1 ANTIMICROBIAL STEWARDSHIP: START SMART - THEN FOCUS Guidance fr Antimicrbial Stewardship fr Hspitals in Wales
2 Antimicrbial Stewardship: Start Smart - then Fcus Right Drug, Right Dse, Right Time, Right Duratin -Every time. Current evidence clearly demnstrates that the inapprpriate use f brad-spectrum antibitics is assciated with the selectin f antibitic resistant bacteria such as Extended- Spectrum Beta- Lactamase (ESBL)-prducing Gram-negative bacteria as well as the specific acquisitin f MRSA and the inductin f Clstridium difficile infectin (CDI). In particular, it has been recmmended that the use f brad spectrum antibitics such as cephalsprins, quinlnes and brad-spectrum penicillins (including c-amxiclav) and clindamycin shuld be avided unless there are clear clinical indicatins fr their use. Data published by the Welsh Antimicrbial Resistance Prgramme shws that resistance in E. cli and ther clifrms is increasing The data als shws significant variability in antibitic use acrss Wales with stable use in sme Health Bards, and increasing use in thers. Cntrl f Antibitic use can cntrl the spread f resistance, supprt reductins in CDI, and reduce unnecessary expense. An Antimicrbial Stewardship prgramme is seen as a key cmpnent in the reductin f HCAI infectins in a healthcare setting. The elements f an Antimicrbial Stewardship Prgramme shuld include the fllwing: An Antimicrbial Stewardship Cmmittee r Management Team: A multidisciplinary Cmmittee shuld be set up t develp and implement the Health Bard s antimicrbial stewardship prgramme fr all adults and children admitted t hspital. The cmmittee/team shuld reprt t the rganisatin s Directr f Infectin Preventin and Cntrl/ Infectin Cntrl Cmmittee and the Drugs and Therapeutic Cmmittee (r equivalent). The key rles f the Antimicrbial Stewardship cmmittee shuld be t: Ensure that evidenced based lcal antimicrbial guidelines are in place and reviewed annually. Ensure regular auditing f the guidelines, antimicrbial stewardship practice and quality imprvement measures. Frmally reprt a regular review f the rganisatin s retrspective antibitic cnsumptin data. Identify actins t address nn-cmpliance t lcal guidelines, antimicrbial stewardship guidelines and prescribing issues highlighted. In additin t the cmmittee/management team, it is suggested that rganisatins develp an Antimicrbial Stewardship Ward Fcused Team (Antimicrbial pharmacist and/r cnsultant micrbilgist) that reprt t the Cmmittee/Management Team and are available t review prescriptins at ward level if required. Evidence based antimicrbial prescribing guidelines: It is recmmended that evidence based lcal guidelines fr the diagnsis and treatment f cmmn infectins and fr prphylaxis f infectin shuld be drawn up by each rganisatin based n natinal guidance. Prescribers shuld t adhere t guidelines and adherence shuld be mnitred and supprted by senir clinicians and pharmacists. Gals f lcal prescribing guidelines shuld be t: Minimise unnecessary prescribing f antimicrbials by prviding clear clinical case definitins and assciated evidence f infectin. Emphasise the need fr infectin preventin and cntrl precautins where apprpriate. Fr severe r life-threatening infectin, emphasise the urgent need t start treatment with brad-spectrum antibitic agents (particularly where the surce f infectin is uncertain).
3 Fr less severe infectin, ffer antibitic agent(s) with an adequate spectrum t cver nly the expected pathgens. Remind prescribers t cnsider the risk f resistant pathgens such as MRSA r ESBLprducing rganisms, and ffer alternative treatment regimens accrdingly, r encurage prescribers t seek expert advice. Highlight the imprtance f checking allergy status and ffer alternative treatment chices fr patients intlerant f recmmended antibitic agents. Require prescribers t take apprpriate specimens fr micrbilgical investigatin befre starting antibitic treatment wherever pssible, but nt t delay starting treatment in patients wh are severely ill. Recmmend intravenus administratin nly t patients wh are severely ill r unable t tlerate ral treatment. Recmmend antibitic dses, and remind prescribers t adjust dsing in renal r hepatic impairment. Require prescribers t review micrbilgy results daily, and de-escalate t pathgen-directed narrw-spectrum treatment prmptly. Require prescribers t review the need fr intravenus treatment daily, and switch t the ral rute f administratin prmptly accrding t lcal IV-t-ral switch guidance. Offer ral switch chices fr intravenus antibitics. Prvide advice regarding mnitring and fllw-up and cntingency advice fr treatment failure. Suggest typical treatment curse length fr intravenus and ral agents. Require single dse surgical prphylaxis regimens as apprpriate. Quality Imprvement Measures/Audits: Prcedures shuld be in place t ensure prudent antibitic prescribing and antimicrbial stewardship. There shuld be an nging prgramme f audit, revisin and update mnitred by the antimicrbial management team. A multi-disciplinary quality imprvement/audit prgramme fr antimicrbial stewardship shuld be develped and sustained in each Health Bard. Regular (at least annual) feedback f adherence t prescribing standards shuld be prvided t the Trust Bard (as part f the annual infectin cntrl cmmittee (r equivalent) reprt), prescribers, lead clinicians and micrbilgists, nurses, pharmacists and the DIPC. The Antimicrbial Stewardship Cmmittee/Management Team shuld review antibitic cnsumptin trends regularly (at least annually). Actin shuld be taken t investigate and address nn-adherence t best practice fr antibitic prescribing r unexpected trends in prescribing. Quality imprvement measures and audits shuld include: Mnitring ttal antibitic cnsumptin (at least annually). Regular mnitring/audit f cmpliance t cmpnents f the Antimicrbial stewardship algrithms and best practice fr antibitic prescribing. Examples include: % f antibitic prescriptins that fllw lcal antibitic plicy/guidelines. % f patients with evidence f clinical review and decisin at 48 hurs. Use f the five ptins after clinical review as auditing interventins e.g. % f IV t ral switch, % f OPAT, % changed t narrw spectrum antibitic, % f ward based interventins. The All-Wales Antimicrbial Pint Prevalence Study (PPS) may be used as a methd f cllecting data t mnitr cmpliance and fr use as evidence f cmpliance with patient safety measures
4 ANTIMICROBIAL STEWARDSHIP: Start Smart then Fcus All Clinicians shuld ideally within ne hur (r as sn as pssible) - START SMART: Initiate prmpt effective antibitic treatment within ne hur (r as sn as pssible) in patients with life threatening infectins Dcument n drug chart and in medical ntes: Rute, Indicatin, Dse, Duratin (RIDD) Antibitics in hspitals are ften cntinued unnecessarily because clinicians caring fr the patient d nt have infrmatin indicating why the antibitics were initially cmmenced and hw lng they were planned t be cntinued. This challenge is cmpunded where primary respnsibility fr patient care is frequently transferred frm ne clinician t anther. Ensuring that all antibitic prescriptins are always accmpanied by an indicatin, the crrect dse and a clear duratin will help clinicians change r stp therapy when apprpriate. Obtain Cultures First Knwing the susceptibility f an infecting rganism can lead t narrwing f brad spectrum therapy, changing therapy t effectively treat resistant pathgens and stpping antibitics when cultures suggest an infectin is unlikely. Prescribe: Single dse fr surgical prphylaxis where antibitics have been shwn t be effective Critical t this advice is that the single dse is administered up t 60 minutes prir t surgical incisin t enable peak bld levels t be present at the start f the surgical prcedure. A repeat dse f antibitic prphylaxis is required when the peratin is lnger than the half-life f the antibitic given. Antibitic treatment (in additin t prphylaxis) shuld be given t patients having surgery n a dirty r infected wund (Surgical Prphylaxis Algrithm figure 2) THEN FOCUS Review the clinical diagnsis and the cntinuing need fr antibitics by 48 hurs and make a clear plan f actin - the Antimicrbial Stewardship Decisin Antibitics are generally started befre a patient's full clinical picture is knwn. By 48 hurs, when additinal infrmatin is available, including micrbilgy, radigraphic and clinical infrmatin, it is imprtant fr clinicians t re-evaluate why the therapy was initiated in the first place and t gather evidence n whether there shuld be changes t the therapy. The five Antibitic Stewardship Decisin ptins are Stp, Switch, Change, Cntinue and OPAT:
5 1. Stp antibitics if there is n evidence f infectin 2. Switch antibitics frm intravenus t ral 3. Change antibitics ideally t a narrwer spectrum r brader if required 4. Cntinue and review again at 72 hurs 5. Outpatient Parenteral Antibitic Therapy (OPAT). It is essential that the review and subsequent decisin is clearly dcumented in the medical ntes.
6 Figure 1: Antimicrbial Stewardship Antibitic Treatment Algrithm Figure 1: Antimicrbial Stewardship Antibitic Treatment Algrithm Advcating patient safety and auditing f antimicrbial stewardship in hspitals shuld be based arund the principles stated in this ASP algrithm. Examples f audit tls are shared in Appendix 2 ARHAI Antimicrbial Stewardship Guidance Final Draft Page 8 f 20
7 Figure 2: Antimicrbial Stewardship Surgical Prphylaxis Algrithm Advcating patient safety and auditing f antimicrbial stewardship in hspitals shuld be based arund the principles stated in this ASP algrithm. Examples f audit tls are shared in Appendix 2
8 Cmpnents f Best Practice fr Antibitic Prescribing (Treatment) Descriptin Ratinale Audit(s) and frequency 1. Urgent treatment f infectin emergencies 2. Cmmunicatin f decisin t prescribe antibitics 3. Micrbilgical investigatin Fr severe r lifethreatening infectin, start prmpt treatment with brad-spectrum antibitic agents urgently (within ne hur f diagnsis). Dcument the decisin t start antibitic therapy alng with the indicatin r prvisinal diagnsis in medical recrds and n medicatin charts (must include clear identificatin f prescriber and cntact details) Apprpriate specimens shuld be btained fr MC&S accrding t lcal guidelines. 4. De-escalatin Review f MC&S results shuld be dcumented within 24 hurs f reprting and brad-spectrum therapy de-escalated r a ratinale dcumented fr cntinuing. 5. Guideline chice f agent(s) Select antibitic therapy accrding t lcal guidelines where available. Dcument ratinale fr deviatin frm lcal guidelines. Delay t starting adequate antibitic therapy in severe infectin is assciated with increased mrbidity and mrtality Cmmunicatin between healthcare teams is vital t safe and effective patient care and mandated by the Ryal Clleges. Requirement t dcument prescribing will discurage antibitic prescribing where evidence f infectin is lacking. Allws fr prmpt deescalatin f bradspectrum agents r tailring therapy in cases f treatment failure. Unnecessary cntinuatin f brad spectrum antibitics is assciated with healthcare-assciated infectin Cmmunicatin mandated by Ryal Clleges. Will discurage ff-guideline prescribing whilst allwing fr exceptinal cases. May pt t include dse and rute f administratin in audit. Regular (mnthly r quarterly) audit f the Time t 1 st dse frm decisin f severe sepsis. Regular (mnthly/ quarterly) audit f Dcumentatin f indicatin in medical recrds (Chart and/r ntes) and duratin / review n prescriptins Annually fr specific infectins. Annually fr brad-spectrum antibitics. Mnitr cnsumptin f brad-spectrum agents. Needs t be based n patient level e.g. brad spectrum per Finished Cnsultant Episde (FCE) Regular (mnthly/ quarterly) audit f Adherence f chice f agent, dse, r ratinal f alternative chice against guidelines.
9 Cmpnents f Best Practice fr Antibitic Prescribing (Treatment) Descriptin Ratinale Audit(s) and frequency 6. Review date An expected duratin r review date shuld be dcumented n the prescriptin when antibitics are prescribed. Cmmunicatin mandated by Ryal Clleges. Will discurage pen-ended prescriptins. Regular (mnthly/ quarterly) audit f Dcumentatin f indicatin in medical recrds (Chart and/r ntes) and duratin / review n prescriptins. 7. IV duratin Treatment with IV antibitics shuld nt cntinue beynd hurs unless recmmended by lcal guideline r micrbilgist. Ratinale fr cntinuing IV shuld be clearly dcumented. Unnecessary cntinuatin f IV treatment increases the risk f line infectin. Regular (mnthly/ quarterly) audit t Mnitr the cnsumptin f IV versus ral antibitics. Mini PPS f IV AB >48h? Audit f the utcme f the 48h review in terms f result e.g. stp, IVOS, De-esc, OPAT r Cntinue. 8. IV-t-ral switch (IVOS) Treatment with IV antibitics shuld be switched t ral therapy within 24 hurs f meeting lcal switch criteria. Unnecessary cntinuatin f IV treatment increases the risk f line infectin. Annually accrding t lcal switch criteria, Mnitr the cnsumptin f IV agents. See cmments abve 9. Ttal duratin Treatment with antibitics shuld nt cntinue beynd 7 days (IV and ral) unless recmmended by a lcal guideline r micrbilgist. Ratinale fr cntinuing shuld be clearly dcumented. Prlnged treatment with antibitics fr uncmplicated infectin is nt assciated with imprved utcme. Regular (mnthly/ quarterly) audit t Mnitr ttal cnsumptin f antibitics per FCE.
10 Cmpnents f Best Practice fr Antibitic Prescribing (Peri-perative prphylaxis) Descriptin Ratinale Audit(s) and frequency 1. Need fr prphylaxis 2. Guideline chice f agents Indicatin shuld cmply with NICE 74: Preventin and treatment f surgical site infectin r ther evidence based recmmendatins i.e. prphylaxis recmmended r shuld be cnsidered fr a prcedure Antibitic prphylaxis is usually nly recmmended fr cleancntaminated, cntaminated r dirty prcedures, in accrdance with lcal guidelines. Prescribe prphylaxis with apprpriate agents accrding t lcal guidelines. Use narrw spectrum agent(s) when pssible. Avid cephalsprins, clindamycin, quinlnes and camxiclav whenever pssible. Fr certain clean prcedures, evidence suggests a lack f benefit f antibitics. Ensure adequate cverage f expected pathgens accrding t surgical site. Integrate int current Saving Lives r WHO Safer Surgery Checklist* audits fr surgery Integrate int current Saving Lives r WHO Safer Surgery Checklist* audits fr surgery Use apprpriate alternatives fr patients with penicillin/ betalactam allergy 3. Timing Administer antibitics within 60- minutes prir t incisin (r turniquet) r accrding t lcal guidelines18. Lwest surgical site infectin rates assciated with pre-incisin administratin. Integrate int current Saving Lives r WHO Safer Surgery Checklist* audits fr surgery * [Accessed 08 August 2011]
11 Cmpnents f Best Practice fr Antibitic Prescribing (Peri-perative prphylaxis) Descriptin Ratinale Audit(s) and frequency 4. Duratin/Repeat Single dse is indicated fr the Antibitics ften dses majrity f prcedures. Reasn fr antibitic shrt half-life r haemdilutin administratin beynd effect with ne f dse shuld be replacement dcumented fluid r bld and cmply Significant with intra-perative criteria belw: prducts. bld lss - >1.5 litre (redse fllwing fluid replacement). Prlnged prcedure (> 4 hurs) depending n halflife f the antibitic given fr example additinal dse nt required fr teicplanin r vancmycin) Primary arthrplasty (Single dse is preferable but up t 24 hurs prphylaxis acceptable). 5. MRSA psitive Declnisatin therapy is Integrate int patients recmmended prir t surgery and antibitic prphylaxis shuld include cver fr MRSA. Glycpeptides r ctrimxazle are suitable agents. Gentamicin may als be cnsidered if lcal resistance rates are lw current Saving Lives audits fr surgery r MRSA declnisatin audits
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