AMS Case Study – EGYPT National Antimicrobial Stewardship Program

Home , ATC code A07

Rational Drug Use (RDU) Department Hospital Pharmacy Administration HPA CAPA

Aalaa Afdal B.Sc Pharm, M.Sc Pharm, BCPS, ASP Pharmacist Outline

1- Introduction

2- National Antimicrobial Stewardship Program

3- Egyptian Point Prevalence Survey

4- Results

5- Conclusion

1 1

Introduction

2 National Antimicrobial Stewardship Program (NASP)

Antimicrobial MOH One Project In WHO Call Misuse and Health National Many Problem In For Policy Resistance Action Plan Countries Egypt Makers World Wide For Drug (Global Calls) Combating AMR Authorities

3 National Antimicrobial Stewardship Program (NASP)

Antimicrobial Misuse and Resistance World Wide (Global Calls)

4 Antimicrobial use in Egypt

Minors Data on Antimicrobial Unstandardized Use in Egypt

Sporadic

5 GAP

Set Up Governance Structures

Conduct Surveillance System Awareness Regular Antimicrobial Campaigns Use and Consumption Global Action Plan

Track and Intervention Measure Progress Rational Use of of The NASP Antimicrobials

6 Egyptian National Action Plan Fighting AMR

• Four Main Pillars Infection Optimizing Prevention AB use & control

Education AMR & public surveillance Awareness

7 2

National Antimicrobial Stewardship Program

8 NASP 4 National Level 3 Do Interventions Conduct and follow up training & 2 Awareness Specify Campaigns Antimicrobial Use measures

1 Set Up Governance Structures

9 Hospital Level NASP 4 3 Do Interventions Conduct and follow up training & 2 Awareness Specify Campaigns Antimicrobial Use measures

1 Set Up Governance Structures

10 1- Set Up Governance Structures

National level (NAP-AMR)  Stakeholders meetings in collaboration with the WHO.  Three Mega meetings (April 2017 - Nov 2017 - March 2018).  Followed by multiple taskforce meetings (finalization). 11  N-AMS Committee 1- Set Up Governance Structures

National level (CAPA)

 Introduction of Antimicrobial Formulary list.  Updated OTC list excluding systemic antimicrobial agents.

12 1- Set Up Governance Structure

Hospital level (CAPA)  Rational Drug Use Publication (4\2017) of ASP in hospitals.

13 NASP 4 3 Do Interventions Conduct and follow up training & 2 Awareness Specify Antimicrobial UseCampaigns measures

Set Up Governance 1 Structures

14 2-Specify Antimicrobial Use measures

National level Hospital level

 DDD/1000 inhabitants Quality Quantity

Use  DDD/100 bed days  DOT/100 bed days 15  Point

NASP 4 3 Do Interventions and follow up Conduct training & Awareness 2 Campaigns Specify Antimicrobial Use measures

1 Set Up Governance Structures

16 3- Conduct trainings

 AMR Awareness

 AMS Activities

17 NASP 4

3 Intervene and follow up Conduct training & 2 Awareness Specify Campaigns Antimicrobial Use measures 1 Set Up Governance Structures

18 4- Intervene and follow up

Hospital level (CAPA)

1. Use Specific Antibiotic prescribing sheet 2. Generate Quality indicators of antimicrobial prescribing 3. Promote Culture withdrawal promptly 4. Enforce Data specific Interventions 5. Follow up data 19 3 The Egyptian Point Prevalence Survey Of Antimicrobial Consumption And Resistance (E- PPS)

20 Egyptian PPS aims to :

1. Monitor rates of antimicrobial prescribing in hospitalized adults, Pediatrics and Neonates. 2. Identifies targets for quality improvement (e.g. duration of peri- operative prophylaxis; compliance with local hospital guidelines; documentation of indication for prescription of antibiotic therapy). 3. Helps in designing hospital interventions that aim at promoting prudent use of antimicrobials. 4. Allows to assess the effectiveness of such interventions, through repeat PPS. 21 E-PPS

• conducted in 17 Second Wave hospitals (1388 patients ) from 4 different (2018) governorates (Cairo- Giza-Qualyobia-Alex) • conducted at 41 hospitals (2542 • 5 pilot hospitals plus 4 within the directorates patients) Cairo-Giza-Qualiobia-Alex- and SMCs. Behira-Baniswef-Dakhlia-Menofia- additional enthusiastic Alfayoum) from different sectors hospitals in 4 different MOH (Directorates, Educational and directorates (Damitta, Health insurance sector, SMCs), Universities (Menofia) and Interior Qalyoubia, Fayoum, Ministry. Alexandria)

First Wave Third Wave (2017) (2019)

22 E-PPS Hospitals Interventions Hospitals feedback Results reports

24 4- Intervene and follow up

 E-PPS Event (first wave)

25 4

Results

26 4,995 antimicrobial prescriptions

4,498 (90.0%) antibacterials for systemic use (ATC J01)

149 (3.0%) antimycotics for systemic use (ATC J02)

58 (1.2%) drugs to treat tuberculose (ATC J04)

99 (2.0%) nitroïmidazole derivatives (ATC code P01AB)

35 (0.7%) intestinal anti-infectives (ATC code A07)

156 (3.1%) antivirals for systemic use (ATC code J05)

27 E-PPS Top prescribed antibiotics

% 25 2017 2018

% 20

% 15

% 10

% 5

% 0 Ceftriaxone CefotaximeAmpicillin and enzyme MetronidazoleinhibitorAmoxicillin and enzyme inhibitorMeropenem

28 E-PPS Most common diagnosis Bron, 7.40% Surgical proph, 5.50% SSTIs, 7.30% UNK, 12.20% sepsis, 7.60%

FN, 3.60% PUO, 2.20%

GI, 6.00%

Pneu, 35.70% CNS, 10.60%

29 E-PPS The Most Prevalent Antibiotics for LRTI In Egypt %

27.40 30%

25%

% 18.63 20% % 14.82

15% % 12.54 % 9.14

% 7.92 10% % 6.46 % 5.48 % 3.82 % 3.65 5%

0% Adults

Paediatrics

30 E-PPS

GUIDELINE COMPLIANCE STOP/REVIEW DATE DOCUMENTATION No information 11% Yes NA 41% 16% 15% Yes No 85%

No 32% 31 E-PPS REASONS IN NOTES

ROUTE OF ADMINISTRATION

Yes No Parentral Oral TREATMENT 0% Inhalation0.2% 15% Targeted 4%

96% 7.3% Biomarker based

85%

Emperic 32 E-PPS

Selection hospitals with ≥ 10 patients receiving surgical prophylaxis (n=14 hospitals)

SP1 = Single dose SP2 = One day SP3 = > 1 day

33 5

Conclusion

34 Targets for Improvement

 Decrease the prevalence of broad spectrum beta lactams antibiotic use in different wards  Encourage culture based treatments – Biomarkers  Develop guidelines and ensure compliance  Enforce quality indicators for antimicrobial prescribing  Rationalize the use of Parenteral Antimicrobials

35 E-PPS fortune

Tailored interventions according to the available resources of each institution:  Development of Antibiotic policy  Development of Surgical prophylaxis policy  Development of restricted list of Antibiotics  Development of IV to Oral therapy shift policy  Establishment of Prospective audit for Antimicrobial use  Conduction of Educational programs  Development of Antibiograms  Development of updated formulary list 36 Limitations

. Inconsistent sustainability of supportive administration . Insufficient resources, tools, and materials supporting ASP activities (e.g. Culture Discs, Qualified human resources, poor culture withdrawal techniques, automated software….) . Weak multidisciplinary coordination . Resistance of some prescribers . Insufficient awareness of proper AB use and AMR for different HCPs . Shortage of some empiric antimicrobials

37 SPECIAL THANKS TO:

 WHO – AMR team  IPC Admin. MoHP  Central Lab MoHP  NASP members  Head of HPA  Head of CAPA

38 39 AMS

Any Questions!!!