This document discusses antimicrobial stewardship and the role of microbiologists in stewardship programs. It notes that excessive antimicrobial use has led to increased resistance, and that 30-50% of antimicrobial use may be unnecessary. Antimicrobial stewardship programs aim to optimize antimicrobial use through education, formulary restrictions, prior approval programs, and prospective audits. The document emphasizes that microbiologists should be core members of stewardship teams by providing surveillance data on local resistance trends, patient-specific information to guide therapy, and ensuring high quality specimen collection and reporting to support optimal antibiotic use.

1. Antimicrobial Stewardship
Dr. Abhijeet Mane
July 28, 2016 1

2. Index
 Introduction
 Reasons for inappropriate use of
antimicrobials
 Concept of Antimicrobial Stewardship
 Antimicrobial Stewardship program
 Antimicrobial Stewardship strategies
 Role of Microbiologist
 Conclusion
July 28, 2016 2

3. Introduction
 Excessive use of antimicrobials in
early 1940s
 Jawetz (1956) recognised this
problem
 60% of all hospitalised patients in USA
– 1 dose atleast
 50% of this use is unnecessary
July 28, 2016 3

4. The 30% rule
 Antimicrobial prescribing facts: the 30%
rule
 30% of all hospitalised inpatients…
 30% prescribed inappropriately
 30% of all Sx prophylaxis inappropriate
 30% hospital pharmacy cost due to
antimicrobials
 10-30% cost can be saved by
Antimicrobial Stewardship Programs
(ASPs)
July 28, 2016 4

5.  In India, drug resistance
emerged to
Carbapenems
 Due to OTC availability
of antimicrobials for use
of human, animal,
industry use
 Guidelines for RNTCP,
NACP, NVBDCP,
present
 Not available for enteric
fever, July 28, 2016 5

6. Role of animals…
 Use of Antimicrobial Avoparcin:
development and amplification of VRE
 Enerofloxacin use approved in many
countries: resulted in Ciprofloxacin
resistant Salmonella spp and
Campylobacter spp --- humans too
 Animal feed supplements with Tylosin –
Erythromycin resistant Streptococci and
Staphylococci in animals and handlers
 WHO called for strict legislation to
minimise use
July 28, 2016 6

7.  Unwanted consequences of
antimicrobial therapy
 MDR organisms
 Increase in resistance rates not
matched by development of newer
antimicrobials
 Hence smart use is advised
July 28, 2016 7

8. Reasons for inappropriate use of
antimicrobials
 Good intentions
 Inappropriate dosing
 Inappropriate prophylaxis
 Use of multiple antimicrobial agents
 Pressure from patient
◦ Treating trivial infections / viral Infections
with Antibiotics
July 28, 2016 8

9.  Time constraints
 Cost and availability of
Radiographic/Lab studies
 Inadequacy of Physicians’ knowledge
of diagnostic procedures
 Fear of litigation
 Pressure/Perks by Pharma companies
 Poverty
July 28, 2016 9

10. Antimicrobial Stewardship
 Coined in 1996
 Stewardship: the activity or job of
protecting and being responsible for
something (Marriam – Webster
dictionary)
 Antimicrobial Stewardship: “Processes
designed to optimize the appropriate use
of antimicrobials by ensuring that every
patient receives an antibiotic only when
one is needed, with right agent, at right
dose, by right route, right duration, in
order to improve patient care and
optimize health care outcomes while
minimizing unintended consequences”July 28, 2016 10

11. Antimicrobial Stewardship (AS)
program
 Running an AS program needs an :
◦ AS team
◦ AS strategies
 AS team:
◦ Multidisciplinary team with core membership
of
◦ An ID physician
◦ A Clinical Microbiologist
◦ A Clinical Pharmacist with expertise in ID
◦ Other members: ICNs, Hospital
Epidemiologist, Director (IT), Infection
July 28, 2016 11

12. Antimicrobial Stewardship
strategies
 Educational
Programs
◦ Hallmark activity of
ID physician
◦ Staff conferences,
lectures by visiting
Professors,
newsletters,
bulletins, email
alerts, etc.
◦ Continuous
reinforcement
necessary
 Antimicrobial
formulary
restrictions
◦ Most direct method
◦ Prohibit use of
newer, more
expensive antibiotics
◦ Landmark study by
Woodward et al:
cost saving of USD
24000/month for all
antibiotics
July 28, 2016 12

13.  Prior approval
programs
◦ Telephone approval
◦ Antibiotic order forms
◦ Automatic stop orders
◦ Direct interaction with AS
team
◦ Cost per treatment day,
cost per admission and
total doses differed
significantly from pre-
study periods
 Prospective audits
and feedback
programs
◦ Feedback to be
educational & evidence
based
◦ i/v to oral Rx: switch or
stepdown Rx
(fluoroquinolones,
metronidazole,
clindamycin,
trimethoprim-
sulfamethoxazole,
fluconazole)
◦ Broad spectrum to
Narrow spectrum
(streamlining) may be
tried
July 28, 2016 13

14.  Computer assisted
stewardship
programs
◦ Instant feedback,
education and
prescription alteration
◦ LDS hospital in Salt
Lake city, Utah, USA
◦ Epidemiology, detailed
info, warnings, etc.
◦ www.theradoc.com
◦ WHONET
 Antibiotic rotation
(cycling)
◦ Due to HAIs
◦ Rationale
◦ Kolleff et al: switched
empiric therapy of
suspected GN
infections from Ceftaz
to Cipro at 6 month
intervals
◦ Led to decrease in
VAP from 11.6% to
6.7% and lowered
bacteremia
July 28, 2016 14

15. Role of Microbiologist
 Antibiogram reporting
◦ Conducts surveillance on local antimicrobial
resistance trends among microbial pathogens
◦ Collection, organization and communication
of resistance data : Antibiogram
◦ Antibiograms provide critical information to
ASPs
◦ Individual physicians can refer to their
institution antibiogram for guidance
◦ Antibiograms can be used for developing
specific guidelines for prescribing
◦ Cumulative antibiograms helpful
July 28, 2016 15

16.  Example 1:
 Drug A overall
susceptibility <80%
 All LTCFs showed
low susceptibility
 Microbiologist
investigated
 Conclusion
July 28, 2016 16

17.  Example 2:
 Susceptibility of
Drug A decreased
10%
 Change in empiric
therapy advised
 Microbiologist
investigated
 Conclusion
July 28, 2016 17

18.  Hence, patient demographic factors
such as differences in age, co-
morbidities, hospital exposure and
prior antibiotic exposure significantly
impact cumulative antibiogram reports
 Hence Microbiologist should be
included in ASP as core member
July 28, 2016 18

19.  Patient specific information
◦ Lab provides patient specific info
◦ Info necessary for narrowing down therapy
◦ Directed therapy: prescription that targets
isolated pathogens
◦ Lesser risk for AM resistance, decrease ADR
◦ More effective, less expensive
◦ Helps to discontinue therapy if pathogen
absent
◦ Eg. c/o critically ill pt. with sepsis (Piptaz + Ak
+ Vanco)
◦ Procalcitonin
July 28, 2016 19

20.  Specimen & Reporting quality
 Labs should ensure that high quality
specimens are only processed
 Promotion of appropriate specimen
collection
 Sample rejection
July 28, 2016 20

21. Tenets of Specimen
Management
 Reject poor quality specimens
 Don’t report “everything that grows”
 “Background noise” to be avoided
 Lab requires a specimen, not swab of
specimen
 Follow lab procedure manual religiously
 Collect specimen prior to antibiotics
 AST on clinically significant isolates only,
not all
 Specimens to be labeled accurately
July 28, 2016 21

22.  Improving patient care with rapid
diagnostics
 MALDI – TOF
 Quantitative PCR, etc
 Greatly reduce time to pathogen
identification
July 28, 2016 22

23.  Communication is the key
 May be verbal or written
 Reporting should be timely, clear,
understandble and accessible to
clinicians
 New test started – educate clinicians
 Lab rounds:
◦ Microbiologist: discusses culture growth
◦ Clinician: clinical details of patient
July 28, 2016 23

24. Conclusion
 Healthcare is changing
 High quality care in cost constrained
environment
 Although data still evolving,
comprehensive ASPs have potential to
decrease costs while improving
patient care and institutional outcomes
24 24

25. References
 Mandell, Douglas, and Bennett’s Principles and practice of
infectious diseases 7th edition 2010
 Baron et al. A guide to utilization of the microbiology
Laboratory for diagnosis of infectious diseases: 2013
recommendations by the infectious Diseases society of
america (IDSA) and the American society for microbiology
(ASM) Clinical Infectious Diseases 2013
 Srivastava BK. National policy for Containment Of
Antimicrobial resistance. India 2011
 Redell M. The Microbiologist as an Active Member of the
Antimicrobial Stewardship Team: A Value Proposition. CLSI
communities. www.clsi.org
 Dellit TH et al. Infectious Diseases Society of America;
Society for Healthcare Epidemiology of America.
2007.Infectious Diseases Society of America and the Society
for Healthcare Epidemiology of America guidelines for
developing an institutional program to enhance antimicrobial
stewardship. Clin. Infect. Dis. 44: 159 –177.July 28, 2016 25