Components of a Stewardship Programme

In this short presentation I’m going to take you through the basics of antimicrobial stewardship, and show how point prevalence surveys fits into an antimicrobial stewardship programme. Let’s now consider the components of a stewardship programme. We have several core components and these are essential for any stewardship programme. So we have surveillance of antimicrobial use. We have audit with feedback, and point prevalence surveys form part of this audit programme. Formulary restriction and pre-authorisation for specific antibiotics. And education for health care staff. There are also some supplemental components, and established stewardship programmes will generally also have these elements. So we have guidelines and pathways for specific infections. Order forms for some antibiotics. De-escalation processes to go from broad spectrum to narrow spectrum agents.

Dose optimisation for individual patients. And an IV to oral conversion process.

So why do we need antimicrobial stewardship? It is one of the key methods to address antimicrobial resistance, which, as we all know, is a growing problem across the world. Along with prevention of transmission of resistant organisms through infection control measures and improved environmental decontamination, stewardship is one of the ways that we can tackle resistance. The overuse and misuse of antimicrobials is well-documented in the literature so there is plenty of room for improvement. Effective stewardship has been shown to reduce health care associated infections, and this will have associated benefits for patient outcomes such as morbidity and mortality rates.

There is a wealth of evidence supporting stewardship in terms of the relationship between antibiotic use and resistance, and this Clinical Infectious Diseases paper provides a good summary of how this relationship has been measured.

Antimicrobial policies are the cornerstone of antimicrobial stewardship programmes and they can provide standards for audit. There will usually be separate policies for hospital and primary care prescribing, and these are evidence-based guidance on the empirical treatment of common infections. They should include alternative choices for penicillin-allergic patients, and they should mandate the information required– the five Rs that we mentioned earlier. The antibiotic name, dose, frequency, route, and durations. For hospitals there should be guidance on IV to oral switch therapy to allow treatment to be deescalated as soon as possible. It’s also important that policies are reviewed regularly, usually every two years. This is because there is always new evidence emerging about the best options for treating infections.

But also there will be changes in the local patterns of resistance to antibiotics which need to be addressed within the local policy.

It’s helpful to think of antimicrobial stewardship activities as a cycle. So we have the three elements– information, quality improvement, and engagement and education. In the centre we have clinicians because they are crucial to all three elements. And we can see from the diagram how point prevalence surveys fit into all three of the elements.

Let’s now think about the three elements in more detail. So firstly information. We require information about the quantity of antibiotic use and we can do this through surveillance of antibiotic use to provide trends over time. In primary care settings we can measure the number of items or prescriptions per head of population, and in hospitals we can use the quantity of antibiotics dispensed or administered to patients if we have electronic prescribing. Or if we don’t, we can measure the quantity issued from the pharmacy department to the wards. It’s also possible to relate this to activity data, such as the number of admissions to the hospital or the number of occupied bed days.

It’s also useful to have information about the quality of antibiotic prescribing. So point prevalence surveys are an example of this, as they provide a snapshot of clinical practice. We can also use prescribing quality indicators to give us smaller, more regular measurements of clinical practice. And with both of these interventions, the feedback of the results to prescribers is very important because this can highlight areas for improvement, and allow discussion of these with those that can make the changes.

So point prevalence surveys can provide us with some key information about antimicrobial use. It’s collected by the antimicrobial team and sometimes some other clinicians, and then fed back to the clinical team. The types of information that this may include is the percentage of patients prescribed an antimicrobial, the percentage receiving IV versus oral treatment, what types of infections are being treated, which antimicrobials are being used and in which wards. We can compare the data with previous point prevalence surveys with that from other wards or other hospitals, and we can look at what’s improved and requires further improvement. And we’ll discuss all of this in a bit more detail as we go through the course.

Compliance audits are another technique which uses quality improvement methodology to review clinical practice in real time. We can collect and report data on a sample of patients every week or every month, and feed this data back to the staff involved in prescribing. Key measures that are often used for compliance audits are the documentation of the reason for antimicrobial therapy in the medical notes, and the choice of antibiotic being compliant with the local policy.

Quality improvement is one of the key elements of the cycle of antimicrobial stewardship. We’ve already mentioned information about quantity and quality of antibiotic use, which can identify the areas for improvement. We can use a quality improvement approach to change processes or behaviours around prescribing. The QI methodology that is commonly used is called the method for improvement, where we use a Plan, Do, Study, Act cycle that allows us to test changes that may improve practice. It’s important to involve clinical teams and quality improvement initiatives to give them ownership, as this means they will be more likely to succeed. If you’re interested in learning more about quality improvement in health care, then this web address here provides some useful information.

The third element of the stewardship cycle is engagement and education. These are very important to achieve effective stewardship. An ongoing education programme focused on local policy and specific high-risk antibiotics, such as gentamicin and vancomycin and the carbapenems, is useful for all staff prescribing or administering these agents. The information about the quantity and quality of antibiotic use should also be shared with the clinical team. And ideas to improve processes for prescribing and behaviours around prescribing must be developed by the clinical team, and communicated to all to achieve success. The antimicrobial stewardship cycle gives us a useful way to assess progress. We can revisit the quantity and quality of antibiotic use regularly.

We can assess trends and use, perhaps looking at the total quantity of antibiotics used or at specific antibiotics that we’ve been trying to improve prescribing of. We need to discuss and agree with clinical teams’ ideas to improve practice. We can then re audit clinical practice and compare with the previous audit results. We need to engage clinical teams on a regular basis to discuss antibiotic use and the impact of improvement initiatives.

So to summarise this presentation on antimicrobial stewardship and point prevalence surveys, I hope I’ve shown you that antimicrobial stewardship is essential to optimise the use of antibiotics to tackle antimicrobial resistance. Point prevalence surveys are an essential part of hospital antimicrobial stewardship programmes to help us assess the quality of antibiotic use. So let’s now go on to learn more about point prevalence surveys. How to get started, and how to use point prevalence surveys in your own setting.