1. Enoch Omonge University of Nairobi
Antibiotic Stewardship Programme at the Kenyatta National Hospital , Nairobi , Kenya
Enoch Omonge
University of Nairobi

2. Genesis of antibiotic stewardship initiatives at the Kenyatta National Hospital
National Medicines and Therapeutic Committee (Ministry of Health) - AMU
Kenyatta National Hospital (KNH)Medicines and Therapeutic Committee
KNH Formulary Committee
KNH Infection Prevention and Control Unit
Kenya Antibiotic Consensus Group (Education)

5. Challenges of infection prevention and Antimicrobial resistance
Referral hospital - large patient population, inadequate patient isolation space and protocol
Liberal use of antimicrobials . No preauthorisation policy
Delay microbiological sample collection and predominant empiric antibiotic therapy
Absence of treatment protocols and guidelines
Inadequate local PK/PD data
Inappropriate OPAT and easy access to antibiotics

10. Antibiotic protocols as strategy to appropriate antimicrobial use
Providing safe use of antimicrobial
Managing antimicrobial resistance
Improving quality of care by enhancing appropriate antimicrobial selection
Ensuring cost effectiveness

11. Therapeutic options HOST EVIDENCE STANDARDS BUG DRUG AUDITS GUIDELINES
Clinical
Laboratory
Imaging
EVIDENCE
EBM
STANDARDS
BUG
DRUG
AUDITS
GUIDELINES
INTERVENTION
Rational
Cost effective
Evolve
Omonge e

12. Composition of the multidisciplinary protocol development team
Medical specialists
Microbiologists
Clinical pharmacists
Infection prevention and control team
Medicine and therapeutic committee
Representative of the hospital administration

13. Process of protocol development
KNH antibiogram used to establish the antibiotic susceptibility pattern
Similar protocols to be developed for other hospital units
Periodic revision envisaged every two years
Modifications in special groups e.g pregnant/lactating mother, renal/hepatic failure, recent antimicrobial therapy, hypersensitivity , drug interactions

14. Antimicrobial stewardship
Selecting appropriate antibiotic
Optimising dose and duration of therapy
Minimising toxicity
Reducing resistance selection

16. Principles of AAU Principles for appropriate prescribing
and effective (locally compliant) guidelines:
TREAT bacterial infection only
OPTIMIZE diagnosis / severity assessment
MAXIMIZE bacterial eradication
RECOGNIZE (local) resistance prevalence
UTILIZE pharmacodynamics - for effective agents and dosage
INTEGRATE local resistance, efficacy and cost-effectiveness
Appropriate prescribing conforms to these criteria
Ball et al. Antibiotic therapy of community respiratory tract infections: strategies for optimal outcomes and minimized resistance emergence. J Antimicrob Chemother 2002; 49:31–40

18. How to use the protocol
Identify type of infection – bloodstream, respiratory, intra-abdominal, urinary tract, SSTI
Identify location- CCU
Risk stratify the patient- category 1,2 or 3
Refer to the empiric therapy column
Send respective cultures before starting antibiotics
De-escalate with culture reports

20. Data from Jones RN. Clin Infect Dis. 2010;51(S1):S81–7.
Incidence of pathogens isolated in aspirates of patients hospitalised with pneumonia in 2012 at the KNH CCU
Incidence of pathogens isolated from patients hospitalised with pneumonia in the United States in the last 5 years of the SENTRY Antimicrobial Surveillance Program
Pathogen
Incidence
(%)
n=197
K. pneumonia
22.3
Citrobacter spp.
16.2
Ps. aeruginosa
12.7
E. coli
9.6
Acinetobacter spp.
Enterococcus
S. pneumoniae
8.1
Proteus spp.
6.6
Enterobacter spp.
5.1
Incidence (%)
Pathogen
n = 31,346
S.aureus
36.3
Ps. aeruginosa
19.7
Klebsiella spp
8.5
Enterobacter spp
6.5
Acinetobacter spp
4.8
E. coli
4.6
Serratia spp
4.1
Stenotrophomonas maltophilia
3.1
S. pneumoniae
2.5
H. influenzae
Data from Jones RN. Clin Infect Dis. 2010;51(S1):S81–7.
Data from KNH

21. Algorithm for classifying patients with hospital-acquired pneumonia according to the Consensus Statement of the American Thoracic Society. Adapted with permission of the American Thoracic Society. Copyright 1996 American Thoracic Society. Hospital-acquired pneumonia in adults: diagnosis, assessment of severity, initial antimicrobial therapy, and preventative strategies. A consensus statement. Am J Respir Crit Care Med 1996; 153:1711–1725.

22. ATS/IDSA algorithm for initiating empirical antibiotic therapy for hospital- acquired pneumonia (HAP), ventilator-associated pneumonia (VAP), and health care–associated pneumonia (HCAP) *Prior antimicrobial therapy (within 90 days), hospitalization for 5 days, high frequency of antibiotic resistance in the community or the hospital unit, immunosuppressive disease or therapy. Adapted with permission of the American Thoracic Society. Copyright American Thoracic Society. Am J Respir Crit Care Med. 2005; 171:388–416.

23. Potential Microorganisms in Each Group According to the 1996 Consensus Statement of the American Thoracic Society.
Group 1
Group 2
Group 3
Enteric gram-negative bacilli
E. coli
Enterobacter spp.
Klebsiella spp.
Proteus spp.
Serratia marcescens
H. influenzae
MSSA
S. pneumoniae
Anaerobes
MSSA and MRSA
Legionella spp.
Ps. aeruginosa
Acinetobacter spp.
MRSA
MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible Staphylococcus aureus.
Am J Respir Crit Care Med 1996; 153:1711–1725

24. Recommended treatment
Initial Empirical Antimicrobial Treatment for Patients with Hospital-Acquired, Ventilator-Associated, or Healthcare–Associated Pneumonia
Potential pathogen
Recommended treatment
No risk factors for MDR, early onset and any disease severity
Ceftriaxone; levofloxacin, moxifloxacin, ciprofloxacin; ampicillin-sulbactam or ertapenem
S. pneumoniae
H. Influenzae
MSSA
Antibiotic susceptible, enteric gram-negative bacilli
E. coli
Klebsiella pneumoniae
Enterobacter spp.
Proteus spp.
Serratia marcescens
ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus aureus; MSSA, methicillin-susceptible S. aureus.

25. Initial Empirical Antimicrobial Treatment for Patients with Hospital-Acquired, Ventilator-Associated, or Healthcare–Associated Pneumonia,
Potential pathogen
Recommended treatment
Late onset disease or risk factors for MDR pathogens and all disease severity
Combination antibiotic therapy: antipseudomonal cephalosporin (cefepime or ceftazidime); antipseudomonal carbapenem (imipenem or meropenem) or b-lactam or b-lactamase inhibitor (piperacillin-tazobactam) plus antipseudomonal); fluoroquinolone (ciprofloxacin or levofloxacin) plus linezolid or vancomycin (if risk factors)
Ps. aeruginosa
K. pneumoniae (ESBL)
Acinetobacter spp.
Legionella pneumophila
MRSA
ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus aureus;