ANTIBIOTIC POLICY

Delta hospitals ,Rajahmundry

 The primary aim of the hospital antimicrobial policy is to minimize the
morbidity and mortality due to antimicrobial-resistant infection; and
to preserve the effectiveness of antimicrobial agents in the treatment
and prevention of communicable diseases.
Process for the development of
hospital antibiotic policy
STEPS TO FOLLOW THE
PROTOCOLS
 1. Identify the type of infection viz. bloodstream, respiratory, intra-
abdominal or urinary tract
 2. Define the location — OPD, ICU or In- patient
 3. Wait for at least 48hrs of antimicrobial therapy before labeling the
patient as nonresponding to the therapy and to switch to the next
higher line of therapy. Also consider escalation if patient’s condition
deteriorates.
 4. Send samples for cultures and or primary set of investigations
before starting antibiotic therapy
 5. Once culture / sensitivity report is available initiate specific
antimicrobial therapy. Antimicrobial may require being changed/de-
escalated.
The choice of antimicrobial may
need to be modified in the following
situations:
  Hypersensitivity to first choice antimicrobial
  Recent antimicrobial therapy or preceding cultures indicating
presence of resistant organisms
  In pregnant or lactating patients
  In renal or hepatic failure
  Where significant drug interactions may occur
Antimicrobial Prescribing: Good
Practice
 1. Send for the appropriate investigations in all infections as
recommended. This is the minimum requirement for diagnosis,
prognosis and follow up of these infections.
 2. Microbiological samples must always be sent prior to
initiating antimicrobial therapy. Rapid tests, such as Gram stain,
can help determine therapeutic choices when empiric therapy is
required.
 3. Differentiation between contamination, colonization and infection is
important to prevent overuse of antibiotics.
 4. Choice of antibiotics: This depends on antibiotic susceptibility of
the causative organism. There are some infections which can be
treated by one of several drugs. The choice can be based on toxicity,
efficacy, rapidity of action, pharmacokinetics and cost. Use the most
effective, least toxic and least expensive antibiotic for the precise
duration of time needed to cure or prevent infection.
 Before prescribing consider following:
 a. Which organism is likely to cause the syndrome?
 b. What is the clinical diagnosis and what are the steps should be
taken to improve the diagnostic precision?
 c. Which antimicrobial agents are available and active against the
presumed cause of the illness? Is their range of antimicrobial activity
appropriate and what information is available about the likelihood of
drug resistance?
 d. Check for factors which will affect drug choice & dose, e.g. renal
function, interactions, allergy, pregnancy and lactation.
 e. Check that the appropriate dose is prescribed. If uncertain, contact
Physician or check in the formulary.
 f. What is the duration of treatment?
 g. Is treatment working?
INFECTION CONTROL PROCESSES

Standard Precautions:

 Standard Precautions are designed to reduce the risk of transmission

of micro-organisms from both recognized and unrecognized sources
of infection in the hospital. Standard Precautions applies to all
patients regardless of their diagnosis. Standard Precautions shall
be implemented when contact with any of the following are
anticipated:
  Blood
  All body fluids, secretions and excretions, with the exception of
sweat regardless of whether or not they contain visible blood.
  Non-intact skin (this includes rashes)
  Mucous membranes
Standard Precautions Requirements
A. Hand hygiene:
 Pathogenic organisms from colonized and infected patients (and
sometimes from the environment) transiently contaminate the
hands of staff during normal clinical activities and can then be
transferred to other patients.
 Hand transmission is one of the most important methods of spread
of infectious agents in health care facilities.
 Proper hand hygiene is an effective method for preventing the
transfer of microbes between staff and patients.
 Increasing hand-washing compliance by 1.5 – 2 folds would result in
a 25-50-% decrease in the incidence of healthcare associated
infections.
 Wash hands with plain or antimicrobial soap and water or rub hands
with an alcohol-based formulation before handling medication or
preparing food (steps shown in figure1 b)
B. Personal protective equipment
 1. Use of Gloves:
Clean gloves must be worn when touching blood, body fluids, excretions,
secretions and contaminated items and when performing venipuncture.
 2. Face Mask, eye protection & face shield:
Face Mask must be worn during procedures or patient care activities that
are expected to generate splashes or sprays of blood, body fluids, 17
secretions and excretions. For example, suctioning, irrigating a wound,
performing certain laboratory tests, etc.

 3. Gown or Apron: Gown/apron must be worn to protect skin and to

prevent soiling of clothing during procedures or patient care activities that
are expected to generate splashes or sprays of blood, body fluid,
secretions and excretions.
Respiratory hygiene/cough etiquette:
 Instruct symptomatic persons and health care workers to
cover their mouths/noses when coughing or sneezing, use and
dispose of tissues, perform hand hygiene after hands have
been in contact with respiratory secretions and wear surgical
mask if tolerated or maintain spatial separation, >3 feet if
possible.
PREVENTION OF HEALTHCARE
ASSOCIATED INFECTIONS
 The four major HCAIs are:
 1. Catheter associated Urinary tract infection (CAUTI)
 2. Surgical site Infection (SSI)
 3. Catheter related blood stream infection (CRBSI)
 4. Ventilator Associated Pneumonia (VAP)
Recommendations to Prevent
Catheter-associated UTI
 1. Personnel Only persons who know the correct technique of aseptic
insertion and maintenance of the catheter should handle catheters.
 2. Catheter Use
 Urinary catheters should be inserted only when necessary and left in
place only for as long as it is required. They should not be used solely
for the convenience of patient-care personnel. For selected patients,
other methods of urinary drainage such as condom catheter drainage,
suprapubic catheterization, and intermittent urethral catheterization
may be more appropriate.
 3. Hand hygiene
 4. Catheter Insertion
 5. Closed Sterile Drainage
 6. Irrigation Continuous irrigation should be avoided unless indicated
(e.g. after prostatic or bladder surgery).
 7. Specimen Collection
If small volumes of fresh urine are needed for examination, the
distal end of the catheter, or preferably the sampling port if present,
should be cleansed with a disinfectant, and urine then aspirated with a
sterile needle and syringe. Larger volumes of urine for special analysis
should be obtained aseptically from the drainage bag.
 8. Urinary Flow
 9. Meatal Care
 10. Catheter Change Interval
B. SURGICAL SITE INFECTIONS (SSI)
Staphylococcus aureus from the exogenous environment or patient’s skin
flora is the usual cause of infection.

 Surgical site infection prevention:

 1. Whenever possible, identify and treat all infections remote to the
surgical site before elective operation and postpone elective
surgeries on patients with remote site infections until the infection
has resolved.
 2. Keep preoperative hospital stays as short as possible while
allowing for adequate preoperative preparation.
 3. Do not remove hair preoperatively unless the hair at or around the
incision site will interfere with the operation.
 4. If hair needs to be removed, it is done immediately before
operation, preferably using electric clippers and not razor blade.
 5. Adequately control blood glucose levels in all diabetic patients.
 6. Encourage nonsmoking/use of cigarettes, cigars, pipes, or any
other form of tobacco consumption for at least 30 days prior to the
surgery.
 7. Do not withhold necessary blood products transfusion.
 8. Encourage patients to shower or bathe at least the night before the
operative day.
 9. Use an appropriate antiseptic agent for skin preparation.
 10. Apply preoperative antiseptic skin preparation in concentric
circles moving towards the periphery. The prepared area should be
large enough to extend the incision or create new incisions or drain
sites, if necessary.
C. VENTILATOR-ASSOCIATED PNEUMONIA

Prevention of VAP
 1. Adhere to hand-hygiene guidelines.
 2. Health-care worker should wear a mask and an apron or gown when
anticipates soiling of respiratory secretions from a patient (e.g. intubation,
tracheal suctioning, tracheostomy, and bronchoscopy) and change it after
the procedure and before providing care to another patient.
 3. Elevate the head of the bed 30 – 45 degrees of a patient on mechanical
ventilation or at high risk for aspiration (e.g. on oro or nasoenteral tube)
 4. Remove devices such as endotracheal, tracheostomy, oro/ nasogastric
tubes from patients as soon as they are not indicated.
 5. Perform orotracheal rather than nasotracheal intubation unless
contraindicated.
 6. Use non-invasive ventilation whenever possible.
 7. Perform daily assessments of readiness to wean and use weaning
protocols.
 8. Avoid unplanned extubation and reintubation.
 9. Use a cuffed endotracheal tube with in-line or subglottic suctioning.
 10. Avoid histamine receptor blocking agents and proton pump
inhibitors for patients who are not at high risk for developing a stress
ulcer or stress gastritis.
 11. Perform regular oral care with an antiseptic solution.
 12. Avoid gastric overdistension.
 13. Remove condensate from ventilatory circuits. Keep the ventilatory
circuit closed during condensate removal.
 14. Change the ventilatory circuit only when visibly soiled or
malfunctioning.
 15. Store and disinfect respiratory therapy equipment properly.
 16. Educate healthcare workers who provide care for patients
undergoing ventilation about VAP.
D. CATHETER-RELATED BLOOD
STREAM INFECTIONS
Aseptic technique during catheter insertion and care
 1. Maintain aseptic technique for the insertion and care of
intravascular catheters. Wearing clean gloves rather than sterile
gloves is acceptable for the insertion of peripheral intravascular
catheters if the access site is not touched after the application of skin
antiseptics.
 2. Sterile gloves should be worn for the insertion of arterial, central,
and midline catheters.
 3. Change the dressing on intravascular catheters using aseptic
technique.
Catheter Site Dressing Regimens
 1. Use either sterile gauze or sterile, transparent, semipermeable
dressing to cover the catheter site.
 2. Replace the catheter site dressing if the dressing becomes damp,
loosened, or visibly soiled.
 3. Replace dressings used on short-term CVC sites every 2 days for
gauze dressings.
 4. Replace dressings used on short-term CVC sites at least every 7
days for transparent dressings, except in those pediatric patients in
which the risk for dislodging the catheter may outweigh the benefit of
changing the dressing.
 5. Monitor the catheter sites visually or by palpation through the
intact dressing on a regular basis, depending on the clinical situation
of individual patients. If patients have tenderness at the insertion
site, fever without obvious reasons, or other manifestations
suggesting local or BSI (Blood Stream infections), the dressing should
be removed to allow thorough examination of the site.
ANTIBIOTIC STEWARDSHIP
PROGRAM

Dr.P.RAVI KUMAR MD,DNB,DPAA

Consultant Pulmonologist & Allergist,

Delta hospitals ,Rajahmundry

14.07.2023
WHY????
 ANTI MICROBIAL RESISTENCE
Timeline leading to Anti biotitic
stewardship
Antimicrobial stewardship

Good antimicrobial stewardship involves selecting an appropriate

drug and optimizing its dose and duration to cure an infection while

minimizing toxicity and conditions for selection of resistant bacterial

strains.
Contents

 Why do we need AMSP

 STRATAGIES of antimicrobial stewardship programme
 Antimicrobial stewardship team
 BARRIERS
 Conclusion
Thank you