Understanding Antimicrobial Stewardship in Healthcare

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Human & Animal Health
Case Scenarios
 
Aoife Hendrick
CPhO Clinical Fellow
Public Health England
 
@AoifeJHendrick
 
James Russell
Junior Vice President
British Veterinary Association
   @uttoxeterjames
 
Why should we bother?
 
Around 38% of patients are on antimicrobials
Unnecessary use leads to increased side effects, infections and wastes
money
Increased resistance locally, nationally and internationally
Limited supply of novel antibiotics
Financial rewards and penalties
(CQUIN, C.Diff, MRSA)
Direct benefit to patient outcomes
What is causing resistance?
 
Bacteria evolve to survive
Broad spectrum antibiotics
Longer durations than required
No clear evidence of bacterial infection
(viral) – inappropriate prescribing
Inadequate doses
Illogical combinations
Patient non-compliance and self
medication
 
What to think about when prescribing?
 
PMHx
DHx and interactions
Food – drug interactions
Previous microbiology results
Investigations required
Samples
Allergies
Source of infection
Likely organism
Route
Dose
 
Side effects
Monitoring
TDM
Antibiotic Guidelines
Microbiology advice
Duration
Availability
Formulary
Cost
Resistance
Frequency of administration
 
The Stewardship Checklist
 
Does the patient have any allergies?
Is the indication documented on the prescription?
Is the duration documented on the prescription?
Has the treatment been reviewed within 24-72 hrs?
Is the plan clearly documented?
Does the treatment make sense? Is it appropriate?
Is there sufficient supply of the antibiotic?
Are levels or samples needed?
 Avoid missed doses or delays to STAT doses
 
Antimicrobial Stewardship Toolkits
 
 
 
 
Start Smart then Focus stewardship campaign (PHE)
highlighted the importance of stopping antibiotics
and shortening duration when infection is not
confirmed and the developed toolkits encourage
this activity
 
6
 
National Early Warning Score (NEWS)
 
NEWS is a tool developed by the 
Royal College of Physicians
 which
improves the detection and response to clinical deterioration in adult
patients and is a key element of patient safety and improving patient
outcomes.
 
A score is allocated to physiological measurements:
respiration rate
oxygen saturation
systolic blood pressure
pulse rate
level of consciousness or new confusion
temperature.
 
 
 
7
 
Antimicrobial Stewardship Toolkits
 
8
 
NICE/PHE Guidance
 
https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/antimicrobial-prescribing-
guidelines
 
9
 
WHO – AwARe
 
Aims to increase the proportion of global
consumption of antibiotics in the Access group to at
least 60%, and to reduce use of the antibiotics most
at risk of resistance from the Watch and Reserve
groups.
 
Antimicrobial Resistance & Stewardship UCL Pharmacy Lecture        Dr Diane Ashiru-Oredope/ Aoife Hendrick
 
10
10
 
Antibiotic Allergy Status
 
First principle good drug history – ensure first line treatment option is available to
the patient.
Self-reported beta-lactam ‘allergy’ is common
up to 20% of hospitalized patients
10% of the general population in the UK
only 1–10% of these patients have evidence of type I hypersensitivity on testing.
 
Amoxicillin and ampicillin are associated with delayed maculopapular rashes in 5–10% of
patients particularly in the presence of a viral infection. “Childhood Rash”
 
There is morbidity, mortality, and economic cost associated with the label of penicillin
allergic. Including increased length of stay, increased risk of healthcare associated
infections and increased cost.
Access
 
 
Reserve Antibiotics
 
11
11
 
Summary of a vets thoughts
on AMR
 
James Russell BVetMed MRCVS
Aston University
16
th
 November 2019
 
One Health
Metaphylaxis
Are vets better than medics?
 
The wormer experience
 
94% resistant to white wormers
 
68% to yellow
 
50% to clear
The wormer experience
 
Summary thoughts
 
Final comments?
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Exploring the critical aspects of antimicrobial stewardship, including the reasons for antibiotic resistance, considerations for prescribing antibiotics, stewardship checklists, and the role of toolkits in promoting responsible antibiotic use to combat resistance. The importance of monitoring, documentation, and patient-specific factors in antibiotic therapy is emphasized to optimize patient outcomes and combat the global challenge of antimicrobial resistance.


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  1. Human & Animal Health Case Scenarios James Russell Junior Vice President British Veterinary Association @uttoxeterjames Aoife Hendrick CPhO Clinical Fellow Public Health England @AoifeJHendrick

  2. Why should we bother? Around 38% of patients are on antimicrobials Unnecessary use leads to increased side effects, infections and wastes money Increased resistance locally, nationally and internationally Limited supply of novel antibiotics Financial rewards and penalties (CQUIN, C.Diff, MRSA) Direct benefit to patient outcomes

  3. What is causing resistance? Bacteria evolve to survive Broad spectrum antibiotics Longer durations than required No clear evidence of bacterial infection (viral) inappropriate prescribing Inadequate doses Illogical combinations Patient non-compliance and self medication

  4. What to think about when prescribing? PMHx Side effects DHx and interactions Monitoring Food drug interactions TDM Previous microbiology results Antibiotic Guidelines Investigations required Microbiology advice Samples Duration Allergies Availability Source of infection Formulary Likely organism Cost Route Resistance Dose Frequency of administration

  5. The Stewardship Checklist Does the patient have any allergies? Is the indication documented on the prescription? Is the duration documented on the prescription? Has the treatment been reviewed within 24-72 hrs? Is the plan clearly documented? Does the treatment make sense? Is it appropriate? Is there sufficient supply of the antibiotic? Are levels or samples needed? Avoid missed doses or delays to STAT doses

  6. Antimicrobial Stewardship Toolkits Start Smart then Focus stewardship campaign (PHE) highlighted the importance of stopping antibiotics and shortening duration when infection is not confirmed and the developed toolkits encourage this activity 6

  7. National Early Warning Score (NEWS) NEWS is a tool developed by the Royal College of Physicians which improves the detection and response to clinical deterioration in adult patients and is a key element of patient safety and improving patient outcomes. A score is allocated to physiological measurements: respiration rate oxygen saturation systolic blood pressure pulse rate level of consciousness or new confusion temperature. 7

  8. Antimicrobial Stewardship Toolkits 8

  9. NICE/PHE Guidance 9 https://www.nice.org.uk/about/what-we-do/our-programmes/nice-guidance/antimicrobial-prescribing- guidelines

  10. WHO AwARe Aims to increase the proportion of global consumption of antibiotics in the Access group to at least 60%, and to reduce use of the antibiotics most at risk of resistance from the Watch and Reserve groups. Antimicrobial Resistance & Stewardship UCL Pharmacy Lecture Dr Diane Ashiru-Oredope/ Aoife Hendrick 1 0

  11. Antibiotic Allergy Status First principle good drug history ensure first line treatment option is available to the patient. Self-reported beta-lactam allergy is common up to 20% of hospitalized patients 10% of the general population in the UK only 1 10% of these patients have evidence of type I hypersensitivity on testing. Amoxicillin and ampicillin are associated with delayed maculopapular rashes in 5 10% of patients particularly in the presence of a viral infection. Childhood Rash There is morbidity, mortality, and economic cost associated with the label of penicillin allergic. Including increased length of stay, increased risk of healthcare associated infections and increased cost. Access Reserve Antibiotics 1 1

  12. Summary of a vets thoughts on AMR James Russell BVetMed MRCVS Aston University 16th November 2019 @uttoxeterjames @BritishVets

  13. One Health @uttoxeterjames @BritishVets

  14. Metaphylaxis @uttoxeterjames @BritishVets

  15. Are vets better than medics? @uttoxeterjames @BritishVets

  16. The wormer experience 94% resistant to white wormers 68% to yellow 50% to clear @uttoxeterjames @BritishVets

  17. The wormer experience No testing metaphylaxis No efficacy testing @uttoxeterjames @BritishVets

  18. Summary thoughts @uttoxeterjames @BritishVets

  19. Final comments? @uttoxeterjames @BritishVets

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