Antibiotic

Stewardship
Combined Lecture of Dr. Renato Montenegro
& Dr. Anne Louise Gabriel-Chan

Re-echo by MARK JHERVY S. VILLANUEVA

Post Graduate Medical Intern
Antibiotic Misuse

 Between 20-50% of antibiotic

prescriptions are either
unnecessary or inappropriate
Antibiotic Misuse

 Given when they are not needed

 Thewrong antibiotic is chosen to
treat on infection
 Continued when they are no longer
necessary
 Given at the wrong dose
 Broad spectrum agents are used to
treat very susceptible bacteria
Antibiotic Resistance

 Theability of a microorganism to
stop an antimicrobial from
working against it
 Standard treatments become
ineffective, infections persist and
may spread to others
Antibiotic Resistance

 Newresistance mechanisms are

emerging and spreading globally
 Resistanceincreases the cost of
health care with lengthier stay in
hospitals and more intensive care
required
Cost Associated with AMR

Treatment Failure
Morbidity and Mortality
(Collateral Damage)
Length of Hospital Stay
Need for Broad Spectrum
Antibiotics
AMR in the Philippines

DOH Antimicrobial
Resistance Program
2017 Data
Summary Report
Most Common Isolates
Streptococcus pneumoniae
Staphylococcus aureus
MRSA
Escherichia coli
Klebsiella pneumoniae
Pseudomonas aeruginosa
Acinetobacter baumannii
Most Common Isolates in
BGH
RESPIRATORY BLOOD
Pseudomonas aeruginosa Staphylococcus aureus
Klebsiella pneumonia Staphylococcus coagulase
Enterobacter cloacae negative
CUTANEOUS/WOUND URINE
Staphylococcus aureus Escherichia coli
Pseudomonas aeruginosa Klebsiella pneumonia
Klebsiella pneumoniae Enterobacter cloacae
RESPIRATORY
Pseudomonas aeruginosa
n=80
25%
20%
15%
10%
5%
0%
m e e m m i n n m
ta i m i m e e ac aci ta
ac
zi
d e p en en o x ik ac
lb ta
f ip ro
p l m ob
Su f Ce Im of A z
e Me pr Ta
l li n C Ci in
ci ll
pi aci
m r
A
i pe
P

n=80
RESPIRATORY
Klebsiella pneumoniae
n=79
80%

60%

40%

20%

0%

n=79
RESPIRATORY
Enterobacter cloacae
n=56
70%
60%
50%
40%
30%
20%
10%
0%

n=56
WOUND
Staphylococcus aureus
n=99
60%

50%

40%

30%

20%

10%

0%
Penicillin Oxacillin Clindamycin Erythromycin Vancomycin Cotrimoxazole

n=99
WOUND
Pseudomonas aeruginosa
n=22
16%

12%

8%

4%

0%
m e e m m i n n m
ta i m i m e e ac aci ta
ac
zi
d e p en en o x ik ac
lb ta
f ip ro
p l m ob
Su f Ce Im of A z
e Me pr Ta
l li n C Ci in
ci ll
pi aci
m r
A
i pe
P

n=22
WOUND
Klebsiella pneumoniae
n=16
120%
100%
80%
60%
40%
20%
0%

n=16
URINE
Escherichia coli
n=93
80%

60%

40%

20%

0%
in e e n n ne e
il l ta
m
i m z ol n em aci a ci tam o i m
ic c p a x ik c x d
p l ba e fe ox o pe f lo m ba tria azi
o t
Am Su C rim Mer pr
o A
az ef ef
in t i T C C
i ll Co C in
p ic c i ll
a
Am per
Pi

n=93
URINE
Klebsiella pneumoniae
n=34
80%

60%

40%

20%

0%
in e e n n ne e
il l ta
m
i m z ol n em aci a ci tam o i m
ic c p a x ik c x d
p l ba e fe ox o pe f lo m ba tria azi
o t
Am Su C rim Mer pr
o A
az ef ef
in t i T C C
i ll Co C in
p ic c i ll
a
Am per
Pi

n=34
Antibiotic Stewardship

 Systematic effort to educate and

persuade prescribers of
antimicrobials to follow
evidence-based prescribing, in
order to stem antibiotic overuse
and thus, antimicrobial resistance
Antibiotic Stewardship

 Coordinated interventions
designed to improve and measure
the appropriate use of agents
promoting the optimal selection,
dosage, duration, and route of
administration of antimicrobials
Antibiotic Stewardship

Goals:
 Improve patient outcome
 Improve patient safety
 Improve rates of antibiotic
susceptibilities
 Reduce healthcare costs
AMS in Hospitals

Antimicrobial
Stewardship
Program in
Hospitals
Manual of
Procedures 2016
AMS in Hospitals
Leadership

A dedicated multi-disciplinary
AMS Committee and Team
supported by the hospital
administration
Leadership

 Responsible
to successfully
implement, perform, and monitor
the AMS Program in each hospital
Policies, Guidelines,
Clinical Pathways
 Antibiotic policies and
standardized clinical guidelines
and clinical pathways on the
treatment and prophylaxis of
infections
Policies, Guidelines,
Clinical Pathways
 Provide evidence-based guidance
to clinicians and other healthcare
professionals on the management
of infectious diseases and in the
selection of the most appropriate
antimicrobial agent
Recommended Antibiotics
for CAP-MR
Etiology: S.pneumonia, H.influenza, C.pneumonia,
M.catarrhalis, Enteric Gram (-) bacilli, Legionella
pneumophila, Anaerobes
Preferred Regimen:
(DOT: 7-10 days) PLUS

Ampicillin-Sulbactam 1.5g IV Azithromycin 500mg PO OD

q6h -OR-
-OR- Clarithromycin 500mg PO
Cefuroxime sodium 1.5g IV BID
q8h -OR-
-OR- Levofloxacin 750mg PO OD
Ceftriaxone 2g IV q24h
Recommended Antibiotics
for CAP-HR
Etiology: S.pneumonia, H.influenza, C.pneumonia, M.
pneumonia, M.catarrhalis, Enteric Gram (-) bacilli,
L.pneumophila, Anaerobes, S.aureus, P.aeruginosa
Preferred Regimen:
(DOT: 7-10 days) PLUS

No risk for P.aeruginosa Azithromycin 500mg PO OD

Ceftriaxone 2g IV q24h -OR-
-OR- Clarithromycin 500mg PO
Cefepime 2g IV q8h BID
-OR- -OR-
Ceftazidime 2g IV q8h Levofloxacin 750mg PO OD
Recommended Antibiotics
for CAP-HR
Etiology: S.pneumonia, H.influenza, C.pneumonia, M.
pneumonia, M.catarrhalis, Enteric Gram (-) bacilli,
L.pneumophila, Anaerobes, S.aureus, P.aeruginosa
Preferred Regimen:
(DOT: 7-10 days) PLUS

Risk for P.aeruginosa Amikacin 15mg/kg IV OD

Cefepime 2g IV q8-12h
-OR-
Ceftazidime 2g IV q8h
Recommended Antibiotics for
Skin & Soft Tissue Infections

Preferred Regimen: Preferred Regimen:

Parenteral (DOT: 5-10 Oral (DOT: 5-10 days)
days)
Clindamycin 300-450mg PO
Clindamycin 600mg IV q8h TID
-OR- -OR-
Vancomycin 15-20mg/kg q8- Cotrimoxazole 160/800mg
12h 1-2 tabs BID
-OR-
Doxycycline 100mg PO BID
Recommended Antibiotics
for Diabetic Foot Infections
Etiology: Aerobic Gram (+) cocci, including MRSA, are most
common, Aerobic Gram (-) bacilli and anaerobes are
common secondary organisms
Preferred Regimen: Preferred Regimen:
Mild to moderate DFI Severe DFI

Clindamycin 300mg PO/IV Ceftazidime 1-2g IV q8h (or

QID Cefepime)
-OR-
Cotrimoxazole 160/800mg PLUS
1-2 tabs PO BID Metronidazole 500mg IV q8h
-OR-
Levofloxacin 750mg PO/IV
OD
Recommended Antibiotics
for Urinary Tract Infections
Etiology: E.coli, Group B Streptococcus, Enterobacteriacea
Preferred Regimen: Preferred Regimen:
Parenteral (DOT: 7 days) Oral (DOT: 7 days)

Amikacin 15mg/kg q24h Cefixime 200mg BID

-OR- -OR-
Gentamicin 3-5mg/kg q24h Ciprofloxacin 500-750mg BID
-OR- -OR-
Ceftazidime 2g IV q8h Levofloxacin 500-750mg OD
-OR-
Cefepime 2g IV q8h
Recommended Antibiotics
for Complicated UTI
Etiology: More varied and may include drug-resistant
organisms (e.g. ESBL-producing E.coli), P.aeruginosa and
enterococci
Preferred Regimen: Preferred Regimen:
Parenteral (DOT: 7-14 Oral (DOT: 7-14 days)
days)
Ciprofloxacin 500-750mg BID
Amikacin 15mg/kg q24h -OR-
Gentamicin 3-5mg/kg q24h Levofloxacin 500-750mg OD
Ceftazidime 2g IV q8h
Cefepime 2g IV q8h
Levofloxacin 750mg IV q24h
Piperacillin Tazobactam
2.25-4.5g q6-8h
Surveillance of AMU &
AMR
 Antimicrobial Use (AMU) and
Antimicrobial Resistance (AMR) are
intricately related
 Surveillance of AMU provides
important insights into prescribing
patterns that may explain for the
evolution of AMR, and is useful in the
development and evaluation of AMS
interventions
Surveillance of AMU &
AMR
 AMR surveillance allows for the
development of an antibiogram that
informs empiric antimicrobial
choice, characterizes the impact of
AMS activities on resistance, and
identification of specific AMR
problem areas that needs to be
addressed notwithstanding the
infection control measures
Action

 TheAMS Program employs a

coordinated multi-pronged,
multi-disciplinary approach to
safeguard and optimize use of all
antimicrobials used within the
hospital
Action

 Activeinteraction between the

AMS team and prescribers (and
other healthcare professionals) is
pivotal in encouraging
compliance to AMS interventions
and being able to effectively
persuade and influence change in
prescribing practices
Education

 AMS practitioners need to gain

competency through
comprehensive education and
clinical training to effectively and
safely perform AMS interventions
Education

 Education of all healthcare

professionals on the principles of
judicious use of antimicrobials is
also necessary to enable positive
behavioral change
Performance Evaluation

 Measuring process and clinical

indicators to assess the overall
quality management
improvement and effectiveness
of AMS interventions
Performance Evaluation

 Fundamental in guiding the

progressive implementation of
the program towards achieving
the goal to combat AMR
But that is in the Hospital Level…

What can we do
individually as
doctors?
What can we do?

 Realize that the cornerstone of

AMS is making a correct diagnosis
 Establish an invasive bacterial
infection before prescribing an
antibiotic
What can we do?

 Realizethat antimicrobial
resistance happens not only with
inappropriate antibiotic use but
also with appropriate use
What can we do?

 Realizethat even before a new

antibiotic is released in the
market, there are resistance
mechanisms already present in
bacteria
In a Nutshell

 Prescribing the right antibiotic,

at the right dose, for the right
duration, and at the right time
helps optimize patient care and
fight antibiotic resistance
 Thisshould be viewed as an
important patient safety issue
THANK YOU AND GOD BLESS!