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• Antipseudomonal cephalosporincarbapenemquinolone and Pseudomonas spp
• Vancomycin and MRSA
12.4 Determine and identify antimicrobial use of concern that necessitate for a audit
feedback report.
1. Compliance to guidelines -Appropriateness –base on NAG
2. High usage – antibiotic specific
3. Resistance problems
4. High collateral damage such as quinolones,
5. Antimicrobial use of concern as reported to HIACC shall necessitate for measure to
improve antimicrobial control. Measures can be either for specific antimicrobial, specific area such as surgical ward or specific indication such as antimicrobial for
pneumonia.
6. We can adopt certain strategies to prevent and control the spread of antimicrobial
resistance from Goldman et al 1996 and Rekha 2001. Goldman et al 1996 recommended a few outcome measures in monitoring empiric antimicrobial therapy:
No of patients infected with resistant strain to antimicrobial use No of patients given these antimicrobial
7. Costquantity of empiric antimicrobial administered in a specified period.
Recommendations by Rekha 2001 can be divided into antimicrobial prophylaxis and empiric antimicrobial therapy. Process measures for antimicrobial prophylaxis
are recommended as follows: No of patients received inappropriate prophylactic antimicrobial
No of patients having procedures No of patients received antimicrobial prophylaxis for 24 hours
No of patients received antimicrobial prophylaxis No of patients received antimicrobial within 30 min -1H preceding surgical incision
No of patients received antimicrobial prophylaxis Process measures for empiric antimicrobial therapy is as follows :
No of inappropriate empiric regimens No of patients received empiric therapy
No of patients given empiric therapy without having a culture obtained No of patients given empiric therapy
Meanmedian time interval between initiation of empiric therapy and arrival of microbiology diagnosis in patients who eventually have a diagnosis
No of patients with microbiology diagnosis received inappropriate empiric therapy No of patients given empiric therapy
Meanmedianduration of empiric therapy
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12.5 Antimicrobial management programstrategies
Success of antimicrobial restriction in hospitals varies on the basis of the genesis of the antimicrobial resistance program. Workshop on Antimicrobial Resistance in Hospitals:
Strategies to Improve Antimicrobial Use and Prevent Nosocomial Transmission of Antimicrobial-Resistant Microorganisms in 1994 under CDC have identify five strategic
goals to optimize antimicrobial use Goldman et al, 1996 :
• Optimizing antimicrobial prophylaxis for operative procedures
• Optimizing choice and duration of empiric therapy
• Improving antimicrobial prescribing by educational and administrative means
• Monitoring and providing feedback regarding antibiotic resistance
• Defining and implementing local guideline National Antibiotic Guideline as reference
Paterson, 2006 have recommended implementation of a program using a front-end approach and back end approach through discussion with and endorsements from the clinical
departments that will be affected e.g., the ICU, surgical department, emergency department, and outpatient clinics, as well as other affiliated hospitals.
1. Use of front end approach
• Pre-approval before administration of restricted agents
• Use of special antimicrobial request forms
• Antimicrobial cycling
2. Use of back end approach
• Post-prescription reviewAutomatic stop order
A back-end approach to antimicrobial management permits empirical use of broad- spectrum antimicrobial agents, followed by post-prescription review and, then,
by streamlining de-escalation or discontinuing antimicrobial therapy on day 2 or 3, if this decision is supported by culture and susceptibility testing results and
by the patient’s clinical response.
3. However, it should be noted that reacting to resistance against individual antibiotics
by instituting antibiotic restriction may lead to increased use of alternate antibiotics, which, in turn, leads to increased resistance to other antibiotic classes.
4. Feedback mechanism
There are many possible intervention could be proposed to reduce inappropriate or excessive antimicrobial use but deciding which one is the most effective measures
in any particular setting can be difficult. It is best that each individual hospitals institute their own programs to improve antimicrobial prescribing practice and to do
comparison before and after each programs is initiated. These programs can be conducted as quality improvement activities as a continuous process.
12.6 Antimicrobial policy
Addressing the problem of antimicrobial resistance requires both infection control and regulation of antimicrobial use; addressing either alone is insufficient. Therefore, collaboration with Infectious
Disease physicians, clinical microbiologist and infection control nurses is necessary to developed strategies to developed antimicrobial policy to improved antimicrobial control.
