Infection Control & Hospital Epidemiology Table 2. Common Gaps and Challenges in Relation to Implementing AMS Programs in Hospitals in Asia
Common Gaps and Challenges in Implementing Hospital AMS Programs in Asiaa
Lack of epidemiological data and surveillance systems
Lack of awareness of AMR Weak infrastructure
Insufficient education and training of hospital staff
Limited funding Prescriber resistance to AMS Poor infection control Potential Solutions to Overcoming Gaps in Hospital AMS Programsb
∙ Prioritize obtaining support for microbiology laboratory services for reliable culture-guided therapy, AMR surveillance and provision of hospital antibiograms
∙ Provide regular report of AMR data and AMS program performance to relevant hospital departments and hospital administration
∙ If there is no infrastructure to set up IT systems to support a hospital AMS program, a paper-based system can be used in conjunction with syndrome-specific guidelines.
∙ Obtain formal support from hospital administration for infectious disease and AMS training, and appropriate time commitment and remuneration for AMS providers based on the size of the hospital
∙ Consider obtaining external infectious disease specialist advice and training from a more well-resourced hospital
∙ Provide hospital administrators with credible business case to persuade them that funding of an AMS program is beneficial to the hospital
∙ Start small and build capacity over time; gradually introduce AMS interventions by hospital unit or ward
∙ Provide regular feedback and education to prescribers in an easily interpreted format ∙ Make efforts to understand the reasons for noncompliance to AMS recommendations and rectify the problems.
∙ Include an infection control personnel in the AMS core team ∙ AMS and infection control teams work together under the same leadership to achieve the goal of reducing the rate of multidrug-resistant infections.
Note. AMR, antimicrobial resistance; AMS, antimicrobial stewardship. aSee Supplementary Material S1 for an AMS program assessment checklist, for Asian hospitals to assess which aspects of the AMS programs are in place and what gaps need to be addressed. bSee Supplementary Material S2 for a flowchart of potential next steps and solutions to overcome gaps and challenges in AMS programs in Asian hospitals.
Table 3. Suggested Process-Related Measures and Outcome Measures for AMS Programs
Process-Related Measures Antibiotic consumption DOT or DDT Prescription rates Appropriate antibiotic use Time to IV to oral switch Duration of antibiotic therapy
Outcome Measures Length of infection-related ICU or hospital stay MDR bacterial infection and colonization rates Changes in MDR patterns Infection-related mortality Readmission and reinfection rates Antibiotic-associated toxicity Treatment-related costs
Note. AMS, antimicrobial stewardship; DDT, defined daily dose; DOT, days of therapy; ICU, intensive care unit; IV, intravenous; MDR, multidrug resistant.
pathogens that are most relevant to their own region and hospital.8 In Asian hospitals, this will include carbapenem consumption, with a focus on carbapenem-resistant A. baumannii and carbapenemase- producing, carbapenem-resistant Enterobacteriaceae infection.
All AMS programs should focus on classes of antibiotics andMDR
How to build a multidisciplinary AMS team and define roles and responsibilities
additional AMS training,8,24 many hospitals in Asia do not have adequate personnel to make up the AMS team.19 In these cases, hospitals should work within their resources to create the most effective team possible.25,29 For example, the team leader could be an interested clinician from another specialty or a clinical phar- macist.10,30 External ID specialist advice and AMS training could be obtained from other hospitals to support the local AMS team.31,32 The minimum personnel for an effective AMS team should include an interested clinician, a pharmacist, and a collaborating micro- biologist.29 However, because of the value ID training offers to hospital AMS programs,33–35 we encourage all hospitals to commit to ID specialty training for AMS team members. Several stages are involved in building and establishing a
In agreement with IDSA/SHEA guidelines,8,24 we believe that AMS teams should include an ID specialist, clinical pharmacist (with ID training, if possible), a clinical microbiologist, an infection control specialist, and an information technology expert as core team members (Fig. 1). In this AMS team scenario, the ID specialist leads the team, and is responsible for implementation and evaluation of the program, and the clinical pharmacist/ pharmacologist performs many daily AMS program tasks and supports the team leader. Clinical microbiologists, clinicians with expertise in infection control and epidemiology, and information technology experts should also have key roles in AMS teams. Although AMS programs may be best led by ID physicians with
successful AMS team. First, a business plan should be developed, and formal approval and financial support should be obtained from hospital administration, followed by the appointment of a team leader and core team members with clearly defined roles and responsibilities (Table 4). The team should then start working within their budget and existing resources to decide on
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