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Core Interventions

Watch this video where Laila Alwadah gives an overview of the core interventions which may be implemented in AMS strategies.
There are multiple antimicrobial stewardship strategies that an institution may choose to implement. Overall, there are strategies that can occur before a prescription or “front end” strategies and strategies that can occur after a prescription or “back end” strategies. In general, the hospital is advised to implement a hybrid of both interventions. Another way of thinking about antimicrobial stewardship interventions is to classify them as either structural interventions, such as institutional wide rapid diagnostic based guideline approach for antibiotic prescription or persuasive interventions, such as stuff that you do to persuade prescribers or frontline prescribers to adjust their habits in antibiotic prescriptions, such as a prospective audit and feedback.
Another way is restrictive interventions, such as pre-authorisation approach or enable an intervention, which include development of facility specific antimicrobial guidelines and followed by education interference monitoring. Or finally, an intervention bundle where multiple types of intervention can be grouped together in one way. For example, a bundle can contain a guideline, education, face-to-face feedback for the prescribers. And published evidence demonstrates that the most effective interventions are perspective audit and feedback and pre-authorisation. Another name for perspective audit in the feedback is post-prescription review.
You can also think about antimicrobial search strategies as either provider driven, for example, providers perform antibiotic timeout where they document the dose and duration and an indication for antibiotics at 48 to 72 hours, or mandating for them to assess for allergies, or it can be a facility wide intervention where institution specific to antibiotic guidelines are implemented, or a pharmacy driven intervention. And these include a lot of possibilities, such as, for example, mandating written documentation of indication in each antibiotic prescription, or automatic transition from intravenous to oral antibiotics for those antibiotics with high bio availability, or, for example, automatic stop orders for specific antibiotics or drug-drug interaction alerts, or alerts for duplicative spectrum overlap.
So these are a lot of potential pharmacy driven interventions Moreover, the interventions can also target a specific pathogen, for example, distributing carbapenem resistant enterobacteriaceae, for example, or Acinetobacter species infections, or it can be specific to a specific syndrome, for example, community acquired pneumonia or urinary tract infection and so on. The practise of antimicrobial stewardship is complex. And guidelines advise that institutions should tailor their interventions based on their infrastructure needs and resources. It’s commonly said that there is no one size fits all in antimicrobial stewardship programmes. And the programmes don’t– there is a very large variation between programmes as they don’t look alike. Data comparing interventions are lacking.
And majority of the literature is talking about the effect of interventions compared to no intervention, which is a standard of care. So eventually the goal is to do some sort of stewardship on antibiotic prescription practises. So one should actually spend some time to understand the culture of antibiotic prescribing in an institution and tailor interventions to low hanging fruit strategies that can be simple to implement within the infrastructure of that institution. So for example, in our children’s specialised hospital, K5 Medical Centre, we started with restrictive interventions. And then we slowly grew to mandate infectious disease consultations to all these restricted antimicrobials to ensure appropriate use, duration, and indication.
Then we moved to another step where we created guidelines and student specific guidelines for antibiotic prescription. And then we moved into requiring antibiotic timeouts for each prescribed antibiotic on medical floors. Then we implemented surgical prophylaxis guideline and order sets. And then now we’re currently– we’re moving to a prospective audit and feedback at least once or twice a week to medical surgical floors because of our limited resources. So the goal here is to start small, be focused, have an annual direction before your anti-microbial stewardship programme. Celebrate your achievements and build upon them. And have some sort of milestones for your programme that you build on every year. And remember that every single antibiotic prescription matters.
So don’t underestimate any achievement in that regard.

In this video, Laila Alwadah discusses core antimicrobial stewardship (AMS) strategies that a hospital may implement.

There are multiple strategies that may be chosen – there are strategies that can address gaps in antibiotic prescribing at a front end or before prescription and strategies that are done at a back end or post prescription. In general, in a hospital setting, it is advised to implement a hybrid of both interventions.

Another way of thinking about antimicrobial stewardship interventions is to classify them as either:

  1. Structural interventions (e.g. using rapid diagnostics or inflammatory marker guided approach for antibiotic prescription).

  2. Persuasive interventions which includes the prospective audit and feedback approach.

  3. Restrictive interventions such as the pre-authorisation approach.

  4. Enabling interventions which includes development of facility specific treatment guidelines followed by education and adherence monitoring.

  5. Intervention bundles which is a combination of different interventions, for example a bundle containing guidelines, education, face-to-face feedback to prescribers and so on.

Evidence demonstrates that prospective audit and feedback (sometimes referred to as post prescription review and pre-authorisation) are the two most effective antibiotic stewardship interventions in hospitals.

The practice of AMS is complex, and guidelines advise to tailor the used strategies to fit the needs of and infrastructure of each institution – there is no “one size fits all” when it comes to ASPs. The overall goal is to use antibiotics appropriately, so it is useful to spend time understanding the local culture and start with addressing “low hanging fruit” before aiming for more complex issues.

It is important to start small, have a focused annual direction for your program, celebrate your achievements, maintain them, and build upon them every year. Every single antibiotic adjustment matters.

Do you have an example of an AMS implementation in your healthcare setting that worked well?

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Antimicrobial Stewardship for the Gulf, Middle East and North Africa

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