A Lecture given by Dr. Mary Ann Lansang during the 23rd PHICS Annual Convention at the Crowne Plaza Manila last May 19, 2017

1. Formulating
Institutional Antibiotic
Policy
MARY ANN D. LANSANG, MD, FPCP, FPSMID
PHICS 23RD ANNUAL CONVENTION
MAY 19, 2017

2. Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an institution
Why: the need for an institutional antibiotic policy
How: evidence-guided recommendations, best practices, and
experiences in the formulation of antibiotic policies in an
institution
Who: stewards of rational antibiotic use and stakeholders

4. The Development of Antimicrobial Resistance
From: Faces of Antimicrobial Resistance, IDSA, 2017

5. 2020 Targets of the Action Plan
(5-year time frame)
- Reduce by 30% carbapenem-resistant
Enterobacteriaceae infections acquired during
hospitalization
-Maintain the prevalence of ceftriaxone-resistant N.
gonorrhoeae to zero
-Reduce by at least 30% MRSA bloodstream infections
compared to 2014 rates
-Reduce by 30% MDR Pseudomonas spp. Infections
acquired during hospitalization compared to 2014 rates
- Reduce by 25% ciprofloxacin-resistant non-typhoidal
Salmonella infections compared to 2014

6. November 14 – 20, 2016

8. WHO Global Priority Pathogens List
for R&D of New Antibiotics
(released 27 Feb 2017)
# Mycobacteria not included – already established as a global priority.

9. WHO Global Priority Pathogens List
for R&D of New Antibiotics

10. WHO Global Priority Pathogens List
for R&D of New Antibiotics

11. Yearly resistance rates of E. coli to
ceftriaxone, gentamicin and imipenem
ARSP, 2006 - 2015
2015 carbapenem resistance rates: Ertapenem: 4.2% (n=3,036); Imipenem: 3.5% (n=6,132);
Meropenem: 3.4% (n=5,794)

12. Yearly resistance rates of K. pneumoniae to
carbapenems
ARSP, 2006 - 2015
Imipenem: 2014 = 6.9%; 2015 = 11.1%; Meropenem: 2014 = 7.6%; 2015 = 11.9%;
Ertapenem: 2014 = 10%; 2015 = 15.3%

13. Yearly resistance rates of S. aureus
ARSP, 2006-2015
MRSA rate for bloodstream infections, 2015: 60.25% (n=570)

14. From: Philippine Action Plan to Combat Antimicrobial Resistance, 2015

15. “… the concerted implementation of systematic,
multi-disciplinary, multi-pronged interventions
in both public and private hospitals in the
Philippines to improve appropriate use of
antimicrobials…”

16. Strategies for controlling AMR:
inter-related approaches
Antibiotic
stewardship
• Surveillance
• Antibiotic policies &
guidelines
• Antibiotic manage-
ment programs
Prevention of spread
• Infection prevention &
control in healthcare settings
• Isolation when needed
• Hand hygiene
• Environmental hygiene
Reduction
• Usage control
• Appropriate use
• Human
• Animal
• Environmental

17. Core elements of the
DOH AMS Program

18. Strategies for controlling AMR:
inter-related approaches
Antibiotic
stewardship
• Surveillance
• Antibiotic policies
& guidelines
• Antibiotic manage-
ment programs
Prevention of spread
• Infection prevention &
control in healthcare settings
• Isolation when needed
• Hand hygiene
• Environmental hygiene
Reduction
• Usage control
• Appropriate use
• Human
• Animal
• Environmental

19. Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an institution
Why: the need for an institutional antibiotic policy
How: evidence-guided recommendations, best practices, and
experiences in the formulation of antibiotic policies in an
institution
Who: stewards of rational antibiotic use and stakeholders

20. Why do we need a hospital
antibiotic policy? (1)
• High level of antibiotic use in hospitals. CDC report (MMWR, 7Mar2017):
• 56% of patients discharged from 323 US hospitals received antibiotics
• 37% of antibiotic prescribing could be improved
• Patients with multiple pathogens are concentrated in hospitals
• Close proximity of patients with multiple healthcare worker contacts
• Sicker, more vulnerable patients in the hospitals
• Transfer of patients with MDR organisms into the hospital from the
community, another facility, or another country

21. From: Paterson DL. The Role of Antimicrobial Management Programs in Optimizing Antibiotic Prescribing within Hospitals
Clin Infect Dis. 2006;42(Supplement_2):S90-S95. doi:10.1086/499407

22. Why do we need a hospital
antibiotic policy? (2)
• To improve patient outcomes through appropriate
antibiotic use: the RIGHT indication, choice, dose,
route of administration, timing, duration
• To minimize harm to the patients (and future patients)
• To reduce health care-related costs: shorter hospital
stay, use of less costly antibiotics, less ADRs
• To prevent or control the emergence of AMR

23. Outline
Context: global and local actions; the infection control unit
and the
antimicrobial stewardship program of an institution
Why: the need for an institutional antibiotic policy
How: evidence-guided recommendations, best
practices, and experiences in the formulation of
antibiotic policies in an institution
Who: stewards of rational antibiotic use and stakeholders

24. Hospital antibiotic policy
development cycle

25. Ideal organizational structure
for the AMS program

27. From:

28. From:
All hospitals should have a hospital antibiotic
policy to promote rational antimicrotial
prescribing and dispensing practices.

29. From:

35. From:
All hospitals should 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.

39. From:
Simple and clear clinical pathways
should be created to guide and
standardize treatment for timely
and appropriate management of
infections.

40. Example of clinical pathway: Severe sepsis
(from The Medical City)

41. Summary of strategies to improve antibiotic use (1)
Pulcini & Gryssens. Virulence 2013; 4:192-202
Passive educational measures Developing/updating local antibiotic guidelines
Educational sessions, workshops, local conferences
Clinical rounds discussing cases
Active interventions Prospective audit with intervention & feedback
Reassessment of abtic prescriptions, with streamlining &
de-escalation of therapy
Academic detailing, educational outreach visits
Restrictive measures Limiting no. of abtics on the hosp. formulary
Antibiotic order form (compulsory)
Automatic stop order
Formulary restriction & pre-authorization
Limiting reporting of susceptibilities by the micro lab
Regulating contacts with the pharma industry

42. Summary of strategies to improve antibiotic use (2)
Pulcini & Gryssens. Virulence 2013; 4:192-202
Supportive/supplemental measures Multidisciplinary AMS team
Consultancy service (infectious diseases, pharmacy,
microbiology)
Computer-assisted management program
Parenteral to oral conversion
Therapeutic drug monitoring service

43. Carrot or stick approach to
improving antibiotic use?

44. Carrot or stick approach to
improving antibiotic use?

45. Positive
Clinical
Impact
Positive
Financial
Impact
Political
Expediency
Resource
Requirements
Ease of
Implementation
0 = None
5 = High
0 = None
5 = High
0 = Impossible
5 = Win/Win
0 = Impossible
5 = None
0 = Impossible
5 = Easy
Prioritize potential interventions

46. Outline
Context: global and local actions; the infection control unit and the
antimicrobial stewardship program of an institution
Why: the need for an institutional antibiotic policy
How: evidence-guided recommendations, best
practices, and experiences in the formulation of
antibiotic policies in an institution
Who: stewards of rational antibiotic use and
stakeholders

47. Ideal organizational structure
for the AMS program

48. Clinicians/
Prescribers
Patients
Patient’s
relatives
Public? PhilHealth?

49. DOH timelines for selected core
elements of the AMS Program

50. 2015 WHO WPRO and Philippines partnership:
Pilot AMS Program implementation in Hospitals
TRAINING OF TRAINORS
WORKSHOP ON THE
ANTIMICROBIAL STEWARDSHIP
ADVOCACY PACKAGE
(March and September 2015)
Baguio General Hospital and Medical
Center
CAR
Jose B. Lingad Memorial Regional
Hospital
Region III
Rizal Medical Center NCR
Research Institute for Tropical Medicine NCR
Corazon Locsin Montelibano Memorial
Regional Hospital
Region VI
Vicente Sotto Memorial Medical Center Region VII
Northern Mindanao Medical Center Region X
Southern Philippines Medical Center Region XI