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directed therapy is based on microbiology results. However, as a caution, the prescriber needs to understand that microbiology results can be confusing as to whether the isolated pathogen is causing the infection or is just a contaminant or colonizer.59
Dose optimization (using pharmacokinetic/pharmacodynamic models and therapeutic drug monitoring) (strong recommendation, low-to-moderate–quality evidence). Dose optimization does not necessarily require therapeutic drug monitoring, and can be implemented on the basis of identifying deviations from recom- mended dosing schedules, making recommendations to optimize dosing based on pharmacokinetic/pharmacodynamic princi- ples.54,58 In patients who are critically ill, with fluctuating hemodynamic parameters, and with sepsis from infection caused by MDR pathogens, dose-optimization via therapeutic drug monitoring will help ensure adequacy of treatment.60
IV to oral switching (strong recommendation, moderate-quality evidence). Intravenous to oral conversion of the same antibiotic is a relatively simple intervention and applicable to many settings.8 During the prospective audit process, pharmacists should encourage the appropriate use of oral formulations.
Recommended microbiology-driven interventions
Use of rapid diagnostic testing in addition to conventional diagnostic testing (strong recommendation, moderate-quality evidence). Delayed (≥72 hours) conventional bacterial culture and anti- microbial susceptibility testing results are barriers to optimizing therapy.61 Few hospitals in Asia use rapid diagnostic testing, and many are not in a position to deliver accurate and reliable con- ventional pathogen-defining testing. It is essential to strive toward strengthening laboratory capacity that can deliver such services. In the meantime, early AMS review and prospective interventions, such as use of monotherapy, de-escalation, and IV-to-oral switch, can be implemented to help optimize empiric antibiotic therapy.62
Selective antibiotic susceptibility reporting (strong recommendation, low-quality evidence). Some evidence suggests an association between antibiotics listed in susceptibility reports and their prescription. When feasible, reporting susceptibility to broader-spectrum drugs only when isolates are resistant to narrow-spectrum agentsmay guide physicians to select the more appropriate narrow-spectrum drugs.59,61 Although the practice of reporting susceptibility results for a limited number of antibiotics instead of all tested antibiotics may promote appropriate antibiotic use, it requires the specialized expertise of a clinical microbiologist and could be difficult to implement in many Asian hospitals. This reporting needs to be carefully monitored so that errors are not made (eg, no active anti- biotic treatment is found in the laboratory report).
Site-specific hospital antibiograms with or without active surveillance testing (strong recommendation, low-quality evidence). Active sur- veillance testing and availability of hospital antibiograms can pre- sent unique susceptibility patterns that help AMS programs develop optimized treatment guidelines and recommendations for empiric treatment.38,57 In resource-constrained settings, targeted and stra- tegic surveillance testing (eg, point-prevalence surveys for resistant gram-negative bacteria) may be more feasible than continuous active surveillance of all bacterial isolates.
Use of computer systems to support AMS programs
As hospitals move toward adopting electronic health records, there are increasing opportunities to integrate surveillance and
Anucha Apisarnthanarak et al
decision support into information technology systems.25,63 A recent systematic review has shown that using information technology systems to streamline AMS program processes and guide prescribing decisions can help to improve appropriate antibiotic use in acute-care hospitals.63 Computer-assisted AMS strategies, ranging from computer-
ized systems for data analysis and recording to online AMS sys- tems and computerized decision support systems, are being implemented in various hospitals across Asia.55,64–67 However, these can be costly and time-consuming to implement and maintain, and they may not be readily accepted.67,68 If a hospital does not have the infrastructure to set up information technology systems to support an AMS program, a paper-based system can be used in conjunction with syndrome-specific guidelines.
How to combine AMS programs and infection control
Implementation of AMS programs alone may not reduce rates of MDR pathogens.4,16,59,64,65,69 Infection control measures, includ- ing hand hygiene, contact precaution, environmental cleaning, and disinfection, are critical for controlling MDR pathogens in hospitals. Practices to prevent common healthcare-associated infections (eg, central-line–associated blood stream infection and catheter-associated urinary tract infection) are also important.70,71 We strongly recommend that AMS and infection control teams work together under the same leadership to achieve the goal of reducing the rate of MDR infections.24,70
How can organizations and stakeholders work together to advocate for AMS?
The World Health Organization (WHO) is positioned to promote worldwide antimicrobial stewardship, and it acknowledges the roles of the Asia-Pacific Economic Cooperation (APEC) and the Association of Southeast Asian Nations (ASEAN) for successful implementation of AMS in the Asia-Pacific region.5 The Vietnam Resistance Project (VINARES) is an example of a national project that addresses hospital-related priorities in the WHO policy package on antimicrobial resistance,13 and a national campaign to enforce Ministry of Health regulations for the rational use of antibiotics has been conducted with a positive effect in China.37,72,73 The VINARES project and Chinese Ministry of Health initiatives are models for similar healthcare settings.2,37 To operate successfully, AMS programs require buy-in from
hospital administration and local stakeholders, and adequate finan- cial support.13,15,25,74 Formal statements of support for AMS should be given by organizational leadership.15 AMS-related duties should be included in job descriptions, and staff should be given sufficient time and financial support to contribute to AMS activities.15
Making AMS programs sustainable
The foundation of a sustainable AMS program lies in starting small and progressively building capacity, with regular monitoring and reporting AMS program performance, modifying and adapting the AMS program, and continuing AMS education. Tracking of long- term trends of pre-specified AMS program process and outcome measures are as important as initial changes. A timeline for reporting progress toward AMS program goals should be specified to clarify expectations from stakeholders because some outcomes take longer to show noticeable changes from baseline.25 In conclusion, we also recommend that AMS team members stay up-to-date with the latest AMS guidelines from relevant
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