Distribution of sterile items

Policies and Procedures on Infection Control Ministry of Health Malaysia 169

12.1 Introduction

One of the major issue in our health care today is that of controlling the increase in antimicrobial resistance. Although multiple factors play a role in this problem, the selective pressures of inappropriate and widespread use of antimicrobials are considered as major contributors.

12.2 Establish a system

The establishment of a system to monitor antimicrobial use and responding to the data, in the context of external benchmarking has been a successful way to create changes in antimicrobial practice Scott et al, 2002. Therefore, monitoring antimicrobial use or antimicrobial surveillance will serve as a tool for: • Comparison in antimicrobial use within MOH by having national benchmark data aggregated from all hospitals. • Determine and identify antimicrobial use of concern that necessitate for a an audit feedback report • Identify and develop strategies to improve antimicrobial control through multidisplinary efforts involving Infectious Disease PhysiciansClinicians, Clinical Microbiologist Microbiologist, Pharmacist and Infection Control Nurses.

12.3 Surveillance on antimicrobial use

12.3.1 Antibiotic classes for antimicrobial surveillance

Antimicrobial surveillance for four types of antibiotic, from four different classes, was conducted in fifteen major hospitals within MOH since 2001. At present, there are 14 additional antimicrobial monitored, total of 18, as listed below : 1. Cephalosporin • Cefuroxime • Ceftriaxone • Cefoperazone • Ceftazidime • Cefotaxime • Cefoperazonesulbactam • Cefepime

12. PRINCIPLES OF ANTIBIOTIC SURVEILLANCE

Policies and Procedures on Infection Control Ministry of Health Malaysia 170 2. Carbapenems • Imipenem • Meropenem • Ertapenem 3. Quinolones • Ciprofloxacin • Pefloxacin 4. Aminoglycoside • Gentamicin • Netilmicin • Amikacin 5. Antibiotic indicated for MRSA infection • Vancomycin • Linezolid 6. Anti-pseudomonal penicillins • PiperacillinTazobactam

12.3.2 Monitoring antimicrobial use using aggregated data on Defined Daily

Dose DDD Antimicrobial use express as Defined Daily Dose per 1000 patient days is accepted to be used as this is a WHO standard for drug utilization studies. DDD for each drug is as listed above [DDD] and the calculation is as follows: Total Antibiotic Usage Grams for Adults Inpatient in a year = No of DDD’s per year DDD from WHO For 1000 adults inpatients days : No of DDD’s per year X 1000 = No of DDD’s per 1000 patients days No of patients dayswarded for that particular year Policies and Procedures on Infection Control Ministry of Health Malaysia 171

1. Each hospital shall send report on DDD every 6 months to National Infection

Control and Antibiotic Control Committee. Data on DDD aggregated from all hospitals will be used as national benchmark data aggregated from all hospitals as a comparison to individual local data.

2. However, individual local data shall be reported according to discipline

department on regular basis

3. It is recommended to have a national benchmark data specifically for Intensive

Care Unit ICU, considering its high usage of antimicrobial and higher incidence of antimicrobial resistance

4. It is also beneficial if each state have their own benchmark data from their

secondary and tertiary hospitals which can be used to compare the prescribing pattern

5. A report of local monitoring data for hospital compared with national

benchmark i.e aggregate summary data from all hospital in this program should be disseminated to all hospital

6. The aggregate benchmark data included numeric presentation of pooled

means, medians, and key percentile distributions of prevalence of selected antimicrobial-resistant organisms and maybe stratified by certain specific discipline, such as ICU.

7. This report shall recognized excessive use of specific antimicrobial agents

against problematic pathogen. Upon receiving the report, the respective hospital; through Hospital Infection and Antibiotic Control Committee HIACC shall give feedback and report to the main committee on any antimicrobial control practice and strategies to improve their control on specific antimicrobial of concern.

12.3.3 Correlation between antimicrobial use and resistance rate

Recent reports from the special task force of the American Society for Microbiology and from a joint committee of the Society of Healthcare Epidemiology of America and the Infectious Disease of America advocate that individual hospitals monitor the relationship between antimicrobial use and resistance within specific patient-care areas Reports of the ASM Task Force on Antibiotic Resistance, 1995. A graphic analysis done by Harbath et al 2001 can be used as an example to assess this relationship, it is done by plotting DDDs per 1000 patients days for specific antibiotic class of interest agains susceptibility percentages of unique nosocomial isolates, according to time and space i.e year and ward, third generation cephalosporin was plotted against Enterobacteriaceae for example refer to Appendix 1. Since we are monitoring both data of antimicrobial use and resistance rate, it will be more meaningful if we can plot both data in one graph. Therefore the committee have to select which antimicrobial use is to be plotted against which resistance rate of concern. Here are a few suggestions : • Third generation cephalosporins and ESBL • Cefoperazonesulbactam and Acinetobacter spp