Antibiotic Resistant :

The Role of Antibiotic Stewardship and

Quality Strategies

Dr Muhammad Nazri Aziz; MD.,MPath. (Med Microbiology)

Pathologist Medical Microbiologist
Hospital Pulau Pinang

Outline
Introduction

Antimicrobial Resistant (AMR)

Antibiotic Stewardship Programme (ASP) and Quality

Strategies

1. Controlling antibiotic use

2. Infection control measures

Conclusion / recommendation

Antibiotic Resistance
Global Problem

MRSA
MDR & XDR Acinetobacter baumannii
ESBL-producing organisms
CRE - Carbapenem Resistant Enterobacteriaceae
Clostridium difficile

Attack of the superbugs...

.

Antibiotic
Patients
How to maximize
treatment?

How to minimize
selection of resistant
pathogens?

Conflicts

Prof Didier Pittet_Book Launch_The evolving threat of AMR_March 8 2012

Prof Didier Pittet_Book Launch_The evolving threat of AMR_March 8 2012

Prof Didier Pittet_Book Launch_The evolving threat of AMR_March 8 2012

Outline

Introduction

Antimicrobial Resistant (AMR)

Antibiotic Stewardship Programme (ASP)and Quality

Strategies

1. Controlling antibiotic use

2. Infection control measures

Conclusion / recommendation

Klebsiella pneumoniae Bad Bugs

Limited drugs
Antibiotics

Klebsiella
pneumoniae

ESBL producer
Kleb pneumoniae

Carbapenem Resistant
Klebsiella pneumoniae
(CRE)

Ampicillin

Augmentin

Cefuroxime

Ceftriaxone

Geftazidime

Ciprofloxacin

S/R

Gentamicin

S/R

Amikacin

S/R

Imipenem

Meropenem

Ertapenem

Colistin

Treatment-Related Comments : MIC result, Antibiotic selection (CLSI 2012), Infection

Control Measures (Infection Control Policies and Procedures) etc..

Genetic Transfers

Carbapenem Resistant Entebacteriaceae

(CRE) KPC and NDM-1

2003

2000
2005

2008

NDM1-Positive CRE
1st Isolate in Malaysia 2010
Antibiotics

NDM-1-Positive CRE
Klebsiella pneumoniae

Tazocin

Augmentin

Cefuroxime

Ceftriaxone

Geftazidime

Gentamicin

Amikacin

Netilmicin

Imipenem

R (MIC 12 g/ml)

Meropenem

R (MIC > 32 g/ml)

Ertapenem

Nitrofurantoin

Ciprofloxacin

Polymyxin B

S (MIC 0.094 g/ml)

Colistin

S (MIC 13.0 g/ml)

MHT - Positive

EDTA-disc synergy test - Positive

Imipenem/Meropenem + EDTA disc

test methods - Positive

The sequences of PCR products were

100% identical to the respective
segments of NDM-1 (GenBank
accession no. FN396876)

Positive for other -lactamase genes,

namely CTX-M 15, TEM-1 and SHV11

No PCR product was observed with

KPC and CMY primer

Reference: Norazah A et al (2013). Characterization of the first isolate of Klebsiella

Pneumoniae carrying New Delhi metallo--lactamases and other extended spectrum
-lactamase gene from Malaysia

National Trending of CRE Cases

(infection and coloniser), 2011-2013

Infection Control Unit, MOH

CRE cases - Malaysia

Infection Control Unit, MOH

Escherichia coli

Antibiogram Data KPJ Group of Hospitals

Klebsiella pneumoniae

Antibiogram Data KPJ Group of Hospitals

Outline

Introduction

Antimicrobial Resistant (AMR)

Antibiotic Stewardship Programme (ASP)and Quality

Strategies

1. Controlling antibiotic use

2. Infection control measures

Conclusion / recommendation

Antibiotic Stewardship Programme

1.

Optimize clinical outcomes while minimizing

unintended consequences of antibiotic use

Toxicity, selection of pathogenic organisms and

emergence of resistance

2. Combine with comprehensive infection control to limit

emergence and transmission of resistance

Reduce health care costs without adversely impacting

quality of care

What is antibiotic stewardship?

2. Combine with comprehensive infection
control to limit emergence and
transmission of resistance

Reduce health care costs without

adversely impacting quality of care

Controlling Antimicrobial Resistance

WHO Global Strategy

2001

2012

The evolving threat of antimicrobial

resistance

Surveillance to track antimicrobial use and resistance in bacteria

Measures to ensure better use of antibiotics

Reducing antibiotic use in animal husbandry

Infection prevention and control in healthcare

facilities

Fostering innovation to combat antimicrobial

resistance

The way forward, political commitment to

enable options for action

Surveillance to track antimicrobial use and

resistance in bacteria

Acinetobacter baumannii

Antibiogram Data KPJ Group of Hospitals

Pseudomonas aeruginosa

Antibiogram Data KPJ Group of Hospitals

Alert Organisms Surveillance 2013

Alert organisms data KPJ Group of Hospitals

Meropenem

Antibiotic Use KPJ Group of Hospitals

Statistical Process Control Chart (SPCC)

KPJ TAWAKKAL SPECIALIST HOSPITAL

Statistical Process Control Chart (SPCC)

KPJ TAWAKKAL SPECIALIST HOSPITAL

Implementing
an antimicrobial stewardship program
in the institutional setting
can present a challenge

Antibiotic Stewardship Programs

Multidisciplinary Team Approach

Antibiotic Stewardship Programs

Multidisciplinary Team
Infectious disease physician / paediatrician
Consultant/Specialist from all clinical disciplines
Clinical Pharmacist
Pathologist - Medical Microbiologist
Epidemiologist & Information System Specialist
Medical Officer, House Officer, Nurses/ICN/ICLN & Laboratory
Scientist/Medical Lab Technologists

Antibiotic Ward Round

Antibiotic Use : Surveillance and Audit

Antibiotic Use KPJ Group of Hospitals

Automatic Stop Order

Imipenem
Meropenem

Vancomycin

But..culture
always no
growth!!!

3 days
only!!!

Endorsement
Head of Department
Hospital Sultan Ismail

Selective Reporting - Microbiologist

Antibiotics

Klebsiella
pneumoniae

ESBL producer
Kleb pneumoniae

NDM & Non NDM

producer Klebsiella
pneumoniae

Ampicillin

Augmentin

Cefuroxime

Ceftriaxone

Geftazidime

Ciprofloxacin

S/R

Gentamicin

S/R

Amikacin

S/R

Ertapenem

Meropenem

Imipenem

Colistin

Treatment-Related Comments : MIC result, Antibiotic selection (CLSI 2012), Infection

Control Measures (Infection Control Policies and Procedures) etc..

Formulary Restriction

Education is essential
for any program that is designed
to influence people behaviors

Guidelines
and
clinical pathways

Dissemination of the information

Imipenem, Meropenem & Vancomycin

Narrow-spectrum carbapenem
Beta-Lactam/Beta-lactamase Combination
3rd Gen cephalosporins
2nd Gen Cephalosporins
1st Gen Cephalosporins
Penicillin

De-escalation of antibiotic therapy

Outline

Introduction

Antimicrobial Resistant (AMR)

Antibiotic Stewardship Programme (ASP)and Quality

Strategies

1. Controlling antibiotic use

2. Infection control measures

Conclusion / recommendation

Infection Control Ward Round

Acinetobacter baumannii
Infection/Colonization
Ward A Population at risk
3 Acute Cubicle

5 - Chronic Patient

1 Pre-Op

2 Pre-Op

4 - Recovery

Nurse Counter

Entrance

Upper Control Limit

Central line

Rates

CL

Ja
n
Fe
b
M
ar
20 Ap
09 r
m
ay

Au
g
Se
pt
O
ct
No
v
De
c

Lower Control Limit

Ju
ly

Ju
ne

40
35
30
25
20
15
10
5
0

20
08

Rate/100 Admission

Surveillance of Acinetobacter baumannii infection

and colonization Ward 4A Jun 2008 - May 2009

UCL

LCL

Unit Mikrobiologi & Kawalan Infeksi HKL

Acinetobacter Infection/Colonization
Ward A Index Case
Infection Control Ward Round 30 April - 7 May 2009
3 Acute Cubicle

5 - Chronic Patient

1 Pre-Op

WM

FC

IK

SB
2 Pre-Op

4 - Recovery

Old Case

Nurse Counter

Entrance

Acinetobacter Infection/Colonization
Ward A Cross-infection/Colonization
Infection Control Ward Round 7 May 11 May 2009
4 - Recovery 3 Acute Cubicle

5 - Chronic Patient

2 Pre-Op

1 Pre Op

PL WM

FZ
SB

FC

IK

NF DK

Patient Died

Old Case

Nurse Counter
New Case

Entrance
Patient Died

Acinetobacter Infection/Colonization
Ward A - Outbreak
Infection Control Ward Round 11 May 18 May 2009
5 - Chronic Patient 4 - Recovery 3 Acute Cubicle

PL WM

FZ
KO

FC

2 Pre-Op

1 Pre-Op

MW

IK

NF DK

? Poor
Decontamination
Procedure

Old Case

Nurse Counter

New Case

Entrance

Acinetobacter spp, Infection/Colonization

Ward A Index Case
Infection Control Ward Round 30 April - 7 May 2009
3 Acute Cubicle

5 - Chronic Patient

1 Pre-Op

C4
WM

FC

IK

C1
SB
2 Pre-Op

4 - Recovery

Old Case

Nurse Counter

Entrance

Acinetobacter Infection/Colonization
Ward A Cross-infection/colonization
Infection Control Ward Round 7 May 11 May 2009
4 - Recovery 3 Acute Cubicle

5 - Chronic Patient

2 Pre-Op

1 Pre Op

C1
PL WM

FZ

FC

IK

C1
SB

NF DK

C1

Patient Died

Old Case

Nurse Counter
New Case

Entrance
Patient Died

Acinetobacter Infection/Colonization
Ward A Different Strain/Clone
Infection Control Ward Round 11 May 18 May 2009
5 - Chronic Patient 4 - Recovery 3 Acute Cubicle

C1

FZ
KO

1 Pre-Op

C4
PL WM

C1

2 Pre-Op

FC

MW

IK

NF DK

C1

? Poor
Decontamination
Procedure

Old Case

Nurse Counter

New Case

Entrance

Acinetobacter Infection/Colonization
Ward A - Outbreak
Infection Control Ward Round 1 Jun 2009
3 Acute Cubicle

5 - Chronic Patient

2 Pre-Op

1 Pre-Op

C4

C1

FZ

NF KO

MW PU

FC

MAS

C1

C1
WM DK

C1

Nurse Counter
Patient Died

Transfer K9

Entrance
Old Case

New Case

WARD D
C2

C1

WARD B

C2
C4

C1

C1

WARD A
C5

C3

WARD C

Environmental Culture
Suction tubing
Solution

Cardiac Table
Floor
Door Knob
Case Note
Stetoscope

Chest & forearm

Bedrail
Wall
Power Point

Finger Impression 18 June 2009

Specimen

Result - Pre

Result - Post

Staff Nurse 1

CONs, Acinetobacter spp & Bacillus spp.

No Growth

Staff Nurse 2

No Growth

No Growth

Staff Nurse 3

CONs

No Growth

Staff Nurse 4

Acinetobacter spp. Bacillus spp. Pseudo

aeruginosa

Bacillus spp.

Staff Nurse 5

Bacillus spp.

Bacillus spp.

Physiotherapist 1

CONs

CONs

Physiotherapist 2

CONs & Acinetobacter spp.

CONS

Dietician 1

CONs & Bacillus spp.

Bacillus spp.

Doctor 1

CONs, Staph aureus & Bacillus spp.

No Growth

Doctor 2

CONs

CONs

Surveillance Sample - Rectal Swab

No Name

Date

Result

Comments

1.

21 May

ESBL-Esche coli
ESBL-Klebsiella

Selective Pressure
Collateral Damage

2.

21 May

ESBL-Escherichia coli

.3.

21 May

Escherichia coli
Sensitive Strain

Normal Gut Flora

4.

21 May

XDR-Acinetobacter

5.

21 May

XDR-Acinetobacter

Selective Pressure
Collateral Damage
Source of
Acinetobacter infection

6.

21 May

ESBL-Enterobacter

Selective Pressure
Collateral Damage

7.

21 May

Escherichia coli
Sensitive Strain

Normal Gut Flora

8.

21 May

Escherichia coli
Sensitive Strain

Stool/Faeces

Contamination of
Hospital/Ward Environment
& Health Care Workers

Contaminated secretion

Acinetobacter spp, Infection/Colonization

Ward A Index Case
Infection Control Ward Round 30 April - 7 May 2009
3 Acute Cubicle

5 - Chronic Patient

1 Pre-Op

C3
WM

FC

IK

SB

C5
2 Pre-Op

4 - Recovery

C2
Old Case

Nurse Counter

Entrance

Hospital Environment/Equipment
Stethoscope

Clone 2

Clone 5

Hospital Environment Bed Rail

Clone 3
Hospital Environment Suction Tube/Container

Outline

Introduction

Antimicrobial Resistant (AMR)

Antibiotic Stewardship Programme (ASP)and Quality

Strategies

1. Controlling antibiotic use

2. Infection control measures

Conclusion / recommendation

2
1

Controlling antimicrobial
use

Comprehensive
Infection Control
measures

Management
Of
Linen

Appropriate use of
PPE

Hand
Hygiene

Terima Kasih