Antibiotics are powerful drugs to treat serious infections. However decades of over prescribing and misuse have resulted in organisms that are increasingly resistant to these potent drugs, creating a growing threat of superbugs that are difficult and sometimes even impossible to treat. Patients who are unnecessarily exposed to antibiotics are placed at risk for serious adverse events with no clinical benefit, and spread of ESBL. 

Unlike other medications, the potential spread of resistant organisms means that the misuse of antibiotics can adversely impact the health of patients who are not even exposed. According to CDC, drug resistant bacteria cause 2 million illnesses and 23,000 deaths annually.

A growing body of evidence demonstrates that hospital based programmes dedicated to improving antibiotic use commonly referred to as antibiotic stewardship programmes can both optimise the treatment of infections and reduce adverse events.

Rising threat is due to lack of new antibiotics and infections caused by multidrug resistant pathogen becoming untreatable.

Antimicrobial Stewardship is defined as an inter-professional effort across the continuum of care that involves timely and optimal selection of dose, duration, route of an antimicrobial agent. It aims at obtaining best clinical outcome of the treatment or prevention of infection with minimal toxicity to patient and minimal impact on resistance and other ecologically adverse events  such as C.diff diarrhea.

At the SSSIHMS, Prasanthigram a multidisciplinary team including the IPC, pharmacy department, microbiology section and physicians  work towards a formulatory and implementing the AMS. 

GOALS AND EVIDENCE OF SUCCESS  

1.  To Improve Patient Outcome : So that we can improve infection cure rate, reduce surgical infection rate and decrease mortality and morbidity. 

2. To improve patient safety: By minimizing unintended consequences, decreasing consumption of drugs and thereby reducing colonisation. 

3. Reducing resistance: Anti-Microbial Resistance (AMR) is a rising threat across the globe. Extensive misuse of antibiotics is the single most important factor for bacteria to undergo mutation, to become resistant, which further flourish exponentially in the presence of selective pressure of antibiotics. 

4. Reducing health care costs: The initial focus needs to be targeted towards hospital-wide utilization and prescribing practices related to four antibiotics, meropenem, linezolid, vancomycin and colistin.

BARRIERS TO THE PROGRAMME 

1. Lack of Information 

2. Prescriber opposition

3. Overuse without prescription for self-limiting infection and treatment of colonizer or containment

4. Use of redundant antibiotics with overlapping spectra

5. Inappropriate administration errors due to wrong dose, wrong frequency, wrong infusion time and missed dose.

6. Lastly, poor antibiotic research 

At SSSIHMS, Prasanthigram the Anti-Microbial Stewardship programme provides the foundation to influence prescribing behavior and facilitates proper antibiotic selection by updating, publishing and disseminating  antibiogram  every quarter.

The 3 pillars approach followed in SSSIHMS, Prasanthigram as part of AMS are

1. Optimize use of existing antimicrobial agents

2. Prevent transmission of drug resistant organism through hand hygiene 

3. Active surveillance and infection control

4.  Improve environmental decontamination

8 key steps for implementation 

1.      Assess the motivation

2.      Ensure accountability and leadership 

3.      Set up structure and organization 

4.      Define priorities and how to measure progress and success

5.      Identify effective intervention for your setting 

6.      Apply key measurements for improvement

7.      Education  and training

8.      Communication

PRIMARY DRIVERS 

The microbiologist helps the team to explore factors and act as communication tool, for explaining a change of strategy. This helps in timely and appropriate initiation and de-escalation.

SECONDARY DRIVERS

• To identify patients who require antibiotics. 

• Obtain their cultures, prior to starting antibiotics. 

• Not to give antibiotics with overlapping activity or combination not supported by evidence or guidelines.

If you cannot measure it, you cannot improve it, therefore, there are three types of measurements, which provide the real picture. 

1. Process measure 

2. Outcome measure 

3. Balancing measure 

Identifying wards with high antibiotic usage by using pareto charts. Data collected for quality improvement -> plan, do , act and study.

Tracking  patterns of antibiotic prescribing by initiating unit specific and hospital wide defined  daily dose (DDD) per 1000 patient days. Also tracking antibiotic resistance patterns of targeted organism to drug of choice. It also establishes pre authorization and prospective audit and feedback interventions with regards to antibiotic utilization and patient outcome in critical areas and surgery

Dose optimization, is done based on renal/liver function test. Clinicians revisit the case after 48 hrs of initiation of antibiotic, and doses are not changed daily. 

 ANTIBIOTIC DIVERSITY

1. Offline cycle to on cycle: Mixed  use of different antimicrobial classes for different patients in units

2. Quarterly Rotation 

3. True cycling

Prudent use of antibiotic in respiratory tract infection

When sputum becomes yellowish green, do not try to use antibiotics because bacterial infection complicates roughly 0.5% to 2 % of upper respiratory tract infection.

Indiscriminate use of antibiotics sensitise population, produces superinfection,masking serious infection without eradicating it and produces drug resistance and toxicity.

The low hanging fruit of AMS i.e., implementation of most obtainable interventions with limited  resources include: culture sent before antimicrobial start, IV to oral, pathogen directed antimicrobial treatment, therapeutic substitution, surgical  antimicrobial prophylaxis compliance and lastly avoiding use of > 1 antimicrobial with over lapping spectra.

Procalcitonin has been used as biomarker guide to determine the duration of antibiotic treatment for bacterial infection, a very important interventional tool for antibiotic stewardship. It has better advantage over CRP and WBC count. Also it is very useful unless culture results arrives and also in sepsis.

IDSA recommends Therapeutic Drug Monitoring (TDM), for antimicrobials particularly aminoglycosides and vancomycin. It should be included as a component of stewardship. IDSA also recommends use of continuous infusion for broad spectrum antibiotics and vancomycin, rather than standard infusion,  for better patient outcome and to decrease cost.

MINDME strategy guidelines, concept is useful to prescribers

M-Microbiology guided therapy, whenever possible

I-Indication should be evidence based 

N-Narrow spectrum required

D- Doses individualised to patient, and appropriate to the site and type of infection

M-Minimise duration of therapy

E- Ensure use of oral therapy, where clinically appropriate

Training programme followed at SSSIHMS, Prasanthigram, has been designed for 

1. Active Intervention with clinical rounds and discussing cases, reassessment of prescription  

2. Changing clinician behavior by conducting workshop sessions and updating local antibiotic guidelines.

SPECIFIC SITUATION WHERE ANTIBIOTIC TO BE WITHHELD ARE  

•          Viral pharyngitis 

•          Asymptomatic bacteriuria 

•          low grade fever 

•          Bed sores  

•          COPD 

•          Acute diarrhea and 

•          Microbial colonization and culture contamination.

Antibiotics directly do not cause resistance. They kill normal flora and decrease the movements of flora and spread resistant flora, leading to collateral damage

4 points Before prescribing Antibiotics 

•          Whether patient is stable or unstable

•          To know which is your enemy (appropriate system)

•          Do you have right weapon 

•          Special war land ( It reaches CNS )

Pillars of empirical treatment for serious hospital acquired infections 

• Timely: Any delay in initiation of treatment is potentially lethal 

• Streamlining is based on clinical response  

• Appropriate based on PK/PD parameters 

• Prompt discontinuation 

Also new updated antibiotic prescription policy has been provided in the SSSIHMS intranet for quick reference for empirical  treatment.

ANTIBIOTIC USE IN UTI

Drug concentration in urinary tract (Example: Tigecycline usage is avoided in UTI because of poor MIC ). 

• One dose or multiple dose. 

• Effects of oral/enteric/vaginal flora. 

• Patients’ age. 

• Local antibiotic pattern.

On some occasions antibiotics do not work because 

• Organisms is not covered for viral and fungal superinfection. 

• Noninfectious cases like autoimmune and malignancy 

• Dose, if not correct. Antibiotics can’t reach if road is closed ( Biofilm, chest tube prosthetic valve, abscess). 

Balance to present for : Appropriate treatment (susceptibility and timing). Adequate treatment (penetration). Optimal treatment( Pharmacokinetic and pharmacodynamic) 

UNNECESSARY COMBINATION is to be avoided: An example i) Augmentin with Tazobactam and Metronidazole for deep seated abscess ii) Linezolid usage for soft tissue infections though clindamycin is sensitive iii) Meropenem usage ,though tazocin and cepahalosporin sensitive despite culture result.

Combination of antibiotics is indicated in synergism, sepsis, neutropaenia, ESBL,drug resistant cases. Otherwise discussion to be done with Antibiotic  team, before initiating.

Recent  days there is no bacteriostatic or bactericidal term effective . It is always Minimum Inhibitor Concentration (MIC) that should be considered while giving treatment. This is exclusively important for cardiac and orthopedic patients.

CONCLUSION

Use antibiotics when needed, with evidence based practice, for better professional development. We have to  protect for future generation's benefits. Hit hard and hit early. Antibiotics use to be viewed as a medical  treasure and it is a  precious resource. It is a long term  process, hence lack of AMS  causes significant cost and mortality.