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PROPOSED TOPICS	S	M	A	R	T	TOTAL
Medication administration error in wards	3+3+3+3+3	3+2+3+3+3	1+1+1+1+1	1+2+2+1+2	1+1+1+1+2	47
Accumulation of non floor stock medications in wards	1+2+1+2+1	1+2+2+1+2	2+1+2+1+1	3+3+2+2+3	1+1+2+2+1	42
Heavy usage of controlled antibiotics in wards	3+3+3+3+2	2+3+3+3+2	2+2+2+2+3	3+2+2+2+2	3+2+2+3+3	65
Illegible handwriting prone for medication errors	2+3+3+2+3	1+2+1+1+2	2+1+2+2+3	1+1+1+1+1	1+1+1+2+2	42
Inconvenient accessibility to quota medications name list	1+1+1+1+2	1+1+1+1+1	1+2+2+2+2	3+3+2+2+3	3+3+3+3+3	48

PROBLEM PRIORITIZATION

Rating scale: 1=low 2=medium 3=high Done as a group Group members: 5

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TERMS DEFINITION

CRE : Carbapenem-Resistant Enterobacteriaceae
DDD : Defined Daily Dose
ESBL : Extended-spectrum beta-lactamase
FBW : Farmasi Bekalan Ward (Inpatient Pharmacy)
NAG : National Antibiotics Guideline
BHT : Bed Head Ticket
CMR : Cumulative Medication Record
AMR : Antimicrobial Resistance

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Heavy usage of controlled antibiotics in wards

Heavy usage = DDD above upper limit

Controlled antibiotics = Cefepime, Tazocin, Imipenem, Meropenem, Ertapenem, Vancomycin and Ciprofloxacin

Total Antibiotics Usage (GRAM)

for Adults Inpatient in a year

----------------------------------------------- = No of DDD’s per year

DDD _WHO

No. of DDD’s per year

No. of Patients days X 1000 = No of DDD’s per 1000

for that particular year patient days

Upper limit formula= Average DDD + Std Deviation

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SMART�

PARAMETERS	EXPLAINATION
Seriousness	Increase hospital stay Increase cost of medication/accessories Increase CRE incidence/outbreak due to resistance Increase DDD Increase mortality rate
Measurable	DDD is measurable Resistance rate is measurable
Appropriateness	Resistance is an issue which requires urgent attention and immediate action due to AMR!
Remediable	Strict review by prescribers Monitor usage by pharmacists
Timeliness	Effect to be seen in 1 to 2 years

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VERIFICATION STUDY

DDD in HSJ exceeds the upper limit

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EXPENDITURE COMPARISON

Total Cost Increment:

RM 38,797.60

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ANTIBIOGRAM 2018

Green color- Sensitive

Orange- Intermediate

Red- Resistant

Sensitive E. coli

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REPORTED CRE CASES IN HSJ

reported CRE case by 7 FOLDS!

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LITERATURE REVIEW

Recent years, the rate of Carbapenem-resistant bacteria has steadily increased [1, 2]. Antibiotic resistance greatly limits therapeutic options, consequently resulting in higher patient morbidity, mortality and considerable economic burden [3].
According to the study conducted by Ping Yang et al. there is a correlation between increased Carbapenem use and increased CRE [4].

Penicillin and 3^rd gen cephalosporins

ESBL

Carbapenem Rx

Increased CRE

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PROBLEM STATEMENT

There is a problem of heavy usage of controlled antibiotics.

This will lead to increase hospital stay, increase cost of medication/accessories, increase CRE incidence/outbreak due to resistance, increase DDD and increase mortality rate.

Heavy usage of controlled antibiotics may be due to incomplete review of antibiotic form, pending culture and sensitivity result, unclear SOP in supplying antibiotic and inappropriate selection of antibiotic upon initiation and post 72 hours.

We hope to identify factors contributing to the heavy usage of controlled antibiotics and propose appropriate remedial measures to overcome the problem effectively.

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CAUSE-EFFECT ANALYSIS

Heavy usage of controlled antibiotics in HSJ

Inappropriate selection of antibiotic during initiation of therapy (61%)

Inappropriate selection of antibiotic after 72 hours (88%)

Pending culture and sensitivity result (36%)

Selection of antibiotic not based on accepted guideline

No proper criteria to decide on the continuation of antibiotic

Lack of working experience in inpatient pharmacy

Incomplete review of antibiotic after 72 hours (84%)

No active tracing of results via i-lab

Unclear SOP in supplying antibiotic (49%)

Treating specialist busy/ not available

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PROCESS OF CARE

Initiation of controlled antibiotic

Physician prescribes Antibiotic Order Form

FBW screens the a/b form & supplies the a/b

Physician reviews antibiotic use after 72 hours

A/b form countersigned?

Supply for 3/7

YES

Lab releases culture and sensitivity result

Supply for 1/7 + passing over antibiotic form for C/S

Reviewed?

FBW supplies accordingly

YES

Withhold the supply

Physician selects appropriate a/b thereafter

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MODEL OF GOOD CARE

Process	Criteria	Standard
Physician prescribes Antibiotic Order Form	Antibiotic selection based on National Antibiotic Guideline or ICU Guideline	100%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics )	100%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:-temperature WBC CRP procalcitonin inotropic ventilator support.	100%�

For the septic parameters, minimum 2 criteria need to be fulfilled

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GENERAL OBJECTIVE

To reduce the heavy usage of controlled antibiotics in Hospital Seberang Jaya by reducing DDD from above upper limit in year 2018 (UL: 186.18) to below upper limit by ≥30% in year 2022.

SPECIFIC OBJECTIVE

To determine the DDD of controlled antibiotics in HSJ
To identify the possible causes and contributory factors attributing to high DDD
To formulate remedial actions as to reduce the DDD
To implement remedial actions to accomplish the objective
To evaluate the effectiveness of the remedial measures implemented.

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STUDY INDICATOR

STANDARD

Percentage reduction of DDD from upper limit =

Average upper limit -DDD per 1000 patient days x 100%

Average upper limit of DDD

≥30%

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STUDY INDICATOR JUSTIFICATION

STANDARD

≥ 30%

HOSPITALS	DDD 2019	AVERAGE DIFFERENCE (%)
HSJ	220
HPP	176	11.1%
HKL	164	14.6%
HRPB	159	16.1%

AVERAGE = 15% X 2

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METHODOLOGY

Type of study	Cross sectional study
Study period	Verification study phase- 1^st June 2019 – 30^th June 2019 Pre-remedial phase- November 2019 Remedial phase 1- January- April 2020 Post 1- May 2020 Remedial phase 2- August- November 2020 Post 2- December 2020 Remedial phase 3- August- November 2021 Post 3- December 2021 Post 4- June 2022
Study population	Patients started on any of the 7 types of controlled antibiotics in the medical (3 wards) and ICU
Sampling technique	Convenience sampling method
Inclusion Criteria	All patients 15 years old and above Started on any of the 7 types of controlled antibiotics Admitted into the medical and ICU
Exclusion Criteria	Untraceable patients- missing data
Sampling tools	Controlled Antibiotic Order Form Antimicrobial Stewardship Database Knowledge assessment questionnaire

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Sampling Tool 1: �Controlled Antibiotic �Order Form

Order form created in 2014 by inpatient pharmacy
To provide brief data on the infection treated and previous antibiotic history
To review the antibiotic use at 72 hours for empirical cases

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Created and maintained by Pharmacy Department HSJ
Data will be entered by FBW based on completed controlled antibiotics forms
To facilitate statistical analysis for antibiotic usage in HSJ.

Sampling Tool 2: �Antimicrobial Stewardship Database

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Sampling Tool 3: �Knowledge Assessment Questionnaire�

Consists of sets of questions targeting both doctors and pharmacists
Verified by ID Specialists and Senior Pharmacists
To access the knowledge on antibiotics selection based on multiple case studies
To access the understanding on the SOP of controlled antibiotic supply in HSJ.

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Knowledge Assessment Questionnaire

QUESTIONNAIRE FOR PHARMACIST

QUESTIONNAIRE FOR PHYSICIAN

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PLAN FOR DATA COLLECTION

Factors	Variables	Source of data	Method of collection	Sample unit	Sample size	Standard
Prescribing antibiotic form	Knowledge on selection of antibiotics	Questionnaire Audit	Self-administered	Medical wards and ICU	50 medical officers &house officers	100% adherence
Screening antibiotic form and supplying antibiotic	Knowledge on SOP of supplying antibiotics	Questionnaire Audit	Self-administered	Pharmacists & pharmacist assisstants	All FRP, PRP & PPF	100% understanding
Pending culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	Antimicrobial Stewardship Database	Online tracing	Medical wards and ICU	100 patients	100% tracing
Reviewing antibiotic use after 72 hours	Review of antibiotic use at 72 hours for empirical treatment	Antibiotic Order Form Antibiotic Application	Review antibiotic form	Medical wards and ICU	All medical & anesthesiology specialists	100% understanding
Physician selects appropriate a/b	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:-temperature WBC CRP procalcitonin inotropic ventilator support	Antibiotic Order Form Antibiotic Application	Review antibiotic form	Medical wards and ICU	All medical & anesthesiology specialists	100% understanding

For the septic parameters, minimum 2 criteria need to be fulfilled

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DATA ANALYSIS

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CONFORMATION TO MOGC

Processs	Criteria	Standard	Pre-remedial November 2019
Physician prescribes Antibiotic Order Form	Antibiotic selection based on National Antibiotic Guideline or ICU Guideline	100%	39%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics)	100%	51%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%	64%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%	16%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:- temperature WBC CRP procalcitonin inotropic ventilator support.	100%�	12%

For the septic parameters, minimum 2 criteria need to be fulfilled

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ACTUAL BENEFIT NOT ACHIEVED (ABNA)

Standard ≥ 30%

November 2019

25.5%

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No.	Shortfall in Quality (SIQ)	Strategy for Change
1	Inappropriate selection of antibiotic after 72 hours (88%)	HSJ Inpatient Empirical Antibiotic Guide HSJ Antimicrobial Guideline HSJ Antibiotic Application
2	Incomplete review of antibiotic after 72 hours (84%)	Antimicrobial Formulary Restriction Persistency on Culture Updates HSJ Antimicrobial Guideline HSJ Antibiotic Application Flow Chart on Supply of Controlled Antibiotics Antibiotic e-form Manual
3	Inappropriate selection of antibiotic during initiation of therapy (61%)	HSJ Inpatient Empirical Antibiotic Guide Antimicrobial Formulary Restriction HSJ Antimicrobial Guideline HSJ Antibiotic Application
4	Unclear SOP in supplying antibiotic (49%)	Antimicrobial Formulary Restriction HSJ Antimicrobial Guideline HSJ Antibiotic Application Flow Chart on Supply of Controlled Antibiotics Antibiotic e-form Manual
5	Pending culture and sensitivity result (36%)	Antimicrobial Formulary Restriction Persistency on Culture Updates HSJ Antimicrobial Guideline HSJ Antibiotic Application Antibiotic e-form Manual

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STRATEGY FOR CHANGE

REMEDIAL PHASE 1

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Strategy 1:�HSJ Inpatient Empirical Antibiotic Guide

This general guideline is pasted on the medication chart as reference
A simplified guide for a quick reference
To facilitate on the appropriate selection of antibiotics based on various indications
A collaboration project among the pharmacists, microbiologists and ID physicians.

SIQ 1: Inappropriate selection of antibiotic after 72 hours

SIQ 3: Inappropriate selection of antibiotic during initiation of therapy

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PASTED ON THE MEDICATION CHART IN MEDICAL WARDS

SCAN ME!

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Strategy 2:�Antimicrobial Formulary Restriction

Decided on the category of various antibiotics based on the spectrum and implications it may cause for over usage
7 types of antibiotics have been listed as controlled antibiotics
To control the usage of broad spectrum antibiotics
A collaboration between pharmacy and Infection Control Unit.

SIQ 3: Inappropriate selection of antibiotic during initiation of therapy

SIQ 4: Unclear SOP in supplying antibiotic

SIQ 2: Incomplete review of antibiotic after 72 hours

SIQ 5: Pending culture and sensitivity result

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Strategy 3:�Persistency on Culture Updates- Microbiology Unit

Each doctors and pharmacists are requested to create an account in the i-lab system to facilitate the active culture tracing process
A permanent lab assistant is assigned to update the culture on daily basis
Active tracing via verbally is also encouraged.

SIQ 2: Incomplete review of antibiotic after 72 hours

SIQ 5: Pending culture and sensitivity result

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EFFECTS OF CHANGE

AFTER REMEDIAL PHASE 1

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CONFORMATION TO MOGC

Processs	Criteria	Standard	Pre-remedial November 2019
Physician prescribes Antibiotic Order Form	Antibiotic selection based on National Antibiotic Guideline or ICU Guideline	100%	39%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics )	100%	51%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%	64%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%	16%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:- temperature WBC CRP procalcitonin inotropic ventilator support.	100%	12%

For the septic parameters, minimum 2 criteria need to be fulfilled

Post 1 May 2020
70%
78%
87%
59%
68%

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STRATEGY FOR CHANGE

REMEDIAL PHASE 2

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Strategy 4: HSJ Antimicrobial Guideline

A more comprehensive guideline based on the local antibiogram as reference
Both manual and electronic (QR code) versions were distributed
To ease the accessibility of the guideline in timely manner
To facilitate on the selection of antibiotics based on various indications
A collaboration project among the pharmacists, microbiologists and ID physicians.

SIQ 1: Inappropriate selection of antibiotic after 72 hours

SIQ 2: Incomplete review of antibiotic after 72 hours

SIQ 3: Inappropriate selection of antibiotic during initiation of therapy

SIQ 4: Unclear SOP in supplying antibiotic

SIQ 5: Pending culture and sensitivity result

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EFFECTS OF CHANGE

AFTER REMEDIAL PHASE 2

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CONFORMATION TO MOGC

Processs	Criteria	Standard	Pre-remedial November 2019	Post 1 May 2020
Physician prescribes Antibiotic Order Form	Antibiotic selection based on HSJ Antimicrobial Guideline or ICU Guideline	100%	39%	70%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics)	100%	51%	78%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%	64%	87%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%	16%	59%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:- temperature WBC CRP procalcitonin inotropic ventilator support	100%	12%	68%

For the septic parameters, minimum 2 criteria need to be fulfilled

Post 2 Dec 2020
75%
86%
94%
55%
65%

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STRATEGY FOR CHANGE

REMEDIAL PHASE 3

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Strategy 5: HSJ Antibiotic Application

An electronic way to create, approve and review the antibiotic use
To ensure complete review of antibiotic form
To ensure active tracing of culture and sensitivity results before review
Initiative by HSJ Pharmacy Department
In parallel to KKM Strategic Plan 2021-2025 – towards digital healthcare services

SIQ 1: Inappropriate selection of antibiotic after 72 hours

SIQ 2: Incomplete review of antibiotic after 72 hours

SIQ 3: Inappropriate selection of antibiotic during initiation of therapy

SIQ 4: Unclear SOP in supplying antibiotic

SIQ 5: Pending culture and sensitivity result

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HSJ Antibiotic Application

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Is the e-Antibiotic form created?

Rx received

Yes

Has physician approved the form within 48hours (working days)?

To supply the antibiotic

Have physician reviewed the antibiotic use after 72hours (working days)?

To continue the supply

Yes

To continue the supply

Yes

To withhold the supply & inform the ward pharmacist or staff nurse

Is the manual antibiotic form sent?

Yes

OFFICE HOURS: To supply the antibiotic and notify the ward pharmacist to inform the doctors to create the e-form

AFTER OFFICE HOURS: To supply the antibiotic until the next working day and to notify the ward pharmacist to inform the doctors to create the e-form

Is the e-antibiotic form created on the following day?

To supply the antibiotic

Yes

No supply. To send back the Rx with advice note.

To follow the existing SOP for the manual antibiotic form

FLOW CHART ON SUPPLY OF CONTROLLED ANTIBIOTICS IN HSJ

Has physician approved / reviewed the form within 48/72 hours (working days)?

To continue the supply

Yes

To withhold the supply & inform the ward pharmacist or staff nurse

Updated by ALA on 24/02/2021

Strategy 6:

SIQ 4: Unclear SOP in supplying antibiotic

SIQ 2: Incomplete review of antibiotic after 72 hours

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Strategy 7: ANTIBIOTIC e- FORM MANUAL �

HOW TO USE ANTIBIOTIC

e- FORM?

EDITION 1/2022; Pharmacy, HSJ

SIQ 4: Unclear SOP in supplying antibiotic

SIQ 5: Pending culture and sensitivity result

SIQ 2: Incomplete review of antibiotic after 72 hours

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EFFECTS OF CHANGE

AFTER REMEDIAL PHASE 3

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CONFORMATION TO MOGC

Processs	Criteria	Standard	Pre-remedial November 2019	Post 1 May 2020	Post 2 Dec 2020
Physician prescribes Antibiotic Order Form	Antibiotic selection based on HSJ Antimicrobial Guideline or ICU Guideline	100%	39%	70%	75%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics)	100%	51%	78%	86%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%	64%	87%	94%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%	16%	59%	55%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:- temperature WBC CRP procalcitonin inotropic ventilator support	100%	12%	68%	65%

For the septic parameters, minimum 2 criteria need to be fulfilled

Post 3 Dec 2021
99%
87%
100%
100%
82%

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SUSTAINABILITY

POST 4- JUNE 2022

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CONFORMATION TO MOGC

Processs	Criteria	Standard	Pre-remedial November 2019	Post 1 May 2020	Post 2 Dec 2020	Post 3 Dec 2021
Physician prescribes Antibiotic Order Form	Antibiotic selection based on HSJ Antimicrobial Guideline or ICU Guideline	100%	39%	70%	75%	99%
FBW screens the a/b form & supplies the a/b	Supply made after review with justification (as per the flow chart on supply of controlled antibiotics)	100%	51%	78%	86%	87%
Lab releases culture and sensitivity result	Trace results latest by 72 hours after antibiotic use	100%	64%	87%	94%	100%
Physician reviews antibiotic use after 72 hours	Review of antibiotic at 72 hours for empirical cases	100%	16%	59%	55%	100%
Physician selects appropriate a/b thereafter	For all empirical a/b cases, decision made based on the reported C&S result and septic parameters:- temperature WBC CRP procalcitonin inotropic ventilator support	100%	12%	68%	65%	82%

For the septic parameters, minimum 2 criteria need to be fulfilled

Post 4 June 2022
99%
90%
100%
100%
87%

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ACTUAL BENEFIT NOT ACHIEVED (ABNA)

Standard ≥ 30%

Post 1

May 2020

Post 2

Dec 2020

Post 3

Dec 2021

Pre Remedial

Nov 2022

Post 4

June 2022

Percentage reduction of DDD from the upper limit

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Discussion with ID Specialists on HSJ Inpatient Empirical Antibiotic Guide.

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CME on the use of HSJ Antibiotic Application to all the departments.

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Finalization of HSJ Antimicrobial Guideline Edition 1/2020

CME to the pharmacy staff on the Antibiotic Application

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Launching of HSJ Antimicrobial Guideline Edition 1/2020 during Cluster Hospital Seberang Perai event in conjunction with World Antimicrobial Awareness Day.

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IMPACT OF CHANGE

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HPP

HSJ

HBM

HKB

HSB

HBP

UL 2020: 191.54

UL 2021: 168.14

UL 2019: 198.49

UL 2018: 186.18

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EXPENDITURE COMPARISON

ANTIBIOTICS USAGE

Total Cost Savings:

RM 165,878.50

2020 & 2021

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REPORTED CRE CASES IN HSJ

ANTIBIOTIC USAGE AND CONTACT PRECAUTION

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ANTIBIOGRAM 2019

Green color- Sensitive

Orange- Intermediate

Red- Resistant

Sensitive E. coli

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ANTIBIOGRAM 2020

Green color- Sensitive

Orange- Intermediate

Red- Resistant

Sensitive E. coli

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ANTIBIOGRAM 2021

Green color- Sensitive

Orange- Intermediate

Red- Resistant

Green color- Sensitive

Orange- Intermediate

Red- Resistant

Antibiotics	Sensitivity 2018 (%)	Sensitivity 2019 (%)	Sensitivity 2020 (%)	Sensitivity 2021 (%)
Augmentin	36	35.9	62.2	65.4
Unasyn	46	38.5	72.9	75.3
Ceftriaxone	55	56.8	98.2	95
Ceftazidime	56	75.7	97.2	94.1
Cefepime	57	67.3	97.7	96
Cefuroxime	50	42.3	94.9	91.1
Tazocin	60	75.2	94.9	93.1
Ertapenem	98	88.8	100	100
Imipenem	99	88.8	100	100
Meropenem	98	88.8	100	100

Sensitive E. coli

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SATISFACTORY SURVEY FORM IN USING ANTIBIOTIC e-FORM (n=135)

1) Does this antibiotic e-form EASE your daily work process?

2) Does this antibiotic e-form is READILY ACCESSIBLE to all HSJ staff?

3) Do you feel the Antibiotic e-Form is USER FRIENDLY?

17%

83%

84%

89%

16%

11%

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NEXT STEP

HBM adapted on our method in developing the customized facility antimicrobial guideline. Once its developed, would further study on the implications towards DDD, resistance rate and cost savings.
Antibiotic Application (e-form) is being implemented in other cluster hospitals. Currently being adapted by Mr Leow (hepatobiliary surgeon from HSB) and HBM. A proposal has been presented during recent HIACC meeting in HPP.
HSJ Antimicrobial Guideline has been used as the reference for Point Prevalence Study (MOH).
Dosage adjustment for antimicrobials (appendix in HSJ Antimicrobial Guideline) is being adapted for development of another guideline for renal dosing by HSJ.
e-form is in the process of being adapted for other medications which requires local purchase (LP) form in order to monitor the usage. (E.g. Human Albumin, Injection Levetiracetam).

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CONCLUSION

The DDD of controlled antibiotics in HSJ is determined and tabulated.
The possible causes and contributory factors attributing to high DDD are incomplete review of a/b form, inappropriate selection of a/b upon initiation of therapy and post 72 hours, unclear SOP in supplying a/b and pending C&S result.
The formulated remedial actions are HSJ Inpatient Empirical Antibiotic Guide, Antimicrobial Formulary Restriction, HSJ Antimicrobial Guideline, HSJ Antibiotic Application, Persistency on Culture Updates, Flow Chart on Supply of Controlled Antibiotics in HSJ and Antibiotic e-form manual.
The effectiveness of the remedial measure is evaluated as below:-

ABNA: Achieved!

Cost Savings: RM 165,878.50

Antibiogram: Sensitivity improved tremendously & able to maintain

CRE cases: From 49 (2019) reduced to 21 (2021).

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GANTT CHART

Task	Responsibility	05/19- 06/19	07/19-10/19	11/19-12/19	01/20-05/20	06/20-10/20	11/20-03/21	04/21- 12/21	01/22-02/22	03/22-06/22
Problem Identification	All members

Briefing and Questionnaire Preparation	All members

Data Collection and Analysis	All members

Formulate Remedial Measures	All members

Implementation of Remedial Measures	All members

Re-evaluation	All members

Report Writing	All members

	Proposed		Actual

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REFERENCES

1. World Health Organization, Guidelines for the Prevention and Control of Carbapenem-Resistant Enterobacteriaceae, Acinetobacter baumannii and Pseudomonas aeruginosa in Health Care Facilities,Geneva. 2017.
2. Fupin HU, Yan GUO, Demei ZHU. Resistance Trends among Clinical Isolates in China reported from CHINET Surveillance of Bacterial Resistance 2005–2014. Chin J Infect Chemother. 2017;17:93–9.
3. Chandy SJ, Naik GS, Balaji V, et al. High Cost Burden and Health Consequences of Antibiotic Resistance: The Price to Pay. J Infect Dev Ctries. 2014;8:1096–102.
4. Joseph NM, Bhanupriya B, Shewade DG, et al. Relationship Between Antimicrobial Consumption and The Incidence of Antimicrobial Resistance in Escherichia Coli and Klebsiella Pneumoniae Isolates. J Clin Diagn Res. 2015;9:DC08–12.
5. Agodi A, Auxilia F, Barchitta M, et al. Antibiotic Consumption And Resistance: Results of The SPIN-UTI Project of The Gisio-siti. Epidemiol Prev. 2015;39:94–8.
6. Ping Yang, et al. Association Between Antibiotic Consumption and The Rate of Carbapenem-resistant Gram-negative Bacteria from China Based on 153 Tertiary Hospitals Data in 2014. Antimic Rest & Infec. 2018;7:137.

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