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AMS case study: UAE Dr. DirarAbdallah Consultant Internal Medicine, intensivist Head of Adult Critical Care Services Chair of Antibiotics Stewardship Program ASP Member of UAE national ASP Committee Member of ESCMID, ESGAP, ESICM Prime Hospital- Dubai – UAE [email protected] 4.2.2020 AMS: UAE Experience contents: • Structure of National AMR and ASP committees • Functions and activities of National AMR & ASP committees • History of ASP in UAE • Overview of main ASP experiences in UAE public and private. • Conclusions [email protected] 2018 cumulative antibiogram Abu Dhabi Emirate Antimicrobial stewardship programs need to be tailored to suit the needs ASP/AMS and available resources of individual institutions. [email protected] [email protected] • Although non-prescription sale of antibiotics is illegal in the GCC states: According to studies ▪ 68 per cent of pharmacies in AD in 2016 ▪ 78 per cent in Riyadh ▪ 87 out of 88 pharmacies in Saudi Arabia sell them without a prescription. [email protected] [email protected] AMS in UAE • MOHAP, DOH-Abu Dhabi and DHA mandated the implementation of AMS across public and private hospitals. • Pharmacies are not allowed by law to sell antibiotics without prescription. • There is a national AMR and AMS committee with representatives from different sectors in UAE. • ASP as a concept is not new in UAE and any effort by healthcare providers to use antimicrobials in the right dose for the right indication for the right duration is a stewardship effort or action. • However, using the agreed definition of AMS/ASP narrows the practice to few facilities in UAE. [email protected] National ASP Committee 2018 Infectious diseases Infection control Medical intensivists specialists practitioners Public health Epidemiologists Microbiologists specialists Researchers Clinical practicing in public pharmacists and private sectors. [email protected] National • Lab and diagnostics ASP • Policies and guidelines Committee • Baseline data and surveys task forces • Research and publications • Academic and educational activities • Link person or focal point to connect ASP sub-committee to the UAE Sub-Committee on AMR Surveillance [email protected] [email protected] National ASP Committee& National AMR Committee activities ▪ UAE NAP Feb 2019 : WHO workshop ▪ Antibiotics PPS Nov 2019 after WHO & MOH workshop ▪ Educational activities CME: ➢ MOH: UAE – ICAMR March ➢ DICID April ➢ ID WEEK October ➢ APIC conference November ➢ DOH, DHA, MOH workshops ➢ RAK University ➢ UAE University ➢ Zayed University ▪ WAAW walk Nov 2019 Al Khor Park [email protected] UAE NAP Feb 2019 [email protected] WAAW 2019 walk Tawam Hospital 461-bed tertiary care facility located in Al Ain City [email protected] Five Infectious Disease consultants ASP at Tawam Two Clinical Pharmacists with infectious diseases Hospital: training Clinical microbiology support Started 2005 TEAM: Information technology support Department of Performance Innovation support (Quality). [email protected] Strategies • Formulary restriction. • Antibiotic use guidelines. • Computer-based antimicrobial management. • Formal scheduled rounds in high-risk units and one-on-one physician education. • A ‘stewardship’ consult order has been created in the EMR with the ability to bill for services rendered. • Monthly audit of antimicrobial use is based on DDD/1000 inpatient days. [email protected] Antibiotics Requiring Pre-AuthorizationList Ertapenem Carbapenems Imipenem ID Physicians / Intensivists - for 48 hrs Meropenem Ciprofloxacin Fluoroquinolones (Oral Levofloxacin ID Physicians/Urologists & Parenteral) Moxifloxacin Cefotaxime Ceftriaxone ID Physicians or IDapproval 3rd & 4th Generation Ceftazidime Exception is made for the 1st dose in ER for Pediatrics for fever of unknown source in patients between ages of 3months to 3 years and in all cases of Cephalosporins Cefdinir meningitis Cefixime Cefepime Ampicillin/Sulbactam ID Physicians Others Colistin ID Physicians (Oral & Parenteral) Linezolid ID Physicians / Intensivists – for 48 hrs Tigecycline ID Physicians Poster presented at ID Week, San Francisco, CA 2013 Rayhan Hashmey, MBBS1, Asad Khan, MBBS1, Aqeel Saleem, MBBS1, Kholoud Jamal2, Dalal Mansouri1 and Yousuf Naqvi, MBBS3, (1)Medicine, Tawam Hospital, Al Ain, United Arab Emirates, (2)Pharmacy, Tawam Hospital, Al Ain, United Arab Emirates, (3)Health Regulation Division, Health Aurthority of Abu Dhabi, Abu Dhabi, United Arab Emirates Cleveland Clinic Abu Dhabi CCAD: 364 (expandable to 490) bed facility six Centers of Excellence: Heart & Vascular, Neurological, Digestive Disease, Eye, Respiratory, and Critical Care [email protected] CCAD ASP THREE INFECTIOUS TRAINED INFECTIOUS INFECTION CONTROL started 2015 DISEASES CONSULTANTS, DISEASES PHARMACIST TEAM: MICROBIOLOGY NURSING RESPIRATORY AND CRITICAL CARE MEDICINE, AND HOSPITALISTS. [email protected] Strategies at CCAD: CDSS and Prospective-audit Pre-authorization Rapid diagnostics. electronic real-time with intervention of antimicrobials. surveillance. and feedback. Development of Automatic Optimized dosing Consumption electronic order intravenous to oral of antimicrobials (DOT) per 1000 sets and treatment therapy conversion and caregiver inpatient days. guidelines. protocol. education. Antimicrobial cost per 1000 inpatient days. [email protected] [email protected] CCAD publication 2017 El-Lababidi R, Mooty M, Nusair A, Bonilla MF. Implementation and Outcomes of an Advanced Antimicrobial Stewardship Program at a Quaternary Care Hospital in the United Arab Emirates. Open Forum Infect Dis. 2017;4(Suppl 1):S265. Published 2017 Oct 4. doi:10.1093/ofid/ofx163.584 [email protected] Results: • Decrease in antimicrobial utilization, antimicrobial expenditure • Hospital-onset Clostridioides difficile infection (CDI) rates decreased from 0.46 cases per 1000 patient days in 2015 to 0.12 cases per 1000 patient days in 2017 • Hospital-onset infections due to multidrug-resistant organisms (MDROs)decreased from 2.39 cases per 1000 patient days in 2015 to 0.38 cases per 1000 patient days in 2017 CCAD publication 2019 [email protected] CCAD publication Conclusion: 2020 In patients with bloodstream infections the addition of rapid organism identification and antimicrobial resistance marker detection to an established ASP reduced the time to effective therapy and improved antimicrobial use compared to ASP alone. To our knowledge, this is the first study to report on the impact of the use of BCID with an established ASP in the Middle East. [email protected] ASP Academy at CCAD [email protected] • Rashid Hospital (560 bed hospital) is a tertiary specialized academic hospital, Emergency and Trauma Centre, which is a regional center of excellence for emergency and trauma care. • ID team & Clinical pharmacists • Started 2008 DHA: Rashid Hospital [email protected] Chaired by Senior Pharmacist Medical Surgical RH AMS ICU committee Pharmacy microbiology IC teams [email protected] Started 2008, DHA central committee and RH committee In 2018: EMR: AMS module in SALAMA that was modified to meet the requirements for DHA prescribers Updated guidelines IN 2019 Implementation Order set for drugs as per our guidelines process Restricted items will be ordered on line and dispensed by the pharmacy for 72 hrs only If the drug is required for longer duration, it needs to be renewed every 72 hrs Each restricted item will need a separate form to be filled It is the responsibility of MRP to ensure that the patient will receive required medication in timely manner without delay [email protected] Restricted • Vancomycin • Anidulafungin • Teicoplanin • Caspofungin antimicrobial • Linozolid ( IV and PO) • Voriconazole list • Ertapenem • Meropenem • Ceftazidime-Avibactam • Ceftalozane-Tazobactam • Tigecyclin • Levofloxacin ( IV and PO) • Moxifloxacin ( IV and PO) [email protected] DHA: Dubai Hospital • Dubai Hospital (449 beds) is a specialized hospital with numerous specialized centers that include cardiology, oncology and kidney disease. It also includes around 26 surgical and medical departments. [email protected] • ASP started in 2012 by measuring baseline resistance pattern and prescribing profile. • No ID service • Team mainly intensivists and microbiologists • Appropriateness of antibiotics prescribed in hospital departments STRATEGIES: ASP in • Prospective Audit & Feedback to prescriber Antibiotic form for last 24 hours, rounds, feedback Dubai • De-escalation & Stream lining: culture>>microbiologist>>IC head>>review>>email to Hospital prescriber • Plan for CDSS in 2020 ,clinical pharmacist role Results: • Achieved significant reduction in inappropriate prescriptions from 37.7% to 16% [email protected] 362-bed tertiary government hospital with 235 in-patient beds, approved training center for undergraduate and postgraduate medical training. MOH – Northern Emirates & Dubai Al Qassimi Hospital [email protected] ASP at Al Qassimi Hospital ID, Clinical pharmacist Started 2018 • Colistin • Daily review of “Restricted Parenteral Antibiotic List” by Infectious disease • Tigecycline consultant and clinical pharmacist. • Meropenem • Imipenem/Cila • Awareness sessions for head of departments, physicians & nursing in-charges statin • Piperacillin/Ta • Report data of restricted antibiotic use to Pharmacy and zobactam Therapeutics Committee quarterly • Cefepime • Linezolid
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