“Multidrug Resistant Organisms (MDROs)” is another word for “superbugs.” The number of superbug infections is on the rise and the number of new drugs to treat these nasty infections is low. In response to this emerging concern, Sault Area Hospital has created an Antibiotic Stewardship Program (ASP) aimed at promoting rational antibiotic prescribing with the goal of reducing the incidence of superbug infections.
SAH has had clinical pharmacists embedded in patient care areas for many years. Part of their daily work has been to review patients on antibiotics to ensure they are on the right drug for the particular “bug” they are growing, the right dose for their renal function, and the right route by recommending step-down to an oral antibiotic when appropriate. However, through the formalized ASP, we will be collecting and analyzing our antibiotic usage and our resistance patterns by organism. With this improved reporting, we can see the impact of our efforts over time.
Other areas of focus for our ASP include:
Our multidisciplinary ASP Team includes representatives from Infection Control, Laboratory, Pharmacy, and Nursing. Information Technology has also been a key support to our team as we work on our measures of success. Our ASP team is also working with our ICU department and Mount Sinai Hospital ASP Team to complete targeted ASP rounds with the team to ensure every patient is on the right antibiotic.
We hope that the core strategies of the ASP will improve outcomes for individual patients by optimizing treatment of infections and decrease over-exposure to antibiotics when they are not needed. The efforts of the ASP are essential to preserve the effectiveness of the limited number of antibiotics at our disposal and improve patient care.
THE 3 RIGHTS OF ANTIMICROBIAL STEWARDSHIP PROGRAM
Right Drug. Right Dose. Right Timing
Empiric selection of antibiotics considers the likely pathogens based on the source of the infection. Other considerations include patient factors- previous antibiotic use, COPD, immunocompromised patients, lifestyle habits. Local resistance patterns are also considered to make the best guess of which antibiotic is mostly like to provide just the right amount of coverage to treat the infection, but not over-treat it with a broader-spectrum antibiotic than necessary.
Once culture and sensitivity information is back, the choice of antibiotic can be targeted to cover what the patient is growing. De-escalation of antibiotics in a timely manner, including converting the patient to oral alternatives, is key to preserving our broader spectrum antibiotics for the future.
Ensuring adequate antibiotic levels at the site of infection while minimizing any chance for toxicity from too high doses is necessary to get the best possible outcome for your patient. Underdose and our patient will fail to improve and possibly grow more resistant bacteria. Overdose and the patient is at risk of adverse events. Evidence informed dosing recommendations and treatment guidelines are available for most infections.
Initiating the first dose antibiotic quickly improves outcomes in septic shock patients1. Some organizations consider the first dose of an antibiotic like a STAT order. The ordered “timing” or frequency of doses will also impact the patient’s treatment. This works closely with ensuring the “right dose” to achieve and sustain levels that kill bacteria. Missing doses or doses that are several hours late mean that the bacteria have time to regroup and may slow the patient’s recovery.
Lastly related to “timing” is stopping treatment at the right time. Evidence supports discontinuing post-op antibiotics within 24 hours of close time. As well, most other infections have evidence supported recommended duration of treatment so the patient is not over-exposed to antibiotics unnecessarily.
LINKS FOR PATIENTS
LINKS FOR CLINICIANS