ANTIMICROBIAL STEWARDSHIP Introduce the concept of antimicrobial - - PDF document

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ANTIMICROBIAL STEWARDSHIP

AN INTRODUCTION TO MICROBIOLOGY

July 2020

Session Outcomes

• Discuss the origins of bacteria, antibiotics and the development
• f antimicrobial resistance (AMR)
• Introduce the concept of antimicrobial stewardship (AMS) in

response to AMR

• What is your role in AMS?
• How can we improve patient outcomes?

Bacteria: friend or foe?

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Fighting back

Antibiotics in response to bacteria

The origins of antibiotics

Streptomyces

Penicillium

Other bacteria Man-made “Synthetic”

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What is Antibiotic Resistance (AMR)?

Antibiotic resistance is the ability of microbes to resist the effects of life-saving drugs (e.g. penicillin)

• simple infections require hospitalisation for treatment
• severe infections result in higher mortality rate
• developing microbes with no treatments available

Staph aureus Pneumococci Enterococci Gonococci Clostridium difficile Corynebactera

• E. Coli

Klebsiella Salmonella Pseudomonas Acinetobacter Stenotrophomonas Helicobacter …plus many others

Multi-drug resistant bacteria: a rough overview

Staph aureus (MRSA) Pneumococci Enterococci (VRE) Gonococci Clostridium difficile Corynebactera

• E. Coli

Klebsiella Salmonella Pseudomonas Acinetobacter Stenotrophomonas Helicobacter …plus many others

Multi-drug resistant bacteria: a rough overview

Staph aureus (MRSA) Pneumococci Enterococci (VRE) Gonococci Clostridium difficile Corynebactera

• E. Coli

Klebsiella Salmonella Pseudomonas Acinetobacter Stenotrophomonas Helicobacter …plus many others

Multi-drug resistant bacteria: a rough overview

Resistance to ESBL producing Enterobacterales Penicillins, Cephalosporins Carbapenem resistant Enterobacterales (CRE) (VIM,NDM-1, KPC-2,oxa-48) Penicillins, Cephalosporins Carbapenems + others

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https://www.cdc.gov/vitalsigns/protect-patients/images/graphic-a_920px.jpg

30-day mortality Sensitive 6% ESBL 6 – 18% CRE >38%

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Costs associated with CRE

• Approx £15K additional treatment costs
• Reduced activity at acute trusts (closure of infected units across UK in last 24 months)
• Additional screen costs incurred for hospitals (£7.5 million / year at CMFT, Manchester)

Resistance

Defining antimicrobial resistance in the lab

Klebsiella pneumoniae Pseudomonas aeruginosa

ESBL present Porin loss High dose ABX needed

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AMR in Practice

Empiric Guidelines – Septic shock

Case Presentation:

• An 81 year-old woman was

admitted to the A&E with nausea, vomiting and hypotension. She had a history of hypertension, Type II Diabetes, renal insufficiency and dementia

• Pyrexia – 38.7
• Hypotensive (95/62) unresponsive

to fluid challenge

• U/O – (Less than 30ml/hr)
• Rx:

– ?

Empiric Guidelines – Septic shock

Case Presentation:

• An 81 year-old woman was

admitted to the A&E with nausea, vomiting and hypotension. She had a history of hypertension, Type II Diabetes, renal insufficiency and dementia

• Pyrexia – 38.7
• Hypotensive (95/62) unresponsive

to fluid challenge

• U/O – (Less than 30ml/hr)
• Rx:

– Broad-spectrum beta-lactam – Add aminoglycoside (likely AKI)

Consequences of under-Rx:

N Engl J Med 2017; 376:2235-2244

Empiric Guidelines – Septic shock

Case Presentation:

• An 81 year-old woman was

admitted to the A&E with nausea, vomiting and hypotension. She had a history of hypertension, Type II Diabetes, renal insufficiency and dementia

• Pyrexia – 38.7
• Hypotensive (95/62) unresponsive

to fluid challenge

• U/O – (Less than 30ml/hr)
• Rx:

– Broad-spectrum beta-lactam – Add aminoglycoside (likely AKI)

Consequences of under-Rx:

N Engl J Med 2017; 376:2235-2244 Time Line: Day 0: Blood Culture + 24 hours: Culture stain (Gram –ve rod) + 48-72 hours: ABX sensitivities Time Line: Day 0: Blood Culture + 24 hours: Culture stain (Gram –ve rod) + 48-72 hours: ABX sensitivities KPC: Negative OXA 48: Positive NDM: Negative

• ORGANISM:

Enterobacter cloacae ++ isolated METHOD: DISC SENSITIVITY Gentamicin: Resistant Ciprofloxacin: Resistant Cefuroxime: Resistant Tazocin: Resistant Amoxycillin: Resistant Temocillin: Resistant Cefotaxime: Resistant Meropenem: Resistant Trimethoprim: Resistant Ceftazidime: Resistant Augmentin: Resistant Amikacin: Sensitive

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Minimise the ecological impact of Antimicrobial Resistance:

• Infection Prevention & Control

 Avoidance of infection and exposure to resistant organisms is key  We expose our most vulnerable patients to our highest-risk practice

• Antimicrobial Stewardship

 Any reduction in antimicrobial usage will reduce risk of resistance  The ‘easy win’ is inappropriate usage

• reduce broad spectrum ABX (traditional AMS role)
• reduce durations (greatest impact?)
• reduce ABX when no infection is present (pt

education)

Antimicrobial Stewardship in response to AMR

Defining Antimicrobial Stewardship:

(evolving terminology that rapidly changes in response to new antimicrobial related challenges)

“Antibiotic stewardship refers to a set of coordinated strategies to improve the use of antimicrobial medications with the goal of enhancing patient health outcomes, reducing antimicrobial resistance, and decreasing unnecessary costs” Relatively new concept, created in response to the C.difficile related infections of 10-15 years previously, that was linked to excessive and inappropriate antimicrobial usage AMS services embedded into secondary care and has evolved across boundaries

• f healthcare for a more holistic approach in light of rising AMR

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O.J. Dyar et al. / Clinical Microbiology and Infection 23 (2017) 793e798

The function of Antimicrobial Stewardship service Individual Patient focus

Optimise the outcome of infected patients

• Timely recognition and treatment
• Appropriate antimicrobial choice
• Adequate drug dosing based on

patient characteristics

• Adjusting therapy based on

clinical response

• Minimising harm to patient

Population level focus

Minimising ecological impact of antimicrobial usage Reduce selective pressure of antimicrobial usage

• Working in collaboration across

all boundaries of healthcare

• Educating our clinical colleagues
• n precious resource of

antimicrobials

• Promoting evidence base

guidelines that balance population risk vs individual risk

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Reducing ABX in self-limiting infections

Diagnostic Code % ABX prescription respiratory tract (including ENT) 46.0 cough 22.7 Lower RTI 17.9 Sore throat 16.7 Upper RTI 14.5 Ear-related diagnosis / other 28 urogenital tract 22.7 skin and wounds 16.3

• ther body systems

10.3 multiple body systems 4.7

Scale of Infection Risk of Mortality Low risk invasive infection Low risk of invasive infection Severe / invasive infection

Targeted Broad spectrum

Changing Behaviours

How to improve AMS performance A confusing time for prescribers

• Sepsis

 More aggressive management of septic patients  Net widening to identify sub-acute presentations (specificity reducing) NICE Sepsis 2016 / NCEPOD vs AMS (reduce ABX) / ESPAUR Resistance

• Antimicrobial Stewardship

 Targeted reduction in overall ABX usage  National target to:

• reduce total ABX usage (1-2% / year)
• reduce broad-spectrum ABX usage
• reduce all carbapenem usage

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Patient-tailored Antimicrobial Prescribing

i) Reducing HARM

Healthcare Professions

 First do no harm (understandable risk adverse approach to medicine)  Culture of ABX prescribing to change due to adjustment of known risk benefit

NICE Sepsis 2016 (aggressive initiation of ABX) / CQUIN vs AMS (reduce ABX) / ESPAUR Resistance / CQUIN

** 1st 60 minutes **

Time-line

48 hours 72 hours More patients treated (Increased Sensitivity but reduced Specificity) Investigate Blood tests Imaging Diagnosis

Clinical Review & Decision @48-72hr STOP – if no signs of bacterial infection;

minimise harm of Antimicrobials

1 in 5 patients have some adverse effects with ABX * *24% require longer admission *3% require re-admission

Patient-tailored Antimicrobial Prescribing

ii) AMR = Less Robust Guideline Cover

Antimicrobial Guidelines

Evidence-based prescribing guidance for common infections Adapted to reflect local microbiology results Target >90% of likely organisms / resistant pathogens

** 1st 60 minutes **

Time-line

48 hours 72 hours

Empiric Treatment

(based on guidelines)

Respond to Empiric (blind) Antimicrobial Rx

• Good treatment outcomes
• Minimise impact on mortality / morbidity
• Shorted length of stay

FAILURE of Empiric (blind) Antimicrobial Rx

• Poor treatment outcomes / patient outcomes
• Need ESCALATION of Antimicrobials
• Antimicrobial / ID team review
• MDT discussion (surgical / IR / etc)

0-10% 90-100%

The Need for Off-Guideline Prescribing

Antimicrobial Guidelines

Evidence-based prescribing guidance for common infections Adapted to reflect local microbiology results Target >90% of likely organisms / local pathogens EXCLUDES: Patients with known MDRO infections / colonisation (e.g. RBH CF patient, recent ITU discharge) High risk groups: Recent travel to high-risk area in last year

Bespoke Empiric Antimicrobial Prescribing

S&STI – add Vancomycin (MRSA) CNS – add Vancomycin (S.pneumoniae) UTI – add Amikacin (ESBL/CRO) Abdo – add Amikacin (ESBL/CRO)

A reflection on AMR & AMS

• A complex problem!
• Requires a collaborative approach; our

actions can & will have unintended consequences

• The supply pipeline is running dry
• Do more with what we got
• Optimise care in ‘at risk’ patients
• Minimise complications for patients / Trust
• Changing behaviours will be key to

success

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