What is it, Why is it Important and What is Your Role? Aug 16, 2017 - - PowerPoint PPT Presentation

What is it, Why is it Important and What is Your Role?

Aug 16, 2017

Paul Bonnar (MD, FRCPC) & Andrea Kent PharmD

paule.bonnar@nshealth.ca andrea.kent@nshealth.ca

http://www.cdha.nshealth.ca/nsha-antimicrobial-stewardship

What is Antimicrobial Stewardship?

• Coordinated interventions designed to

improve and measure the appropriate use of antibiotics

• Barlam. CID. 2016;62(10):e51–e77

Tamma CID 2017;64(5):537–43

Right drug Right dose Right duration Right route

WHY IS AMS IMPORTANT?

What Does a ‘Post Antibiotic Era’ mean?

It means we are heading back to a time where common illnesses like pneumonia and minor surgical procedures will once again be feared killers because we do not have antibiotics to combat them due to developing resistance. Fluoroquinolones which were introduced in 1980 with zero resistance now have as much as 50% resistance to

• E. coli in some countries

MRSA counts for almost 90% of Staph infections in parts of the USA People with MRSA infections have a 64% increase risk of death

Why is AMS Important?

O’Neill. 2014. Antimicrobial Resistance: Tackling a crisis for the health and wealth

• f nations

Why is AMS Important?

• Increasing MDR organisms
• Side-effects / costs of antimicrobials
• Accreditation Canada ROP

O’Neill. Antimicrobial Resistance: Tackling a crisis for the health and wealth of nations

• Tamma. JAMA Intern Med. 2017 Jun 12

VISION

• Safe and effective use of antimicrobial

agents in patients cared for in the NSHA

TENETS

• Promote a culture of optimal antibiotic use
• Respect and promote regional strengths
• Act in collaborative and engaging manner
• Make evidence-based recommendations
• Maintain an open/transparent program
• Start small, build on success

Team members

Andrea Kent Paul Bonnar Ian Davis Jason Reynolds Kim Abbass Valerie Murphy Stephen Smith

WHAT IS NURSING’S ROLE?

CID 2016;62(1):84–9

CID 2016;62(1):84–9

Situation

• 30 – 40% of patients will receive an

antibiotic while in hospital

• Growing number of resistant bacteria
• Most nursing staff will come face to face

with the consequences of our antimicrobial resistance crisis

Survey of nursing staff in Australia

• 65% knew or had heard of the term Antimicrobial

Stewardship or AMS

• 57% rated their knowledge of antimicrobials as

minimal or limited

• Hand hygiene, infection control, and knowledge of

antimicrobials were most commonly seen as nursing role

• Prompting switch from IV to oral, therapeutic drug

monitoring and checking restriction status were less frequently thought of as nursing roles

Infection, Disease & Health (2017) 22, 57e64

Why has nursing not been a focus?

• Prescribing emphasized over

MANAGING antibiotics

• Hierarchy & Tradition
• Time constraints
• Knowledge

What is Nursing’s Role in AMS?

• AMS is multidisciplinary
• Nurses are the operational and

communication hub

• Trusted by patients and families
• Many existing roles of nursing already

fit well with AMS roles

Nursing benefits

• Better patient outcomes
• Less resistance: less isolation
• Less C. difficile
• Less abx administration

CID 2016;62(1):84–9

CID 2016;62(1):84–9

Triage

• Early recognition of sepsis

Early cultures and Abx Clarification of allergies

Daily nursing care

• Monitor abx (duration, dose, IV)
• Early C diff / sepsis
• Correct culturing
• Culture reports
• Educating families
• Prevention (catheter removal)

Discharge

• Duration
• OPAT
• Follow-ups

Allergies

• Penicillin most commonly reported allergy
• 95% are not truly allergic reactions
• Minor adverse reactions or intolerances (eg

nausea or diarrhea)

• Non severe delayed type hypersensitivity

reactions (eg. maculopapular rashes)

Allergies

• Over reporting of allergies is NOT benign
• Alternative antibiotics may be less effective or

have more adverse effects

• Increased selection of resistant bacteria
• More often on more than one antibiotic
• Increased risk of ICU admission
• Longer lengths of stay
• Increased risk of death

What can Nursing Do?

• Ask what the reaction was
• If on old charts – question further

Catheters and CAUTI

• In one centre a nurse directed catheter

removal protocol reduced catheter use by 50% and CAUTI by 70%.

• ICU nurse reminders to physicians for

catheter removal reduced both CAUTI and costs

https://www.ammi.ca/?ID=127

https://choosingwiselycanada.org/nursing/

Managing the Patient with a possible UTI:

Facts !!

 Malodorous /cloudy urine alone is NOT a sign /symptom of a UTI  Changes in cognitive function or ADL’s require a clinical assessment first before assuming this is due to a UTI  Urine should always be collected as a midstream or in/out catheterization

Managing the Patient with a possible UTI:

Facts!!

 Positive urine cultures in asymptomatic patients should NOT be automatically treated (except in pregnancy or prior to urological/gynecological procedures  UTI is a clinical diagnosis…not a lab diagnosis!!  Delirium is not considered a typical symptom of a UTI for non-catheterized patients.

Questions?