Antimicrobial Resistance

Prevention and Containment

Training Course for Health Professionals

1
 Chapter One

Overview of Antimicrobial Resistance

2
Chapter Description
• This chapter emphasizes the global and national magnitude of
Antimicrobial Resistance and factors contributing to the
emerging of AMR
• In addition it addresses Global and National Response to
Antimicrobial Resistance

3
Objectives

Primary Objective:
 to discuss the global and national threat of Antimicrobial Resistance
and its Prevention and containment strategy
Enabling Objectives:
 Describe antimicrobial resistance and the factors contributing to its
emergence and spread as well as mechanism of resistance
 Discuss the global and national magnitude of Antimicrobial resistance
 Describe the impact of antimicrobial resistance
 Discuss AMR prevention and containment strategy

4
1.1 Introduction

Activity 1.1 Brainstorming

 What is Antimicrobial Resistance (AMR)?

5
1.1 Introduction
• Infectious diseases have accounted for a very large proportion of diseases
ranked top ten causes of death worldwide in 2016 by WHO.
• Approximately 60% of all human infectious diseases recognized so far, and
about 75% of emerging infectious diseases that have affected people over
the past three decades, have originated from animals (WHO).
• Unfortunately many of these diseases could be prevented or cured for as
little as a single dollar per head

6
7


Distribution of the leading causes of death in Africa in
2016

8
Int..cot’d
• It was not until the latter half of the 18th century that micro-
organisms were found to be responsible for a variety of infectious
diseases
• The discovery of these infectious agents stimulated the search for
appropriate preventative and therapeutic regimens; however,
successful treatment came only with the discovery of antibiotics
half a century later.

9
Activity 1.1 Brainstorming
 H o w d o y o u s e e n a t u ra l h i s t o r y o f
A n t i m i c ro b i a l s / W h a t w a s t h e f ir s t
antibiotic discovered?

10
Figure 1: Events occurred in the age of Antimicrobials


11
Natural History of Antimicrobials

 Salvarsan (Arsphenamine) an organoarsenic compound-1910

 Prontosil, a sulfonamide- 1935
 In 1928, Fleming discovered penicillin
 In 1940 penicillin was introduced on a large scale as treatment of bacterial
infections and this was taken as the “Golden Era” of antibiotic.

12
Nat Hx…cot’d

• Antibiotics have revolutionized medicine in many respects, and countless

lives have been saved; their discovery was a turning point in human history.
• Antimicrobials are probably one of the most successful forms of
chemotherapy in the history of medicine.
• Unfortunately, we now live in an era where people around the world are
dying from untreatable infections because of the emergence and spread of
Antimicrobials resistance.

13
Figure 3: Pattern of Antimicrobials and Resistant bacteria
14
15
1.2 Magnitude of AMR

Activity 1.2 Individual reflection

 How deep is the problem of AMR?
 What do you think are the commonest etiologies
involved in AMR in your setup?

16
Mag..cot’d
• Antimicrobial resistance is increasing globally because of greater access
to antibiotic drugs especially in developing countries and spread of
resistant strains among humans and animals.
• Each year in the U.S., at least 2.8 million people are infected with antibiotic
-resistant bacteria or fungi, and more than 35,000 people die as a result.

17
Table 1: Cross-sectional Retrospective study on Antibiotic
resistant pattern at HUCSH July 2019

18
Figure 4: S.aureus Resistant over years in Ethiopia
19
Mag..cot’d - commonest etiologies
• Resistance to multiple drugs was first detected among enteric
bacteria—namely, Escherichia coli, Shigella and Salmonella—in the late
1950s to early 1960s.
• Several resistant bacteria have been increasingly involved in infectious
diseases
-ESKAPE; WHO as priority antibiotic-resistant bacterias’
-S. aureus is the resistant bacterium most familiar in the clinical setting

20
Mag..cot’d
 In Ethiopia, AMR baseline survey conducted in 2009, revealed that
Coagulase negative staphylococcus, Streptococcus pneumoniae,
Salmonella species, and Staphylococcus aureus showed a considerable
degree of resistance to commonly used first line antibacterial agents.

21
Mag..cot’d

22
1.3. Causes and Mechanisms of AMR

Activity 1.3 Group Discussion

What are the factors associated with the
development and spread of antimicrobial resistance?

23
Causes
• heavy use of antimicrobials in hospitals and food
producing animals and agriculture
• inadequate dosing, substandard antimicrobials and
poor adherence
• not prescribing according to microbiology
results/absence of diagnostic facilities
• weak monitoring and regulatory systems
• poor infection control systems in health facilities:
improper disposal of antimicrobials…
• lack of surveillance and the dearth antimicrobial
stewardship programs
24
Mechanisms of AMR

Activity 1.3 Individual Reflection

• What are the types of microbial resistance?
• What are the possible mechanisms of antimicrobial
resistance?

25
Types of Microbial Resistance

• Some bacteria can be resistant naturally from plasmid proteins,

Intrinsic Resistance but most acquire resistance as a
consequence of evolution through a random error or
spontaneous mutation that occur during bacterial replication
upon exposure to antibiotics.
• Resistance genes can be transmitted among bacterias via
Vertical or Horizontal transmission

26
Development of microbial resistance

Figure 5: Natural selection of antibiotic resistant bacteria

27
Examples of microbial resistance pathways

1) Decreased Uptake/modifying ab target: GM-ve, MRSA(PBP)/

2) Efflux Pumps: E-coli/TTC, quinelones…
3) Enzyme inactivation: b-lactamase(Salmonella..
4) Biofilms : periodontal disease, cystic fibrosis, chronic acne and
osteomyelitis

28
1.4.1. Consequences of AMR

Activity 1.4 Individual reflection

 List some of the major consequences of
AMR?

29
1.4.1. Consequences of AMR ….
• AMR crisis will have a devastating cost on human society as
both debilitating and lethal consequences.

30
1.4.1. Consequences of AMR ….
 Increased morbidity & mortality.
 Longer duration of illness.
 Longer treatment
o Excess length of stay 6.4 – 12.7 days/patient
 Treatment with expensive drugs
 Increased burden on health system
 Negates technological advances in medical sector
o Complex surgeries
o Transplantations and other interventions

31
1.4.2. Impacts of AMR

Activity: Group activity on impacts of AMR

 In your small group discuss the impact of AMR in health and
economic aspects?

32
1.5.Global and National Response to
AMR

Activity 1.5 Individual reflection

 Mention the some of the global and national
responses to AMR

33
1.5.Global and National Response to
AMR

• To combat AMR appropriately and effectively, concerted

collaborative efforts are necessary across the human health,
animal health, and environment sectors. - One health approach

34
Global response to AMR
• The 68th World Health Assembly (WHA) passed a resolution in
May 2015 on the global action plan to contain AMR with Five
Strategic Objectives that member states can adapt and use.
• FAO’s Thirty-ninth Conference (in June, 2015) adopted
Resolution 4/2015 on AMR which recognized that it poses an
increasingly serious threat to public health and sustainable food
production, and that an effective response should involve all
sectors of government and society.

35
Global response to AMR

36
National response to AMR

37
National response to AMR….

38
National response to AMR …
• Established/strengthened multisectoral coordination
• Conducted various awareness creation events
• Provided training for health care and mass media professionals
• Developed national AMR Prevention and containment training
materials for health professionals;
• Established National AMR Coordinating Team, a secretariat
office in the Ministry of health;

39
National response to AMR …
• Developed National Human AMR Surveillance and Research
Plan
• Implementing various health facility and community-based
infection prevention and containment initiatives
• Developed Guidance of Antimicrobial Stewardship (AMS) for
hospitals in Ethiopian
• Undertaken Antimicrobial Use Point Prevalence Survey
• Categorized Antibiotics in the revised National Essential
Medicine List following AWaRe principles and use this as basis
for up-dating National Standard Treatment Guideline
40
1.6. Summary

• Antimicrobials resistance is one of the greatest global public health

challenges of our time.
• In Ethiopia, there are indications of the misuse of antibiotics by health care
providers, unskilled practitioners, and drug consumers. These, coupled
with rapid spread of resistant bacteria and inadequate surveillance,
contributed to the problem.
• The consequences of AMR are serious and global. Annual overall global
death toll could soar to 10 million by 2050 resulting in a sustained global
economic impact similar to, and likely worse than, the 2008 financial crisis.
• AMR is a biological, behavioural, technical, economic, regulatory, and
educational problem and requires a comprehensive response strategy
developed on the basis of evidence.
41
THANK YOU

42














Chapter 2:




Rational Use of Antimicrobials

Antimicrobial Resistance Prevention and Containment

Training Course for Health Professionals

43
44
Chapter description
• This chapter equip participants with the concepts of rational use
of antimicrobials.
• It describes
• the magnitude and causes of irrational use of antimicrobials
• consequences of irrational use of Antimicrobials
• medication safety.
• types of interventions to promote rational use of antimicrobials,
• the ethical and legal considerations.
45
Objectives
Primary Objective:
• At the end of this chapter, participants will be able to promote
rational use of Antimicrobials.
• Enabling Objectives:
• Interpret the basic concepts of rational Antimicrobial use
• Describe Magnitude and Causes of irrational antimicrobial use
• Demonstrate Medication safety
• Examine the consequences of irrational antimicrobial use
• Practice interventions to promote rational antimicrobial use
• Examine ethical and legal considerations in Antimicrobial use
46
2.1. Introduction to Rational Use of AMs

Activity 2.1: Concern for the then “Miracle Drugs”/

Large Group Discussion
 Antibiotics are miracle drugs, Explain the statement and the
terms medicines/Drugs, antimicrobials and antibiotics.
 Discuss The budget share and consumption trends antimicrobials.
 Explain the quote “One that doesn’t kill me will make me stronger”
 Describe safety and cost of newer antibiotics
3 min

47
Int. Cont…
• RMU Rt Drug Rt Dose

• The concern for

Irrational use goes
Rt. Time &
back to 300BC, Duration
Rt dosage form
Herophilus
• 5Rs
• If one of these is not Rt. Route of
RM
U
admn
right, then it is irrational.
48
Int. Cont…
• Medicines Cornerstone of every healthcare system both in
trustworthiness and budget share
• Discovery of antimicrobials ⇨ Great achievement of mankind,
saved countless lives.
• The emergence and expansion of AMR ⇨ critical challenge
(Health, economic and social).
• Multifaceted challenge requiring multidimensional intervention.

49
 Int. Cont…

• Good prescribing Practices

Prescribing • Meaning and the
considerations in
prescribing
Antimicrobial
• Good Dispensing Practices
s
• Meaning and the Six steps
Patient use Dispensing • Patient use

Fig 2.1 Actors of Rational Medicine

Use

50
2.2 Magnitude/Int: Component of Drug
Use Cycle

51
2.2 Magnitude/Int: Component of Drug
Use Cycle

Activity 2.2A Individual reflection

Is there signif icant problem of irrational use of
Antimicrobial in your area? Justify your answer
from practical experience, from prescribers,
dispensers and patients perspective. Who to
blame?
Time: 5 minutes
52
2.2 Magnitude ….
• Irrational Prescribing
 Either the diag nosis or the treatm ent or b oth - are
wrong/inappropriate
Types of irrational prescribing
 Extravagant prescribing
 Over Prescribing
 Multiple prescribing
 Under prescribing
 Wrong prescribing

53
2.2 Magnitude ….
• Irrational Dispensing
 It can happen any of the six steps in Good Dispensing
Practice
• Patient Related include
 Compliance
 Self medication
 Use AMs as OTC
 Influencing prescribers
 Sharing

54
Magnitude of irrational use
• WHO estimates ˃ 50% of all medicines are
prescribed, dispensed or sold inappropriately, and
that 50% of all patients fail to take them correctly.
• Ethiopia:
• The overall prevalence of medication error was 57.6%
• The pooled burden of medication administration and
prescription error was 58.4% and 55.8% respectively.
• Adequacy of labeling practice was only 19.9%

55
Magnitude of irrational use
Activity 2.2 B – Individual Reflection
Ref lect your understanding on the health and economic
burden of irrational antimicrobials use.
NB. The total hard currency earning of Ethiopia in
2013EFY was $3.6Billion, correlate the amount we may
lose in terms of HFs…
Time: 2 minutes

56
2.3 Causes of Irrational Antimicrobials
use
Activity 2.3A. Brainstorming
What are the causes for irrational
use of Antimicrobials?
Time: 5 minutes
57
 2.3 Causes of Irrational Antimicrobials use ….

Case study #1
MG is 24 years old man presented with Chief Complaint of Headache,
photophobia, painful and stiff neck, nausea and vomiting (5 to 6
episodes).
After thorough investigation of his clinical presentation the emergency physician suspected meningitis and
gave him 1gm ceftriaxone IV stat, 500mg azithromycin PO stat and 1gm paracetamol. Then after the patient is
transferred to the adult medical ward. The assigned resident in the medical ward make lumbar puncture for
CSF analysis and the sample was sent to the nearby laboratory facility. But, the laboratory investigation does
not revealed the presence of bacteria in the CSF but other findings are consistent with pyogenic meningitis.
Answer the following questions based on the above case scenario
a. Comment on the microbiology lab test
b. Reflect on the antimicrobial therapy of this patient
c. How can such practice contribute to antimicrobial resistance?
d. Based on the comment adjustment taken and the patient has improved after 2 days. It was decided to
discharge, suggest actions to be taken by prescribers and dispensers.
58
 2.3 Causes of Irrational AM use …. •
Knowledge, Competency
and Ethics in:
Prescribing,
Side Professional Dispensing
Effec related Lab
Dura t,
tio n •Legal f
of ra
Trea Produc •Inform mework
tmen t Relat System ation, ST
t Related F ormular G,
ed RMU y, GXP m
Referen anuals,
c es
factors •Supply
•Infrastructur Availabi
system/
lity
e •Patien
t load/ w
•Workload ork plac
Environme Patient •Dem e
nt Related Related ograp
•E c o n o m i c •Percep
tio n
hy
motives
59
2.4 Medication Safety
Activity 2.4A: Brainstorming
Explain the term medication safety?
From experience or reports how do you rate
the severity of medication safety?
Discuss the reasons/ factors and some
solutions to the medication safety problem?
10min
•
60
Strategic measures to make medication use
safer
1. Leadership, commitment
7. Clear Communication
2. Use generic names 8. Develop checking habits
3. Practice collecting complete 9. Report & learn from medication
medication histories errors
4. Good Knowledge of 10. Detecting and reducing possible
medications and associated interactions and/or
risks of ADEs contraindications

5. Good prescribing, disp. &

61
2.4 Medication Safety… Medicines Safety
Monitoring Vs Drug development process

The medicine in
the market took
extended and huge
investment
Yet, safety?
Exploring the Drug Development Process | Technology Net
62
2.4 Medication Safety

Activity 2.4 B: Large group

discussion
- What is the importance of monitoring
safety of medicines, pharmacovigilance?
- Who is the responsible organization
and how?
10 min

63
2.4. Drug safety cont…

Activity 2.4 C: Case study

XY, 35 years old lady (body weight=56kg) who is on oral
contraceptive has started Augmentin 625-mg po every 8-hrs
on 22/11/13 for Pneumonia. After the 3 rd dose, she came
with diarrhea, abdominal pain, and skin rash. Finally,
Aug m entin was disc ontinued, she was adm itted f or
observation and discharged (recovered) after 24-hours. Use
this info to fill the ADR reporting form
Discuss What to report and How to report using the ADR
reporting form.
Consider one ADR complete the reporting form 64
.
National ADE Guideline ADE reporting Form

65
 2.4.4 Medication safety of Antimicrobials

• Antimicrobial toxicity may take many forms:

• varying from mild, transient phenomena to dramatic, life-
threatening events such as seizures or cardiac arrhythmias.
• Category (5)
1. Direct Effect,
e.g. Chloramphenicol ⇨ Anemia, Aminoglycosides on 8th
Cranial nerve.
2. Hypersensitivity

66
AM safety…..Category (5)

3. Changes in microbial flora.

AM⇨ vaginal candida
4. Drug Interaction,
Synergistic or antagonistic, chelation
5. Microbial lysis.
e.g. Penicillin, Dapsone
67
2.5 Consequences of irrational Antimicrobial use

Activity 2.5A: Brainstorming

Discuss the consequences of irrational use
of antimicrobials at micro (individual) and
macro (societal level)

68
2.5 Consequences of ….

69
2.5 Consequences of….
AMR
Costs of
AMR

Patient Healthcare Societal

perspective Perspective perspective
(list from PM) (list from PM)
(list from PM)

Response physician in East African study to perform

activity 2.5B 70
2.6 Interventions promote rational use of Antimicrobials.

Activity 2.6A Large group discussion

Discuss the interventions that

promote rational use of Antimicrobials.
Time: 5 minutes

71
Strategies
Educational: Managerial:
 Inform or persuade  Guide clinical practice
– Health providers – Information systems/STGs
– Consumers – Drug supply / lab capacity

Use of
Medicines

Economic: Regulatory:
 Offer incentives  Restrict choices
– Institutions – Market or practice controls
– Providers and patients – Enforcement

72
2.6 Interventions promote rational use of Antimicrobials cont…

Activity 2.6B Group discussion

Check prescription on your hand (distributed)
and compare it with the standard prescription
in the RMU directive and discuss f indings vis-à
-vis the directive.
a. Any difference in format
b. Any deviation in completing the form
Time: 10 minutes
73
74
75
Standard Prescription Paper

76
2.7 Ethical legal Considerations

Activity 2.7A Group Discussion

what is ethics in general?
Why we worry about ethics in relation to Antimicrobials use?
Discuss some unethical/illegal practices in the use of
antimicrobials?
I s there any legal responsibility to professional use
antimicrobials?
10 min
77
2.7 Ethical Legal….

Activity 2.7B. Case study

Dr. DK saw his high school classmate Mr. AM on a street. Mr. AM told him that he
has some sort of cough and asked him whether he contracted COVID 19. Dr. DK
orally investigated the case and assured AM it is not Corona. Dr. DK usually
carries prescription paper with him and ordered for his friend Zithromax 500mg
once daily for three days and a cough syrup. As card no. is not labelled on the
prescription the Pharmacist BW asked AM told and came to know the truth.
Answer the following questions:
1. Can BW dispense the medicines? Why and why not?
2. Discuss your comment on Dr. DK. From ethical and legal point of view.
3. To what extent such practice contribute to AMR
78
Session Summary
• Medicines are cornerstone of healthcare delivery, needs to
used Rationally.
• AMs saved/saving countless lives
• One of the alarming consequences of misuse of
antimicrobials is AMR
• Medication safety is also a concern in Rational Use of AMs.
• Four major strategies for promotion of Rational Use of
Antimicrobials
• Rational use of medicines/ antimicrobials is supported by
ethical and legal instruments
• We all are directly responsible to promote Rational use of
AMs
79
 u !
y o
nk
ha Stand to save the next
T generation Ref, Q&A

Combating antimicrobial
resistance: No action today, no
cure tomorrow
80
 Chapter 3:




Infection Prevention & Control and Antimicrobial Resista

Antimicrobial Resistance Prevention and

Containment
Training Course for Health Professionals
81
Outline of presentation

• Introduction

• Basic concepts of IPC

• Core components of IPC

• Healthcare-Associated Infection

• IPC measures relevant to AMR prevention

• Summary
82
Chapter description

• This chapter familiarizes participants with basic concepts of IPC.

• In addition, it describes the core components of IPC and provides an

overview of IPC measures relevant to the prevention and containment of
AMR

83
Objectives
Chapter Objective:
• By the end of this chapter, participants will be able to discuss the relationship
between IPC and AMR

Enabling Objectives:
 Discuss basic concepts of IPC
 Describe the core components of IPC
 Identify IPC measures relevant to AMR prevention and containment
 Describe interventions to prevent HCAI

84
3.1. Introduction
• Infectious diseases remain a major public health threat globally and could affect anyone
with the highest burden in LMICs

• In healthcare settings, the risk for infection is usually high due to risk factors such as the
presence of a wide range of infectious agents from various sources

• Antimicrobials are used either to prevent or treat these infections

• IPC refers to scientifically sound practices aimed at preventing harm caused by infection to
patients, health workers and the community.
• It is a systematic effort or process of placing barriers between a susceptible host and infectious
agents.

Thus, IPC is a critical component at every level of the health service delivery.

85
Introduction …

How does IPC measures

relate with AMR?
3 minutes

86
Introduction …
• IPC has two-fold benefit in containing emergence of AMR
• Reduces the risk of transmission of infections, thus minimize the necessity for, and
use of antimicrobials. This prevents the emergence of AMR
• Contains the spread of resistant microbes once resistance has emerged

• IPC is the 3rd strategic objective of the global and national action plan on AMR
(Reduce the incidence of infections though sanitation, hygiene and infection
prevention measures)

87
3.2. Basic concepts of IPC

88
Elements of the infection chain
Direct transmission: an immediate Bacteria,
transfer offungus,
virus, the infectious
agent parasite

• Direct contact -direct body surface to body surface contact-

(STI )
Human • Droplet spread -coughing, sneezing and talking (influenza,)
Animal Human
Animal
Environment
Indirect transmission: intermediaries required for the transfer
of the infectious agent
• inhalation • Airborne, - droplet/ dust particles containing infectious
• ingestion
• absorption
agents(TB) RT, GIT, Blood,
• break in skin • Vehicle-borne -food, water, medications, medicalSkin…devices
• introduction by
medical
• Vector borne – insect bites (Malaria)
procedures
Direct
Indirect 89
Standard and Transmission-based
Precautions
• Standard precautions
• First level precautions to all patients
• Assumptions: every client and patient is potentially infectious or susceptible to
infection
• Maintenance of a physical, mechanical, or chemical barrier between
microorganisms, the environment, and an individual

• Key components
• Hand hygiene
• Use of Personal Protective Equipment (PPE)
• Respiratory hygiene and cough etiquette
• Safe injection practice
• Cleaning and disinfection of patient care equipment, instruments, devices, and
environmental surfaces
• Healthcare waste management 90
Standard and Transmission-based
Precautions…
• Transmission-based precautions
• Second level precautions
• For patients who may be infected or colonized with certain infectious
agents for which additional precautions is required
• used when the route (s) of transmission is (are) not completely interrupted
using standard precautions alone

• Three categories of transmission-based precautions

• Contact precautions
• Droplet precautions
• Airborne precautions

91
3.3 Core Components of IPC

92
Reading assignment

• Cross reference your response to the above question by

reading the core components of IPC from the participant’s
manual for 5 minutes

93
Core components of IPC
• IPC is one of the fundamental strategy to combat AMR

• WHO recommends eight equally important core components crucial for the
establishment and effective functioning of IPC programmes and practices

1. IPC programmes: necessary premise for any IPC action at healthcare facility.
Link IPC to pertinent national programmes such as TB control, HIV/AIDS,
MNCH etc. for improved outcomes and sustainability.

2. Evidence-based IPC guidelines: adapted to local context

3. Education and training: use the right educational method to achieve behavior
change. Monitor adherence with guideline recommendations.
94
Core components of IPC
4. Healthcare-associated infection (HCAI) surveillance: identify specific infections as
a priority for surveillance

5. Multimodal strategies: implementation of several elements/components of IPC (3-5)

in an integrated manner

6. Monitoring and audit of IPC practices and feedback: a quality improvement process
to achieve behavioral change and increase adherence to recommendations

7. Workload, staffing and bed occupancy at health facility level

8. Built environment, materials and equipment for IPC at the health facility level:
availability of basic equipment at point-of-care

95
3.4 HealthCare-Associated
Infections

96
Healthcare-associated Infections…
• The burden is growing globally
• Pooled prevalence of HACI in mixed patient populations in high-income countries
is 7.6% while 15.5% in low and middle-income countries
• Most commonly reported HCAIs are surgical site infections, urinary tract
infections, bloodstream infections (BSI) and hospital acquired pneumonia

Countries Catheter-related BSI Urinary catheter-related Ventilator-associated

per 1000 central line UTI per 1000 urinary pneumonia (VAP) per 1000
days catheter days ventilator days
High income
3.5 4.1 7.9
countries

Low and middle

12.2 8.8 23.9
income countries
97
Healthcare-associated Infections…
• Microbiological patterns of HCAI reported gram-negative bacteria
(e.g. E. coli) and S. aureus as the most frequent single pathogens

• A systematic review of HCAI in Africa, reported

• the prevalence of methicillin-resistant Staphylococcus spp. ranged between
3.9% and 80% among the Staphylococcus spp.
• whereas gram-negative bacteria producing Extended Spectrum Beta-
Lactamase (ESBL) ranged between 1.9% and 53%

98
Healthcare-associated Infections…
• Risk factors includes
• age >65 years,
• admission as an emergency and to the ICU,
• hospital stay longer than 7 days,
• placement of a central venous catheter,
• Indwelling urinary catheter, or an endotracheal tube,
• undergoing surgery,
• neutropenia,
• a rapidly or ultimately fatal disease and impaired functional or
coma status

99
3.5 IPC measures relevant to AMR prevention…

100
IPC measures for AMR prevention …
1. Hand hygiene
• Single most important practice
• Hand washing with soap & water or alcohol-based hand rub
• The cleansing activity is due to friction & the detergent properties of the
soap
• Time is also an important factor in hand washing (30 sec vs 15 sec)
• The entire hand washing procedure, if completed properly should take
40–60 seconds
• Volunteer to demonstrate steps of proper hand washing

101
Steps of hand
washing
Reprinted from: “How to Hand wash,”
© World Health Organization (2009).
https:
//www.who.int/gpsc/5may/How_To_
HandWash_Poster.pdf?ua=1.
Accessed May 26, 2020.

Hand washing steps

Hand hygiene & AMR

you.be/IisgnbMfKvI

102
103
 IPC measures for AMR prevention …
Alcohol-based hand rub
• More effective in killing transient and resident flora than hand washing
• Has long-lasting activity
• Quick and convenient to use and can easily be made available at the point of
care
• Contains a small amount of an emollient (e.g. glycerol, propylene glycol, or
sorbitol) that protects and softens skin

104
Group discussion
• When is hand washing recommend as compared to alcohol-
based hand rub (ABHR)?

105
Group discussion
• When is hand washing recommend as compared to
alcohol-based hand rub (ABHR)?
• Hands visibly soiled or contaminated with blood or body fluids
• After using toilet
• Before eating
• To remove the buildup of emollients (e.g. glycerol) after repeated use of
ABHR

106
When is hand hygiene so relevant?

107
Hand hygiene and level of HCAI/resistant infection reduction
• A hospital-wide study in Saudi Arabia* showed that with significant increase
in HH compliance from 38% in 2006 to 83% in 2011, a reduction in
• MRSA infection from 0.42 to 0.08
• Ventilator associated pneumonia from 6.1 to 0.8
• Central line associated BSI from 8.2 to 4.8
• Catheter-associated UTI from 7.1 to 3.5
• Another study demonstrated sustaining HH at 80% or higher was
associated with a 48% further reduction of MRSA acquisition in a unit that
had comprehensive MRSA prevention measures**
*Al-Tawfiq JA, Abed MS, Al-Yami N, Birrer RB. Promoting and sustaining a hospitalwide, multifaceted hand hygiene program resulted in
significant reduction in health careassociated infections. Am J Infect Control. 2013 Jun;41(6):482-6.
**Song X, Stockwell DC, Floyd T, Short BL, Singh N. Improving hand hygiene compliance in health care workers: strategies and impact on patient outcomes. Am J
Infect Control. 2013;41(10):e101–5.

108
IPC measures for AMR
prevention…
2. Use of PPE: proper donning and doffing is crucial

3. Sharps and injections safety: globally 50% of injections are unsafe. In Ethiopia,
74% injections are unsafe. Best practices in injections safety includes eliminating
unnecessary injection, safe administration of injections and disposal of injection
wastes and sharps properly

4. Environmental measures: cleaning and disinfecting surfaces that are most likely
to be contaminated

5. Healthcare waste management: apply to all the generation, segregation,

collection, transport, storage, and disposal. The preferred strategy to implement is
minimizing waste generation

109
Summary
• IPC is an important components of the global and national AMR prevention &
containment strategy
• IPC has twofold benefit in AMR prevention.
• Minimize the need and use of antimicrobials at individual and community level by
reducing the occurrence of infections.
• It breaks the cross transmission of infections due to resistant microorganisms at
healthcare facilities
• Consistent hand hygiene practice has great impact in reducing HCAI and AMR
• Behavior change interventions targeting healthcare workers are fundamental
• Implementation of combination of IPC measures will
• Result in better patient outcomes,
• Reduce cost of medical care,
• Minimize length of stay,
• Reduce antimicrobial use and subsequently the emergence of AMR. 110
111


Chapter 4:







Antimicrobial Stewardship Program

Antimicrobial Resistance Prevention and

Containment
Training Course for Health Professionals
112
Objectives:
Chapter Objective: to Promote the implementation of Antimicrobial
Stewardship program (ASP)

Enabling Objectives:
• Describe basic concepts, principles and strategies of Antimicrobial
Stewardship program
• Perform core and supplemental strategies of Antimicrobial Stewardship
program
• Categorize Antibiotics into AWaRe classif ic ations based on WHO
recommendations
• Perform prospective Audit and feedback
• Identify steps and requirement to institute Antimicrobial Stewardship
program in hospitals
• Develop a workable action plan that will enable a health facility to
achieve AMS
113
Overview of Antimicrobial Stewardship…
Objectives of AMS program

• Optimize the use of antibiotics

• Promote behavior change in antibiotic prescribing and dispensing practices

• Improve quality of care and patient outcomes

• Reduce further emergence, selection, and spread of AMR

• Prolong the lifespan of existing antibiotics

• Limit the adverse economic impact of AMR- Save on unnecessary health care
costs

• Build the best practices capacity of health care professionals regarding the
114
rational use of antibiotics
Overview of Antimicrobial Stewardship… Benefits

115
Overview of Antimicrobial Stewardship- Benefits…

Conceptual value framework for implementation 116

Overview of AMS- Important considerations when prescribing antimicrobial
therapy:
• Obtaining an accurate diagnosis of infection;

• Understanding the difference between empiric and definitive therapy;

• Identifying opportunities to switch to narrow-spectrum, cost-effective oral agents

for the shortest duration necessary;

• Understanding drug characteristics that are peculiar to antimicrobial agents (such

as pharmacodynamics and efficacy at the site of infection);

• Accounting for host characteristics that influence antimicrobial activity;

• Recognizing the adverse effects of antimicrobial agents on the host.

117
Overview of AMS- General guiding principles

118


General guiding principles- 1. Principles of Testing

• Diagnostic test should be used wisely to avoid unnecessary
antimicrobial therapy or therapy that is unnecessarily broad-
spectrum.
• Rapid diagnostic tests and decision rules that have acceptable
performance characteristics to differentiate bacterial vs. non-
bacterial infection should be used.
• Bacterial cultures with susceptibility testing should be collated,
handled and processed promptly and appropriately to identify
specific bacteria causing infection.
• Avoid diagnostic testing without an appropriate clinical indication
119


General guiding principles- 2. Principles of Treatment

• Initial antimicrobial therapy choices should balance:
• treatment efficacy,
• severity of illness
• the potential for adverse events including the development of antibiotic resistance.

• When multiple therapeutic options are available, a hierarchy of antibiotic

treatment recommendations should be provided with “f ir st choice”
options:
• Adequate therapeutic efficacy
• The lowest risk of facilitating antimicrobial resistance
• The lowest risk of healthcare value.
120


General guiding principles- 2. Principles of Treatment

• Optimal dosing of antibiotics should be based on:

• efficacy studies,
• Pharmacokinetic
• pharmacodynamics principles.

• Duration of therapy should be made, emphasizing the shortest

effective duration.

121
Overview of AMS- Core elements of ASP

122
123
Antimicrobial stewardship program Strategies

124
Overview of AMS- interventions
Persuasive • Educational meetings (e.g. basics on antibiotic use, case-based
(education) discussions etc.)
• Distribution of and training on educational material (e.g. clinical practice
guidelines)
• Using local key opinion leaders (champions) to advocate for key
messages
Persuasive • Audit with feedback to prescribers on their prescribing practice
(feedback) • AMS as a component of ward rounds (real-time feedback with educational
component)
Restrictive • Formulary restrictions
• Restricted prescribing of identified antibiotics (expert approval prior to
prescription)
125
Structural • Rapid laboratory testing made available
Core strategies of Antimicrobial Stewardship program

The three core AMS strategies

• Formulary restriction with preauthorization

• Prospective audit with intervention and feedback

• Establishing multi-disciplinary AMS Program in health facilities

126
Formulary restriction and preauthorization

Why some medicines requires restriction or preauthorization? Potential to

promote resistance
 Potential to documented overuse or misuse (e.g. use of broad spectrum
antimicrobial over narrow spectrum agents are more appropriate)
 Need to reserve for treatment of multidrug resistant organisms
 Broad spectrum
 High cost
 Risk of serious adverse effects

127
AWaRe Classification of Antibiotics

128
AWaRe Classification of Antibiotics
ACCESS
• 1st-choice ATBs: sensitive, narrow-spectrum, low toxicity, propensity to develop
resistance
• 2nd-choice ATBs: sensitive, broader spectrum, higher risk of toxicity, potential to develop
resistance
• ATB of choice for most common infectious syndromes
• Must be available at all times
• Affordable and quality assured
• Lower priority for stewardship activities
• 60% or more of all ATBs consumed by 2023

129
AWaRe Classification of Antibiotics

WATCH
• Includes most of the highest-priority, critically important antimicrobials for
human and animal health
• Recommended only for specific, limited indications
• Includes sensitive ATBs with higher toxicity concerns, higher potential to
develop resistance
• Should not be used for prophylaxis in animal and agricultural production
• Target of AMS activities
• Must undergo active monitoring by using
– Prescription audits
– Point prevalence surveys

130


AWaRe Classification of Antibiotics

Reserve


 Used as a last resort, when all other ATBs have failed or cannot be used
due to contraindications
 Must also be accessible when needed
 Newer generation ATBs
 Use must be strictly limited to very specific patients and clinical settings
 Protected and prioritized as key targets of strict AMS activities, central
monitoring and reporting

131
132
Core strategies of ASP –AWaRe Classification of Antibiotics

133
Core strategies of ASP –Implementing AWaRe Guidelines and EML at the Facility
Level
• Start with creating or strengthening functionality of your DTCs/AMS Committee.
• Study national list of essential ATBs developed using the AWaRe criteria.
• Identify classes of ATBs stipulated for your level of facility.
• Study national treatment guidelines.
• Review your facility’s list of essential ATBs.
• Group your facility’s ATBs according to the national AWaRe categorization.
• Organize training of all prescribers and provide them with tools for planning,
implementation, and monitoring of AMS activities.
• Develop or adapt pocket guides, electronic apps, and other tools for prescribing
ATBs by following AWaRe guidelines.
• Set up a system to monitor implementation of AWaRe categorization.

134
Core strategies of ASP –Implementing AWaRe Guidelines and EML at the Facility Level

Exercise: As per the assignment from the Hospital DTC, the

formulary sub-committee requests the ASP team to review the
hospital’s specific list and classify Antibiotics in AWaRe.

1. What criteria will you follow to classify antibiotics

2. Classify the list as per the criteria and submit to the ASP team
before communicating to the formulary sub-committee.

(Use draft list at Annex 4.1 for the exercise)

135
Core strategies of ASP –Performing prospective audit and feedback
Introduction

What do you understand with the

terms Audit and feedback?

136
Core strategies of ASP –Performing prospective audit and feedback
Introduction

Definition:
Audit and feedback refers to the assessment of
prescribed antibiotic treatment with feedback when
antibiotic treatment considered as inappropriate.

137
Core strategies of ASP –Performing prospective audit and feedback

What do you think about

1. The advantages of prospective Audit and feedback?

2. The limitations of prospective Audit and feedback?

138
Core strategies of ASP –Performing prospective audit and feedback

139
Performing prospective audit and feedback

140
Retrospective audit with feedback:

• A method of collecting antibiotic data to evaluate the impact of

AMS interventions on antibiotic use.

• An audit involves assessing antibiotic therapy in hospitalized

patients

• We prefer prospective Audit with feedback to retrospective

audit with feedback!

141
Core strategies of ASP Establishing multi-disciplinary Antimicrobial
Stewardship Program in health facilities

Think pair and share

How would the ASP team been established?

What do you think who will be the members of ASP and the requirements to
establish ASP?

142
Governance structure of Hospital’s Antimicrobial Stewardship
team

143
Core strategies of ASP Establishing multi-disciplinary Antimicrobial
Stewardship Program in health facilities

What steps will you follow to establish AMS

program at your health facility

144
Antimicrobials

145
146


Chapter 5:




Use of Clinical microbiology in the
prevention and containment of AMR

Antimicrobial Resistance Prevention and Containment

147
Outline

• Objectives

• General Concepts and Overview of Specimen Collection

• Role of Clinical microbiology laboratory for antimicrobial

resistance and Diagnostic medical microbiological methods

• Antibiogram production and How to use

148
Chapter description
Participants will be looking at details of clinical microbiology sample
collection, types of bacterial identif ic ation ,interpretation tests and
Antibiogram preparation and interpretation.

149
Objective
At the end of this chapter the participants will be able to describe the role
of clinical microbiology and surveillance in the prevention and
containment of AMR.
Enabling Objectives: participants will be able to;
 Introduce understand the impor tance of proper specimen
collection and transport
 Role of Clinical microbiology laboratory for antimicrobial
resistance and Diagnostic medical microbiological methods
 Guide empiric antibiotic selection and to detect bacterial resistance
patterns (Antibiogram production and how to use ) 150
Concepts and overview Specimen Collection and Transport
Activity:5.1.1 Brainstorming

 Why are sample transport delays problematic?

 Should specimens be collected BEFORE or AFTER administration of
antibiotics?

• Laboratory results influence therapeutic decisions and can have

significant impact on patient care and outcomes

• Proper specimen collection for culture is the most important step

in the recovery of disease-causing organisms

• Proper sample management is critical for accurate and reliable

testing and results
151
Pre analytic –analytic-Post analytic phase

152
Proper Specimen Collection is Essential for
Optimal Use of Laboratory Services!

153
Test menu
S.
NO TEST SPECIME TRANSPORT CONTAINER TAT
TRANSPORT TIME Remark/ COMMENTS
N
1
Inoculate the blood into 8days Volume-Adults 8-10 ml/bottle 2
the Blood culture bottle Immediately on collection Do not
1

Blood culture Blood - 3 cultures per septic episode.

immediately refrigerate
Infants 1-2 ml
2
Sterile screw cap tube Immediately on collection Do not 4 days
Body fluids culture Body Fluid Volume-5 ml (minimum-1ml)
refrigerate
3
Sterile screw cap tube Immediately on collection Do not
CSF culture CSF 4 days Volume-5 ml (minimum-1ml)
refrigerate
4
Eye swab culture Conjuncti Swab in Transport Media/ 4 days Submit a swab from the
Within 2 hours of collection
va/ Eye Amies uninfected eye for comparison
5
Ear swab culture Ear(Otiits Swab in Transport Media 4 days Inner ear specimens are
Refrigerate if >2hour delay in transport
Externa) /Amies collected by a physician
6
Genital culture Swab in charcoal 4 days For diagnosis ofN.gonorrhoeae
Genital For diagnosis of N.gonorrhoeae
Transport submit swab in charcoal
Males transport immediately Vaginal swabs -
Media/ Amies Transport Media. Do not
& females refrigerate if >2 hour delay in transport
refrigerate
9
Throat culture Swab in Transport Media 4 days Avoid touching mouth or gums
Throat Immediately on collection
/Amies with the swab
10
Urine culture Sterile wide-mouthed 3 days 24 hour urines and those from
Urine container Refrigerate if > 2 hour delay in transport catheter bags are
unacceptable
11
Wound culture Swab in Transport Media Aspirates and tissues to be delivered 4 days
Wound Aspirate, tissue in sterile immediately Refrigerate swab if delay in - 154
container transport media
Patient Identification Process

• Ask the patient to state identifying information.

• Patient name
• Medical record number
• Date of birth
• Government-issued photograph identification

155
Keeping specimens free of contamination
There are three main ways specimens are contaminated:
•
• From you, the person collecting the specimen

• From the patient, usually from the skin around where the
specimen was collected

• From the collection container, usually because the container

was broken or not stored properly

156
Agents commonly used to clean and prepare skin for specimen
collection

(example for blood culture collection)

157
Collecting specimens in the right container

• The shape of a container can prevent contamination and may

limit volume (amount).

• Some containers have chemicals that are needed for certain

tests but will ruin the specimen for others.

• Collect in the appropriate, clean, leak proof-sterile containers.

158
Timing: Collecting specimens at the right (optimal)
time
• Collect specimens before antibiotics are given. If not possible
indicate on the requisition form.

• Collect specimens during acute phases of illness (e.g., when a

patient is febrile) as etiologic agents are more likely to be
detected.

• Collect urine specimens early in the morning ideally as the f irst

urination.

• Minimize Transport Time or Maximize Transport Media. There is Always

Some Loss of Viability During Transport ( if so the quality of result will
compromise ) 159
Volume: Collecting the right amount

• A suf fic ient quantity of the specimen must be obtained to

perform all the requested tests.

• Volume may differ by patient age

• Small specimens are especially problematic

• For blood, the sensitivity of culture is directly related to the

amount of blood submitted

160
A sufficient quantity of the specimen must be obtained to
perform the requested tests

161
Safe Specimen Labeling

• For any specimen, there are necessary items that need to be

present on the label and they must all be correct or the
specimen will be rejected

• EVERY individual tube, container, specimen sent to the lab must

have a label applied to it (not loose in the bag).

162
Transporting specimens to the lab

• Minimize transport time

• If transport time increases, microorganisms can die and others can

overgrow

• Specimens should be transported to the lab within 2 or accordingly

• Transport media may need to be used if transport time >1 hour

• Delay in transport compromise the quality of sample and result

inaccurate result

163
Institution Policies

The institution needs to provide the following information before

the collection of the specimen:
• Laboratory operation hours
• Contact person information
• List test performed routinely (laboratory guide) including the
time to results or days of testing (batched test and STAT
(immediate) testing

164
Requisition Form

• A completed requisition should include:

• Patient’s name and identification number
(patient’s unique identifier)
• Patient’s address, location (hospital ward,
clinic, etc.)
• Patient’s age, gender, phone number
• Description and source of specimen
• Date and time of specimen collection
• Date and time of sample arrival at lab
• Name of collector and who to contact with results
165
Rejection Criteria

• These are the conditions upon which a sample that the clinician
collected will be rejected:
1. Unlabeled sample
2. Broken or leaking tube/container
3. Obviously contaminated specimen
4. Insufficient patient information
5. Sample label and patient name on the test request form do
not match

166
Sample Disposal

• Set policy for sample disposal, or refer to lab policy

• Compliance with local, country and international regulations

167
Summery

• Culture results are dependent on the quality of the specimen

submitted. This includes:
• Collection from the correct anatomic site
• Using the proper technique and the required supplies
• The most important step in sample management is proper
sample collection for culture

168
Role of Clinical microbiology laboratory for
antimicrobial resistance and Diagnostic
medical microbiological methods

169
Role of Clinical microbiology laboratory for antimicrobial
resistance and Diagnostic medical microbiological methods

170
Role of Clinical microbiology laboratory for


antimicrobial resistance

• Determine differential diagnosis

• Efficient patient care accurate and representative AMR surveillance

data to inform treatment guidelines, and AMR control strategies.

171
Diagnostic medical microbiological methods

. D irect s m ea r (G ra m • Microbial antigen testing

staining) • Serology;
• Conventional(Bacterial
identification using classical • Nucleic acid (DNA and RNA)
method i.e Culture and detection
biochemical test)
• Automated (Vitek, Microscan
AST and Others
• D i s k di f f us i o n: K i rby-
Bauer (KB)
• Agar and Broth dilution
• E-test
172
Overview of common pathogen
• Gram Negative Rods
• Gram Positive Cocci • Enterobacteriacea
• Streptococci • E.coli. Klebsiella pneumoniae
• Staphylococci • Serratia, Proteus
• Gram Negative Cocci • Salmonella, Shigella
• Neisseria • Pseudomonas
• Moraxella • Acinetobacter
• Gram Positive Rods • Haemophilus
• Bacillus species • Vibrio
• Lactobacilllus species • Brucella
• Corynebacterium species • Pasteurella
• Campylobacter 173
174
Escherichia coli Identification

Tests used for ID of E. coli

• KIA - A/AG
• Indole +
• MR +
• VP neg.
• Citrate neg.

KIA
175
Klebsiella pneumoniae Identification

Tests used for ID of K.

pneumoniae
• KIA - A/AG
• Indole neg
• MR neg
• VP +
• Citrate +
• Non-motile
• Weakly urease +
Can be isolated from multiple specimen types, urine,
sputum, nosocomial infections. 176
Pseudomonas aeruginosa
Important properties
− Blue-green diffusible pigment
− Fruity, grape-like odor
− Tends to be very antibiotic resistant
− Primarily a water organism but is found as normal GI
flora in about 20 - 25% of people.

Important opportunistic pathogen. Causes many

nosocomial infections, severe infections in neutropenic
patients, pneumonia if cystic fibrosis patients. Serious
infections have a high mortality rate.

177
Pseudomonas aeruginosa Identification

Important properties:
− Non-fermenter - ALK/ALK
− Oxidase positive
− May be weakly urease
positive

178
Pseudomonas aeruginosa Identification

179
Acinetobacter species
Non-fermenter Important properties:
− Gram-negative coccobacilli
− May appear gram-positive
− Oxidase negative
− Fishy odor
− Widely distributed in environment
− Extremely antibiotic resistant

Causes primarily nosocomial infections

180
Acinetobacter species

181
 Summary of lab role
Laboratory systems in resistance containment:
 Antimicrobial susceptibility testing and surveillance, AMR
management and control.
 Laboratory tests for pathogens or rule out specific infectious causes.

 Provide critical support to infection control programs.

182
ANTIMICROBIAL SUSCEPTIBILITY TESTING

• AST Methods
• Reading and interpretation of AST plates
• CLSI Guidelines - Document M100

183
 READING PLATES

• KB is a standardized procedure for performing AST by disk diffusion

• Results are recorded as sensitive, intermediate, or resistant based on

a standardized table of zone sizes

• Plates should be read after 16 to 18 hours* of incubation.

Zone measurements compared to CLSI

Guidelines to interpret susceptibilities

184
SELECTING ANTIMICROBIALS FOR SUSCEPTIBILITY TESTING

• Selection of the most appropriate antimicrobial agents to test and

report must be determined for each hospital

• The clinical laboratory must consult with Infectious disease

practitioners and the pharmacy to determine what antimicrobial
agents to use in the laboratory for testing and reporting

185
Cont’d….
• Group A are considered appropriate for inclusion in a routine,
primary testing panel, as well as for routine reporting of
results for the specific organism groups.
• Group B includes antimicrobial agents that may warrant
primary testing, but they may be reported only selectively,
such as when the organism is resistant to agents of the same
antimicrobial class, as in group A

186
Cont’d..

Group C - alternative or supplemental agents that may require

testing in institutions for one of the following reasons:
• Hospital harbors epidemic or endemic strains of organisms
resistant to several of the primary drugs (Group A)
• For treatment of patients allergic to primary drugs (penicillins)
• For treatment of unusual organisms

187
Cont’d …
Group U (“urine”) – inc ludes c er t ain ant imic rob ial ag ent s (eg ,
nitrofurantoin and certain quinolones) that are used only or primarily for
treating UTIs.
Group O (“other”) – includes agents that have a clinical indication for the
organism group, but are generally not candidates for routine testing
and reporting in the US
Group Inv. (“investigational”) - includes agents that are investigational
for the organism group and have not yet been approved for use in the
US
188
Example SELECTING ANTIMICROBIALS FOR SUSCEPTIBILITY TESTING

189


Antibiogram production and How to use

190
Antibiogram production and How to use

Activity:5.1.3 Check-In Questions power points

presentation
 What is a cumulative antibiogram?

 Describe how to analyzing and presenting

Antimicrobial test data for clinical microbiologis
t ,pharmacists and physicians (How is a
Cumulative Antibiogram Useful?)

191
Antibiogram
 An antibiogram is an overall prof il e/summery of antimicrobial
susceptibility testing (AST) results of a specif ic microorganism to a
battery of antimicrobial drugs.
 This prof ile is generated by the laboratory using aggregate data from
a hospital or healthcare system; data are summarized periodically
and presented showing percentages (%) of organisms tested that are
susceptible to a particular antimicrobial drug.
 Only results for antimicrobial drugs that are routinely tested and
clinically useful should be presented to clinicians.
192
Recommendations for Antibiograms/General conventions
– CLSI M39
 Analyze/present cumulative antibiogram report at least annually;
 Include only final, verif ied test results;
 Include only species with testing data for ≥ 30 isolates.
 Include only diagnostic (not surveillance) isolates
 Eliminate duplicates by including only the f ir st isolate of a
species/patient/analysis period, irrespective of body site or
antimicrobial profile
 Include only antimicrobial agents routinely tested; do not report
supplemental agents selectively tested on resistant isolates only.
 Report %S (Susceptible) and do not include %I (intermediate) in the
statistic.
193
Antibiogram Uses:
• Guide the clinician and pharmacist in selecting the best empirical
antimicrobial treatment in the event of pending microbiology culture
and susceptibility results.
• Tools for detecting and monitoring trends in antimicrobial resistance.
• Guide clinicians/ pharmacists ability to de-escalate therapy once
pathogen ID is known but before AST available.
• May increase patient exposure to targeted, appropriate therapy
• May reduce the time a patient spends on broad-spectrum antibiotics,
which decreases the chance for development of resistance

194
Scope of applications of
ABG:
Staff utilizing
• Clinical decisions (e.g. clinical microbiologists, Infectious
disease specialist other clinical infectious practitioners,
pharmacists,
• Epidemiologists and others

195
 Data Required to perform
ABG
1. Patient:
- Required: ID,
- Desirable: Age, Sex, Location (Ward), Admission date;
2. Specimen information:
- Required: number, type & date of collection.
- Desirable: Body site e.g. right orleft

196
3. Organism information:
- Required: identif ication up to the genus or species level
- Desirable: Isolate number, change in name of isolate (if
happen), Infection control data e.g. colonization or
infection, community- acquired, or healthcare
associated CA or HAI
4. AST information:
- Required: final MIC or zone diameter (ZD) used,
method used, special tests for detection of B-
lactamase, mecA gene, PBP2a by agar screening , PCR
or latex testing respectively.
- Desirable: detailed MIC or ZD

197
 Frequency of Performance
 At least once yearly.
 More frequent with high number of isolates, new antimicrobial
introduced, or presence of important medical changes.

• Facility:
 ABG is performed based upon local institution- specif ic
susceptibility data.

198
Table Staphylococcus aureus susceptibility test results for a sample patient.

Data presentation
 In a tabular form.
 Separate tables for Gram-positive, and Gram- negative,
 Arrange the organisms within the table alphabetically, by organism
group of by the prevalence.
 Some labs may present data by body site e.g. urine gram-negative
or gram-positive.
 Antibiogram for critical care units (more resistant) e.g. ICUs better
to be separated to compare %S with the total hospital.
 Comments upon the table must be included to explain it.

 Recommended species to be included (even if <30 isolates) in the

tables
200
Example of ABG data Report by alphabetically

201
Presenting Emerging Resistance Trends:
 Presentation of resistant organisms over years can be presented in
tables or graphs e.g.:
 MRSA (S. aureus – %R for oxacillin - inpatient and outpatient);
 VRE (Enterococcus spp. – %R for vancomycin isolates from sterile body
sites);
 E. coli – %S to trimethoprim-sulfamethoxazole (urine isolates) and
fluoroquinolones;
 ESBLs (K. pneumoniae and E. coli – % of isolates that produce ESBLs);
 P. aeruginosa – %S to fluoroquinolones and/or imipenem.

202
Different ABG presentation formats
 By nursing unit or care sits: i.e. patient location e.g. ICU, Burn unit,
Ward, OPD, nursing home for the better selection of site specif ic
empirical therapy.
 By organism’s resistance character: especial for MDROs e.g.
MRSA, VRE, MDR Acineto., ESBLs.
 By specimen type or infection site: e.g. urine isolates, blood
isolates).
 By clinical service or patient population: to guide initial empirical
antimicrobial therapy for specif ic patient types (e.g. surgical,
pediatric, cystic f ibrosis, transplant, burn).

203
 Distribution Formats:
 In easy accessible formats to all prescribing Physicians,
Infection control staffs, Pharmacists, Epidemiologists &
Microbiology Staffs‘:-
 Small cards in coat pocket

 Or in laminated sheets.

 In the institution website (Intranet). As application or PDF.

 Printed formats especially in special areas like ICUs.

204
 Antibiogram examples
This appendix contains examples of local antibiograms. Note that not all antibiograms may be entirely consistent with this specif ic ation, they are included to provide guidance on the variety of formats may suit different facilities.

Figure A1: Example of a cumulative, hospital-level antibiogram for blood culture isolates

Ciprof loxacin

Gentamicin (High

Erythromycin/Cl
Amoxicillincla

Tetracyclines
Flucloxacillin

Vancomycin
Meropenem

Clindamycin
trimethoprim

Quinupristin-
Ceftazidime

Fusidic Acid
Ceftriaxone

Gentamicin
Cephalotin
Amoxicillin

Rifampicin
Piperacillin-
Organisms

dalfopristin
arithr omycin
Cefepime
Cefazolin

Amikacin
Penicillin

tazobact

Sulpha-
%Total
Organism Group

No.

vul

Level)
All isolates 2142 100.0
Coagulase negative % 11 41 40 40 R 59 79 79 98 44 64 68 100
Staphylococci 637 29.7 n 627 621 621 621 629 609 623 626 626 625 628 632
% 43 79 92 77 90 93 100 91 99 69 86
Escherichia spp 407 19.0 n 407 407 406 40 407 406 407 407 *329 407 407
7
Staphylococcus aureus (ALL) % 26 89 89 89 R 95 92 95 100 86 87 95 100
211 9.9 n 211 211 211 211 211 *185 *186 *186 211 211 211 211
% R 94 92 84 93 95 100 99 100 86 93
Klebsiella spp 147 6.9 n 147 147 14 147 147 147 147 *119 147 147
7
% 85 100 89 68 R 100 50 85 74 100
viridans Streptococci 118 5.5 n 117 *15 115 *25 *83 117 117 117 116
Pseudomona s aeruginosa % R R 89 R R 92 94 94 96 96 R 94 R
100 4.7 n
Specif ication for a Hospital Cumulative Antibiogram – September100
2019 100
205 100 100 100 *77 100
% 77 R R R R R R 43 81 R R 30 33 87
Enterococcus spp 90 4.2 n 90 *23 *83 90 *76 90
% 17 75 92 97 76 49 78 98
Spore forming GPB 57 2.7 n *54 *12 *25 *39 *21 *53 *50 *52
Enterobacter cloacae % R R 66 R 71 86 98 93 100 77 93
complex 56 2.6
Colour coding for all antibiograms tables is shown below. n 56 56 56 56 56 *43 56 56
Gram Positive Organism ≥90% of isolates susceptible ≥90% of isolates susceptible (where sample size <95% of total isolates tested)

Gram Negative Organism 70-89% of isolates susceptible 70-89% of isolates susceptible (where sample size <95% of total isolates tested)

Antibiotic Not recommended to be used in children without specialist advice <70% of isolates susceptible <70% of isolates susceptible (where sample size <95% of total isolates tested)

Restricted or 2nd Line Antibiotics R Intrinsic Resistance is present with this organism– antibiotic combination * Sample size <95% of the total isolates tested

Restricted or 2nd Line Antibiotics and Antibiotic Not recommended to be used in children without % Percentage of isolates sensitive to this particular antibiotic n Number of isolates tested with this antibiotic 205
specialist advice


Example

206
Limitations of Data, Data Analysis, and Data
Presentation
 Culturing Practices: sample collection, transport and storage.
Bias in treatment e.g. in OPD, change in culturing technique in the
lab.
 Influence of Small Numbers of Isolates: number of isolates to b
e > 30.
Limitations ABG
 Data do not take into account patient factor history of infection or
past antibiotic use

207
Summary

Antibiogram development is a multi- disciplinary process
• Utilizing standardized guidelines for antibiogram development
enhances the accuracy, integrity and comparability of the data
• Cumulative antimicrobial susceptibility data reports are useful for
guiding appropriate empiric antimicrobial use

208
Overview of Ethiopian laboratory-based AMR
surveillance system

209
 Introduction
• The Ethiopia AMR Surveillance Plan was developed and launched by
the Ethiopian Public Health Institute (EPHI) in 2017.

• It began and started at four laboratories (Phase I sites) and now

it is in its second year of implementation and expanded to phase II

sites(5 sites).

• The AMR surveillance is implemented in collaboration with partners:

Center for Disease Control and Prevention CDC), American Society for
Microbiology(ASM) & Ohio State University(OSU)

210
Methods
• Ethiopian public health laboratory –based surveillance system
Captures priority isolated data from routine clinical laboratory.

• Manual microbiology methods were used for antimicrobial

Susceptibility testing

211
Priority surveillance pathogens for AMR, &
Sample collection
Three priority pathogens – Escherichia coli, K. pneumoniae– isolated from
urine, and Staphylococcus aureus isolated from wound specimens, as well
as carbapenem-resistant Acinetobacter spp., Pseudomonas aeruginosa, and
Enterobacteriaceae from any clinical specimen.

212
Current AMR sentinel sites and activities

213
AMR surveillance report or findings
• Data management and analyses are done using WHONET
software.

214
 Surveillance Limitations and Challenges
• The availability of quality microbiology testing
• Staff turnover, shortage, and lack of motivation at all levels.
• Poor infrastructure of microbiology laboratories in many health care
facilities across the country
• Weak communication b/n clinicians and laboratory technologists
• Weak ownership of the program by participating sites
• Data management related operational challenges
• Resource challenges to expand surveillance sites
215
Summery

Antimicrobial surveillance system to inform the implementation

of targeted prevention and control program with having an
Estimate the extent and burden of priority AMR pathogens.
This will valuable for its ability to strengthen the knowledge and
evidence around antimicrobial resistance in the country and the
international community

216
THANK YOU FOR YOUR ATTENTION

217









Chapter Six:




Supply Chain Management
for

Antimicrobials and
Laboratory commodities

218
Outline
• Introduction
• The impact of supply chain management in Antimicrobial stewardship (ASP)
• The impact of SCM in AWaRe classification of antibiotics
• Supply chain management in microbiology laboratory supplies
• Strategies to improve supply chain and access of Antibiotics and Laboratory
commodities
• What can be done in supply chain management challenges to improve
antimicrobial resistance prevention at health facilities level?
• Summary

219
Objectives
Chapter Objective:
• At the end of this chapter the participants will be able to identify peculiar issues in supply chain
management of Antimicrobials and Laboratory commodities
Enabling Objectives: At the end of this session participants will be able to:
• Explain the pharmaceutical logistic cycle and Antimicrobial resistance
• Discuss the impact of supply chain management for ASP and AWaRe classification
• Discuss the supply chain management for microbiology laboratory supplies
• Explain strategies to improve supply chain and access Antimicrobials and Laboratory
commodities
• Discuss what can be done in supply chain management to improve antimicrobial resistance
prevention and containment at the health facility level.

220
The Pharmaceutical logistic cycle
221
6.1. Introduction

Activity 1. Brainstorming question

How can excess and shortages of antimicrobials lead to

Antimicrobial Resistance?

10 minutes

222
6.2. The Impact of supply chain management in Antimicrobial stewardship
program (ASP)

Activity 2. Group discussion and reflection

 What do you think the impact of SCM in ASP?

Time: 10 Minutes

223
6.3. The impact of Supply chain management in AWaRe Classif ication of
Antibiotics

Activity 3. Individual reflection

 How can you relate SCM and AWaRe classification?

Time: 5 Minutes

224
6.5. The impact of substandard/falsified
Antimicrobials for AMR
What are the Characteristics of substandard/falsified
drugs?
• Inappropriate packaging
• Reduced stability and bioavailability
• Reduced concentration of active ingredient
• Altered chemical content
• Have manipulated expiration dates
• Contain an active agent other than the one specified

225
6.4. Supply chain management for Laboratory commodities

Activity 4. Group discussion and reflection

What are the major Laboratory commodities SCM challenges in
Ethiopia?

Time: 10 Minutes

226
6.5. Strategies to improve supply chain and access of
Antimicrobials and Laboratory commodities

A. Demand planning
B. Ensuring sufficient, uninterrupted supply
I. Procurement
II. Local Manufacturing
III. Shortage mitigation
IV. Information for decision making
C. Strengthening the distribution chain

227
6.6. What can be done in supply chain management challenges to
improve AMR prevention and containment at the Health facility level?

Activity 5. Group exercise and Gallery walk discussion

 What are the challenges regarding SCM of antimicrobials
and Laboratory commodities in your health facility?
 How to strengthen SCM of antimicrobials and lab supplies
at health facility level?
20 Minutes

228
Summery

• The rise of AMR is being accelerated by excessive antibiotic use in

humans, animals and the agricultural sector.
• Shortage of the right antibiotics and suboptimal antibiotics prescribed are
accelerating the resistance among bacterial population
• ASP and AWaRe classification cannot exceed without involvement of
medicine procurement to insure timely availability of antimicrobials
• Ensuring a strong supply chain of reliable diagnostic tests, reagents, and
consumables is one of the key factors for creating a sustainable, strong
diagnostic laboratory system.
• There are three broad strategies stakeholders need to use to improve the
effectiveness and efficiency of supply chains and improve access.

229
THANK YOU


Chapter Seven:

Roles of Health Professionals
in the prevention and
containment of Antimicrobial
Resistance

231
Outline
• Introduction
• Role of Health professionals in the prevention
and containment of AMR
• Inter-professional collaboration in the Prevention
and Containment of AMR
• Summary

232
1.1. Introduction

Activity 1: Brainstorming

Which AMR strategic objective(s) of WHO or Ethiopia

address the role of health professionals in the prevention
and containment of Antimicrobial Resistance?

( 5 minutes)

233
1.2.1. The role of prescribers in the
prevention and containment of AMR
Activity 2: Group reading, discussion and reflection
What are the role of prescribers in the prevention and
containment of AMR?

(10 minutes)

234
1.2.2. The role of Nurses in the
prevention and containment of AMR
Activity 2: Group reading, discussion and reflection
What are the role of Nurses in the prevention and
containment of AMR?

(10 minutes)
1.2.3. The role of Pharmacy professionals
in the prevention and containment of AMR
Activity 2: Group reading, discussion and reflection
What are the role of Pharmacy professionals in the
prevention and containment of AMR?

(10 minutes)
1.2.3. The role of laboratory professionals
in the prevention and containment of AMR
Activity 2: Group reading, discussion and reflection
What are the role of Laboratory professionals in the
prevention and containment of AMR?

(10 minutes)
1.3. Inter-professional collaboration in the
prevention and containment of AMR
Activity 3: group discussion and reflection

 What is Inter-professional collaboration?

 W h a t i s t h e i m p o r t a n c e o f i n t e r - p r o fe s s i o n a l
collaboration for AMR prevention and containment?

( 10 minutes)
 Session Summary

 All health professionals have a crucial role in the prevention and

containment of Antimicrobial resistance.
 Health institution shall play their role for AMR prevention and
containment.
 Effective collaboration among Prescribers, Pharmacists, Nurses,
laboratory technologist and health care administrator is an
essential for prevention and containment of AMR

239
THANK YOU














Chapter 8:




Monitoring and Evaluation of AMR Activities

Antimicrobial Resistance Prevention and Containment

Training Course for Health Professionals

241
Chapter description

• This chapter enables the participants to identify monitoring and

evaluation parameters of AMR, AMR indicators, and reporting
formats.

• In addition, it enables trainees to have the skill and knowledge for

monitoring and evaluating AMR related activities.

242
Objectives

Primary Objective:
• By the end of this chapter, participants will be able to monitor and evaluate
AMR related activities in health facilities.

Enabling Objectives:
 Define monitoring and evaluation

 Identify selected performance indicators

 Discuss the reporting process of AMR activities

243
8.1. Introduction to monitoring and evaluation of AMR
activities

244
8.2. Performance Indicators

Large group discussion and reflection (5 minutes)

 What are performance indicators?

 What type of indicators do you know?

245
8.2. Performance Indicators cont’d

• Indicator is what we use to measure the extent of performance

using qualitative or quantitative variables.

• There are various types of indicators that are used to measure

the performance of a given project or program. These includes:
 leading and lagging indicators

 Core and supplementary indicators and/or

 input, process, output, outcome, and impact indicators

246
 8.2. Performance Indicators cont’d

Group activity:
• Group 1: Performance Indicator for Rational Use of Antimicrobials
• Percentage of encounters with an antibiotic prescribed in health
facility
• Group 2: Performance Indicator for Antimicrobial Stewardship Program
(ASP)
• Availability of Functional ASP in health facilities
• Group 3: Performance Indicators for Infection Prevention and Control (IPC)
• Availability of Functional IPC committee in health facilities
• Group 4: Performance Indicator for Microbiologic Diagnosis and
Surveillance
• Availability of functional microbiologic diagnosis and
surveillance in health facilities
247
8.3. Reporting of AMR activities

248
8.4. Session Summary

 Routine monitoring and evaluation enable to measure and assess its

performance.

 Indicators shall be used to assess the performance of the service at

facility and administrative levels.

 Activities related to AMR in a facility shall be aggregated and reported

using the national reporting system to the next administrative level.

249
Thank you

250