Antimicrobial Stewardship

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  • Created by: LBCW0502
  • Created on: 17-01-20 09:12
Why do we need to optimise antimicrobial usage? (1)
Overuse of antimicrobials drives resistance. Use of inappropriate antimicrobials leads to worse clinical outcome. Inappropriate use of combination antimicrobial therapy can lead to no better outcome, increased ADRs and increased costs
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Why do we need to optimise antimicrobial usage? (2)
Delays in administration of antimicrobials can lead to worse clinical outcomes. Excessive duration of antimicrobial use leads to resistance, HCAIs and increased costs
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Why do we need to optimise antimicrobial usage? (3)
Impact on patient if an inappropriate antimicrobial is used - stay longer in hospital, high morality rate, further resistance. Pharmacists help HCPs use the appropriate antimicrobials. Particular risk factors
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Why do we need to optimise antimicrobial usage? (4)
Different infection can be caused by a different organism e.g. patient acquires an infection during travel
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Why should combination therapies be avoided?
Cost, ADRs, polypharmacy, not better outcome if more than one antibiotic is used (no benefit of a second agent with the same function as the first agent. Sometimes a combination is effective if it is required for multiple organisms
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What is the consequence of delaying an antibiotic when there are suspicions of sepsis in a patient?
Identify sepsis within 30 mins. Longer delay in antibiotic given to patient leads to a poorer prognosis (mortality rate increases every hour by 7.5%)
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How does a pharmacist determine appropriate aspects of drug?
Look at the PK and PD of the possible drugs (find appropriate dose). Adjust doses/medicines if there is renal/hepatic impairment or drug interactions). Ensure appropriate duration
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What are the consequences of under-dosing or overdosing a patient?
Under-dose - poor outcome. Overdose - toxicity/poor outcome (need the right balance)
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What is the consequence of using an antimicrobial for too long?
Patient becomes exposed to drug longer than needed, causes resistance, super infection, organism no longer susceptible to antibiotic. Also increases cost
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What is the consequence of using IV drugs in patients for a long period of time?
Patients stay in hospital for longer
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Give examples of the national drivers for antimicrobial stewardship (1)
UK 5 year AMR strategy 2013-18. Guidelines for surveillance programmes, management of infection in primary care, behaviour change/antibiotic prescribing in healthcare settings. Start smart, then focus (antimicrobial stewardship in secondary care)
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Give examples of the national drivers for antimicrobial stewardship (2)
CQUIN, health and social care act 2008, patient safety alerts, tackling AMR 2019-24 etc
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What are the ambitions in the UK for antimicrobial stewardship?
Continue to be a good global partner. Drive innovation. Minimise infection. Provide safe and effective care to patients. Support sustainable supply and success. Demonstrate appropriate use of antimicrobials. Engage the public on AMR
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How is the success of these ambitions measured? (1)
By the targets - reduce the incidence of a specific set of drug-resistant infections (e.g. E.coli) in humans in the UK by 10% by 2025 and halve the number of healthcare associated Gram -ve blood stream infections
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How is the success of these ambitions measured? (2)
Reduce UK antimicrobial use in humans by 15% by 2024 including 25% reduction in antibiotic use in community from the 2013 baseline and 10% reduction in use of reserve/watch antibiotic in hospitals form 2017 baseline
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How is the success of these ambitions measured? (3)
Be able to report on the % of prescriptions supported by use of a diagnostic test or decision support tool by 2024 with improvement targets set up by 2025
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What is the extent of antimicrobial usage at GSTT and associated risks? (1)
50% of antimicrobials are used inappropriately. 50% (600) of in-patients are on antimicrobials. 300 patients/day may require an intervention. 15 patients/day added to informal referral/watch list
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What is the extent of antimicrobial usage at GSTT and associated risks? (2)
Robust data is time consuming to generate/hard to maintain. Consistency is lacking
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What are the important factors to consider as a pharmacist giving antimicrobials to patients?
Choice of drug, ROA, duration, dose, frequency, adjustments if there is hepatic/renal impairment/drug interactions)
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What are the factors affecting antimicrobial usage?
Drug factors (spectrum of activity, ROA). Organism factors (potential for resistance, Gram state). Patient factors (renal/hepatic impairment, severity of infection (IV/high dose/time of treatment), allergies)
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How do we tackle the problem?
Cut down the use of antibiotics or optimise the use of antibiotics (antimicrobials have ecological impacts due to overuse)
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State features of the Health and Social Care Act of 2008 (1)
Make registration requirements relating to infection prevention clear to all providers. Guidance for CQCs to make judgement about compliance with requirements for infection prevention
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State features of the Health and Social Care Act of 2008 (2)
Provide information for people who use services of a registered provider. Provide information for commissioners of services on what they should expect of providers. Provide information for general public
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What is the purpose of the NICE guidance on antimicrobial stewardship?
To provide good practice recommendations on systems and processes for the effective use of antimicrobials
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What are the aims of the NICE guidance on antimicrobial stewardship? (1)
Monitor/evaluate antimicrobial prescribing. Produce/review guidance. Study relationship of prescribing to resistance. Provide regular feedback (annually) on prescribing habits/individual prescribing, patient safety incidents e.g. HCAIs, ADRs, CDI
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What are the aims of the NICE guidance on antimicrobial stewardship? (2)
Provide E&T on stewardship/resistance. Integrate audit into existing QI programmes. (Achieve aims as an organisation, not as individuals)
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What are the NICE quality standard statements? (1)
1. People with a self-limiting condition assessed by primary care receive advice on self-management and adverse consequences of overusing antimicrobials
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What are the NICE quality standard statements? (2)
2. Prescribers in primary care use a back-up/delayed antimicrobial prescribing when there is clinical uncertainty about a self-limiting condition deteriorating
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What are the NICE quality standard statements? (3)
3. People prescribed an antimicrobial have the clinical indication, dose, duration of treatment on clinical record
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What are the NICE quality standard statements? (4)
4. People in hospital prescribed an antimicrobial have a microbiological sample taken and treatment is reviewed when the results are available
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What are the NICE quality standard statements? (5)
5. Individuals/teams responsible for antimicrobial stewardship monitor data and provide feedback on prescribing practice at prescriber, team, organisation and commissioner level
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What are the NICE quality standard statements? (6)
Prescribers in secondary/dental care use EPS that link indication with antimicrobial prescription
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Who is involved in the AMS programme?
Multi-disciplinary team (physical/clinical microbiologist, pharmacist, infection control, IT, epidemiology support). AMS committee - members of team, director for infection prevention/control, intensivists, physicians, surgeons, paediatricians etc
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What are the aims of the 'start smart, then focus' guideline (antimicrobial stewardship toolkit for English hospitals)? (1)
Evidence of documentation of indication and review date on chart. Evidence of review of therapy at 48-72h and documentation of decision. Time between onset of sepsis and antibiotics. Adherence to local guidelines. AMR and consumption trends
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What are the aims of the 'start smart, then focus' guideline (antimicrobial stewardship toolkit for English hospitals)? (2)
Monitor outcomes (e.g. increased time to clinical cure, increased length of stay, increased re-admission rate). Local surgical prophylaxis practice
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State the steps of the start smart, then focus strategy (1)
Right drug/time/dose/duration (every time). Start smart, then focus (surgical prophylaxis, one dose, allergy, follow local guidance, document/chart/notes, clinical indication/stop and review date, take appropriate specimens). Clinical decision at 48h
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State the steps of the start smart, then focus strategy (2)
Clinical review. Check microbiology result. Options - stop, switch (IV to oral), continue (review at 72h), change (narrow spectrum), COPAT ((complex) out-patient antibiotic therapy). Document decision
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What are the issues with the start smart, then focus strategy? (1)
Allergy (need to determine severity, childhood, was more than one drug involved, type of reaction e.g. allergic to penicillin - cannot use beta lactam due to cross-sensitivity). Other options (not as good) - tetracyclines, amino-glycosides.
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What are the issues with the start smart, then focus strategy? (2)
Need to record specific indication for antimicrobial e.g. pneumonia, meningitis. Important for hand-overs/information (need to be confident in the reason for the antimicrobial used/be able to discontinue if required)
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State the aspects of stewardship in primary care (1)
TARGET toolkit for GPs. Background information about TARGET. Resources for commissioners. Leaflets to share with patients. Audit toolkits. National antibiotic management guidance. Training resources. Resources for clinical and waiting areas
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State the aspects of stewardship in primary care (2)
Self-assessment checklist. Useful links. Leaflets (treating your infection - find out how long different infections last, self-care, when to get help). Audits (assessment compliance with guidance, determine no. of patients prescribed an antibiotic)
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Give examples of antimicrobial strategies in UK hospitals (1)
Guidelines for antibiotic therapy, guidelines for surgical prophylaxis, antibiotic formulary, restricted list, education campaigns, automatic stop policy, antibiotic committee, antibiotic audit, IV to oral switch guidance, microbiology ward rounds
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Give examples of antimicrobial strategies in UK hospitals (2)
Stewardship ward rounds, antimicrobial consumption surveillance, dedicated antimicrobial prescription chart, inflammatory marker testing
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Give examples of antimicrobial strategies in UK hospitals (3)
Allow antibiotic to be given at home, local infusion centres, nurses visiting patients at home, patient education for self-administration of IV antimicrobials, better for patients to be at home – reduce risk of infection spreading/hospitalisation
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What are the antimicrobial stewardship interventions in the NICE guidance (2015)? - 1
Review prescribing to explore reasons for - increasing very high/low volumes of antimicrobial prescribing, use of antimicrobials not recommended in local/national guidelines. promotion of guideline antimicrobials. Education based programmes
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What are the antimicrobial stewardship interventions in the NICE guidance (2015)? - 2
IT/decision support systems. Provide information on antimicrobial use when a patient's care is transferred to another care setting. Prioritising the monitoring of antimicrobial resistance to support AMS
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What are the antimicrobial stewardship interventions in the NICE guidance (2015)? - 3
Evaluate effectiveness of antimicrobial stewardship interventions
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What other outcome measures/quality metrics can be used? (1)
Allergy documentation and action. Appropriateness of surgical prophylaxis. Appropriateness of treatment antibiotic/compliance with local guideline. Appropriateness and timing of investigations. Documentation of indication/duration/review
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What other outcome measures/quality metrics can be used? (2)
Individual review components. Choice of antibiotics - restricted agents. Use of antibiotics - overall consumption, expenditure, point prevalence data/unit specific data, drug-specific data, organism specific data
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What is the pharmacists role in AMS? (1)
Prescription review on initiation - check allergies, indication, drug, appropriateness, organ function, dose, route, frequency, duration, investigations
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What is the pharmacists role in AMS? (2)
Ongoing review - continuing appropriateness, route (IV/oral), dose/frequency (appropriate?), investigations (scope for optimisation), clinical progress (change therapy?), duration (course length?), monitoring (response markers/toxicity)
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What is the pharmacists role in AMS? (3)
Response markers and diagnostic markers e.g. pneumonia – temperature/pyrexia, difficulty breathing, poor oxygenation (changes in symptoms over course of treatment)
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Why do we need to optimise antimicrobial usage? (2)

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Delays in administration of antimicrobials can lead to worse clinical outcomes. Excessive duration of antimicrobial use leads to resistance, HCAIs and increased costs

Card 3

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Why do we need to optimise antimicrobial usage? (3)

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Card 4

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Card 5

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