Pharma Middle East 2015
Dubai, UAE
Antimicrobial Stewardship Program in
Saudi Arabia;
Experiences and Vision Future
Yousef A. Alomi, Bsc., Msc, BCPS, BCNSP, DiBA
General Manager of General Administration of Pharmaceutical Care
November 2015
yalomi@moh.gov.sa
yalomi@gmail.com
Pharma Middle East 2015
Dubai, UAE
Disclosure
Yousef A. Alomi
Reports No Relevant Financial Relationship
Pharma Middle East 2015
Dubai, UAE
Learning Objectives
Understand Antimicrobial Stewardship Program at MOH Saudi
Arabia
Know the Assessment Plan of Antimicrobial Stewardship
Program
How to Implement Antimicrobial Stewardship Program to all
Middle East countries
Antimicrobial Stewardship Program
“an ongoing effort
by a health care institution to optimize antimicrobial use
among hospitalized patients
in order to improve patient outcomes, ensure cost-effective
therapy, and reduce adverse
sequelae of antimicrobial use (including antimicrobial
resistance)
Allerberger, F. and H. Mittermayer (2008). “Antimicrobial stewardship.”
Clinical Microbiology and Infection 14(3): 197-199.
Three levels of demand were used sequentially until an antibiotic was dispensed or denied [4]:
1) Can I have something to relieve my symptoms?:
2) Can I have something stronger?
3) I would like to have antibiotic.
Saudi Pharmaceutical Journal (2014) 22, 550–554
Saudi Pharmaceutical Journal (2014) 22, 550–554
Saudi Pharmaceutical Journal (2014) 22, 550–554
Alumran et al. Health and Quality of Life Outcomes 2013, 11:39
The antimicrobial stewardship program in Gulf Cooperation
Council (GCC) states: insights from a regional survey
Journal of Infection Prevention October 8, 2015
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Objectives: The purpose of the current study is to describe the prevalence and characteristics
of antimicrobial stewardship programs (ASP) in Gulf Cooperation Council (GCC) states to
explore opportunities and overcome barriers to effective ASP implementation.
Methods: A cross-sectional questionnaire survey was used to evaluate the current status of
ASP: major stewardship components, barriers of implementation and program impact in
acute care hospitals of GCC states.
Results: Forty-seven healthcare professionals responded from four GCC states, the majority
from Saudi Arabia (81%). Twenty-nine (62%) participating hospitals had ASP in place. Of these
established programs, 35 (75%) reported lack of funding and personnel as major barriers to
program implementation. The top three objectives cited for the hospital ASP were to reduce
resistance (72.3%), improve clinical outcomes (70.2%) and reduce costs (44.7%). The
reported impact of existing ASP was reduction of inappropriate prescribing (68%), reduction
of broad spectrum antibiotic use (63.8%), reduction of healthcare-associated infections
(61.7%), reduction of length of stay or mortality metrics (59.6%), reduction in direct antibiotic
cost (57.4%) and reduction of reported antibiotic resistance (55.3%).
Conclusion: Survey participants from GCC states who have implemented ASP report
significant impacts in the reduction of broad spectrum antibiotic use, hospital-acquired
infection, inappropriate prescribing and antimicrobial resistance. These findings suggest a
promising opportunity to enhance existing ASP through sharing of best practices and support
the development of regional guidelines across GCC states.
Antimicrobial stewardship program implementation in a
medical intensive care unit at a tertiary care hospital in Saudi
Arabia.
Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS1.
BACKGROUND AND OBJECTIVES:
Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of
antimicrobial resistance associated with an inappropriate antimicrobial use. The primary
objective of this study was to compare the prescribing appropriateness rate of the empirical
antibiotic therapy before and after the ASP implementation in a tertiary care hospital.
Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD),
physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using
defined daily dose, and total direct cost of antibiotics.
DESIGN AND SETTINGS:
This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in
a prospective fashion under the active ASP arm and compared with historical patients who
were admitted to the same unit before the ASP implementation. This study was approved by
the institutional review board, and the need for informed consent was waived because the
interventions and recommendations were evidence based and considered the standard of
care. The study was conducted at KFSHRC, Riyadh.
Ann Saudi Med. 2013 Nov-Dec;33(6):547-54.
Antimicrobial stewardship program implementation in a
medical intensive care unit at a tertiary care hospital in Saudi
Arabia.
1.
Amer
MR,
Akhras
NS,
Mahmood
WA,
Al-Jazairi
AS
METHODS:
Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the
5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin,
tigecycline), and had no official infectious disease consultation. The interventions were
conducted via prospective audit and feedback.
RESULTS:
A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The
appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical
control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group,
initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0%
on the recommendations implementation. A total of 27 interventions were made with an
acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in
antibiotics utilization and direct cost were also noticed in the ASP arm.
CONCLUSION:
A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics
utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of
such a program and may serve as a foundation for further ASP initiatives particularly in our
region.
Ann Saudi Med. 2013 Nov-Dec;33(6):547-54.
Pharma Middle East 2015
Dubai, UAE
Skeleton of Committees
Central antibiotics
committee
Regional antibiotic
committee
Hospital Antibiotic
committee
Primary Care Centres
Antibiotic committee
Pharma Middle East 2015
Dubai, UAE
Antimicrobial Stewardship Program Plan
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2014
Stage 1
Antibiotic Committee Central
Antibiotic Committee Region 20
Antibiotic Committee Peripheral 90 Hospital
Antibiotic adults Manual booklet and electronic
Antibiotic Training Courses Central
Antibiotic training courses region 20
Antimicrobial Stewardship Program Plan
• 2015
• Stage 2
• Antibiotic Committee Peripheral additional 90 Hospital
• Antibiogram Central
• Antibiogram 20 Region
• Antibiogram 90 Hospital
• Antibiotic pediatrics Manual booklet and electronic
• Review Antibiotic Adults Manual base on antibiogram
• Antibiotic utilization
• Antibiotic consumption
• Antibiotic Training Courses Central
• Antibiotic training courses region 20
• Stewardship Antibiotics Residency Program (ASHP)
Antimicrobial Stewardship Program Plan
• 2016
• Stage 3
• Antibiotic Committee Peripheral additional 60 Hospital
• Antibiogram Central
• Antibiogram 20 Region
• Antibiogram 180 Hospital
• Antibiotic pediatrics Manual booklet and electronic
• Review Antibiotic Adults Manual base on antibiogram
• Antibiotic utilization adults and pediatrics
• Antibiotic consumption adults and pediatrics
• Antibiotic Training Courses Central
• Antibiotic training courses region 20
• Follow Up Stewardship Antibiotics Residency Program (ASHP)
Antimicrobial Stewardship Program Plan
• 2017
• Stage 4
• Antibiotic Committee 90 Private Hospital
• Antibiogram Central
• Antibiogram 20 Region adults and pediatrics
• Antibiogram 250 Hospital adults and pediatrics
• Review Antibiotic pediatrics Manual booklet and electronic
• Review Antibiotic Adults Manual base on antibiogram
• Antibiotic utilization adults and pediatrics
• Antibiotic consumption adults and pediatrics
• Antibiotic Training Courses Central
• Antibiotic training courses region 20
• Follow Up Stewardship Antibiotics Residency Program (ASHP)
Antimicrobial Stewardship Program Plan
• 2018
• Stage 5
• Antibiotic Committee additional 90 Private Hospital
• Antibiogram Central
• Antibiogram 20 Region adults and pediatrics
• Antibiogram 250 Hospital adults and pediatrics
• Antibiogram in 90 Private Hospital
• Review Antibiotic pediatrics Manual booklet and electronic
• Review Antibiotic Adults Manual base on antibiogram
• Antibiotic utilization adults and pediatrics in MOH and Private
• Antibiotic consumption adults and pediatrics in MOH and Private
• Antibiotic Training Courses Central in MOH and Private
• Antibiotic training courses region 20 in MOH and Private
• Follow Up Stewardship Antibiotics Residency Program (ASHP)
Guideline for Establish Antimicrobial Stewardship at MOH hospitals
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Section I: Policy and procedure
Section II: National antimicrobial guideline: Group A streptococcal Pharyngitis
Acute Bacterial Rhinosinusitis Community Acquired Pneumonia Bacterial
Meningitis Brain Abscess Infective endocarditis Urinary Tract Infection
Osteomyelitis Diabetic Foot Infection Skin and Soft Tissue Infection Peritonitis
Sexually Transmitted Disease Pelvic Inflammatory Disease Intra-abdominal
Infection Brucellosis Tuberculosis Antiviral Infection Antifungal Infection Parasitic
Infection Surgical Prophylaxis
Appendix A: Guideline for blood culture collection
Appendix B: Infection Control
Appendix C: Skin test kits, Anaphylactic kits , Skin test procedure and anaphylaxis
algorithm
Appendix D: Antibiotics dosing monitoring
Appendix E: Practical Approaches for Conversion IV antibiotics to Oral therapy
Appendix F: Antibiogram
Appendix G: Antimicrobial Consumption
Appendix H: Formulary/ Pre-Authorization Restricted Forms
Appendix I: Abbreviation
Appendix J: Dose Adjustment for Renal Impairment
Guideline for Establish Antimicrobial Stewardship
at MOH hospitals
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The antimicrobial stewardship team and administrative support
Core members of antimicrobial stewardship:
Infectious diseases physician ( Leader )
Clinical pharmacist with infectious diseases training (Coordinator)
Clinical microbiologist
An information system specialist
An infection control professional
hospital epidemiologist
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Administrative support:
Hospital administration (necessary infrastructure)
Medical staff leadership
local providers ( e.g: nurses)
 Collaborated providers:
• Hospital infection control
• Pharmacy and therapeutics committees
Guideline for Establish Antimicrobial Stewardship
at MOH hospitals
 Core strategies:
• Prospective audit with intervention and feedback
• Formulary restriction and preauthorization:
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Supplemental Antimicrobial Stewardship Strategies:
Education
Guidelines and clinical pathways
Antimicrobial order forms
Combination empirical therapy and de-escalation antimicrobial
Conversion from parenteral to oral therapy
Antimicrobial dosing
 Surveillance of antimicrobial resistance
 Computer Surveillance and Decision Support
 Monitoring of Process and Outcome Measurements
Policy
Pharma Middle East 2015
Dubai, UAE
• This guideline only for adult
• Antibiotics order form is controlled and
guided method to all health
provider(physician, pharmacist, clinical
pharmacist and nurse during prescribing the
antibiotics
• It is formatting as physician order
• Using of this order form only for community
acquired infection.
Antimicrobial Stewardship
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Antibiotic Committees
Infectious Diseases Team
Antibiotics Physician order Form
Antibiotics dosing monitoring Aminogylcoside,
Vancomycin
Switching IV antimicrobial to oral
Dose adjustment for Renal Impairment
Antibiotics Consumption
Antibiogram
Monthly antibiotics consumption
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Antibiotics Committee
(Central)
1
0
1
1
Antibiotics Committee
(Region)
20
0
0
15
Antibiotics Committee
(Peripheral)
250
0
0
20
Antibiotics Committee
(PCC)
80-100
0
0
Antibiotics Manual
Booklet
1
0
0
1
Antibiotics Manual Electronic
1
0
0
1
Antibiogram (Central)
1
0
0
0
Antibiogram (Region)
20
0
0
0
Antibiogram (Peripheral)
250
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Antibiotics Consumption
(Central)
1
0
0
0
Antibiotics Consumption
(Region)
20
0
0
0
Antibiotics Consumption
(Peripheral)
250
0
0
0
Antibiotics Consumption
(PCC)
80-100
0
0
0
Antibiotics Utilization Review
(Central)
1
0
0
0
Antibiotics Utilization Review
(Region)
20
0
0
0
Antibiotics Utilization Review
(Peripheral)
250
0
0
0
1
0
0
0
Antibiotic Conference
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Antibiotics Course
(Central)
2
0
0
1
Antibiotics Course
(Region)
2-4
0
0
0
Antibiotics Course
(Peripheral)
250
0
0
0
Antibiotics Course
(PCC)
80-100
0
0
0
Therapeutic Drug Monitoring
(Central)
1
0
0
0
Therapeutic Drug Monitoring
(Region)
20
0
0
0
Therapeutic Drug Monitoring
(Peripheral)
250
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Resistance Bugs
(Central)
Decrease
20%
0
0
1
Resistance Bugs
(Region)
Decrease
20%
0
0
0
Resistance Bugs
(Peripheral)
Decrease
20%
0
0
0
Infection Rate
(Central)
Will not
increase
0
0
0
Infection Rate
(Region)
Will not
increase
0
0
0
Infection Rate
(Peripheral)
Will not
increase
0
0
0
Stewardship Antibiotics Program Indicators
No
2012
2013
2014
Antibiotics Cost Reduction
(Central)
Decrease
20-50%
0
0
1
Antibiotics Cost Reduction
(Region)
Decrease
20-50%
0
0
0
Antibiotics Cost Reduction
(Peripheral)
Decrease
20-50%
0
0
0
Antibiotics Cost Reduction
(PCC)
Decrease
20-50%
0
0
0
Privilege of Antibiotics Prescribing
(Central)
50%
0
0
0
Privilege of Antibiotics Prescribing
(Region)
50%
0
0
0
Privilege of Antibiotics Prescribing
(Peripheral)
50%
0
0
0
Stewardship Antibiotics Program Indicators
No
2012
2013
2014
Antibiotics Policy Adherence
(Central)
50%
0
0
1
Antibiotics Policy Adherence
(Region)
50%
0
0
0
Antibiotics Policy Adherence
(Peripheral)
50%
0
0
0
Antibiotics Policy Adherence
(PCC)
50%
0
0
0
Antibiotics Automatic Stop order
(Central)
50%
0
0
0
Antibiotics Automatic Stop order
(Region)
50%
0
0
0
Antibiotics Automatic Stop order
(Peripheral)
50%
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Days of Therapy (DOT)
(Central)
0
0
0
1
Days of Therapy (DOT)
(Region)
0
0
0
0
Days of Therapy (DOT)
(Peripheral)
0
0
0
0
Days of Therapy (DOT)
(PCC)
0
0
0
0
Defined Daily Dose (DDD)
(Central)
0
0
0
0
Defined Daily Dose (DDD)
(Region)
0
0
0
0
Defined Daily Dose (DDD)
(Peripheral)
0
0
0
0
Defined Daily Dose (DDD)
(PCC)
0
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Post Marketing Surveillance
(Central)
0
0
0
1
Post Marketing Surveillance
(Region)
0
0
0
0
Post Marketing Surveillance
(Peripheral)
0
0
0
0
Post Marketing Surveillance
(PCC)
0
0
0
0
Drug Quality Reporting System
(Central)
0
0
0
0
Drug Quality Reporting System
(Region)
0
0
0
0
Drug Quality Reporting System
(Peripheral)
0
0
0
0
Drug Quality Reporting System
(PCC)
0
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
Antibiotic Medication Errors
(Central)
0
0
0
1
Antibiotic Medication Errors
(Region)
0
0
0
0
Antibiotic Medication Errors
(Peripheral)
0
0
0
0
Antibiotic Medication Errors
(PCC)
0
0
0
0
Antibiotic Adverse Drug Reaction
(Central)
0
0
0
0
Antibiotic Adverse Drug Reaction
(Region)
0
0
0
0
Antibiotic Adverse Drug Reaction
(Peripheral)
0
0
0
0
Antibiotic Adverse Drug Reaction
(PCC)
0
0
0
0
Antimicrobial Stewardship Program Indicators
No
2012
2013
2014
No of Mortality due to Infections
(Central)
0
0
0
1
No of Mortality due to Infections
(Region)
0
0
0
0
No of Mortality due to Infections
(Peripheral)
0
0
0
0
No of Parenteral Antibiotic
(Central)
0
0
0
0
No of Parenteral Antibiotic
(Region)
0
0
0
0
No of Parenteral Antibiotic
(Peripheral)
0
0
0
0
No of Parenteral Antibiotic
(PCC)
0
0
0
0
Pharma Middle East 2015
Dubai, UAE
Conclusion