AB.jpg | The BCA Antibiotic Stewardship Getting Started Kit | BCA Antibiotic Stewardship Measures | DDD - Defined Daily Dosage (World Health Organisation) | FAQ | Drivers of Antibiotic Stewardship | Links | Prof Dilip Nathwani |


See the FIDSSA website for their latest newsletters and resources including information about the South African Antibiotic Stewardship Program (SAASP).
SA antimicrobial resistance national strategy framework 2014-24 is here: .


Antibiotic Prescribing Chart


Antibiotic Prescribing Tool. (PDF)
It may be helpful to separate antimicrobial prescribing from the ordering of other pharmaceuticals.
A separate order form for in-hospital use could contain suggestions or guidelines as well as serve as a data collection instrument.
The data we would be interested in includes:
  • Indication for the drug (therapy or prophylaxis)
  • Specimen taken
  • Source of infection
  • Condition that is being treated

It could also contain key information that would affect drug selection, dose and duration, such as allergies, kidney or liver impairment, and could contain visual flags for extended duration of therapy.



The BCA Antibiotic Stewardship Getting Started Kit

- change concepts, measurement and principles from three SA private hospital groups



BCA Antibiotic Stewardship Measures


Dr Adrian Brink:
Problem
Measure
Empiric therapy without confirmation
Antibiotics without appropriate cultures
Inappropriate agent choices

Inappropriate combinations
"Double coverage" i.e. concurrent antibiotics in any of these three groups:

Gram-negative cover (GNB)
  • Piperacillin/tazobactam
  • Cefepime
  • Imipenem
  • Meropenem
  • Ertapenem
  • Ciprofloxacin
  • Levofloxacin

Gram-positive cover (GPC)
  • Linezolid
  • Teicoplanin
  • Vancomycin

Anti-fungal cover
  • Amphotericin
  • Fluconazole
  • Voriconazole
  • Caspofungin


≥4 agents concurrently
Failure to de-escalate

Excessive duration of treatment
>7 days
>14 days
Inappropriate surgical prophylaxis (agent/timing/duration)
(Please see the update to this list)
>24 hrs of antibiotic cover

Inappropriate agent:
  • Piperacillin/tazobactam
  • Cefepime
  • Imipenem
  • Meropenem
  • Ertapenem
  • Linezolid
  • Teicoplanin
  • Vancomycin
  • Voriconazole
  • Caspofungin


DDD - Defined Daily Dosage (World Health Organisation)


Cost data do not by themselves adequately tell the story of antibiotic utilisation. Defined Daily Dosage is a World Health Organisation metric for drug utilisation. A DDD is the average maintenance dose of the drug when used for its major indication in adults. Improved understanding of antibiotic overuse (and underuse) is possible using DDDs.

DDDs are suitable for:
  • Comparisons of drug utilization
  • Evaluation of long term trends in drug use |
  • Assessing the impact of certain events on drug use

In this DDD-NAPPI Crosswalk (updated November 2013) the DDD column contains the amount of drug in each NAPPI-coded product in relation to the WHO defined daily dosage for that drug. This system provides a tool for assessing the impact of Best Care Always and of other attempts to reduce infection rates and improve prescribing of antimicrobials, in hospital and outpatient settings.

Discovery Health have crosswalked over 1200 systemic antibiotics to DDDs
  • This list excludes topical antibiotics, anti-viral agents (e.g. ARVs) and anti-TB drugs ||
  • It includes anti-fungals
No assurances of accuracy or integrity are offered. Contribution to the QA process is welcomed.

ATC and DDD are copyright of the World Health Organisation
For further information contact Dr Gary Kantor – garyk@discovery.co.za


References
Introduction to drug utilization research. World Health Organization. 2003
http://www.who.int/entity/medicines/areas/quality_safety/safety_efficacy/Drug%20utilization%20research.pdf




FAQ

What is Antibiotic Stewardship?
Antibiotic stewardship is the responsible use of a critical and threatened health resource, namely the antimicrobial agents we depend on to prevent and treat infectious disease. Stewardship implies not only appropriate clinical decision-making for individual patients, but a population perspective that maximizes overall benefits, minimizes adverse events and costs, and, importantly, delays the onset of widespread microbial resistance to commonly used antibiotics.

Why is it needed?
Antibiotic stewardship is urgently needed because of rising rates of antimicrobial resistance, a limited manufacturing pipeline of new agents, and the morbidity burden and large costs associated with disease that is improperly treated. The misuse of antibiotics is an international problem. Infections with multi-drug resistant organisms kill about 25,000 people a year in Europe and around 19,000 in the United States. S African figures are not known but we do have the distinction of being a world leader in prevalence of gram-negative organisms with resistance (ESBL) to beta-lactam antibiotics.

What is our approach?
Firstly, the Best Care…Always campaign aims to raise awareness of antibiotic prescribing issues – highlighting both misuse, and appropriate use. Secondly it aims to test and implement a small set of defined interventions that measurably and positively impact the situation. Foremost among those interventions are ICU prescribing rounds, the development of tools that both document and assist prescribing decisions, including guidelines, and the development of a team approach that supports the prescriber.

What about TB and HIV/AIDS?
Although clearly the biggest infectious disease threats to our population, these epidemics are not currently the focus of the campaign or the antibiotic stewardship intervention. Clearly however, principles of good antimicrobial prescribing apply as much to TB and HIV/AIDS as to any other infectious disease.

Is there an antibiotic stewardship bundle?
There is no antibiotic stewardship bundle, but one output of the campaign may be something resembling a bundle.

Where is this happening?
The stewardship intervention is to be piloted in the ICUs of a small number of hospitals, public and private, around the country.

Is this research or improvement?
This component of the campaign differs from the infection prevention interventions in that what works is not fully established. In that sense, this is both a research and an improvement initiative. Once we have learned what works, it will be spread to other sites.

Is this about blocking access to antibiotics?**
No. The scientific evidence suggests that limiting choice to only a few antibiotics may be counterproductive and that diversity is important. On the other hand, many local and international experts, such as Prof Guy Richards and Dr Adrian Brink, believe it is time to change the “rules of the game – “it may well be time now to challenge the right of doctors to prescribe whichever antibiotic they wish, including the dosage and duration” - and to guide clinicians towards optimal, evidence-based practice.


Drivers of Antibiotic Stewardship

See this list derived from work done by an IHI/CDC group.


Links



Resources


South African Medical Journal highlights Antibiotic Stewardship in an editorial "Wake up, South Africa! The antibiotic 'horse' has bolted!" and in a research report on the prevalence of inappropriate prescribing practices in ICUs linked with poor patient outcomes. (July 2012)

Prof Dilip Nathwani

Teleconference Oct 31 2011
Slides (PDF) about 4 MB
Article - Scottish Antimicrobial Prescribing Group