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 • Get antibiogram results from Infection Control Committee • Vancomycin • Dissemination of all data related to antibiotic use to the end user • Guidelines for common infectious diseases such UTI, Pneumonia , skin and soft tissue infection, ….etc
[email protected] • Daily follow up on antibiotic utilization, random auditing of patient’s charts and giving feedback to providers.
• Arranging for series of teaching seminars, lectures and grand rounds for hospital providers.
• KPIs: restricted antibiotics. o Reduction of Cost o Consumption of Restricted Antibiotics
[email protected] Significant drop in antifungal utilization between October 2018 and April of this year (36-38%) Results Significant drop in restricted antibacterial utilization between October 2018 and April of this year (26-28%)
[email protected] SKMC: the largest hospital in the UAE, consisting of a 586- bed tertiary hospital
[email protected] • 2013: ID Consult service in ICU as a pilot project to see impact on Antibiotic consumption, cost ,ICU ASP at SKMC: /Hospital LOS and crude mortality>> published
• 2016 : another pilot project dedicated to Internal ID team, medicine, mainly Clinical pharmacist driven to look at Clinical following metrics: Antibiotic consumption, Cost, LOS, C. diff rates, Crude pharmacists mortality >>>> yet to be published (work in progress) and Microbiologist • 2019: hospital wide structured ASP program
[email protected] Antimicrobial restriction: ID Consultant review and approval. ASP program ASP/ MDT Rounds. involve following Pharmacokinetic consult service by Clinical Pharmacist strategies
Antibiotics time out to be done by Primary team ,nurses and assigned clinical Pharmacist every 72 hrs. [email protected] • Antimicrobial use measures : DOT, DDD per 1000 patient days • Clinical Pharmacy intervention for ASP Metrics for • Restricted antibiotics use • IV to PO switch ASP in • Cost of antimicrobials • Infection control department is doing quarterly SKMC measure of MDRO,s ,Healthcare associated C.Difficile infections ,CAUTI/HAPS /VAP on hospital regular basis. • “Cerner Antibiotic stewardship module “ to help streamline ASP activities all across SEHA hospitals and to capture the data on Process, intervention and outcome measures of ASP.
[email protected] [email protected]
SKMC publication 2015
Impact of Infectious Diseases Team Consultation on Antimicrobial Use, Length of Stay and Mortality. Butt, Adeel A.Al Kaabi, NawalKhan, TehminaSaifuddin, MohammedKrishnanreddy, Kalpana M.Pitout, Marthinus et al.The American Journal of the Medical Sciences, Volume 350, Issue 3, 191 - 194 Corniche Hospital: UAE’s largest maternity hospital: 235-bed [email protected] ASP at Corniche Hospital Started 2017
Program leader • Sets the Program’s targets and leads its activities (Consultant Physician)
Program Co- leader • Co-leads program, reviews antimicrobials use and (Clinical Pharmacist) provides recommendations
• Observe negative bedside activities Nurse/Midwife • Promotes activities for optimal use
• Provide data on: MDROs, infections and infection Infection Preventionist control measures
Microbiologist, IT specialist, finance specialist and Others as needed developee. [email protected] Two main intervention targets initially: 1- Timely review of empiric antibiotics orders after (time-out): all neonatal antibiotic orders 2- Review of restricted antibiotic orders: with focus on meropenem
Meropenem Utilization Over 2 Audits/Adult patients 100
90
80
70
60 50 40
30
20
10 0 Number of patients receiving Inappropriate initiation of Hospital addmission for IV Timely de-escalation from meropenem meropeem meropenem only meropenen First audit Second audit Return on Investment (ROI) Future Plans
• Return of investment could be • Begin implementation and estimated at AED utilization of new ASP module • (DRG value of 31.5 reduction in coming soon to Salamtak (Cerner). hospital admission just for IV • Further develop the e-learning antibiotics). modules (interactive, audio-visual). • Expand on program’s targets for intervention. ❑ Monitor duration of antibiotics for surgical prophylaxis (new ASP module will facilitate this target). ❑ Monitor and decrease unnecessary double coverage with antibiotics. Private sector The UAE has a capacity of 12,540 beds, of which nearly 55 per cent is held by the private sector UAE hospital beds contribution
Private Public
https://gulfnews.com/business/companies/uae-s-healthcare-industry-needs- to-watch-its-debt-burden-1.2194649, Published: 14:52 March 26, 2018 [email protected] e • Nearly 70 per cent of the health-care services in Dubai are provided by the private sector.(DHA official)
https://gulfnews.com/news/uae/health/private-sector-playing-bigger-role- [email protected] in-dubai-health-care-1.1910161, Published: 17:22 October 10, 2016 ASP Challenges
Public Private
Specialists prescribe any way they want Sometimes Most of the time
Specialists as ‘customers’ CBD - +++
Independent practice not in teams Teams most of the time Mostly independent
competitive interactions. - ++
Clinical pharmacists role Respected more Mostly rejected/doubted/unaware
Reputation ++ ++++
Pre-authorization Easier Very difficult
ID physician Mostly available Very limited
Full time clinical pharmacist Mostly available Not available most of the time
Junior medical staff Available Not available
Management support Easier More difficult
Effect of Pharmaceutical sales representatives on Limited Much stronger physician antibiotic prescribing. [email protected] Al Zahra Hospital Dubai:
Tertiary 187 beds
[email protected] ASP at AZHD: Intensivist, Clinical pharmacist
Started 2017. Strategies:
• Adopt time out policy • Adopt preoperative antibiotic prophylaxis protocol • Adopt treatment protocols • Education during ASP rounds, Prospective audit and feedback • One-one meeting with physicians/surgeons • Departmental meetings • Asking each department for the latest preoperative antibiotic guidelines • Ask anesthesia to remind surgeon about re-dosing
[email protected] SAP at AZHD Response to ASP interventions at AZHD American Hospital - Dubai 254-bed, acute care, general medical/surgical private hospital [email protected] ASP at AHD: 2017
Task force: • Infectious diseases consultant • Infection control nurse • Clinical pharmacist • IT representative and • Member of performance improvement [email protected] Audit and Physician feedback (Carbapenem use,% of appropriate orders (from 60% to 84%), Targeted: Levofloxacin in the ENT
IT Based: Mandatory indication, Automatic stop orders ASP components Guidelines AHD Microbiology Component: Yearly antibiograms, Monthly CRE/ESBL CRE surveillance
Education: at least 2 hospital wide talks on some aspect of ASP per year [email protected] 100 beds
Multi-specialty
Gyne + peds
Int medicine + subspecialties
Surgery+ subspecialties
18 critical care beds (ICU, CCU, NICU)
[email protected] [email protected]
• Is this practical in Private sector with : No ID specialist, no dedicated clinical pharmacist?
Barlam TF , Cosgrove SE, Abbo LMet al. Executive summary: implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62:1197–202. Management support
[email protected] 1st Antibiogram 2017
Antibiotics Restricted EMR : Antibiotics time out stewardship ,restricted antibiotics, antibiotics guidelines and antibiogram committee
Guidelines – Prophylactic Educational CAP/UTI/MRSA antibiotics activities ..etc Interventions done in Prime Hospital [email protected] ASP Journey at Prime Hospital
-EMR: computerized clinical decision support -Retrospective Audit and monitoring formed Antibiotic Committee started our Surgical Antibiotic and Antibiotic Stewardship PH first Antibiogram & -Patient awareness material Prophylaxis (SAP) guidelines Program measuring resistant data -Collaboration with DHA and MOH -Joining UAE National AMR Surveillance program& UAE 2015 2016 National ASP Committee 2017&2018 2014 2016 2017 2018-2019
started monitoring SAP onwards: developed many Many educational activities Compliance and continued CPGs until now [email protected] OR Antibiotics committee Infectio manage Medical n r director at Prime Hospital control officer Hospital Director 2016 Microbi ologist
Quality manage Registra Clinical r r Chair of ICU- pharmacist surgery chairperson – co- chairperson Chief pharma Head of cist ER
General Nephro surgeon logist Orthop Pediatri edic acian Gynecol surgeon ogist [email protected] EMR: Computerized Clinical Decision Support Antibiotics timeout for IP
Prophylactic : 24 hours Therapeutic : 72 hours
[email protected] • Carbapenems (Ertapenem, Meropenem) • Linezolid • Tigecycline • Piperacillin-Tazobactam • Colistin • Cefepime • Cefotaxime • Ceftazidime • Ciprofloxacin • Moxifloxacin • Levofloxacin Restricted antibiotics • Caspofungin IP & OP • Anidulafungin
[email protected] SAP Compliance over 4 years
100
90
80
70
60
50
40
30
20
10
0 Cefazolin 3rd/4th cephalo other antibiotics right dose 2 g within 60 min 2016 2017 2018 2019 [email protected] ACHS KPI: SAP for LSCS 2019
100
90
80
70
60
50
40
30
20
10
0 Correct SAP & Dose Timing(within 60 min) Jan-June 2019 July-Dec 2019 [email protected] Cefazolin 2 g 100 100 98 96 92 94 94 89.5 89 88 90
80 77 71 70 67
60
2019 LSCS 50
SAP 40
30
20
10
0 Jan Feb March April May June July Aug Sep Oct Nov Dec Cefazolin 2 g
[email protected] Gyne compliance with SAP
[email protected] Effect of ASP interventions based on CDSS incorporated in EMR on the use of two major antibiotics classes in ER.
[email protected] Poster presented in ECCMID 2019
[email protected] Gyne, 11.00%
ER, 7% Number of Ceftriaxone encounters from Jan-Aug 2019 Peds, 40%
Surgery, Int Med, 20.00% 22%
CEFTRIAXONE [email protected] Gyne, 2.00%
ER, 12%
Number of Fluoroquinolones encounters from Surgery, Jan-Aug 2019 Int Med, 44.00% 42%
FLUOROQUINOLONES [email protected] Peds, 4.50% Gyne, 4.90%
Number of
ER, 17% Carbapenems Surgery, encounters from 43.30% Jan- Aug 2019
Int Med, 30%
CARBAPENEMS [email protected] 0 AED Cost of ASP at Prime - Inhouse developed EMR - Interventions added to the EMR upon recommendations of Hospital antibiotics committee - IT team full support [email protected] One to one meetings with doctors, CME, Emails..
[email protected] Patient/Public AWARENESS
[email protected] [email protected] Educational and awareness materials for patients
[email protected] [email protected] [email protected] Social Media [email protected] Summary and conclusions Timeline for ASP in UAE
2005 2012 2015 2017 2019
Tawam Hospital Dubai H CCAD Corniche H, AHD, SKMC, SGH AZHD
Qassimi Rashid H SKMC Prime Hospital Hospital/MOH 2008 2013 2016 2018
[email protected] Conclusions
• Combating AMR and implementing AMS is a priority in UAE >>> UAE NAP & Mandated AMS in public and private sectors. • Unifying AMS across the country started but challenging. • No AMS program look like the other. • Other hospitals are having a form of AMS in place. • More involvement from private sector. • AMS can still be implemented in limited resources settings. • Cost is not always a barrier. • Still need to study the long-term effects of AMS on AMR both at institution & country level. [email protected] • Dr. Laila Al Dabal RH/DHA • Dr. Najiba Abdul Razzaq Kuwait Hospital/MOH • Dr. Jens Thomsen DOH • Dr. Ahmad Subhi Qassimi Hospital/MOH • Dr. Nehad Shirawi AZHD • Dr. Lamia Yahia Corniche Hospital • Abeer Khalaf SKMC Thank you • Dr. Tehmina Khan SKMC • Dr. Rayhan Hashmy Tawam [email protected] • Dr. Khulood Bin Rafea Tawam • Dr. Moeena Zain AHD • Dr. Leili Shamani SGH • Dr. Ashraf Al Hoofi DH • Dr. Rania Lababidi CCAD References
• Cotta MO, Robertson MS, Tacey M, Marshall C, Thursky KA, Liew D, Buising KL. Attitudes towards antimicrobial stewardship: results from a large private hospital in Australia. Healthc Infect 2014; 19 89–94. Loh JAM, Darby JD, Daffy JR, Moore CL, Battye MJ, Lorenzo YSP • Stanley PA. Implementation of an antimicrobial stewardship program in an Australian metropolitan private hospital: lessons learned. Healthc Infect 2015; 20 134–40.e private hospital in Australia. Healthc Infect 2014; 19 89–94. • Cotta MO, Robertson MS, Marshall C, Thursky KA, Liew D, Buising KL. Implementing antimicrobial stewardship in the Australian private hospital system: a qualitative study. Aust Health Rev. 2015;39(3):315-322 • https://www.khaleejtimes.com/news/uae-health/are-uae-doctors-prescribing-antibiotics-unnecessarily • https://gulfnews.com/business/companies/uae-s-healthcare-industry-needs-to-watch-its-debt-burden-1.2194649, Published: 14:52 March 26, 2018 • https://gulfnews.com/news/uae/health/private-sector-playing-bigger-role-in-dubai-health-care-1.1910161, Published: 17:22 October 10, 2016 • UAE National AMR Surveillance System, 2020 • Quarterly Summary Report. Communicable Diseases Bulletin:www.doh.gov.ae, Second Quarter– 2019 (Apr-Jun) Volume 10; Issue Number 2; 2019