antimicrobial stewardship (ams) · most patients do not require iv antibiotics and those who do...

Antimicrobial Stewardship (AMS) AMS Lead Resource Pack – “At a Glance”

Leading an AMS programme is a multi-faceted process requiring a coordinated response that engages colleagues and supports their active involvement. The items within this pack

are designed to help you and your AMS Champions deliver excellent and consistent patient care through collaboration between all members of the hospital team.

Antimicrobial StewardshipWe all have our part to play

If your patient is being treated with antibiotics, are they being used safely and effectively?The central role of nurses in medicines management places you in an important position to review antimicrobial prescriptions.

Is it the right antibiotic that is being administered? At the right time? At the right dose? For the correct duration? Have your patients been on their antibiotics for too long? Has the indication and duration been correctly documented?

If you have concerns talk to someone; for example, after the initial 48 to 72 hour prescribing decision2, if your patient has been taking antibiotics beyond the documented review date, ask the medical team if they still require this treatment. Positively questioning antimicrobial prescriptions is an important part of AMS.

Have the correct microbiology samples been taken?Microbiology samples need to be taken at the correct time to get accurate results. Where possible, all specimens should be obtained before the patient starts antimicrobial treatment. This should not delay therapy though, for example, within one hour of diagnosis (or as soon as possible) for patients with life-threatening infections such as severe sepsis.1

Can your patient be switched from IV to Oral?Most patients do not require IV antibiotics and those who do will normally only need them for 24-48 hours.2

An antimicrobial stewardship programme (AMS) is a co-ordinated effort that aims to slow down and reduce antimicrobial resistance, reduce toxicity, improve patient safety and promote optimal outcomes for them. The success of implementing an AMS programme relies on clinical teams working together in departments across the hospital.

You will already be doing much of what is recommended to reduce antimicrobial resistance but may not be calling it AMS; for example, 'infection control precautions' and 'medicines management'. Many parts of AMS do not require a detailed knowledge of antimicrobials.

Your involvement within the AMS team will be invaluable and there are key areas where you can make a significant contribution.

Your role in antimicrobial stewardship

START SMART, THEN FOCUSAt 48 to 72 hours the five ‘antimicrobial prescribing decision’ options are:

Stop antimicrobials if there is no evidence of infection Switch antimicrobials from intravenous to oral Change antimicrobials – ideally to a narrower spectrum –

or broader if required Continue and document next review date or stop date Outpatient Parenteral Antibiotic Therapy (OPAT)2

Supporting your patients and their carers You are a constant point of frontline care and support for patients, their families and carers. You know how a patient is reacting to the treatment, if there are side effects and whether they are getting better. You can also provide them with essential information and monitor their safety and response to antibiotic therapy.

Check for drug allergies and side effectsIf your patient has a documented allergy, is the antibiotic they have been prescribed safe for them?

Is your patient suitable for OPAT?You are ideally placed to assess whether your patients are medically stable and do not require hospital-based monitoring. If a patient is able to return to the hospital when required and has adequate support at home they may be suitable for OPAT.

There is guidance in place that can help give you a deeper understanding of AMSThe Public Health England 'START SMART, THEN FOCUS'2 toolkit provides an outline of evidence-based antimicrobial stewardship in the secondary healthcare setting.

The NICE Guidance on antimicrobial stewardship aims to change prescribing practice.

Our AMS programme is your opportunity to join the ward-focused team. If you'd like to get involved please ask your local AMS Champion for more information.

Antimicrobial Stewardship We all have our part to play

ANTIMICROBIAL RESISTANCE (AMR)

A continued rise in AMR would lead globally to

10 million people dying every year by 20501

10 million

APPROPRIATE PRESCRIBING

Healthcare professionals should prescribe the

right antibiotic, at the right dose,

for the right duration - monitoring adherence

to “start smart then focus” principles3

ANTIMICROBIAL STEWARDSHIP (AMS)

is an organisational or healthcare system-wide

approach to promoting and monitoring judicious use

of antimicrobials to preserve their future effectiveness2A COORDINATED RESPONSE TO AMS IS EVERYONE’S RESPONSIBILITY

To find out more about ANTIMICROBIAL STEWARDSHIP (AMS)

in your hospital, contact your local AMS champion or your hospital AMS team.

Name..........................................................................................................................................

Contact.......................................................................................................................................

PP-PHP-GBR-0402 Date of preparation: August 2017

This material has been developed by Pfizer Ltd.

START SMART - this means Do not start antimicrobial therapy unless

there is clear evidence of infection

Take a thorough drug allergy history

Initiate prompt effective antibiotic treatment within one hour of diagnosis (or as soon as possible in patients with severe sepsis or life-threatening infections).

Avoid inappropriate use of broad-spectrum antibiotics

Comply with local antimicrobial prescribing guidance

Document clinical indication (and disease severity if appropriate), drug name, dose and route on drug chart and in clinical notes

Include review/stop date or duration

Obtain cultures prior to commencing therapy where possible (but do not delay therapy

Prescribe single dose antibiotics for surgical prophylaxis where antibiotics have been shown to be effective

Document the exact indication on the drug chart (rather than stating long-term prophylaxis) for clinical prophylaxis

Antibiotics are generally started before a patient’s full clinical picture is known. By 48-72 hours, when additional information is available, including microbiology, radiographic and clinical information, it is important for clinicians to re-evaluate why the therapy was initiated in the first place and to gather evidence on whether there should be changes to the therapy

THEN FOCUS - this meansReviewing the clinical diagnosis and the continuing need for antibiotics at 48*-72 hours and documenting a clear plan of action-the ‘antimicrobial prescribing decision’

The five ‘antimicrobial prescribing decision’ options are:

1. Stop antibiotics if there is no evidence of infection

2. Switch antibiotics from intravenous to oral

3. Change antibiotics – ideally to a narrower spectrum – or broader if required

4. Continue and document next review date or stop date

5. Outpatient Parenteral Antibiotic Therapy (OPAT)*

It is essential that the review and subsequent decision is clearly documented in the clinical notes and on the drug chart where possible e.g. stop antibiotics

* Due to advances in rapid diagnostics it may be possible to review prior to 48 hours after first dose.


Antimicrobial Stewardship

TREATMENT ALGORITHM


SURGICAL PROPHYLAXIS ALGORITHM

DO NOT START ANTIBIOTICS IN THE ABSENCE OF CLINICAL EVIDENCE OF

BACTERIAL INFECTION

Surgical Prophylaxis ONE DOSE*Within 60 minutes before

knife to skin

Clean surgery involving placement of a

prosthesis or implant

CLINICAL REVIEW & DECISION AT 48-72 HOURS

Clean contaminated

surgery

Contaminated surgery

Start Smart Then Focus

1. Take thorough drug allergy history2. Initiate prompt effective antibiotic treatment within

one hour of diagnosis (or as soon as possible) in patients with severe sepsis or life-threatening infections

3. Comply with local antimicrobial prescribing guidanceα

4. Document clinical indication (and disease severity if appropriate), doseβ and route# on drug chart and in clinical notes

5. Include review/stop date or duration 6. Obtain cultures prior to commencing therapy where

possible (but do not delay therapy)

Redose for long surgical procedures Intraoperative redosing is needed to ensure adequate serum and tissue concentrations of

the antimicrobial if the duration of the procedure exceeds two half-lives of the antimicrobialof there is excessive blood loss (i.e., >1500mL in adults or >25ml/kg in children). A treatment

course of antibiotics may also need to be given (in addition to appropriate prophylaxis) incases of dirty surgery or infected wounds. The appropriate use and choice of antibiotics

should be discussed with infection specialists for each case

1. STOP2. IV to oral switch 3. Change antibiotic 4. Continue 5. OPAT*

Document Decision & NextReview Date orStop Date

Clinical review, check microbiology and make a clear plan. Document this decision

DOCUMENT ALL DECISIONS

DOCUMENT ALL DECISIONS

α In accordance with surviving sepsis patient safety alert https://www.england.nhs.uk/wp-content/uploads/2014/02/rm-fs-10-1.pdf

β According to weight/age in children refer to local formulary or BNFc

# Use appropriate route in line with severity/patient factors

* Outpatient Parenteral Antibiotic Therapy

AMS Champion

packCase study video



Nurses and Antimicrobial Stewardship

We all have our part to play



References

1. NICE(2016). Sepsis: recognition, diagnosis and early management. Available at https://www.nice.org.uk/guidance/ng51

/chapter/recommendations#managing-and-treating-suspected-sepsis-in-acute-hospital-settings Last accessed October 2016.

2. Public Health England (2015). Start Smart - Then Focus Antimicrobial Stewardship Toolkit for English Hospitals. Available at https://www.gov.uk

/government/uploads/system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF Last accessed October 2016



PP-PHP-GBR-0395 Date of preparation: August 2017This material has been developed by Pfizer Ltd.

The key steps required in implementing or extending an antimicrobial stewardship programme

Antimicrobial StewardshipWe all have our part to play

Supporting



The right drug

The right dose

The right time

For the right duration

We all have a part to play

References

1. Jim O’Neill, (2016). Tackling drug-resistant infections globally: final report and recommendations. Available at https://amr-review.org/sites/default

files/160525_Final%20paper_with%20cover.pdf Last accessed June 2017

2. NICE (2015). Antimicrobial stewardship: systems and processes for effective antimicrobial medicine use. Available at https://www.nice.org.uk/guidance/

ng15?unlid=3488529072015112920111,7153105802016212224627 Last accessed October 2016

3. Public Health England (2015). Start Smart - Then Focus. Antimicrobial Stewardship Toolkit for English Hospitals. Available at https://www.gov.uk/government/

uploads/ system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF Last accessed October 2016





Steps that can help Champions support the

implementation of an Antimicrobial Stewardship programme

Supporting Antimicrobial Stewardship We all have our part to play

Nurse guide

Lead guide

Champions guide

START SMART, THEN FOCUS




7PP-PHP-GBR-0396 Date of preparation: August 2017




ReferencesPublic Health England (2015). Start Smart - Then Focus. Antimicrobial Stewardship Toolkit for English Hospitals. Available at https://www.gov.uk/government/uploads/

system/uploads/attachment_data/file/417032/Start_Smart_Then_Focus_FINAL.PDF Last accessed October 2016

Start Smart, Then Focus guidance summary

This A5 guide helps familiarise nurses with the important role they play in AMS and key areas where they can make a significant contribution.

This guide provides ideas and suggestions around 5 steps that can help Champions support the implementation of an AMS programme.

This guide provides advice, ideas and suggestions around

10 key steps that can lead to a successful AMS implementation.

This video talks about the AMS resources in this pack and how they can be used in practice. View the case study video at www.accesspfizer.co.uk

A summary of Public Health England guidance which can also be used as a poster on ward or staff notice boards.

AMS. We all have our part to play awareness poster

This poster highlights AMR challenges and AMS actions. Champions can put this poster up in department staff rooms.

AMS Lead pack


To view, download or order copies of these resources please visit

www.accesspfizer.co.uk

JOB NO: PROJECT JOB STAGE: VERSION: CREATIVE OPERATOR Q.C ACC. HANDLER4LEAD 1 PAGE GUIDEPF14942.025 CLIENT AFP

References 1. Public Health England (2015). Health Matters: Antimicrobial resistance. Available at https://

www.gov.uk/government/publications/health-matters-antimicrobial-resistance/ health-matters-antimicrobial-resistance Last accessed June 2017.

Antimicrobial Stewardship (AMS)‘We all have our part to play’

“Ensuring responsible and less frequent use of antibiotics will not happen overnight. It will require the full commitment and engagement of healthcare professionals and the public. Everyone has a responsibility and a role to play in making this happen.1”

Public Health England, 2015

AMS Lead Resource PackAntimicrobial Stewardship (AMS) is an important element in the fight against antimicrobial resistance (AMR), aiming to improve the safety and quality of patient care and contributing to reductions in the emergence and spread of AMR.

An effective implementation of an AMS programme within the hospital setting relies on the collective involvement of a range of healthcare professionals to make AMS part of what we do every day. This means having the right people onboard: a core team of professionals who can promote the appropriate use of antimicrobials.

So whether you are extending your existing AMS programme or embarking on your first programme, effective communication, engagement and support for everyone involved is pre-requisite for success. With this in mind, the enclosed AMS “We all have our part to play” resource pack is designed to provide suggestions and ideas to help AMS leads to engage with teams, and implement a well-coordinated AMS programme.

In the resource pack you will find a Lead Guide that details the key steps in implementing an AMS programme, and guidance to help you provide practical direction and support to your programme Champions. The resource also includes fifteen AMS Champions packs explaining the role of an AMS Champion and offers advice, suggestions and tips to help support engagement with colleagues in their teams.

We have been using this toolkit as part of our AMS programme at St George’s. The resources have proven invaluable when engaging staff from board to ward, involving the right members of the team and promoting the message of tackling antimicrobial resistance ‘We all have our part to play’.

Dr Matthew Laundy Consultant Microbiologist, St George’s University Hospitals NHS Foundation Trust.

Dr Matthew Laundy

Dr Laundy is a consultant specialising in microbiology at St George’s University Hospitals NHS Foundation Trust. He is the lead clinician for Antimicrobial Stewardship and has clinical interests in Antimicrobial Stewardship, Outpatient Parenteral Antimicrobial Service (OPAT), Paediatric Infections, Medical Informatics and Infection Control.

To find out how this resource is already being used in practice please view our online case study video at www.accesspfizer.co.uk


antimicrobial stewardship (ams) · most patients do not require iv antibiotics and those who do...

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