Priority areas for AMS interventions

In this activity we will be looking at STEP 3 of setting up an AMS programme (ASP) – the implementation stage. This step involves:

• Identifying common areas where antimicrobial prescribing improvement is required.
• Identifying the priority areas for AMS intervention.
• Categorising types of different AMS interventions.
• Finding evidence to support the effectiveness of these interventions.
• Identifying behaviour change interventions used in ASPs, e.g., PDSA and other models for performing AMS in hospitals.

In this step, we will look at some of the key areas where interventions may be required.

Common infections in LMICs where AMS interventions should focus

A particular area of concern for antimicrobial prescribing is in LMIC hospitals, where physicians are particularly challenged due to:

• A lack of diagnostic facilities.
• Poor level of healthcare systems.
• A lack of ASPs.

For example, a 2016 study among private hospitals in Lahore, Pakistan, found that out of 93 Escherichia coli isolates from urine culture, 82% were resistant to beta-lactam antibiotics. This was attributable to inappropriate antibiotic selection.

A 2019 study evaluated antimicrobial prescribing in hospitals in Lahore, Pakistan. This longitudinal study reviewed how many patients received inappropriate antibiotic treatment based on wrong dosage, wrong indication or both.

The study concluded that 70% of the patients received at least one inappropriate antimicrobial.

The diagram below shows the burden of common infections identified in this study where inappropriate use of antibiotics is high and should be a focus for AMS interventions.

Common areas to improve prescribing

In the prescribing decision making process there are 4 main themes. These are:

Within these themes, several common areas require improvement (see diagram below) and these form the basis of stewardship interventions to improve practice in these areas.

Performing AMS interventions: reviewing prescriptions

Identifying the common areas for improvement in the processes for use of antibiotic treatment and prophylaxis process is critical. Reviewing prescriptions and the decision-making supporting the use of antibiotics is a hugely important step in delivering appropriate care for patients with infections.

As shown in the diagram below, reviewing prescriptions along with the supporting medical records and laboratory results is a fundamental tool to optimise antibiotic use. This is a key role for antimicrobial and clinical pharmacists in hospital practice.

Click here to see a larger version of this image.

Identifying areas for improvement

Several methods can be used to identify areas of sub-optimal practice where improvement interventions should focus. Many utilise audits and feedback, which may be done prospectively (in real-time) or retrospectively by looking at historical data. Regardless of the approach used, the most important point about conducting an audit is to share the results with those responsible for prescribing to allow them to reflect on their practice and change behaviours where indicated.

Simple antibiotic audits can provide data on which patients are receiving antibiotics, indications for treatment and whether the patient is receiving antibiotic treatment that complies with guidelines.

How to choose which antibiotics to audit?

• Antibiotics where consumption has increased significantly over time.
• Antibiotics with a higher potential of inducing and propagating resistance (e.g. Watch and Reserve group antibiotics).
• Broad-spectrum antibiotics (e.g. piperacillin/tazobactam, ticarcillin/clavulanate, carbapenems).
• Last-resort antibiotics (e.g. polymyxins, linezolid).
• Expensive antibiotics.

Note: Keep in mind that restricting audit to one antibiotic may increase the use of others.

Depending on the strategy adopted in the facility, audit might be done via ward rounds, pharmacy alerts, a process of pre- or post-authorisation, self-revision by physicians or a combination of all of these.

The WHO AMS toolkit (chapter 5.8) provides an example of a simple audit for one or more antibiotics (as shown below). This example illustrates doing a common compliance audit with guidelines for one or more antibiotics where consumption has increased.

Ceftriaxone is often overused because of its perceived broad spectrum and ease of dosing (single daily dose), but it has a high potential of inducing resistance and is also associated with a higher risk of Clostridioides difficile infection. In many hospitals with established ASP, its use is now confined to presumed or confirmed meningitis, but in some countries is also for complicated UTIs, severe CAP and other indications.

Click here to see a larger version of this image.

Point Prevalence Surveys (PPS)

The method for evaluating antibiotic use that is now recommended and widely used is a point prevalence survey (PPS). This is a systematic and structured way of collecting data to give a snapshot of antibiotic use. PPS will measure the number of people within a facility receiving antibiotics at a given point in time, and the prescribing data collected can help identify suboptimal practice.

There are at least 5 potential benefits or uses of a health care facility PPS:

• Monitor rates of antibiotic prescribing between different departments/hospitals/regions/countries in hospitalised patients.
• Determine variation in antibiotic choices and indications for use.
• Understand the quality of antibiotic use with respect to guideline compliance and identify targets for improvement.
• Identify areas to target for intervention to promote stewardship.
• Assess the effectiveness of interventions through repeated surveys.

We will describe how to set up and run a PPS later in the course.

Priority areas for AMS intervention

We have already discussed how prioritising AMS interventions is essential. The term “low hanging fruit” is often referred to as identifying the tasks, actions or goals that may be most easily achieved.

The expression “low-hanging fruit” regarding stewardship refers to selecting the most achievable targets for improvement rather than confronting more complicated issues. These targets could include:

• Intravenous-to-oral conversions.
• Batch preparation of intravenous antimicrobials.
• Therapeutic substitution to support compliance with guideline choices.
• Formulary restriction.
• Providing guidelines, education and training.
• Addressing surgical antibiotic prophylaxis.

These strategies require fewer resources and less effort than other more complex stewardship activities; however, they are applicable to a variety of healthcare settings, including limited-resource hospitals, and have demonstrated significant financial savings. To implement these strategies effectively, it is important to use the right data.

In the context of LMIC setting, these interventions and targets may include:

• Limiting the duration of antibiotics.
• Limiting concurrent use of multiple antibiotics, including those providing redundant coverage.
• Reliably taking cultures before starting antibiotics.

The concept of “Low-hanging Fruit” in AMS is explored further in this 2012 paper. This paper describes what happened when an AMS programme implemented “low-hanging fruit” AMS interventions in Ohio, USA. While in a less resource-scarce area than other examples in this course, they opted for simple measures. This ultimately resulted in nearly $1 million in savings throughout the programme. The paper concludes:

“As our stewardship efforts demonstrate, not only is the low-hanging fruit worth picking, it yields an enormous harvest.”

To identify where the areas of poor prescribing occur, you require data from audits or PPS. Where possible, some ad-hoc real-world experiential information from the AMS team or clinicians working within a speciality would also be helpful. AMR is often most prevalent in clinical areas with the most vulnerable patients, such as Intensive Care, and this can also inform where to prioritise interventions. In addition, surgical prophylaxis is often an important and common area of excessive and poor prescribing.

The diagram below shows the areas where AMS interventions should most often be prioritised.

Now it’s your turn! Have a think about these questions and share your answers in the comments below:

• Have you used audits in your practice to identify areas of poor practice? What were your key findings? -What ‘low hanging fruit’ would you tackle first in your hospital?