Mushira Enani, MBBS, FRCPE, FACP,CIC

Head- Infectious Disease Section

King Fahad Medical City

Stewardship: Challenges & Opportunities

in the Gulf Region

• Background of Healthcare system

• Antimicrobial resistance in GCC states

• GCC Antimicrobial Stewardship survey

• KFMC Experience

• Conclusion

Outline

Gulf Cooperation Council (GCC) States

Demographic Indicators C

ou

ntr

y

Are

a (K

m2)

Population

Nat

ion

als

No

n-

Nat

ion

als

Tota

l

Year

UAE 83,600 892,000 3,873,000 4,765,000 08

Bahrain 760.5 537,700 568,800 1,106,500 08

KSA 2000,000 18,543,246 6,830,266 25,373,512 09

Oman 309,500 2,018,000 1,156,000 3,174,000 09

Qatar 11,580 - - 1638,6 09

Kuwait 17,820 1,102,485 2,340,460 3,442,945 09

Human and Material Resources Indicators C

ou

ntr

y

Ph

ysic

ian

s

Ph

arm

acis

ts

He

alth

-re

late

d

pe

rso

nn

el

Ho

spit

al

be

ds

PH

C U

nit

s an

d C

en

ters

#

Ho

spit

als

# H

eal

th c

en

ters

Yr

All per 10,0000 population

MO

H

Oth

er

Go

v P

riv.

se

ct

Yr

Rat

e

Yr

Rat

e

Yr

Rat

e

Yr

Rat

e

Yr

Rat

e

Yr

UAE 27.9 08 6.1 08 12.9 08 19.3

08 0.5 08 14 18 59 08 64 08

BAH 21.1 08 6.0 08 14.2 08 19 08 0.2 08 9 1 13 09 24 09

KSA 21.8 09 5.9 09 23.5 09 22.04 09 0.8 09 244 39 125 09 2037 09

OMAN 17.5 09 3.4 09 39.5 08 17.7 09 0.7 09 50 5 5 09 217 09

QATAR 26.8 09 8.64 09 22.04 09 12.3 09 1.4 09 5 1 4 09 30 09

KUW 19 09 1.6 09 22 09 20 09 0.2 09 15 - 9 09 85 09

Projected increase in treatment demand in GCC by 2025

Projected demand for hospital beds in GCC by 2025 (percent)

Resistant pathogens in clinical isolates GCC countries (Jan 1990 - April 2011)

37,295 bacterial isolates studied for antimicrobial resistance

• E.coli 44%

• K. pneumoniae 20%

• P. aeruginosa 18.7%

• MRSA 5.4%

• Acinetobacter 5%

• C. difficile & Enterococcus reported less than 1%

Prevalence of resistant pathogens in clinical isolates from GCC countries

The percentage of CRE (+MHT) compared to total Enterobacteriaceae

Pseudomonas aeruginosa antibiotic susceptibility (%) KFMC 2009 -2012

71

74

78

85

84

91

78

72

CAZ

CPE

CIP

TZP

GM

AN

MER

IMP

An

tib

ioti

c t

este

d

2012

2011

2010

2009

Cost of Antibiotic Resistance in KFMC

0 500,000 1,000,000 1,500,000 2,000,000 2,500,000 3,000,000 3,500,000 4,000,000 4,500,000

Vanc

Merop

Imip

Pip-Taz

Cipro

Colistin

2012

2011

2010

Cumulative

Antimicrobial Stewardship Survey GCC Countries

GCC Survey

Participants Job Title

0

5

10

15

20

25

Specialist AssistantConsultant

consultant Consultant Others pharmacist

Fre

qu

ecn

y

GCC States

Bahrain

KSA

Oman

UAE

0

2

4

6

8

10

12

14

16

Type of Hospital

Community hospital

District or general hospital

Non-teaching tertiary hospital

Other

Private hospital

200-400 43%

500-700 23%

>800 34%

Number of Inpatient Beds

0

5

10

15

20

25

30

Don't know No Yes

3

15

29

Having Antimicrobial Stewardship program

Barriers

0

5

10

15

20

25

Dedicated funding 17%

Don't know 37%

Funded from savings on antimicrobials

7%

Not applicable 39%

Funding

49%

51%

Having AMS ward Rounds

No Yes

Wards Having AMS Rounds

Both

ICU

NonICU

Having Animicrobial Guidelines

Don't know

No

Yes

Having Restricted Antimicrobial List

Don't know

No

Yes

Having Antimicrobial Audit

Don’t Know

No

Yes

28%

72%

Having Electronic Prescription No

Yes

Reduction in Direct cost Expenditure

Don'tknow

No

Yes

Reduction in Broad Specturm Agents Usage

Don'tknow

No

Yes

Reduction of Inapropriate Prescription

Don't know

No

Yes

Reduction of Health Care Aquired Infection

Don't know

No

Yes

Reduction Of Antmicrobial Resistance

Don'tknow

No

Yes

Therapy for specific infectious syndromes (CMG) 10

Individual drugs? 5

Dosage? 12

Others 1

Dosage for special populations (e.g. renal or liver impairment? 8

Individual drugs?\nDrug class? 1

Surgical prophylaxis guidelines? 9

Antifungal guidelines? 6

Drug Class 7

First choice antibiotic (empirical therapy guidelines) 12

Alternative choice (e.g. if allergic) 3

Route of Administration 9

Duration of prescription 4

Antiviral guidelines 4

Microorganisms covered by antibiotic tested? 5

Side effects 6

Dosage for obese patinets 1

KFMC Experience

Multidisciplinary team approach

OBJECTIVES 1. Improving patients outcome by optimizing the

antimicrobial use, 2. Minimizing irrational use, 3. Reducing adverse events including healthcare-

associated infections such as clostridium difficile infection, MDROs

4. Minimizing healthcare cost.

KFMC Antimicrobial Stewardship

Core Strategies of Successful Antimicrobial Stewardship Program

Prospective audit with intervention and feedback (AI)

Formulary restriction and pre-authorization (AII)

IDSA/SHEA Guidelines for developing an Institutional Program to Enhance Antimicrobial Stewardship, 2007

n= 377

Patients in Medical Wards

on I.V Antibiotics

March – July 2013

Antimicrobial Prescribing

n= 377

69 68

51 49 47

40

13 10 9 6 6 5 4

0

10

20

30

40

50

60

70

80

13%

Indications

n= 377

51%

24%

3% 3%

5%

7%

7% Tazocin

Ceftriaxone

Carbapenem

Ceftazidim

Ciprofloxacin

Vancomycin

Metronidazole

Broad spectrum Antibiotic prescribing with no

evidence of bacterial infection through five months

n=49

122

151

104

planned notdocumented

Not plannednot

documented

planned anddocumented

No.of Rx

Documentation of Duration of Therapy

n= 377

32%

40%

28%

60%

7%

21%

12%

Stop

IV/Po

Deescalate/ change

spescify duration

n = 195/377 (52%)

*Recommendation made by stewardship team

Type of Stewardship Intervention*

73

122

Yes NoIntervention Feedback

37.4%

Intervention Implementation*

*Compliance with Stewardship team Recommendations

62.6%

Pipracillin-Tazobactam Carbapenem Ceftriaxone

Total Rx No. 69 22 26

Total Intervention 35 14 12

Discontinue 28 12 10

Descalation 7 2 2

No

.of

Rx

Top Three Prescribed Antibiotics vs. Interventions Before

After

Projected Cost

Saving

Avoided

direct cost

of the top 3

antibiotics over 5

months

150,000SR

Average Savings 30,000 SR/month

360,000 SR/year

0 50000 100000 150000 200000 250000 300000 350000 400000 450000 500000

Jan

Feb

Mar

Apr

May

June

July

Aug

Sep

Oct

Cost of Some Antibiotics 2013

VANCOMYCIN 500MG INJECTION

CIPROFLOXACIN 200MG/100ML (CIPRO) INJECTION

CIPROFLOXACIN 250MG (CIPRO) TABLET

CIPROFLOXACIN 500MG (CIPRO) TABLET

COLISTIMETHATE SODIUM 1000.000 UNIT/VIAL (COLOMYCIN)

PIPERACILLIN 4GM + TAZOBACTAM 500MG (AS PIPERACILLIN) (TAZOCIN) INJECTION

MEROPENEM 1GM (MERONEM) INJECTION

IMIPENEM/CILASTATIN 500MG (AS IMIPENEM) INJECTION

Hospital-acquired Clostridium difficile Medical wards - 2012-2013*

0

3.28

7.1

0

1.62 1.64

0 0 0

1

2

3

4

5

6

7

8

1st 2nd 3rd 4th

Quarterly rate (#cases per 10000 patient-days)

Infection rate/10000patient-days2012

Infection rate/10000patient-days2013

*2013 quarter 1-3

Manpower

-Infectious diseases Clinical Pharmacists trained in

antimicrobial stewardship

-Coordinator/ data manager Education of healthcare providers, CMG

Integrated electronic system: CPOE, decision

support, automated approval of restricted

antibiotics

Informatics based monitoring:

Antibiotic consumption

Antimicrobial resistance Rapid diagnostics in Microbiology lab

Compensation/ incentives for stewardship

members

Requirements for Project Sustainability

Conclusion

• The global spread of antibiotic resistance among clinically important Gram-negative bacilli is a growing problem in the GCC states.

• Health care demand and spending are rising sharply in the GCC.

• GCC governments must make major regulatory and policy changes to regulate antibiotic use in the community and hospitals.

Recommendations

• Antimicrobial Stewardship should be implemented across GCC in healthcare facilities

• Prohibiting antibiotic use without prescription

• Educational campaigns about antibiotic use, antimicrobial resistance, & infection prevention for prescribers and consumers.

• Developing regional surveillance system on antibiotic resistance and antibiotic consumption for benchmarking .