Transcript Antibiotic Stewardship Programme at the Kenyatta National

Antibiotic Stewardship Programme
at the Kenyatta National Hospital ,
Nairobi , Kenya
Enoch Omonge
University of Nairobi
Genesis of antibiotic stewardship
initiatives at the Kenyatta National
Hospital
• National Medicines and Therapeutic
Committee (Ministry of Health) - AMU
• Kenyatta National Hospital (KNH)Medicines
and Therapeutic Committee
• KNH Formulary Committee
• KNH Infection Prevention and Control Unit
• Kenya Antibiotic Consensus Group (Education)
Challenges of infection prevention and
Antimicrobial resistance
• Referral hospital - large patient population,
inadequate patient isolation space and protocol
• Liberal use of antimicrobials . No
preauthorisation policy
• Delay microbiological sample collection and
predominant empiric antibiotic therapy
• Absence of treatment protocols and guidelines
• Inadequate local PK/PD data
• Inappropriate OPAT and easy access to antibiotics
Antibiotic protocols as strategy to
appropriate antimicrobial use
• Providing safe use of antimicrobial
• Managing antimicrobial resistance
• Improving quality of care by enhancing
appropriate antimicrobial selection
• Ensuring cost effectiveness
Therapeutic options
HOST
EVIDENCE
•Clinical
•Laboratory
EBM
•Imaging
STANDARDS
AUDITS
BUG
GUIDELINES
INTERVENTION
•Rational
•Cost effective
•Evolve
Omonge e
DRUG
Composition of the multidisciplinary
protocol development team
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Medical specialists
Microbiologists
Clinical pharmacists
Infection prevention and control team
Medicine and therapeutic committee
Representative of the hospital administration
Process of protocol development
• KNH antibiogram used to establish the
antibiotic susceptibility pattern
• Similar protocols to be developed for other
hospital units
• Periodic revision envisaged every two years
• Modifications in special groups e.g
pregnant/lactating mother, renal/hepatic
failure, recent antimicrobial therapy,
hypersensitivity , drug interactions
Antimicrobial stewardship
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Selecting appropriate antibiotic
Optimising dose and duration of therapy
Minimising toxicity
Reducing resistance selection
Principles of AAU
Principles for appropriate prescribing
and effective (locally compliant) guidelines:
– TREAT
bacterial infection only
– OPTIMIZE
diagnosis / severity assessment
– MAXIMIZE
bacterial eradication
– RECOGNIZE
(local) resistance prevalence
– UTILIZE
pharmacodynamics - for effective agents and
dosage
– INTEGRATE
local resistance, efficacy and cost-effectiveness
Appropriate prescribing conforms to these criteria
Ball et al. Antibiotic therapy of community respiratory tract infections: strategies for optimal
outcomes and minimized resistance emergence. J Antimicrob Chemother 2002; 49:31–40
How to use the protocol
• Identify type of infection – bloodstream,
respiratory, intra-abdominal, urinary tract, SSTI
• Identify location- CCU
• Risk stratify the patient- category 1,2 or 3
• Refer to the empiric therapy column
• Send respective cultures before starting
antibiotics
• De-escalate with culture reports
Incidence of pathogens isolated from patients
hospitalised with pneumonia in the United
States in the last 5 years of the SENTRY
Antimicrobial Surveillance Program
Incidence of pathogens
isolated in aspirates of
patients hospitalised with
pneumonia in 2012 at the
KNH CCU
Incidence
(%)
Pathogen
Incidence (%)
n = 31,346
S.aureus
Ps. aeruginosa
Klebsiella spp
Enterobacter spp
Acinetobacter spp
E. coli
Serratia spp
36.3
19.7
8.5
6.5
4.8
4.6
4.1
Pathogen
Stenotrophomonas
maltophilia
S. pneumoniae
H. influenzae
3.1
2.5
2.5
Data from Jones RN. Clin Infect Dis.
2010;51(S1):S81–7.
n=197
K. pneumonia
22.3
Citrobacter spp.
16.2
Ps. aeruginosa
12.7
E. coli
9.6
Acinetobacter
spp.
9.6
Enterococcus
9.6
S. pneumoniae
8.1
Proteus spp.
6.6
Enterobacter
spp.
5.1
Data from KNH
Algorithm for classifying patients with hospital-acquired
pneumonia according to the Consensus Statement of the American Thoracic
Society. Adapted with permission of the American Thoracic Society. Copyright
1996 American Thoracic Society. Hospital-acquired pneumonia
in adults: diagnosis, assessment of severity, initial antimicrobial
therapy, and preventative strategies. A consensus statement.
Am J Respir Crit Care Med 1996; 153:1711–1725.
ATS/IDSA algorithm for initiating empirical antibiotic therapy for hospitalacquired pneumonia (HAP), ventilator-associated pneumonia (VAP),
and health care–associated pneumonia (HCAP)
*Prior antimicrobial therapy (within 90 days), hospitalization for
5 days, high frequency of antibiotic resistance in the community or the
hospital unit, immunosuppressive disease or therapy. Adapted with permission
of the American Thoracic Society. Copyright 2005 American
Thoracic Society.
Am J Respir Crit Care Med. 2005; 171:388–416.
Potential Microorganisms in Each Group According to the 1996
Consensus Statement of the American Thoracic Society.
Group 1
Group 2
Group 3
Enteric gram-negative
bacilli
E. coli
Enterobacter spp.
Klebsiella spp.
Proteus spp.
Serratia marcescens
H. influenzae
MSSA
S. pneumoniae
Anaerobes
MSSA and MRSA
Legionella spp.
Ps. aeruginosa
Ps. aeruginosa
Acinetobacter spp.
MRSA
MRSA: methicillin-resistant Staphylococcus aureus; MSSA: methicillin-susceptible
Staphylococcus aureus.
Am J Respir Crit Care Med 1996; 153:1711–1725
Initial Empirical Antimicrobial Treatment for Patients with HospitalAcquired, Ventilator-Associated, or Healthcare–Associated Pneumonia
Potential pathogen
No risk factors for MDR, early onset and
any disease severity
Recommended treatment
Ceftriaxone; levofloxacin,
moxifloxacin, ciprofloxacin;
ampicillin-sulbactam or ertapenem
S. pneumoniae
H. Influenzae
MSSA
Antibiotic susceptible, enteric gram-negative
bacilli
E. coli
Klebsiella pneumoniae
Enterobacter spp.
Proteus spp.
Serratia marcescens
ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus
aureus; MSSA, methicillin-susceptible S. aureus.
Initial Empirical Antimicrobial Treatment for Patients with HospitalAcquired, Ventilator-Associated, or Healthcare–Associated Pneumonia,
Potential pathogen
Late onset disease or risk factors for MDR
pathogens and all disease severity
Recommended treatment
Combination antibiotic therapy:
antipseudomonal cephalosporin
(cefepime or ceftazidime);
antipseudomonal carbapenem
(imipenem or meropenem) or b-lactam
or b-lactamase inhibitor (piperacillintazobactam) plus antipseudomonal);
fluoroquinolone (ciprofloxacin or
levofloxacin) plus linezolid or
vancomycin (if risk factors)
Ps. aeruginosa
K. pneumoniae (ESBL)
Acinetobacter spp.
Legionella pneumophila
MRSA
ESBL, extended-spectrum b-lactamase; MDR, multidrug resistant; MRSA, methicillin-resistant Staphylococcus
aureus;