1. Antimicrobial Stewardship

2. The Problem Antibiotic resistance is a worldwide problem
Antibiotics are among the most commonly prescribed drugs used in human medicine
Up to 50% of antibiotics prescribed for people are unnecessary or inappropriate
Misuse of antibiotics leads to the emergence and spread of
antibiotic resistant organisms (e.g., methicillin-resistant Staphylococcus aureus, vancomycin-resistant enterococci, etc.)
Healthcare-associated infections (e.g., Clostridium difficile, etc.)

3. “…the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism.”
Alexander Fleming

4. National Action Plan to Combat Antibiotic Resistance
The Centers for Disease Control and Prevention (CDC) advised acute care hospitals to implement antibiotic stewardship programs (ASPs)
The Joint Commission (TJC) implemented antimicrobial stewardship standard MM effective date January 1, 2017
The Centers for Medicare & Medicaid Services’ (CMS) intends to require all acute care hospitals and long-term care facilities to incorporate an ASP as a mandatory Condition of Participation

5. Antibiotic Stewardship
Antimicrobial stewardship is a coordinated program that promotes the appropriate use of antimicrobials including antibiotics, improves patient outcomes, reduces microbial resistance, and decreases the spread of infections caused by multidrug-resistant organisms.
Utilizes informatics, data collection, personnel, and policy/procedures to promote optimal selection, dosing, and duration of therapy for antimicrobial agents throughout the course of their use

6. ASP Core Elements
Leadership Commitment: Dedicating necessary human, financial, and IT resources
Accountability: Single physician leader responsible for outcomes
Drug Expertise: Single pharmacist leader responsible for outcomes
Action: Implementing specific, proven interventions
Tracking: Monitoring antibiotic prescribing/resistance patterns
Reporting: Informing key stakeholders of progress regarding antibiotic use & resistance
Education: Updates on resistance & optimal prescribing

7. ASP Goals improve patient outcomes; slow the emergence of resistance;
prevent the spread of infections;
limit toxicity associated with antimicrobials including secondary infections (eg, Clostridium difficile);
contain costs.

8. Optimal Antimicrobial Use
All prescribers at ETMC Tyler are expected to adhere to the following principles when prescribing antimicrobial therapy:
Empiric therapy
initiate promptly after collection of appropriate specimens (whenever appropriate and possible);
target likely pathogen and source (anatomic site of infection);
consider possible antimicrobial resistance based on recent antimicrobial exposure and local resistance patterns;

9. Optimal Antimicrobial Use
Empiric therapy
select the narrowest spectrum possible for achieving the intended effect;
determine the appropriate dose, route and frequency of therapy;
Tailoring therapy
review microbiology results and broaden or narrow therapy as appropriate;
convert intravenous therapy to oral as soon as possible and clinically indicated.
Duration of therapy
use shortest effective duration of therapy.

10. ETMC Antimicrobial Stewardship
ETMC established an ASP in 2007
ASP core membership:
Infectious Diseases physician
clinical pharmacists

11. ETMC Antimicrobial Stewardship
ASP activities
Prospective audit of all inpatient antimicrobial use twice weekly
IV to oral conversion of therapy
Dose adjustment/optimization
Detection and prevention of antibiotic-related drug-drug interactions
Improve adherence to guidelines
Therapeutic drug monitoring

12. ETMC Antimicrobial Stewardship
Tracking and Reporting
Medication use evaluations/antibiotic audits to assess quality of antibiotic use
Days of antibiotic therapy
Detecting/monitoring trends in antimicrobial resistance

13. Bacteria vs Antibiotics
Inappropriate use of antibiotics contributes to emergence and spread of antibiotic resistant organisms and health-care associated infections.
Antimicrobial stewardship is vital for preserving existing antibiotics and improving patient outcomes while minimizing unintended consequences.
Antibiotic prescribing should be prudent, thoughtful and rational.

14. It was on a short-cut through the hospital kitchens that Albert was first approached by a member of the Antibiotic Resistance.