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STEWARDSHIP
WHY? WHAT? and HOW?
Ma. Charmian M. Hufano, MD, FPCP, FPSMID
Infectious Diseases Specialist
WHY
WHAT
HOW
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 2
ANTIMICROBIAL RESISTANCE
http://mostlyscience.com/wp-content/uploads/2014/05/F4.large_.jpg
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 5
ACQUISITION OF AMR
-ANIMAL MEDICINE
-HUMAN MEDICINE
-WRONG DOSE
-WRONG DURATION
-WRONG INDICATION
http://www.who.int/medicines/publications/who_emp_2009.3/en/
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 10
A DRUGSTORE SURVEY OF ANTIBIOTIC
USE IN A RURAL COMMUNITY IN THE
PHILIPPINES
-Reference Laboratory
1) Data management using WHONET software
2) Confirmatory testing
1) Retesting using conventional and
automated methods
2) MIC determination
3) Serotyping
4) PCR testing for resistance genes
5) Whole Genome Sequencing
Outpatient Inpatient
Antimicrobial
No. %R No. %R
ORAL AGENTS
Ampicillin 879 84.4 2446 86.1
Co-amoxiclav 880 28.8 2388 39.6
Cefuroxime 359 39.3 803 41.7
Ciprofloxacin 809 52.2 2310 45.5
Co-trimoxazole 762 63.5 2148 68.7
Nitrofurantoin 614 4.4 1297 4.1
INTRAVENOUS AGENTS
Piperacillin/Tazobactam 888 7.4 2337 12.5
Ceftriaxone 778 38.7 1824 44.8
Ertapenem 421 2.9 982 5.1
Amikacin 742 1.5 2293 2.4
Legend: N=number tested; %R=percentage resistance; Outpatient=specimen taken from patients at the outpatient
Department or emergency room; Inpatient=specimen taken from patient admitted or hospitalized
90
81.2
80
70
60 57 58.3
53
50 46.4 45.7
44.2 43.9 43
39.9
40 36.6 37.2
33.2
30 31.2 30.3
30
21.1
17 18.8
20 15 13.5
10
0
780 247 287 129 228 897 400 141 400 210 258 250 696 154 277 1790 221 52 85 1196 163
BGH BRH BRT CMC CVM DMC EVR FEU GMH JLM LCP MAR MMH NKI NMC PGH RMC RTM STU VSM ZMC
25
20 19.4 18.8
17.7 17.2
15.3 15.1 14.9
15
13.2
10 8.6
0
5149 5416 5308 3608 5233 5377 5522 5146 5266
Pip/Tazobactam Ceftazidime Cefepime Aztreonam Imipenem Meropenem Amikacin Gentamicin Ciprofloxacin
60
54.4 55.6
53.7
52.1
50 47 45.5
40 38.4
30
20
10
0
2651 4102 3967 3564 4064 3939 3553
Ampicillin/Sulbactam Cefepime Imipenem Amikacin Gentamicin Ciprofloxacin Cotrimoxazole
Falagas etal
WHY
WHAT
HOW
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 28
RATIONAL ANTIBIOTIC USE
60
40
20
0
Cure Failure
Fishman N. Am J Med. 2006;119:S53.
RESEARCH INSTITUTE FOR TROPICAL MEDICINE
IMPROVING ANTIBIOTIC USE
SAVES MONEY
$200,000 - $900,000
60
40
20
0
Ticar/clav ImipenemAztreonam Ceftaz Cipro
CID 1997;25:230
RESEARCH INSTITUTE FOR TROPICAL MEDICINE
ANTIMICROBIAL STEWARSHIP
WHY
WHAT
HOW
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 34
DOH AMS Program
Power
Dellit TH et al. CID 2007; 44:158-77
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 44
Core Element 1: LEADERSHIP
MICRO
MEDICAL DIRECTOR
TOP MANAGEMENT ICC
Antibiotic prescription
ASP- approval/disapproval
Patient
Chung GW etal. Virulence 4:2, 151-157; Feb 15, 2013
RESEARCH INSTITUTE FOR TROPICAL MEDICINE 63
PROSPECTIVE AUDIT WITH
INTERVENTION & FEEDBACK
Full Implementation of AMS Program in the Hospital Jan 2022 Jan 2022 Jan 2022
1st Performance Evaluation Report to be submitted to Jan 2021 Jan 2019 Jan 2018
DOH
R. Laxminarayan,
Miklen Institute Review, July 2012