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ANTIMICROBIAL STEWARDSHIP

BRIEFING SLIDE FOR PRP

What You Need to Know to Safeguard Our Future Health

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OUTLINE

  • Objectives
  • Introduction
  • Antimicrobial Resistance
  • Malaysia’s Strategies to Contain AMR
  • Antimicrobial Stewardship
  • Conclusions

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OBJECTIVES

  • Explain the concept of Antimicrobial resistance (AMR), the burden of the problem and its consequences�

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  • Educate on the strategies to contain antimicrobial resistance

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INTRODUCTION

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WHAT ARE ANTIMICROBIALS?

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ANTIBIOTICS

1

ANTIVIRALS

2

ANTIFUNGALS

3

4

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Antimicrobials are used to prevent and treat infectious diseases in humans, animals and plants. It includes:

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ANTIPARASITICS

https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

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ANTIMICROBIAL RESISTANCE

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WHAT IS ANTIMICROBIAL �RESISTANCE (AMR)?

  1. https://www.google.com/url?q=https://www.who.int/health-topics/antimicrobial-resistance&sa=D&source=editors&ust=1726549677198104&usg=AOvVaw1jO3ztYdm9rCq-fDFooD0
  2. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance
  • AMR occurs when bacteria, viruses, fungi and parasites evolve over time and no longer respond to existing antimicrobials.

As a result, antimicrobials become ineffective and infections persist in the body, increasing the risk of spread to others.

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HOW AMR SPREADS

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  • Misuse and overuse of antimicrobials in humans, animals and plants are the main drivers in the development of drug-resistant pathogens.

WORLD HEALTH ORGANIZATION (WHO) HAS DECLARED AMR AS ONE OF THE TOP 10 GLOBAL PUBLIC HEALTH THREATS FACING HUMANITY

  1. https://www.google.com/url?q=https://www.who.int/health-topics/antimicrobial-resistance&sa=D&source=editors&ust=1726549677198104&usg=AOvVaw1jO3ztYdm9rCq-fDFooD0
  2. https://www.who.int/news-room/fact-sheets/detail/antimicrobial-resistance

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Impact of AMR 

(Based on National Data)

Infection control and Antimicrobial Resistance (AMR) Containment Surveillance Programme Annual Report 2022. https://myohar.moh.gov.my/reports-human-health/

All cause mortality of HA-MRSAB:

Increased from 8.4 to 14.9 / 100 cases

(2020 -2022)

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Impact of AMR 

(Based on National Data)

All cause mortality of CRE (2019-2022):

  • Reduced to 34% in 2022 from 45% in 2021
  • However, the rate still remains within 30-40% since 2019

Infection control and Antimicrobial Resistance (AMR) Containment Surveillance Programme Annual Report 2022. https://myohar.moh.gov.my/reports-human-health/

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WHO BACTERIAL PRIORITY PATHOGEN LIST 2024

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CRITICAL GROUP

  • Enterobacterales
    • Carbapenem resistant
    • 3rd Generation Cephalosporin

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  • Acinetobacter baumanii

Carbapenem resistant

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  • Mycobacterium tuberculosis

Rifampicin resistant

HIGH GROUP

  • Salmonella typhi

Fluoroquinolone resistant

  • Shigella spp.

Fluoroquinolone resistant

  • Enterococcus faecium

Vancomycin resistant

  • Pseudomonas aeruginosa

Carbapenem resistant

  • Non-typhoidal Salmonella

Fluoroquinolone resistant

  • Neisseria gonorrhoeae

3rd Gen Cephalasporin and/or Fluoroquinolone resistant

  • Staphylococcus aureus

Methicillin resistant

https://www.who.int/publications/i/item/9789240093461

  • Group A streptococci

Macrolide resistant

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  • Streptococcus pneumoniae

Macrolide resistant

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  • Haemophilus influenzae

Ampicillin resistant

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  • Group B streptococci

Penicillin resistant

MEDIUM GROUP

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THE FOUR MOMENTS OF ANTIBIOTIC DECISION MAKING

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“What duration of antibiotic therapy is needed for my patient’s diagnosis?”

  • “Can I stop antibiotics?”
  • “Can I narrow therapy?”
  • “Can I change from IV to oral therapy?”

MOMENT 1: Initiation of antibiotic therapy

“Does my patient have an infection that requires antibiotics?”

MOMENT 3: Every day of antibiotic therapy

MOMENT 4: When infectious process is clear and patient responds to therapy

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  • “Have I ordered appropriate cultures before starting antibiotics?”
  • “What empiric therapy should I initiate?”

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MOMENT 2: Decision to start antibiotics

https://www.ahrq.gov/sites/default/files/wysiwyg/antibiotic-use/four-moments/poster-one-option.pdf

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MALAYSIA’S STRATEGIES TO CONTAIN AMR

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  • NIACC was established in 2001 to coordinate infection control and antibiotic programme at national level.

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  • National Antimicrobial Resistance Committee was established in 2017 as a national coordinating body for AMR efforts.

MALAYSIA’S STRATEGIES TO CONTAIN AMR

https://myohar.moh.gov.my/malaysias-response/

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Strategy 4.5: Strengthening of the Antimicrobial Stewardship Programme in healthcare facilities

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OUTCOME INDICATORS OF MYAP-AMR 2022-2026

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30% reduction in healthcare associated bloodstream infection due to selected MDROs by 2026 compared to the rate in 2021

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At least 60% of overall antibiotic consumption in humans comprised from ACCESS group of antibiotics by 2026

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30% of critically important antimicrobials for human and veterinary medicine not used as a growth promoter in food-producing animals by 2026

03

5% reduction in antimicrobial use in the animal sector by 2026 compared to the rate in 2022

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Increased level of awareness, knowledge and understanding of AMR among the public

01

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National Antimicrobials Consumption by AWaRe categorization in 2022

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ANTIMICROBIAL STEWARDSHIP

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ANTIMICROBIAL STEWARDSHIP

  • WHAT IS ANTIMICROBIAL STEWARDSHIP?
  • AIM
  • AMS TEAM
  • AMS ACTIVITIES
  • AMS PROGRAMME MEASUREMENT

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What is �Antimicrobial Stewardship (AMS)?

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Stewardship is defined as

“the careful and responsible management of something entrusted to one’s care”

Antimicrobial stewardship has been defined as

“the optimal selection, dosage, and duration of antimicrobial treatment that results in the best clinical outcome for the treatment or prevention of infection, with minimal toxicity to the patient and minimal impact on subsequent resistance.”

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AIM

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Antimicrobial Stewardship

1

Promotes the appropriate use of antimicrobials

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Improves quality of care and patient outcomes

3

Reduce further emergence and spread of antimicrobials resistance

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Prolong lifespan of existing antibiotics

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Save on unnecessary healthcare cost

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1.

Formulation of AMS team in each hospital, Health District Office and Health Clinics

Development and documentation of local antimicrobial policy

2.

Educational programme on AMS via continuous medical education (CME) and antibiotic awareness campaign

3.

GENERAL POLICIES

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SPECIFIC POLICIES

Implementation of AMS activities according to category & type of facilities.

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AMS TEAM

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HOSPITAL

HEALTH CLINIC

  1. Head of AMS Team
  2. Either Infectious Disease (ID) Physician/Paediatrician, Senior Physician or Clinician
  3. Pharmacist
  4. Clinical Microbiologist or Microbiologist
  5. Infection Prevention and Control Practitioner
  6. Other members:
    1. IT officers
    2. Hospital Epidemiologist
    3. Interested Clinicians
    4. Quality Officer
  1. Family Medicine Specialist / Medical Officer in charge
  2. Pharmacist
  3. Assistant Medical Officer
  4. Infection Control / Link Nurse (optional)
  5. Medical Lab Technician (optional)
  6. Information Technology Officer (optional)

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AMS ACTIVITIES

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  • Development of Antimicrobial Hospital Policy
  • Development of hospital-endorsed guideline
  • Development of Formulary Restriction and Pre-authorization list that includes:
    • Approved antibiotics
    • Restricted antibiotics
  • AMS Actions/Interventions:
    • Surveillance data on antimicrobial utilisation (ie. DDD per 1000 patient days)
    • Audit on antibiotic usage, Point Prevalence Survey (PPS), Surgical Antibiotic Prophylaxis (SAP)
    • Antimicrobial Order Tools
    • Reviewing antimicrobial selection
    • Dose optimisation
    • De-escalation/streamlining
    • IV to Oral (PO) Antimicrobial Conversion
    • AMS Rounds
    • Education

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  • Implementation of Treatment Guidelines and Clinical Pathways (refer NAG 2024)
  • Development of Formulary Restriction
  • Antibiotic selection and dose optimisation
  • AMS Actions/Interventions:
    • Surveillance and Feedback
      • DDD per 100 admissions
      • Provision of data to district, state and national surveillance programme.
    • Audit and Feedback
      • Clinical Audit
      • Point Prevalence Survey (PPS)
      • Structure Audit
    • Education

HEALTH CLINIC

HOSPITAL

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ANTIMICROBIAL SURVEILLANCE

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Antimicrobial Surveillance

    • Antibiotic usage, presented as "defined daily dose" or DDD

- Independent of price and dosage form (eg; tablet

strength)

- Enable to assess trends in drug utilisation and

compare between hospital/population groups

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    • Presented by types of antibiotics and department

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    • Can be correlated with resistance patterns

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Antimicrobial

Data

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PROSPECTIVE AUDIT &

FEEDBACK

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HOSPITAL PPS FORM

HEALTH CLINIC PPS FORM

Surveillance on antimicrobial utilisation based on:

  1. Diagnoses
  2. Appropriateness of regimen
  3. Compliance to National Antimicrobial Guideline

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ANTIMICROBIAL REPORT

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Newsletter

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ANTIMICROBIAL STEWARDSHIP ROUNDS

  • Led by ID Physician, joined by Pharmacists, Microbiologists and Infection Control nurses
  • Aims: to promote rational use of antibiotics and to reinforce good infection control measures

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Types of Recommendations

Deescalate to narrow spectrum antibiotic

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Changing/

Escalation

Discontinue redundant coverage/

duplicate antibiotic

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Add appropriate antibiotic for adequate coverage

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Dosing change

of

antibiotic

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Duration change

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Discontinue current antibiotic

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IV to PO switch

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Adaptation of an antibiotic guideline

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FACILITY-BASED GUIDELINES

To adopt/adapt antibiotic guideline with consideration of:

  • local antibiotic susceptibilities
  • formulary options
  • available resources

Antibiotic guideline can be adopted through:

  • creation of clinical pathways
  • development of educational module
  • audit on compliance
  • point of care intervention (such as streamlining)

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ANTIMICROBIAL REQUEST FORM

Meropenem

Imipenem

Ertapenem

Vancomycin

Colistin

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Antibiotic Streamlining/

De-escalation

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ANTIBIOTIC STREAMLINING/ �DE-ESCALATION DEFINITION

Narrowing the spectrum

Decreasing number of antibiotic therapy

Shorten the therapy

Stop or cease therapy

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POTENTIAL BENEFIT OF ANTIBIOTIC STREAMLINING

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Reducing secondary infections such as candidiasis/C. difficile associated diarrhoea

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Decreased antibiotic-related adverse events

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Improved antimicrobial resistance surveillance.

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Antibiotic Selection & Dose Optimisation

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ANTIMICROBIAL SELECTION

  • site of infection
  • common pathogens encountered
  • local epidemiology and resistance patterns
  • antimicrobial stewardship principles (spectrum etc)
  • formulary availability
  • antimicrobial costs

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Optimal Therapy

Pathogen coverage

Timely initiation

Correct dose

Correct route

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Guide for common antibiotic dose for adult with normal kidney function

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Renal dose and TDM guide

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Antibiotic allergy guide

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Clinical Pathways

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IV to PO Switch

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IV to PO Switch

    • Reduce line-related infections
    • Risk of thrombophlebitis
    • Earlier discharge
    • Costs

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OUTPATIENT ANTIMICROBIAL THERAPY (OPAT)

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    • Delivering IV antibiotics without the requirement of inpatient stay
    • In the outpatient settings
    • Requirement for IV is a barrier to discharge
    • Have been implemented in most state hospitals and major specialist hospitals in Malaysia

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EDUCATION

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ANTIMICROBIAL AWARENESS WEEK

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ANTIMICROBIAL RESEARCH

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AMS PROGRAMME MEASUREMENT

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AMS PROGRAMME MEASUREMENT (HOSPITAL)

PROCESS MEASURE

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OUTCOME MEASURE

STRUCTURAL MEASURE

Overview of the AMS programme

Outcomes related to antimicrobial use:

• DDD per 1000 patient-days

• DDD per 100 admissions

• DOTs per 1000 patient-days

• Proportion of DDDs in AWaRe and OTHER groups

​

ii. Outcomes related to patients and microbiology:

• Patient outcomes: In-hospital mortality, length of stay, readmission within 30 days after discharge

• Microbiology outcomes: Clostridium difficile / MDR organism

Outcomes measured from antimicrobial surveillance conducted

Outcomes measured from AMS-intervention implemented

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AMS PROGRAMME MEASUREMENT (HEALTH CLINIC)

B. OUTCOME INDICATORS

  • Percentage of clinics with structure audit score of > 80%.
  • Percentage of good practices in antibiotic prescription (clinical audit score > 80 %).
  • Percentage of appropriate antibiotic prescription for URTI from PPS (based on National Antimicrobial Guideline/ clinical guidelines/ pathways for URTI patients).
  • Pattern of selected antibiotics utilisation using DDDs.

A. PROCESS INDICATORS

  • Percentage of clinics implementing structure audits.
  • Percentage of clinics implementing clinical audits.
  • Percentage of clinics implementing antibiotic PPS.

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  • Many strategies are assisted by AMS in promoting judicious use of antibiotics.

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  • Hospital and Health Clinics may adopt the most feasible stewardship strategies to be implemented at their setting to ensure the appropriate use of antibiotics.

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  • AMS Team formation is fully encouraged so that the stewardship programmes can be well planned and implemented.

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  • AMS surveillance should be complemented with feedbacks and followed by AMS actions/interventions if necessary.

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  • Other outcome measures such as length of stay (LOS), cost savings and readmissions may be considered to complement AMS programme indicators measured.

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CONCLUSIONS

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THANK YOU

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