An ASP aims to improve antibiotic prescribing, minimize harm, reduce antibiotic resistance and HCAI, and promote cost- effective prescribing. These aims are supported by a series of primary objectives, or ‘drivers’, including robust stewardship infrastructure, improved education on anti- biotics, introduction of good antimicrobial prescribing practices, surveillance of antimicrobial usage and resistance patterns, audit and feedback of antimicrobial policies, and application of quality performance indicators. Each intervention is underpinned by the prudent antimicrobial prescribing ethos ‘the right drug at the right time at the right dose for the right duration’ [8] .
Primary objectives may be further broken down by ‘secondary drivers’ or planned projects and activities designed to achieve the primary objectives and overall aims. Activities include develop- ment of infection management and surgical prophylaxis guidelines, development of education packages, and collaborative working with IPC teams. Interventions are therefore measurable, pro- viding an opportunity to track progress towards achieving the overall aims. It is important that
SPEcific aiMS of an antiMicrobiaL StEWardSHiP ProGraMME 15
this plan is dynamic and adjustable to address local and national ASP priorities. An example of an antimicrobial stewardship driver diagram used within ScotMARAP 2 [2] and adapted from the Centers for Disease Control and Prevention and Public Health Institute in the USA [12] is shown in Figure 2.2. The driver diagram includes key ASP themes, two of which are described below together with the need for leadership. The remaining themes are described in other chapters of this book.
Education
To ensure the continued sustainability of any ASP it is important to provide a solid foun- dation of knowledge about antimicrobial stewardship and infection prevention and control tailored appropriately for all healthcare professionals. Embedding the principles of antimi- crobial stewardship and adherence to infection guidelines within medical, pharmacy, and nursing school curricula is fundamental to this end. Of particular importance for medical prescribers as they transition from student to practitioner is practical induction into pru- dent prescribing practice. For post- graduates the development of various multidiscipli- nary educational resources and initiatives, including case- based learning, on- line learning modules, electronic updates, webinars, and ‘bedside learning’ via infection specialist- led antimicrobial rounds, is important. Continuous feedback on prescribing practice and involvement in quality improvement programmes is of particular value in reinforcing
Medical Director
Chief Executive Officer
Infection Prevention and Control Manager
Area Drugs & Therapeutics Committee Antimicrobial Management Team (AMT) Antimicrobial Pharmacists
Ward based clinical pharmacists Risk Management Committee Clinical Governance Committee Infection Prevention and Control Team
Medical Infection Specialists. Microbiologists/ Infectious Diseases
Clinicians Medical and Non-
medical PRESCRIBERS Nurses
AIM PRIMARY DRIVERS SECONDARY DRIVERS Timely and appropriate
antimicrobial use in all health and care settings
• Improved clinical outcomes for patients with infections • Decreased incidence
of antimicrobial- related adverse drug events • Decreased prevalence of antimicrobial resistant healthcare- associated pathogens • Decreased incidence of healthcare- associated Clostridium difficile infection (CDI) • Improved cost- effective use of antimicrobials
• Establish stewardship as an organisational priority and ensure links to management, infection prevention and control and patient safety groups
• Ensure national and local education programmes on antimicrobial stewardship meet the training needs of all healthcare staff
• Promote antimicrobial stewardship in primary care through adoption of training programmes e.g. ScRAP and TARGET training tools
• Increase healthcare provider, patient and public awareness of optimal antimicrobial use through participation in European Antibiotic Awareness Day
• Introduce restricted infection management guidelines and surgical antibiotic prophylaxis guidelines • Commence antibiotic therapy promptly and within one hour of diagnosis of patients with sepsis • Obtain expert antimicrobial advice from infection specialists when required
• Record indication for therapy, dose, dosage frequency, route of administration and duration in notes • Stop, IVOST or de escalate promptly based on culture and sensitivity reports
• Monitor defined daily doses (DDDs) of restricted antibiotics (co-amoxiclav, cephalosporins, clindamycin and ciprofloxacin)
• Monitor DDDs of ‘alert/protected’ broad-spectrum antibiotics (piperacillin/tazobactam, meropenem) • Monitor and report trends of antimicrobial resistance
• Compare antibiotic usage and antimicrobial resistance trends and adjust antimicrobial management guidelines to reflect evolutionary change
• Conduct at least annual point prevalence study of hospital antimicrobial use.
• Target areas of poor antimicrobial prescribing or non-adherence to guidelines and feedback results to the healthcare providers
• Ensure reliable processes in place to monitor and audit for toxicity or unintended consequences of antimicrobial guidelines
Stewardship infrastructure and staff
education
Adherence to good antimicrobial prescribing
principles
Audit and Feedback
Performance indicators
• Develop and implement performance indicators for both primary and secondary care, to assess adherence to antimicrobial guidelines and progress towards achieving Government healthcare targets • Display results on run charts and feedback at both local and national level
Surveillance
Figure 2.2 an example of an antimicrobial stewardship driver diagram used within ScotMaraP 2 [2] (ivoSt, intravenous to oral antibiotic switch therapy).
Source: data from World Health organization, Antimicrobial resistance draft global action plan on antimicrobial resistance, Sixty- Eighth World Health assembly, 27th March 2015, copyright © WHo 2015, available from http:// apps.who.int/ gb/ ebwha/ pdf_ files/ WHa68/ a68_ 20- en.pdf?ua=1; and institute for Health improvement, CDC Antimicrobial Stewardship Driver Diagram, available from http:// www.cdc.gov/ getsmart/ healthcare/ pdfs/ antibiotic_ Stewardship_ driver_ diagram_ 10_ 30_ 12.pdf
tHE iMPortancE of nationaL LEadErSHiP in antiMicrobiaL StEWardSHiP 17 good prescribing practice, whilst demonstration of learning attainment can be used for pro- fessional appraisal and revalidation.
In UK primary care, interactive, case- based antimicrobial education tools include TARGET (‘treat antibiotics responsibly, guidance, education, tools’) [13], which is supported by the Royal College of General Practitioners, and the Scottish reduction in AMR (ScRAP) programme [14].
The Professional Education sub- group of the Expert Advisory Committee on AMR and Healthcare Associated Infections and Public Health England have developed a progressive com- petency framework entitled ‘Antimicrobial prescribing and stewardship competencies’ designed for prescribers across primary and secondary care [15]. This should complement continuous pro- fessional development relating to antibiotics for prescribers at all levels, regardless of speciality. Similarly, NHS Education for Scotland has developed an educational package supporting stew- ardship among nurses [16].
Raising awareness and educating users of the healthcare system is clearly important. The annual European Antibiotic Awareness Day is a public health initiative that provides the opportunity to focus on ASPs by engaging all healthcare staff and members of the public [17].