The role of Antimicrobial

stewardship in optimizing antibiotic

use

Dr Klara Tisocki,
Regional Advisor, Essential Drugs and Medicines
WHO SEARO

International Scientific Conference on Antimicrobial

Resistance
28-29 November, 2018, Jakarta, Indonesia

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 Outline
• What is antimicrobial stewardship (AMS)?
• Why do we need AMS?
• What are the AMS interventions?
• How do we implement AMS?
• Who are responsible for AMS?
• How do we know AMS is working?

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 Impact of Antimicrobial resistance

• Infections more difficult to treat due to resistance

– Longer illness
– Longer hospitalization and higher costs
– More death

• Risk to achievements of modern medicine

– Higher risk to surgery, transplantation, cancer treatment, …

• Risk to national economic development

– Lost productivity, outbreaks, epidemics, health security

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Common Factors driving Antimicrobial Resistance
• Health system factors
– poor surveillance, poor diagnostic capacity
– poor quality antimicrobial products, unregulated
prescribing/dispensing weak infection control, lack of rapid
diagnostic tools

• Behavioural factors
– patients poor adherence, self-medication, cultural
preferences/beliefs
– unclear diagnosis, financial incentives, industry promotion

• Medicines factors
– long drug half-life, cross-resistance between classes, treatment
length and complexity, monotherapy, lack of effective new antibiotics

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How can we prevent/reduce AMR?
• Vaccination
Prevention • Infection prevention, hygiene

• Infection control
Transmission • Environmental controls

• Judicious selection and use

Optimized Use • Stewardship

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 WHO Global Action Plan
endorsed at World Health Assembly on 27 May, 2015
• Priority area – Members States to develop National Plans on
Antimicrobial Resistance within 2 years.
• The Plan has 5 strategic objectives:
1) Improve awareness and understanding of
AMR

2) Improve surveillance and research

3) Reduce spread of infections through

better sanitation, hygiene and control
4) Optimize the use of antimicrobial
agents in humans and animals
5) Ensure sustainable investment in research and
innovation
What is antimicrobial stewardship (AMS)?

• Antimicrobial stewardship (AMS) is a coherent set of

actions which promote using antimicrobials in ways
that ensure sustainable access to effective therapy
for all who need them

• The primary goal of AMS is to optimize clinical

outcomes while minimizing unintended
consequences of antimicrobial use, including
toxicity, the selection of pathogenic organisms, and
the emergence of resistance

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 Why do we need AMS?
- because antibiotics are different
Antibiotics/ antimicrobials are different from other medicines:
• They loose their efficacy over time.
• Antibiotics are a shared resource.
• Individual use may harm others.
• Use is high and often unnecessary
• Antibiotic/ antimicrobial exposure has negative consequences

• Antimicrobial resistance is a global health emergency that

jeopardize the future of medicine and can have broader
negativive societal, developmental impact

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 The 30% evidence
• Over 30% of all hospitalised in-patient receive
antibiotics
• Over 30% of antibiotics are prescribed inappropriately
in the community
• Up to 30% of all surgical prophylaxis is inappropriate
• 30% of hospital pharmacy costs are due to
antimicrobial use
• 0-30% of antimicrobial cost can be saved by
antimicrobial stewardship programs

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 Why do we need AMS?
- because AMS works
Growing evidence shows that AMS can :
• reduce antibiotic use without negative impact on
clinical outcomes
• improve quality of care and patient safety through
increased cure rates, reduced treatment failures,
and reduced adverse events
• Can save costs

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 Impact of antibiotic stewardship programmes in Asia: a
systematic review and meta-analysis. Lee CF1, Cowling BJ1, Feng S1, Aso
H1, Wu P1, Fukuda K1, Seto WH1., J Antimicrob Chemother. 2018 Apr 1;73(4):844-851.

• 91% of these studies reported reduced antibiotic usage and 100% reported
cost savings in the intervention group.
• Duration of antibiotic therapy was reduced in six of seven studies in
association with an ASP.
• Rates of all-cause mortality and HAI were not significantly different between
the intervention and control groups.
• Mortality rates were significantly improved by ASPs using drug monitoring,
while HAI rates were also improved by ASPs that included infection control or
hand hygiene programmes.

ASP reduce antibiotic consumption in hospital and clinic settings and do not
worsen clinical outcomes. The findings strongly support the broad
implementation of antimicrobial stewardship interventions in hospital and clinic
settings in Asia.

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What are the AMS interventions?

Formulary Guidelines/
Education Restrictions Clinical
Pathways

Point-of-Care Drug Selection Active Review

Interventions and Intervention
Dose Direct Feedback
Optimization
 WHO EML List 2017 – New AWARE
categorization
• A access
• Wa watch
• Re reserves

• Aims to ensure that antibiotics are available when needed,

and that the right antibiotics are prescribed for the right
infections.

• It should enhance treatment outcomes, reduce the

development of drug-resistant bacteria, and preserve the
effectiveness of "last resort" antibiotics that are needed
when all others fail. ARE: Access, Watch, Reserve list of
antibiotics
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 Definitions AWARE
• ACCESS group should be available at all times as treatments
for a wide range of common infections.

• WATCH group antibiotics are recommended as first- or

second-choice treatments for a small number of infections.

• RESERVE groups should be onsidered last-resort options, and

used only in the most severe circumstances when all other
alternatives have failed, such as for life-threatening infections
due to multidrug-resistant bacteria.

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 How do we implement AMS?
Hospital Guidelines
Leadership Timely and and Policies
appropriate antibiotic
management
Physicians Clinical
Pharmacists

Infection
Control PATIENT
Antibiogram

Nurses
Microbiologists
Education
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 Who are responsible for AMR?
AMS governance in hospitals
Executive Level Hospital Executive

Clinical Governance Medical Director

Committee Level
Drug and
Therapeutics Divisional
Committee Management
Patient or AMS Infection
Medication Committee Prevention &
Safety Control
Committee Committee
AMS
Team
Frontline Healthcare

External Clinical Antimicrobial Nursing

Sites Pharmacists Prescribers Champions

http://www.cec.health.nsw.gov.au/__documents/programs/hai/quah/fact-
sheet-ams-teams-and-committees.pdf
Need for leadership on AM

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How do we know AMS is working?
Monitoring and Evaluation

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Process measures of antimicrobial use

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 Summary
• AMS can be one of the important strategy to
optimize us and lengthen the efficacy of current
antimicrobials and reduce AMR
• AMS must be delivered by a multidisciplinary
team
• Core elements important to but does not need
wait for all to be in place to start
• Monitoring with clear indicators necessary to
measure impact
• One Health approach needed for broader AMS
strategies too

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https://openwho.org/courses/AMR-competency

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• Belgium
• •Free-of-charge e-learning course from the University of Antwerp (Universiteit
Antwerpen), featured by TRACE and The Tipping Point 10 minutes e-learning: Safe
and effective management of primary care patients with acute cough while
reducing unnecessary antibiotic use

• Germany
• •Training courses on antibiotic stewardship in hospitals for doctors and
pharmacists (Deutsche Gesellschaft für Infektiologie - DGI) ABS Fortbildungen für
Krankenhausärzte und -apotheker
• •Antibiotic stewardship course (Deutsche Gesellschaft für Krankenhaushygiene -
DGKH) ABS-Kurse der DGKH

• Ireland
• •Free of charge online course from the Irish Institute of Pharmacy Antibiotic
Stewardship Programme (for pharmacists) (2016)

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• Tell WHO what will you do about AMR!
• Contact: Dr Klara Tisocki tisockik@who.int

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