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ANTIMICROBIAL

STEWARDSHIP
WHY? WHAT? and HOW?
Ma. Charmian M. Hufano, MD, FPCP, FPSMID
Infectious Diseases Specialist

RESEARCH INSTITUTE FOR TROPICAL MEDICINE


ANTIMICROBIAL STEWARDSHIP

WHY

WHAT

HOW
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ANTIMICROBIAL RESISTANCE

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ANTIBIOTIC DEPLOYMENT
& RESISTANCE TIMELINE

Nature Chemical Biology 3, 541 - 548 (2007)


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ANTIMICROBIAL RESISTANCE &
SELECTIVE PRESSURE

http://mostlyscience.com/wp-content/uploads/2014/05/F4.large_.jpg
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ACQUISITION OF AMR

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ANTIBIOTIC SELECTIVE PRESSURE

APPROPRIATE ANTIBIOTIC USE

INAPPROPRIATE ANTIBIOTIC USE

-ANIMAL MEDICINE
-HUMAN MEDICINE

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INAPPROPRIATE ANTIBIOTIC USE
IN ANIMAL HEALTH

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INAPPROPRIATE ANTIBIOTIC USE

USE OF ANTIBIOTICS USE OF THE WRONG POLYPHARMACY


WHEN NOT NEEDED ANTIBIOTIC DOSE AND
(VIRAL INFECTIONS LIKE DURATION
THE FLU)
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MEDICINE USE IN PRIMARY CARE
IN DEVELOPING & TRANSITIONAL
COUNTRIES
• Review of studies 1990 to 2006

of antibiotics were prescribed


inappropriately

-WRONG DOSE
-WRONG DURATION
-WRONG INDICATION
http://www.who.int/medicines/publications/who_emp_2009.3/en/
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A DRUGSTORE SURVEY OF ANTIBIOTIC
USE IN A RURAL COMMUNITY IN THE
PHILIPPINES

• Cross-sectional survey of drug outlets in Laguna

57% had written prescriptions


6 tablets Median # of antibiotic units
dispensed per visit
61% of the variety stores sold antibiotics
Lansang MA etal. Phil J Microbiol Infect Dis. 1991; 20(2):54-58.
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INCREASING ANTIMICROBIAL
RESISTANCE & DECREASING NEW
ANTIBIOTICS IN THE PIPELINE

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INAPPROPRIATE ANTIBIOTIC
THERAPY IN GRAM-NEGATIVE SEPSIS

Outcomes Inappropriate Appropriate


Antibiotics Antibiotics
(n-238) (n=522)
Length of
hospital stay after 11 days 9 days
diagnosis
Hospital
-Retrospective cohort 51.7%
among patients with GN 36.4%
bacteremia
mortality
and severe sepsis or septic shock

Sharr AF etal. Crit Care Med 2011; 39:46-51


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AMR ANNUAL DEATHS BY 2050

Cost in global productions


from 2014-2050:
$100,000,000,000,000
.00

By Jim O'Neill Chairman of the Review on Antimicrobial Resistance - http://amr-review.org

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ANTIMICROBIAL
RESISTANCE SURVEILLANCE
PROGRAM
2016 ANNUAL REPORT

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ANTIMICROBIAL RESISTANCE
SURVEILLANCE PROGRAM (ARSP)
• WHO Working Group on the Regional Information Network
on Antimicrobial Resistance: a surveillance program be
initiated among member states of the Western Pacific Region to
contain and prevention resistance to antimicrobials

• Philippine Committee on Antimicrobial Resistance


Surveillance Program was created in 1988 by virtue of the
Department of Health’s Department Order 339-J. Aims to
provide critical inputs to the Department of Health’s effort
to promote rational drug use by determining the current
status and developing trends of antimicrobial resistance of
selected bacteria to specific antimicrobials.

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Region Sentinel Site
ARSP National Capital Region (NCR) Lung Center of the Philippines
SENTINEL SITES National Kidney and Transplant Institute
Rizal Medical Center
San Lazaro Hospital
Philippine General Hospital
Research Institute for Tropical Medicine
University of Santo Tomas Hospital
Far Eastern University Nicanor Reyes Medical
Foundation Medical Center
Cordillera Administrative Baguio General Hospital and Medical Center
Region (CAR)
Region 1 – Ilocos Region Mariano Marcos Memorial Hospital and Medical Center

Region 2 – Cagayan Valley Cagayan Valley Medical Center


Region 3 – Central Luzon Jose B. Lingad Memorial Regional Hospital
Region 4-A – CALABARZON Batangas Medical Center

Region 4-B – MIMAROPA Ospital ng Palawan


Region 5 – Bicol Region Bicol Regional Training and Teaching Hospital
Negros Island Region (NIR) Corazon Locsin Montelibano Memorial Regional
Hospital
Region 7 – Central Visayas Celestino Gallares Memorial Hospital
Vicente Sotto Memorial Medical Center
Region 8 – Eastern Visayas Eastern Visayas Regional Medical Center
Region 9 – Zamboanga Zamboanga City Medical Center
Peninsula Zamboanga del Norte Medical Center
Region 10 – Northern Northern Mindanao Medical Center
Mindanao
Region 11 – Davao Region Southern Philippines Medical Center
Region 12 – SOCCSKSARGEN Cotabato Regional Hospital and Medical Center

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Region 13 -MEDICINE
Caraga Region Caraga Regional Hospital
17
ARSP
Reference
Laboratory
Sentinel site data confirmatory Annual Report
testing and data
management

-Reference Laboratory
1) Data management using WHONET software
2) Confirmatory testing
1) Retesting using conventional and
automated methods
2) MIC determination
3) Serotyping
4) PCR testing for resistance genes
5) Whole Genome Sequencing

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ANTIMICROBIAL RESISTANCE
Antimicrobial Resistance
SURVEILLANCE PROGRAM
Surveillance Program
2015 Annual Report
2016 Data Summary
i Report

Antim crobial Resistance Surveillance


Antimicrobial Resistance Surveillance
Reference Laboratory
Research Instit
u Reference Laboratory
te for Tropical Medicine
Department ofResearch
Philippines
Health Institute for Tropical Medicine
Department of Health www.ritm.gov.ph
Philippines
www.arsp.com.ph

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Percent Resistance of Staphylococcus aureus
ARSP, 2016
100 96
90
80
70
61.5
60
50
40
30 24.6
20 13.2
11.4
10 6.1 8
4.3 1.4 0.8
0
4927 5072 3416 4423 4146 5250 5241 4245 3885 4495
Penicillin G Oxacillin Rifampin Ciprofloxacin
Cotrimoxazole
ClindamycinErythromycin Linezolid VancomycinTetracycline

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Yearly penicillin, oxacillin and vancomycin
resistance rates of Staphylococcus aureus,
ARSP, 2007-2016
100
90
80
70
%Resistance

60 60.3 62.6 61.5


54.3 52.7 56.6 53.2
50
46
40
35.6 36.1
30
20
10
0
2007 2008 2009 2010 2011 2012 2013 2014 2015 2016
Penicillin Oxacillin Vancomycin

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Percentage of Urinary Escherichia coli from
outpatient versus inpatient, ARSP, 2016

Outpatient Inpatient
Antimicrobial
No. %R No. %R
ORAL AGENTS
Ampicillin 879 84.4 2446 86.1
Co-amoxiclav 880 28.8 2388 39.6
Cefuroxime 359 39.3 803 41.7
Ciprofloxacin 809 52.2 2310 45.5
Co-trimoxazole 762 63.5 2148 68.7
Nitrofurantoin 614 4.4 1297 4.1
INTRAVENOUS AGENTS
Piperacillin/Tazobactam 888 7.4 2337 12.5
Ceftriaxone 778 38.7 1824 44.8
Ertapenem 421 2.9 982 5.1
Amikacin 742 1.5 2293 2.4
Legend: N=number tested; %R=percentage resistance; Outpatient=specimen taken from patients at the outpatient
Department or emergency room; Inpatient=specimen taken from patient admitted or hospitalized

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Percentage of ESBL suspect (ceftazidime resistant)
Klebsiella species, ARSP, 2016

90
81.2
80

70

60 57 58.3
53
50 46.4 45.7
44.2 43.9 43
39.9
40 36.6 37.2
33.2
30 31.2 30.3
30
21.1
17 18.8
20 15 13.5
10

0
780 247 287 129 228 897 400 141 400 210 258 250 696 154 277 1790 221 52 85 1196 163
BGH BRH BRT CMC CVM DMC EVR FEU GMH JLM LCP MAR MMH NKI NMC PGH RMC RTM STU VSM ZMC

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Percent Resistance of Pseudomonas aeruginosa
ARSP, 2016

25

20 19.4 18.8
17.7 17.2
15.3 15.1 14.9
15
13.2

10 8.6

0
5149 5416 5308 3608 5233 5377 5522 5146 5266
Pip/Tazobactam Ceftazidime Cefepime Aztreonam Imipenem Meropenem Amikacin Gentamicin Ciprofloxacin

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Percent Resistance of Acinetobacter baumanii
ARSP, 2016

60
54.4 55.6
53.7
52.1
50 47 45.5

40 38.4

30

20

10

0
2651 4102 3967 3564 4064 3939 3553
Ampicillin/Sulbactam Cefepime Imipenem Amikacin Gentamicin Ciprofloxacin Cotrimoxazole

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MDR, XDR and PDR Definition
Term Definition
MDR Acquired non-susceptibility to at least one agent in
(Multidrug- three or more antimicrobial categories
resistant)
XDR Non-susceptibility to at least one agent in all but
(Extensively two or fewer antimicrobial categories (i.e. bacterial
drug- isolates remain susceptible to only one or two
resistant) categories)
PDR Non-susceptibility to all agents in all antimicrobial
(Pandrug- categories.
resistant)

Falagas etal

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MDR and Possible XDR Pseudomonas aeruginosa &
Acinetobacter baumannii, ARSP, 2016

No. of isolates % Possible


Organism % MDR
tested XDR
Pseudomonas aeruginosa
All isolates 4430 21% 16%
Blood isolates 213 43% 20%
Acinetobacter baumannii
All isolates 3575 61% 50%
Blood isolates 435 52% 38%

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ANTIMICROBIAL STEWARSHIP

WHY

WHAT

HOW
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RATIONAL ANTIBIOTIC USE

-WHEN TO SAY NO -3 Rs OF ANTIBIOTIC


TO ANTIBIOTICS PRESCRIBING
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ANTIMICROBIAL STEWARDSHIP

IMPROVE RATIONAL ANTIBIOTIC USE

• LIMIT INAPPROPRIATE ANTIBIOTIC USE


• OPTIMIZE ANTIMICROBIAL USE

1) MAXIMIZE CLINICAL CURE/PREVENTION


2) LIMIT ANTIBIOTIC-ASSOCIATED CONSEQUENCES
3) LIMIT EMERGENCE OF ANTIMICROBIAL RESISTANCE

Dellit etal, CID 2007; 44


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CLINICAL OUTCOMES BETTER
WITH ANTIBIOTIC MANAGEMENT
PROGRAM
100
AMP UP
80
Percent

60

40

20

0
Cure Failure
Fishman N. Am J Med. 2006;119:S53.
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IMPROVING ANTIBIOTIC USE
SAVES MONEY

• Comprehensive programs have consistently


demonstrated a decrease in antimicrobial
use with annual savings of:

$200,000 - $900,000

Dellit et al, CID 2007; 44


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SUSCEPTIBILITIES BEFORE &
AFTER IMPLEMENTATION OF
ANTIBIOTIC RESTRICTIONS
Pseudomonas aeruginosa
Before After
100
80
Percent susceptible

60
40
20
0
Ticar/clav ImipenemAztreonam Ceftaz Cipro

CID 1997;25:230
RESEARCH INSTITUTE FOR TROPICAL MEDICINE
ANTIMICROBIAL STEWARSHIP

WHY

WHAT

HOW
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DOH AMS Program

• 2011 WHO Combat AMR: No action today,


No cure tomorrow
• 2014 Creating an Inter-Agency Committee for
the Formulation and Implementation of a
National Plan to Combat AMR in the Philippines
• 2015 The Philippine Action Plan to Combat
AMR: One Health Approach
• Antimicrobial Stewardship Program

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The National Antimicrobial
Stewardship (AMS) Program
• Concerted implementation of systematic, multi-disciplinary,
multi-pronged interventions in both public and private
hospitals in the Philippines to improve appropriate use of
antimicrobials, which is essential for preventing the emergence
and spread of antimicrobial resistance (AMR).

1. Promote rational and optimal antimicrobial therapy;


2. Improve patient outcomes and decrease healthcare costs
by reducing unnecessary antimicrobial use, adverse drug events,
and mortality and morbidity from infections (including secondary
infections by resistant pathogens);
3. Foster awareness on the global and country situation on the
threat of AMR and the compelling need to address it;

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The National Antimicrobial
Stewardship (AMS) Program
4. Effect positive behavior and/or institutional changes
through educational and persuasive interventions towards
improving the use of antimicrobials by the prescribers,
dispensers, other healthcare professionals, and patients;
5. Establish multi-disciplinary leadership and commitment,
clinical governance and accountability in antimicrobial
management to ensure that interventions are sustainable and
well-supported with necessary technical and financial resources;
6. Create an environment where healthcare professionals are
supported with monitoring tools and systems to implement
antimicrobial management;
7. Conduct research aiming to analyse the progress and
challenges on implementing hospital antimicrobial stewardship
program; and,
8. Prevent or slow down the emergence of AMR.
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 37
The National Antimicrobial
Stewardship (AMS) Program
• National goal of reducing the morbidity and mortality due
to AMR as indicated in the Philippine Action Plan to Combat
Antimicrobial Resistance: One Health Approach. The action plan
aims to achieve the following by 2020:

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KEY STEPS IN STARTING ASP
IN YOUR OWN HOSPITALS

1. DEFINING LEADERSHIP &


RESPONSIBILITY

2. DEFINING PRIORITIES & MEASURES

3. ADAPTING STRATEGIES TO YOUR


HOSPITAL
Adapted from Dellit TH et al. CID 2007; 44:158-77
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Core Element 1: LEADERSHIP
• All hospitals shall aim to establish an effective and efficient AMS
program that involves a multidisciplinary, multi-intervention
and coordinated strategy to optimize the use of
antimicrobials. This shall be made explicit through a formal
statement that the hospital supports initiatives to optimize the
use of antibiotics through effective stewardship and monitoring.

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Core Element 1: LEADERSHIP
• The overall responsibility and accountability in implementing a
hospital AMS program lies with the Chief of Hospital and
members of the hospital administration who can ensure
leadership and management support through, but not limited
to the following:
• Dedicating sufficient funding and resources for AMS-related
activities
• Allowing the staff to contribute to the AMS goals of the hospital
through participation in the hospital stewardship program
• Supporting training and continuous education
• Ensuring accountability from all levels and across relevant
clinical departments through continuous monitoring of
performance
• Building an enabling environment to support AMS-related
activities (e.g. IT system to monitor antibiotic use or antibiotic
alert systems)

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1. DEFINING LEADERSHIP &
RESPONSIBILITY
a. Hospital management needs to BUY-IN

Power
Dellit TH et al. CID 2007; 44:158-77
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Core Element 1: LEADERSHIP

• The Chief of Hospital shall create a governance structure


that will make explicit the different roles and
responsibilities, and job descriptions of all hospital staff in
stewardship-related activities and other relevant hospital
initiatives on infection prevention and control, with the end
goal of safeguarding the welfare and safety of patients.

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Core Element 1: LEADERSHIP
The AMS program is ideally
led by an AMS Committee
in partnership with the
Therapeutics Committee,
the Infection Control
Committee and the Patient
Safety Committee to
enable a holistic and
coordinated approach in
implementing AMS
strategies.

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“A” TEAM & ACCOUNTABILITY

MICRO
MEDICAL DIRECTOR
TOP MANAGEMENT ICC

“A” TEAM A TEAM

Dellit TH et al. CID 2007; 44:158-77


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1. DEFINING LEADERSHIP &
RESPONSIBILITY

b) Multidisciplinary “A” team


POWER
EXPERTISE
CREDIBILITY

Dellit TH et al. CID 2007; 44:158-77


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“A” TEAM
1. Infectious Diseases Specialist
2. Clinical pharmacist
3. Clinical microbiologist
4. Infection Control Professional
5. Hospital epidemiologist
6. Information system specialist
7. AMS Champion Doctors

Dellit TH et al. CID 2007; 44:158-77


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Core Element 2: Policies, Guidelines
and Clinical Pathways
• All hospitals shall have a hospital antibiotic policy to promote
rational antimicrobial prescribing and dispensing practices.
• All hospitals shall 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.
• Simple and clear clinical pathways shall be created to guide and
standardize treatment for timely and appropriate management
of infections, especially for common infections and syndromes.
• The AMS Committee, together with PTC and ICC, shall be
responsible for the development, implementation and revisions
of the hospital antimicrobial policy, standard guidelines and
pathways, with the support and commitment from the hospital
administration.

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Core Element 2: Policies, Guidelines
and Clinical Pathways
• A clear strategy for implementation shall be developed, such
that all relevant healthcare professionals are aware and enabled
to comply with the hospital’s antibiotic policy, guidelines and
clinical pathways.
• The policy, guidelines and clinical pathways shall be reviewed
regularly and updated as needed.

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KEY STEPS IN STARTING ASP
IN YOUR OWN HOSPITALS

1. DEFINING LEADERSHIP &


RESPONSIBILITY

2. DEFINING PRIORITIES & MEASURES

3. ADAPTING STRATEGIES TO YOUR


HOSPITAL
Adapted from Dellit TH et al. CID 2007; 44:158-77
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2. DEFINE YOUR PRIORITIES &
MEASURES

WHERE YOU ARE?


WHERE YOU WANT TO GO?

QUANTITATIVE KEY MEASURES:

-Surveillance data on antibiotic use and resistance

-Hospital datasets on consequences of interventions

Clinical Infectious Diseases 2007; 44:159-77


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Core Element 3: Surveillance of
Antimicrobial Use (AMU) and
Antimicrobial Resistance (AMR)
• The AMS Committee shall ensure the regular AMU monitoring
to be reported anually the DOH-PD, as well as to relevant
hospital departments.
• All hospitals shall conduct AMR surveillance for pathogens
defined by ARSP as reflected in their antibiogram which are to
be submitted anually to the Antmicrobial Resistance
Surveillance Program at the Research Institute for Tropical
Medicine (RITM)
• All hospitals shall develop institutional antibiograms at least
once a year. The AMS Committee shall ensure that institutional
antibiograms are accessible to all hospital healthcare staff and
that the latter are able to interpret and apply this information to
patient care.

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Core Element 3: Surveillance of
Antimicrobial Use (AMU) and
Antimicrobial Resistance (AMR)
• The microbiology laboratory of the hospital is required to
participate and pass both the National External Quality
Assessment Scheme (NEQAS) for microbiology and the
Antimicrobial Resistance Surveillance Program Bacteriology
Laboratory Accreditation.
• The ARSP accreditation shall be one of the bases for
reimbursement of select antibiotics by the PhilHealth.
• The hospital management shall strengthen the capacity for
laboratory surveillance that shall allow monitoring of
antimicrobial susceptibility patterns and detection of
resistantpathogens.

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KEY STEPS IN STARTING ASP
IN YOUR OWN HOSPITALS

1. DEFINING LEADERSHIP &


RESPONSIBILITY

2. DEFINING PRIORITIES & MEASURES

3. ADAPTING STRATEGIES TO YOUR


HOSPITAL
Adapted from Dellit TH et al. CID 2007; 44:158-77
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 57
Infectious Diseases Society of America &
Society for Healthcare Epidemiology of America

Guidelines for Developing an


Institutional Program to
Enhance Antimicrobial Stewardship
Clinical Infectious Diseases 2007; 44:159-77

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Core Element 4: Action

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FORMULARY RESTRICTION &
PRE-AUTHORIZATION

Antibiotic prescription

+/- First few doses

Institution restriction criteria

ASP- approval/disapproval

Patient
Chung GW etal. Virulence 4:2, 151-157; Feb 15, 2013
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PROSPECTIVE AUDIT WITH
INTERVENTION & FEEDBACK

•Regular review by A team and feedback


recommendations if necessary

•Optimize therapy on a case by case basis

Clinical Infectious Diseases 2007; 44:159-77


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SUPPLEMENTAL STRATEGIES
Strategies Comments
Dose Pharmacokinetics & dynamics
optimization
Parenteral to High bioavailability antibiotics
oral conversion -Early conversion: reduce LOS,
complications associated with IV
access, costs
-Guidelines when to convert to
PO drugs?
Clinical -Multidisciplinary
pathways -Education and dissemination
Chung GW etal. Virulence 4:2, 151-157; Feb 15, 2013
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Core Element 5: Education
• Education, one of the core elements of AMS, aims to teach all
health professionals the necessary principles of judicious
prescribing and use of antimicrobials.
• All hospitals shall aim to provide training and continuous
education to healthcare staff, who are in contact with patients
on antibiotics. These include not only the prescribers (i.e.
attending physicians), nurses, clinical pharmacists,
microbiologists, and midwives, but also medical students and
paramedical staff under training to ensure that the transfer of
basic and advanced scientific knowledge and skills on the
proper use of antibiotics occurs at an early stage.The AMS
Committee shall ensure that the above-mentioned hospital
personnel attend the standard Training Course on AMS through
an education program certified or recognized by the DOH.

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Core Element 5: Education
• Hospitals, especially teaching and training institutions, shall also
develop training modules with clear learning outcomes and
competencies on AMS starting early in the undergraduate
curriculum up to postgraduate training covering microbiology,
prevention and control of infectious diseases, clinical
pharmacology, hospital pharmacy and patient communication
skills and the prudent use of antibiotics.
• All AMS Practitioners must be on a relevant professional
registry such as the Register of Physicians/Specialists, Register
of Pharmacists, Register of Nurses or their equivalent AND have
completed an AMS training program specifically for AMS
practitioners that is conducted or recognized by the DOH.
• AMS Practitioners shall continually update themselves on the
newest developments in the area of microbiology, infectious
disease management and prevention, pharmacotherapy, and
AMS practice.
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Core Element 5: Education

• Educational strategies must also be targeted to patients and


their caregivers on basic principles of infection prevention and
control, personal hygiene, handwashing, and core messages on
AMR and AMS. All hospitals shall ensure that systems are in
place for patient education and counselling on how to correctly
take their prescribed antimicrobials and responsibly use
antimicrobials.

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KEY STEPS IN STARTING ASP
IN YOUR OWN HOSPITALS

1. DEFINING LEADERSHIP &


RESPONSIBILITY

2. DEFINING PRIORITIES & MEASURES

3. ADAPTING STRATEGIES TO YOUR


HOSPITAL
Adapted from Dellit TH et al. CID 2007; 44:158-77
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 74
Core Element 6: Performance
Evaluation
• Measuring process and clinical indicators to assess the
overall quality management improvement and
effectiveness of AMS interventions in the hospital is a
fundamental component of a successful AMS Program.

• The AMS Committee of all hospitals are to submit to the DOH


Pharmaceutical Division an annual AMS program monitoring
report for tracking of progress of the AMS Program.

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Requirements and Timeline of
Implementation
of AMS Program by Level of Healthcare
Facility
Core Elements Level I Level II Level III

1. Leadership 2018 2018 2018

2. Policy, Guidelines and Clinical Pathways 2018/2019 2018/2019 2018/2019


3. Surveillance of AMU and AMR AMU 2019 AMU 2018 AMU 2018
AMR 2019 AMR 2019
4. Action

Restriction and Preauthorization 2019 2018 2018

7th Day Automatic Stop Order 2019 2018 2018

POC Interventions NA 2019 2019

Audit and feedback NA 2022 2022

5. Education 2018 2018 2018

6. Performance Evaluation 2022 2022 2022

AMS Training Implementation 2020 2018 2017

Full Implementation of AMS Program in the Hospital Jan 2022 Jan 2022 Jan 2022

1st Performance Evaluation Report to be submitted to Jan 2021 Jan 2019 Jan 2018
DOH

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SUMMARY:
ANTIMICROBIAL STEWARDSHIP
1. Inappropriate antibiotic is a main driver
accelerated acquisition of antimicrobial
WHY resistance.
2. Antimicrobial stewardship aims to
improve patient outcomes, prevent
WHAT antibiotic adverse effects and decrease
resistance rates.
3. Collective ownership of an ASP lead by
hospital management and a
HOW multidisciplinary team; with set priorities;
and strategies adapted to your own
hospital are the keys to its successful
implementation.
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 77
REFERENCES
WHY
• Clatworthy AE, Pierson E and Hung DT. Targeting virulence: a new paradigm for
antimicrobial therapy. Nature Chemical Biology 3, 541 - 548 (2007)
doi:10.1038/nchembio.2007.24
• ARSRL. ARSP annual summary report 2013 accessed from www.ritm.gov
• WHO. Medicines use in primary care in developing and transitional countries
accessed from http://www.who.int/medicines/publications/who_emp_2009.3/en/
• Lansang MA, et al. A drugstore survey of antibiotic use in the Philippines. Phil j
Microbiol Infect Dis 1991; 20(2):54-58 accessed from
http://www.academia.edu/4483361/A_Drugstore_Survey_of_Antibiotic_Use_in_a_Rur
al_Community_in_the_Philippines
• Spellberg B etal. The Epidemic of Antibiotic-Resistant Infections, CID 2008:46 (15
January) Clin Infect Dis. (2011) May 52 (suppl 5): S397-S328.doi: 10.1093/cid/cir 153.
• Shorr AF et al. Inappropriate antibiotic therapy in gram-negative sepsis increases
hospital length of stay. Crit Care Med 2011; 29(1):46-51.

RESEARCH INSTITUTE FOR TROPICAL MEDICINE 78


REFERENCES
WHAT
• Dellit TH et al. Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship. CID 2007; 44:158-77.
• Fishman N. Antimicrobial stewardship. Am J Med. 2006;119:S53-S61.
• CID 1997;25:230.
HOW
• Dellit TH et al. Infectious Diseases Society of America and the Society for Healthcare
Epidemiology of America Guidelines for Developing an Institutional Program to
Enhance Antimicrobial Stewardship. CID 2007; 44:158-77.
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A MATTER OF LIFE AND DEATH:
THE ECONOMICS OF ANTIBIOTICS
“One person’s use (or misuse) contributes to
lower effectiveness for everyone. The spread
of resistance by overuse of antibiotics is like
other shared resource problems, such as
global warming or overfishing…”

R. Laxminarayan,
Miklen Institute Review, July 2012

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Disclosure

• Infectious Disease Consultant, St. Luke’s Medical Center, Global


City
• Infectious Disease Consultant, Delos Santos Medical Center,
Quezon City
• Medical Specialist, Antimicrobial Resistance Surveillance
Reference Laboratory, Research Institute for Tropical Medicine
• Member DOH AMS Steering Committee

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