antimicrobial bundle
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Antimicrobial Use BundleAntimicrobial Use BundleAn idea whose time has come ?An idea whose time has come ?
Dr. Ashok Rattan,
Chief Executive,
Fortis Clinical research Ltd.,
Adviser,
Religare SRL Diagnostics labs in
Fortis / Escorts Hospitals, Delhi & NCR
Antimicrobial Prescribing Facts
• ~ 1/3 of all hospitalised inpatients at any given time receive antibiotics
• ~ up to 1/3 to ½ are inappropriate • ~ up to 30% of all surgical prophylaxis in inappropriate • Antimicrobials account for upwards of 30% of hospital
pharmacy budgets. Stewardship programmes can save up to 10% of pharmacy budgets.
• Inappropriate and excessive use leads to resistance, C.difficle & other ecological consequences, increased morbidity, mortality, increased cost, increased litigation and reduce quality of life
100
80
60
40
20
0
19801975 1985 1990 1995 20001997
VISAVISA
VREVRE
PRSPPRSP
MRSAMRSA
MRSEMRSEPercentage ofPathogensResistant toAntibiotics
Increasing Incidence of Resistance in the USMRSE, MRSA, VRE, PRSP, GISA
1980-2006
VRSAVRSA
2006
South Atlantic Ocean South Pacific Ocean
North Pacific Ocean
North Atlantic Ocean
Indian Ocean
Arctic Ocean Arctic Ocean Arctic Ocean
North Pacific Ocean
United States of America
U.S.A.
Canada
Mexico
Brazil
U. S. A.
French Polynesia (Fr.)
Argentina Uruguay
Paraguay
Chile
Bolivia
Peru
Ecuador
Colombia
Venezuela
Greenland (Den.)
Iceland
Madagascar
South Africa Lesotho
Swaziland
Mozambique
Tanzania
Botswana Namibia Zimbabwe
Angola
Zaire
Zambia
Malawi
Burundi
Kenya Rwanda Uganda
Congo
Gabon
Somalia
Ethiopia
Sudan
Egypt Libya
Chad Niger
Algeria
Mali Mauritania
Morocco
Finland Norway
Sweden
Turkey
Yemen
Oman Saudi Arabia
Iran China
Mongolia
Russia
India
Indonesia
Malaysia
Australia
Japan
Antarctica
Kazakhstan
Hawaiian Islands
120° 60° 0° 60° 120° 180°
60°
30°
0°
30°
60°
180° 150° 120° 90° 30° 0° 30° 60° 90° 120° 150°
60°
30°
0°
30°
60°
60°
USA34%
Latin America45%
Europe9-54%
Russia40-90%
China34-38%
TaiwanPhilipinesSingapore>20%
Africa>20%
ESBL is world wide in distribution
Multiple sources & references
India30-80%
Geographical Distribution of
KPC-Producers
Frequent Occurrence
Sporadic Isolate (s)
NDM 1
Consequences of antibiotic use
•Clinical cure
•Inhibition of non pathogenic bacteria
•Selection of resistant mutants
•Toxicity / side effects
Antimicrobial StewardshipPrudent use of antibiotics +
Infection control
Clinical cureClinical cure
•Inhibition of non pathogenic bacteria•Selection of resistant mutants
•Toxicity / side effects
Antibiotic Stewardship
• Effective antimicrobial stewardship– Audit & feedback– Guidelines & algorithms– Antibiotic order form– Combination– De escalation– Dose optimization– Parentral oral– Cycling
Antibiotic Stewardship
• Comprehensive Infection control– Managing data and information– Policies & procedures– Regulatory requirements– Employee health– Prevent transmission, investigate
outbreaks– Education & training– Mobilize resources: human & financial
Antibiotic Guidelines
Linear Causation ProcessSingle intervention is effective
e.g. vaccination
Non linear web of causationMultiple intervention required
Four processes working at 88% can summate to as little as 50% likelihood that each patient will experience
100% correct process
What Is a Bundle?
• A grouping of best practices that individually improve care, but when applied together result in substantially greater improvement.
• Science behind the bundle elements is well established – the standard of care.
• Bundle element compliance can be measured as “ yes/no.”
• “All or none” approach.
What is a bundle ?
• Structured way of improving process of care & patient outcomes
• Small, straight forward set of practices (3 to 5) which when performed collectively, reliably & continuously have been proven to improve patient outcomes
• Data from these frequent measures is fed back to those involved in the procedures
• Reduction in negative actions
• The premise of a bundle: – Reduce variation in practice
– Build a collaborative environment
– Bring about change
– Promote problem solving ability of the staff
Antimicrobial Use Bundle
Initiation bundle:1. 1. Clinical rationale for antibiotic initiation documented
2. 2. Appropriate samples for smear & culture collected & submitted to the laboratory
3. 3. Antibiotic selected according to local policy & risk group
4. 4. Antibiotic ordered as per plan
1. (name, dose, route, frequency & tentative duration)
5. 5. Removal of foreign body or ID, as appropriate, considered
Antimicrobial Use Bundle
Day 3 bundle:1. 1. Was an antibiotic plan documented
1. (name, dose, route, frequency & planned duration ?)
2. 2. Review of diagnosis after lab reports ?
3. 3. If positive microbiology results, was there any adaptation : streamlining or discontinuation
4. 4. Was IV -> oral switch considered & implemented
5. 5. Were all four above mentioned steps followed ?
Antimicrobial Use Bundle
For Surgical Prophylaxis:1. 1. Agent selected matches local guidelines for
that operation and for that patient
2. 2. Timing of first dose in 30 min to 1 hour before incision
3. 3. Antibiotic stopped by 24 hours after the pre operative dose
Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form (Summary)Antimicrobial Use Bundle Data Collection Form (Summary)
Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form: InitiationAntimicrobial Use Bundle Data Collection Form: Initiation
Fortis Hospital Fortis Hospital Antimicrobial Use PlanAntimicrobial Use Plan
Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form: Day 3Antimicrobial Use Bundle Data Collection Form: Day 3
Fortis Hospital Fortis Hospital Antimicrobial Use Bundle Data Collection Form (Prophylaxis)Antimicrobial Use Bundle Data Collection Form (Prophylaxis)
Implementation of a care bundle for antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• 903 bed tertiary care hospital in Michigen• Decided to:
– Employ a trained pharmacist to perform antibiotic audit– Daily monitoring of culture & susceptibility results– Suggest changes to empirical & definitive antimicrobial– Provide educational in service program focused on
hospitals own antibiogram• Study:
– Retrospective control: Sept – Nov 2007– Bundle intervention : Feb – Apr 2008
• Inclusion:– Pts receiving antibiotics admitted into Medical & Surgical wards, 85
antibiotic orders to detect a 20% difference in compliance with beta 0.2 and alpha of 0.05
Implementation of a care bundle for antimicrobial stewardship
Toth NR et al. Am J Health Syst Pharm 2010; 67: 746 - 749
• Compliance with Quality Indicators of Antibiotic Use
Indicator Control Intervention p .
1. Document indication 76 80 0.12
2. Appropriate cultures 70 76 0.09
3. Appropriate empirical 55 65 0.06
4. Appropriate deescalation 41/57 52/58 0.01
5. All indicators concurrently 13 43 <0.001
Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331
• Intervention : 196 patients 204 courses• Control : 226 208• Modification proposed: 93 (46%) of 204 courses
– IV -> Oral switch : 48 (23%)– Discontinuation : 16 (8)– Change antibiotic : 32 (16)– Dose modification : 4 (2)
• Compliance with suggestion: 70 / 93 (75%)• Mean duration : 3.9 + 5.2 days 5 + 6 days• Consumption :• Cost :• Mortality : 11.4 (%) 17.4• Length of stay : 19 + 25 17 + 22
Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331
Impact of standardised review of intravenous antibiotic therapy 72 hours after prescription in two internal medicine wards.
Manuel O, Burnand B, Bady P, Kammerlander R, Vansantvoet M., Francioli P, Zanetti G: Journal of Hospital Infection 2010: 74; 326- 331
Other indicators for Other indicators for Antimicrobial StewardshipAntimicrobial Stewardship
• Antimicrobial costsAntimicrobial costs
• Resistant trendsResistant trends
• Days on therapyDays on therapy
• Defined daily DoseDefined daily Dose
Attributable costs of HAI Stone et al AJIC 2005; 33(9): 501-509
Infection Mean Cost
($ US)
SD Minimum Maximum
Surgical Site Infection
25546 39875 1783 134602
BI 36441 37078 1822 107156
VAP 9969 2920 7904 12034
UTI 1006 503 650 1361
Socio-economic burden of hospital-acquired infections (HAIs)
Incidence Duration of Stay
Overall costs Specific costs %
7.8% 11 days GBP 2915 Hospital overheads / capital charges / management
33
Acquired one or
more HAIs whilst
in hospital
2.5 times more than uninfected
2.8 times longer than uninfected
Nursing care Operations/
Consumables
Paramedics/ nurses
Antimicrobials
Others
42
7
6
4
2
“Whether ‘tis nobler in the mind to suffer the slings and arrows
of outrageous… [prescribing]..
or take to arms against a sea of.. [resistance and diarrhoea]..
and by opposing [irrational antibiotics prescribing]
help end it..”
With apologies to William Shakespeare
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