Antibiotic Stewardship: Current status and implications in India

1
Antibiotic Stewardshipcurrent status and
implications in India

• Dr. S. K. Jindal
• www.jindalchest.com

2
Communicable diseases

• Major public health problems in India and South
  East Asia
• (Dual burden NCDs on the rise)
• CDs account for 40 of 14 million annual death
  and 42 of DALYs in SEAR
• Newer Threats
• Epidemics with new organisms
• Hospital and Health-care facility
  acquired
• infections Cross-infections
• Emergence of resistant organism

3

• Emergence of a new antibiotic resistance
  mechanism in India, Pakistan, and the UK a
  molecular, biological, and epidemiological study
• Kumarasamy KK et al. Lancet Infect Dis. 201010
  597602.
• 44 isolates of NDM-1 (Gram ve Enterobacteriaceae
  with resistance to carbapenem conferred by New
  Delhi metallo-b-lactamase 1) in Chennai, 26 in
  Haryana, 37 in UK and 73 in other sites in India
  and Pakistan, among E. coli and K pneumoniae.
• Potential for a world-wide problem co-ordinated
  international surveillance needed.

4
Emerging Resistance Problem

• Enterococcus foecium (vancomycin-resistant
  enterococci-VRE)
• Staph aureus (methicillin-resistant
  Staphylococcus aureus-MRSA)
• Klebsiella and Escherichia coli that are
  producing extended spectrum beta-lactamases
  (ESBL) enzymes and carbapenemases
• Acinetobacter baumannii
• Pseudomonas aeruginosa
• Enterobacter sp.

5
Emergence of resistance and hospital
cross-infections

• Resistance equation
• Risk of emergency of antibiotic resistance
• Antibiotic Genetic
  Risk of
• Pressure selection
  Cross infection

Antibiotics Life saving No new antibiotic
in pipeline
6
FL Prescription and Pneumococcal Resistance
development
Adapted by Fishman N from Chen
DK et al, NEJM 1999
7
Antibiotic Scene - India

• No functional national (or even local) antibiotic
  policy
• No restriction on OTC sales (More than half of
  pharmacists dispense antibiotics without
  prescription)
• Universal prescription by all
• Varying standards of infection control
• Fast emergence of drug-resistant organisms

8
Why Inappropriate Prescriptions?

• Inadequacy of knowledge
• Poorly designed decision systems
• Doctors biases
• Not up-to-date guidelines and drug charts
• Attempts at early and sure cure
• Commercial incentives and pressures
• Nil or poor antibiotic policies (at hospitals)
• Over the counter availability

9
Control of Anti-microbial Resistance
Fishman N, AJIC 2006
10

• Use Antibiotics Rationally
• World Health Day 2011

11
WHO Use Antibiotic Rationally

• Guiding principles
• Understand the factors, emergence and spread of
  resistance
• Rationalize the use
• Reduce selection pressure by disease control
  measures
• Improve prescribers behaviour
• National coordinated activities
• Promote discovery, development and delivery of
  new agents and tools

12
Antibiotic Stewardship

• Coordinated intervention designed to improve
  and measure and appropriate use of antimicrobials
  by promoting the
• Selection of the optimal antibiotic/s regimens
• Dose, duration and route of administration

13
Use of Antimicrobial Stewardship

• Optimal clinical outcomes Early cure, lesser
  failure rates, morbidity and mortality
• Minimization of toxicity
• Reduction of costs
• Lesser rates of super-infections
• Prevention of resistance

14
Clinical Outcomes of a Stewardship Program (Univ.
of Pennsylvania)
Outcome HUP program (n 96 Usual practice (n 95) R.R. (95 CI)
AM appropriate 90 30 2.8 (2.1 3.8)
Cure 91 55 1.7 (1.3 2.1)
Failure 5 31 0.2 (0.1 0.4)
Clinical 4 11 -
Microbiol 0 8 -
Super-inf. 0 8 -
Service changed antibiotic 0 5 -
Adverse drug effect 0 2 -
Recurrent infection 1 1 -
Resistance 1 9 0.13 (0.02 1.0)
Sum gt 100 Can fail for multiple reasons Sum gt 100 Can fail for multiple reasons Sum gt 100 Can fail for multiple reasons Sum gt 100 Can fail for multiple reasons
Fishman N AJIC 2006 Fishman N AJIC 2006 Fishman N AJIC 2006 Fishman N AJIC 2006
15
(No Transcript)
16
Stewardship Strategies

• Prescribes education
• Formulary restriction
• Prior approval
• Streamlining
• Antibiotic cycling
• Computer-assisted programmes

17
Prudent Antibiotic Prescription

• Empiric guidelines and policies
• Clinical judgment for complicated scenario
  require internationalization of principles
• Make informed choices
• Antibiotic stewardship with multi-disciplinary
  culture

18
Maximizing outcomes Minimizing Resistance

• What should be done
• Appropriate empiric antibiotic therapy with right
  dose, duration and time
• Delayed therapy or modifying initial therapy does
  not improve outcome
• MDRs predispose inappropriate tmt.
• Early accurate identification of the pathogen
  and susceptibility
• Combination or monotherapy chosen on basis of
  pathogen
• De-escalation of initial BSA after definitive
  diagnosis

19
What should not be done

• Treat non-infectious or nonbacterial syndrome
• Treat colonization or contamination
• Treat longer than necessary
• Fail to make adjustment in a timely manner
• Prescribe antibiotic with spectrum of activity
  not indicates

20
Process for the development of hospital
antibiotic policy

• Hospital associated Surveillance of
• Infection Antimicrobial resistance/
• Antibiotic consumption
• Cumulative
• antibiogram
• Hospital/Community
• Antibiotic policy
• Standard treatment guidelines
• Antimicrobial stewardship

21
The hospital antibiotic policy shall be based upon

• Spectrum of antibiotic activity
• Pharmacokinetics/pharmaco-dynamics of these
  medicines
• Adverse effects
• Potential to select resistance
• Cost
• Special needs of individual patient groups

22
Anti-microbial Team (Steward) Functions

• Antimicrobial dose and regimen alteration
• Streamlining and sequential therapy
• Discontinuation of antimicrobials
• Advice on and as a result of therapeutic drug
  monitoring
• Automatic stop orders for antimicrobial
  prophylaxis
• Restricted antimicrobials
• Empirical antimicrobials
• Approval of restricted antibiotics
• Assistance in interpretation of laboratory
  results
• Indication for use of specific antimicrobials
• Suggestion for ordering additional laboratory
  testing and formal educational events

23
StewardshipBy
Brian Froud Partners in Stewardship for
Life
24
Antibiotic Cycling

• Antibiotics of 2 or more classes with similar
  spectra of activity given for a pre-determined
  period (One rotation cycle) chanage to other
  drugs from same/ different classes (2nd cyle) and
  so on.
• Does Antibiotic cycling help to reduce
  resistance?
• Too weak evidence (systematic review)
• Brovon Nathwani, 2005
• Unlikely to reduce emergence or spread of
  resistance (Math. model)
• Bergstrom Lipsitch, 2004
• May lead to excessive resistance (Math. model)
• Magee JT, 2005

25
AMR SurveillanceData collection for action

• Understand when, where, how and why resistance is
  emerging
• Reveal antimicrobial efficacy
• Ensure better management and infection control
• Improve community infection control
• Inform policy-makers
• Improve empiric antibiotic selection

26
Components

• Policies
• Guidelines
• Surveillance
• Prevalence reports
• Education
• Audit of practice

27
Organisms in resistance-surveillance

• Proven pathogens not commensals
• High potential for spread
• Known to acquire resistance
• Have standard interpretation of susceptibility
  tests
• Widespread in the surveillance area frequent
  cause of disease

28
Respir. pathogens for surveillance

• Strep pneumoniae from respir. isolates (sputum,
  ear, sinus) and invasive isolates (blood, CSF,
  pleural fluid)
• H. influenzae As above
• Nosocomial organisms
• Acinetobacter
• Enterobacter
• Klebsiella
• Serratia spp - Proteus

29
National Surveillance System

• National Network and coordinator
• Ensure uniformity of testing and reporting
• Ensure quality of surveillance data
• Disseminate technical information
• Types of surveillance
• i. Lab data from representative hospitals
• (if resources limited)
• ii. Collection of additional data
• (Passive surveillance)

30
Chennai Declaration and Road-Map meeting - 2012

• MOH Need for national policy NTF
• DCGI Rationalizing antibiotic use
• State Depts. of Health Improve infection control
  strategies/Committee
• MCI Curricular changes
• NABH Strict implementation for accreditation
• ICMR Surveillance network
• NGOs Dissemination of information

31
Pharmacological Issues

• Route of administration
• Drug distribution
• Peak levels duration
• Local concentrations (bronchial secretions,
  abscess, pleural cavity)
• Tissue blood barrier
• Concentration
• Degree of binding
• Molecular Size, pK, inflammation etc

32
Selection of antibiotics

• Clinical clues
• Infecting organism
• Epidemiological
• Staining/culture
• Known susceptibility
• Toxicity
• Expense
• Duration

33
(No Transcript)
34
WHO SAVE LIVES Clean Your Hands

• The coming months will see progress in our steps
  towards 5 May 2014!
• The focus this year is very special and provides
  a broader perspective the role of hand hygiene
  in combating antimicrobial resistance (AMR).
• The WHO call to action this year is
• No action today no cure tomorrow make
  sure the WHO 5 Moments are part of protecting
  your patients from resistant germs.

35

• Do Not Use a BOMB
• when a Bullet does the job
• The Bomb will certainly kill
• BUT the Bomb is..
• Not cost-effective
• More destructive
• Responsible for extensive collateral damage
• Accompanied with long lasting effects, including
  rebound and chain reactions.
• It is much wiser to Choose the Bullet correctly

36
Choice architecture

• Steer or nudge prescribers towards desired
  behaviour by making prudent antibiotic
  prescription as the default outcome
• Choice to prescribers
• Outcome as per best practice

37
Prerequisites of STG

• Based on local antibiograms
• Syndrome/diseased based
• Specify type of clinical setting Outpatient
  clinics, inpatient units, ICU setting
• Specify rationale of guidelines
• Provide evidence-based strength of
  recommendations
• Involve treating physicians to bring ownership to
  the guidelines

38
THANK YOU