 - ANTIBIOTIC 148
sessions and standardised measurement ............. 171
STEWARDSHIP EDUCATION
The importance of feedback to facilitate
IN LOW RESOURCE SETTINGS
adjustments to hospital action plans
following self-monitoring ........................................... 171
Recognising a problem ...................................................... 148
Impact of the AMS model ......................................... 173
The Challenge ..................................................................... 148
India ........................................................................................ 175
Making the most of what is already out there .............. 148
Development of drug resistance ............................ 175
Educating health care professionals in low
resource settings – a hospital-based approach ........... 151 Story 1: Making & Utilisation of an antibiogram:
Bugs vs Drugs ............................................................. 176
CHAPTER 15 - 153 Story 2: Prescription auditing as a concept
and interpretation ....................................................... 177
STEWARDSHIP IN
DEVELOPED COUNTRIES Story 3: Focus group discussions ........................... 178
Other contributory factors ........................................ 179
North america ...................................................................... 153
South America ..................................................................... 180
Europe ................................................................................... 155
Story 1: The problems: inappropriate antibiotic
Gulf cooperation states ..................................................... 158
use and antibiotic resistance in Latin
American countries ................................................... 180
Australia ................................................................................ 162
Story 2: The process and impact of introducing
regulations for antibiotic sales in Chile,
Brazil and Mexico ...................................................... 180
Conclusions ................................................................ 183
CHAPTER 17 - 185 Definition ............................................................................... 213
STEWARDSHIP IN LONG
Rationale ............................................................................... 214
TERM CARE FACILITIES
Importance ........................................................................... 214
Long term care facility setting factors ............................ 185 Ranking ................................................................................. 214
Antimicrobial prescribing practices ................................. 187 Requirement/Pre requisite to prevent SSI ..................... 215
Impact of Antimicrobial Resistance ................................. 188 Selection of antimicrobial agent
for surgical prophylaxis ..................................................... 215
Surveillance of Healthcare Acquired Infections
and antimicrobial prescribing ........................................... 190 Time of administration ....................................................... 216
Antimicrobial stewardship ................................................ 190 Repeat dosing ....................................................................... 217
Focus on UTI and CAUTI in LTCF .................................... 192 Duration ................................................................................. 217
Sepsis in LTCF ...................................................................... 195 Topical adminstration of irrigations,
pastes, and washes ............................................................ 218
Antimicrobial Stewardship in LTCFs ............................... 195
Contributory factors in surgical site infection ............... 218
CHAPTER 18 - 197 Summary ............................................................................... 219
STEWARDSHIP IN THE
INTENSIVE CARE UNIT CHAPTER 21 - 220
ANTIFUNGAL STEWARDSHIP
Introduction ........................................................................... 197
introduction ......................................................................... 220
Program Structure ............................................................... 198
Some basic mycology ........................................................ 221
Interventions ....................................................................... 200
What is antifungal stewardship (AFS)? .......................... 222
Outcome Measures ........................................................... 202
Aims of AFS programme .................................................. 222
Summary .............................................................................. 204
What are the benefits of AFS? ........................................ 222
CHAPTER 19 - 205
What are the disadvantages of AFS? ............................ 223
STEWARDSHIP IN THE
What are the differences between
IMMUNOCOMPROMISED
Antifungal Stewardship and
PATIENT SETTING Antimicrobial Stewardship (AMS)? ................................. 223
Funding of antifungals and its effects on AFS ............ 223
Introduction ......................................................................... 205
Types of antifungal use ..................................................... 224
AMS in the Immunocompromised
Not just antibacterials ........................................................ 207 Diagnosing fungal infections ........................................... 224
Challenges to AMS in the AFS: How do you do it? .................................................... 225
immunocompromised ....................................................... 208
Examples of AFS that work include ............................... 226
Opportunities for AMS in the
immunocompromised ......................................................... 211 AFS: What are the challenges? ........................................ 227
Summary ............................................................................... 212 Who do you need to involve? ........................................... 227
What do you need? ........................................................... 228
CHAPTER 20 - 213
How do you continue? ...................................................... 229
SURGICAL PROPHYLAXIS
Background .......................................................................... 213
CHAPTER 22 - 230 CHAPTER 25 - THE ROLE 265
STEWARDSHIP IN PAEDIATRICS OF THE NURSE IN
STEWARDSHIP
Introduction ......................................................................... 230
Why should nurses be involved
Antibiotic prescribing for children
in stewardship? ................................................................... 266
in community based setting ............................................ 232
Expanding the participation of nurses
Antibiotic prescribing for children
in antimicrobial stewardship ............................................. 267
in hospital settings .............................................................. 237
Public health and community nursing
Evaluating the quality of antibiotic
contribution to antimicrobial stewardship .................... 269
prescribing in children ...................................................... 239
Integration between nursing roles
Summary ............................................................................... 241
and activities in AMR and other professionals ............. 270
CHAPTER 23 - 242 Stewardship, a target for nurses
in executive and directive positions ............................... 270
ANTIMICROBIAL
STEWARDSHIP AND OPAT Nurse-focused interventions
in antimicrobial stewardship .............................................. 271
Introduction .......................................................................... 243
Barriers to resolve the participation
of nurses in stewardship ................................................... 273
Transitions of Care from Acute to
Post-acute OPAT Care Settings ...................................... 244
Conclusion ............................................................................ 275
OPAT Patient Diversity and Distinct
OPAT Care Models ............................................................. 245 CHAPTER 26 - THE ROLE 277
The Physician Steward and OPAT OF THE PHARMACIST
care in the Underserved ................................................... 246 IN STEWARDSHIP
OPAT-Stewardship Dilemma ............................................. 247
Patient care .......................................................................... 278
Expanded Role of the Stewardship
Educator ................................................................................ 279
Pharmacist in OPAT ........................................................... 249
Research .............................................................................. 280
Conclusion ........................................................................... 250
Rapid Diagnostic Tests ...................................................... 280
CHAPTER 24 - THE USE 253
Drug Therapy Expert .......................................................... 281
OF INFORMATION
Patient Safety ....................................................................... 281
TECHNOLOGY TO SUPPORT
ANTIMICROBIAL STEWARDSHIP Quality Care ........................................................................ 282
Advocacy ............................................................................. 282
Overview .............................................................................. 253
Using information technology to CHAPTER 27 - 284
support antimicrobial stewardship ................................. 255
INFORMING & INFLUENCING:
Are Antimicrobial CDSSs effective? ............................... 256 STEWARDSHIP, POLITICIANS,
Types of antimicrobial CDSSs ......................................... 256 & THE MEDIA
What are the factors that are likely to result
Going public ........................................................................ 285
in successful implementation of a CDSS? .................... 262
Mainstream media ............................................................. 288
Summary .............................................................................. 263
New media .......................................................................... 288
Politicians ............................................................................. 289
OUTCOMES 294 AUTHORS 325
Chapter 1 .............................................................................. 294 Chapter 1 - Dilip Nathwani ................................................ 325
Chapter 2 ............................................................................. 295 Chapter 2 - Margaret Duguid .......................................... 325
Chapter 3 .............................................................................. 297 Chapter 3 - Eliza Dollard & Lilian M Abbo .................... 326
Chapter 4 ............................................................................. 299 Chapter 4 - Conor Jamieson ............................................ 327
Chapter 5 ............................................................................. 300 Chapter 5 - Paul Pottinger ................................................ 327
Chapter 6 .............................................................................. 301 Chapter 6 - Raheelah Ahmad & Alison Holmes .......... 328
Chapter 7 ............................................................................. 302 Chapter 7 - Nick Brown ..................................................... 329
Chapter 8 ............................................................................. 303 Chapter 8 - Alasdair MacGowan
& Melissa Baxter ....................................................... 329 - 330
Chapter 9 ............................................................................. 304
Chapter 9 - Mark Gilchrist
Chapter 10 ........................................................................... 306
& Orla Geoghegan .................................................... 330 - 331
Chapter 11 ............................................................................. 307
Chapter 10 - William Malcolm ............................................ 331
Chapter 12 ........................................................................... 308
Chapter 11 - Jacqueline Sneddon .................................... 332
Chapter 13 ............................................................................ 309
Chapter 12 - Esmita Charani
& Peter Davey ........................................................... 332 - 333
Chapter 14 ............................................................................. 310
Chapter 13 - Diane Ashiru-Oredope ............................... 333
Chapter 15 ............................................................................. 311
Chapter 14 - Marc Mendelson .......................................... 334
Chapter 16 ............................................................................ 312
Chapter 15 - Debbie Goff, Celine Pulcini,
Chapter 17 .............................................................................. 313
Mushira Abdulaziz Enani, Kirsty Buising &
Chapter 18 ............................................................................ 314 Arjun Rajkhowa ........................................................ 334 - 337
Chapter 19 ............................................................................ 315 Chapter 16 - South Africa: Adrian Brink,
Asia: Chand Wattal & Reena Raveendran
Chapter 20 ........................................................................... 316
South America: Anahi Dreser ................................ 338 - 339
Chapter 21 ............................................................................. 317
Chapter 17 - Aoife Fleming ............................................... 340
Chapter 22 ........................................................................... 318
Chapter 18 - Andrew Morris ............................................. 340
Chapter 23 ............................................................................ 319
Chapter 19 - Haifa Lyster .................................................. 341
Chapter 24 ........................................................................... 320
Chapter 20 - Sanjeev Singh ............................................. 341
Chapter 25 ........................................................................... 321
Chapter 21 - David Enoch & Laura Whitney .................. 342
Chapter 26 ........................................................................... 323
Chapter 22 - Sanjay Patel ................................................. 343
Chapter 27 ............................................................................ 324
Chapter 23 - Priya Nori ...................................................... 343
Chapter 24 - Karin Thursky ............................................... 344
Chapter 25 - Enrique Castro Sanchez ............................ 344
Chapter 26 - Debra A Goff ................................................ 335
Chapter 27 - Michael Corley ............................................ 345
PRESIDENT OF BSAC [2015-2018]
PREFACE
Scientists have known for more than half a century that The importance of education to support the development
patients could develop resistance to the drugs used to of knowledge and skill sets across the professions is a key
treat them. Alexander Fleming, who is credited with creating objective of the WHO and national action plans for AMR.
the first antibiotic, penicillin, in 1928, cautioned of the impending The development of relevant educational content and its
crisis while accepting his Nobel prize in 1945: “There is the cost-effective and sustainable delivery globally is also a
danger that the ignorant man may easily underdose himself major challenge. The need to combine traditional and modern
and by exposing his microbes to non-lethal quantities of the methods to deliver this are increasingly relevant to ensure
drug make them resistant.” Since then antibiotics have proved better awareness and penetration into health care systems
one of the most effective interventions in human medicine. Sadly, and communities. This e-book offers a more blended or hybrid
the overuse and misuse of this precious resource have brought approach to stewardship education that builds on the success
us to a global crisis of antimicrobial resistance (AMR). To address of the massive open on line stewardship course launched in
this crisis nearly seven decades after Fleming’s lecture the first 2015, reaching over 40,000 learners.
UN general assembly meeting on drug resistance bacteria was
convened in September 2017.
It is only the fourth time the general assembly has held a VISIT MOOC SITE
high-level meeting for a health issue. The UN secretary general,
Ban Ki-moon, said antimicrobial resistance is a “fundamental
threat” to global health and safety. He went on to say “If we
The ebook also compliments new on line learning resources
fail to address this problem quickly and comprehensively,
from WHO
antimicrobial resistance will make providing high-quality
universal healthcare coverage more difficult if not impossible.
It will undermine sustainable food production and put the
sustainable development goals in jeopardy.” Just before VISIT WHO SITE
world leaders convened for the meeting, all 193 member
states agreed in a declaration to combat the proliferation of
antibiotic resistance.
which provides a more traditional approach to simple prudent
The need for the solution to AMR requiring a “One Health”
prescribing competencies and how they can be applied to
approach is well accepted. The importance of reducing
common clinical scenarios, and the CDC programme
overuse and misuse of antibiotics by promoting prudent use is
one fundamental component of this solution - the concept of
antimicrobial stewardship. In the human population, ensuring
VISIT CDC PROGRAMME SITE
prudent prescribing across different communities and settings, in
different patient populations, in diverse geographies, resources
and cultures requires a truly innovative, flexible, collaborative
and cross-disciplinary approach. As a global community only by
and ESGAP.
innovating and adapting and adopting the resources we have
available to us can we effect true transformational change in
prescribing practice.
VISIT ESGAP SITE
Those of you who wish to seek an overview of global
stewardship may wish to access the plenary presentation on
the subject at ESCMID in 2017:
VIEW SLIDE SET
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