Antimicrobial Guardians

Dr Brendan Kennedy MBBS FRACP MPHTM

Infectious Diseases Physician

Royal Adelaide Hospital, Australia

What is an antimicrobial guardian?
Someone who:

• Supports the safe and effective use of antimicrobials

• Helps improve behaviour around antimicrobial use and prescribing
• Strives to protect future generations by reducing antimicrobial resistance

Who are they?

• Healthcare professionals, scientists

• Leaders (health, business, agriculture, political)
• Members of the community

Antimicrobials include:

• Antibiotics
• Antifungals
• Antivirals
• Antiparasitic agents
Why do we need antimicrobial
guardians?

ANTIMICROBIAL SAFE AND EFFECTIVE

RESISTANCE USE
Antimicrobial resistance (AMR)
Microscopic organisms (bacteria, fungi, viruses, parasites) are everywhere

Antimicrobial treatment (e.g. antibiotics) can kill or stop some micro-organisms growing

• After antibiotics were first introduced in the 1940s, millions of lives have been saved
• Antimicrobials have also made many other treatments safer, including:
• Surgery, Caesarean section
• Chemotherapy
• Oran and bone marrow transplant

AMR occurs when the micro-organisms that cause disease are resistant to antimicrobial
treatments
• Resistant micro-organisms survive (also, other ‘good’ micro-organisms that provide protection die) and
multiply
• Resistant organisms can be spread from person to person, animal to person or from the environment
• Some resistant genes can spread between micro-organisms
amr.gov.au
Hede. Nature 2014

Resistance develops quickly

New antibiotics aren’t being

developed
Impact of AMR
Estimated 5 million deaths globally associated with bacterial AMR in 2019
• More than deaths associated with HIV and malaria combined
• 1.3 million directly attributed to bacterial AMR

Patients with AMR infections cost more

• Often require less effective and/or more toxic treatment
• More complications, longer hospital stay
• Australian hospitals spend an additional $11.3 million annually treating two AMR infections
• US spend an additional $20 billion on AMR infections

Without action, by 2050 it is estimated that:

• Global AMR related deaths exceed 10 million per year (more than deaths from cancer)
• Increase in global poverty, livestock loss, GDP loss
• Global healthcare costs will exceed $1 trillion per year

One of the top 10 global public health threats facing humanity - WHO

Naghavi et al. Lancet 2022; Wozniak et al. Infect Control Hosp Epidemiol 2019; Dadgostar. Infect Drug Resist 2019; O’Neill. Review on Antimicrobial Resistance 2016
More than AMR…
Adverse effects from antimicrobials occur in 1 in 5 people

• AMR
• Drug toxicity, side effects
• Selection of other pathogenic organisms (e.g. Clostridium difficile)

Choosing the right antimicrobial for the right infection is important

• Leads to less medication toxicity, more effective treatment, less complications, often shorter
hospital stay
• Consultation by infectious diseases specialists often reduces mortality and costs

Antimicrobial guardians promote the safe and effective use of antimicrobials

Tamma et al. JAMA Intern Med 2017; Goldstein et al. Clin Infect Dis 2003
In a hospital setting, antimicrobial
guardians need (ideally):

Antimicrobial
Antimicrobial prescribing Microbiology
stewardship guidelines laboratory
program
(local or national)

Infection control Support (leadership,

program colleagues)
 Example – Royal Adelaide Hospital
• 800 bed hospital, major hospital for South Australia, central Australia
• Infectious Diseases Unit – 8 physicians, 4 trainees/junior doctors
• Provide in-patient care and advice on antimicrobial prescribing, investigation and management of
infections
• Oversee the Antimicrobial Stewardship (AMS) Program including development of local guidelines
• Work in collaboration with:
• Attached Microbiology Laboratory (SA Pathology)
• Infection Control and Prevention Unit
• University of Adelaide
Antimicrobial stewardship (AMS)
Committee
Operational since 1997

3 part-time pharmacists (1.0 FTE) allocated to AMS activities

• Oversight and input from Infectious Diseases Unit

Key functions:

• Development and review of antimicrobial guidelines

• Regular auditing of antimicrobial prescribing
• Providing expert advice and consultation
• Approval service (Infectious Diseases Unit) for restricted antimicrobials
• Meeting national Clinical Care Standards
Guidelines
Local
National
(https://tgldcdp.tg.org.au/)
 Restricted
antimicrobials
• Green = no approval required
• Yellow/amber = no approval required if prescribed for
listed indications
• Red = must call Infectious Diseases team for approval

• Indication and duration should be documented

• Pharmacy ensure an approval number has been given

before dispensing ongoing treatment
Auditing and Education
• Participate in annual National Antimicrobial Prescribing Survey (NAPS),
National Antimicrobial Utilisation Surveillance (NAUSP)

• x3 per week AMS ‘rounds’

• Pharmacist and clinical review case notes of patients prescribed certain
restricted antibiotics (e.g. Vancomycin) to assess suitability
• Also covers medication safety, therapeutic level monitoring etc

• Medical education sessions

• Medical students, doctors, nurses
• Also provide feedback following auditing
Surveillance of AMR (Infection Control)
• Regular surveillance of patients with resistant micro-organisms (infection or
colonisation)
• Primary focus on methicillin-resistant Staph aureus (MRSA), Vancomycin-resistant
Enterococcus (VRE), and extended spectrum beta-lactamase (ESBL) producing Gram
negative bacteria
 Other roles
Assisting with antibiotic
allergy ‘de-labelling’
• Removing historical
and/or inaccurate labels
where safe to do so
• e.g. “allergy to penicillin”
which limits use of other
beta-lactam antibiotics
Providing patient
Education and awareness
information sheets
• Antibiotic information • Opportunities to engage
• Infection information with consumers and
(e.g. Staph aureus clinicians
bacteraemia) • Antimicrobial Awareness
• Developed in consultation Week
with consumers • World Sepsis Day
• Antimicrobial
Stewardship Awareness
Survey (staff)
 Example - Australia
• Focus not just on prescribing in hospitals, but also
primary care, animal health and agriculture

• Education for consumers in the community as well as

prescribers

• Surveillance of antimicrobial resistance at a national

level

• National and international policy

amr.gov.au
 AMS Clinical
Care Standards
1. Life threatening conditions
• Early use of antimicrobials in sepsis

2. Use of guidelines
3. Adverse reactions to antimicrobials
4. Microbiological testing
5. Patient information and shared decision making
6. Documentation
• Accurate dose, frequency, indication, duration

7. Review of therapy
• Review ongoing need, switch to oral therapy etc

8. Surgical/procedure prophylaxis
Surveillance system that captures data on antimicrobial use and antimicrobial resistance
in human health

Comprehensive collection of data from multiple sources, including:

• Australian Group on Antimicrobial Resistance (laboratory-based)
• National Antimicrobial Prescribing Survey (NAPS)
• National Antimicrobial Utilisation Surveillance Program (NAUSP)
• National Notifiable Diseases Surveillance system for specific infections (Mycobacterium
tuberculosis, N meningitidis, N gonorrhoeae)
• The Pharmaceutical Benefits Scheme (PBS)

Helps inform national policy

Also provides education to healthcare workers and community consumers

 Does it work???
Yes!
AMS programs and appropriate antimicrobial prescribing work
• In hospital settings:
• Inappropriate antimicrobial prescribing reduces by more than a third
• Adverse effects related to antimicrobial use decrease resistance, drug toxicity and cost
• Patient outcomes improve
• Even in community settings, once antimicrobial pressure is removed (inappropriate prescribing stops),
resistance can be reversed

Many of these programs also should be in conjunction with other improvement initiatives

• e.g. infection control programs, hand hygiene, improved communication and education

Australian Commission on Safety and Quality in Healthcare. Antimicrobial Stewardship Initiative 2011; Buising et al. J Antimicrob Chemother 2008; Hara. J Glob Antimicrob Resist 2014
 Royal Adelaide Hospital example

• Highlights using AMS, infection control and surveillance to initiate a bundle of interventions to reduce
multi-resistant organism (MRO) infection
• Interventions and surveillance need to be ongoing
 Final advice

Consider Consider your setting and who your target audience is

• Hospital (clinicians) vs primary care (clinicians/patients) vs community (patients/consumers)

Assess Assess what resources are available

• e.g. guidelines, education material, staff, leaders

Look for simple things can be achieved relatively easily before planning and building to bigger
Look projects
• e.g. access to national guidelines, review what antimicrobials are available etc

Gather Gather support - from each other and other antimicrobial guardians, but also within your setting
• (e.g. clinicians, leadership)

Remember Remember the aim is to work together to improve the care of patients and the community
 It can be a long and challenging road…
But many opportunities to improve the care of your patients
and your community

We need antimicrobial guardians and champions to help drive change

Terima kasih dan semoga sukses!