Training package on institutional AMR strategy development

Building an institutional AMR strategy based on the AMR DetecTool

Fighting efficiently against multidrug-resistant bacteria in hospitals

I. Preparatory phase

I.1. Getting information about AMR and multiresistant bacteria

WHO competency framework for health workers’ education and training on antimicrobial resistance:

https://apps.who.int/iris/bitstream/handle/10665/272766/WHO-HIS-HWF-AMR-2018.1-eng.pdf

This competency framework is intended to serve as a reference (for academic institutions, educators, accreditation bodies, regulatory agencies and other users) to help ensure that pre-service education and in-service training equip health workers with the requisite competencies to address AMR. It complements other relevant existing WHO guidance on AMR and lays the foundation for the development of more in-depth educational resources and AMR curricula.

Freely available courses about AMR:

https://www.ecdc.europa.eu/en/all-topics-z/antimicrobial-resistance/directory-guidance-prevention-and-control/training-courses – collection page

courses from
several agencies: WHO, ECDC, USAID
training institutes of some countries: Denmark, Sweden, UK

Antimicrobial resistance and stewardship e-Learning Repository of British Society from Antimicrobial Chemotherapy
https://bsac-jac-amr.com/jac-amr-resources/

I.2. Getting to know the local situation in the hospital

1. Which persons have a high risk of infection (colonisation) with multiresistant bacteria?

2. Which departments of your hospital have a high risk of infection (colonization) with multiresistant bacteria?

3. Are antibiotic susceptibility rates monitored for key bacteria (and reports are shared with prescribers)?

4. What are the recommendations of hospital departments for empirical antibiotic treatment?

 

1. Individual-level risk assessment

Focusing on the assessment of these factors:

    • health status of the patient
    • patient’s underlying diseases (internal risk factors)
    • factors related to the care itself (external risk factors, e.g. device usage)

2. Institutional risk assessment

Hospital departments with a high risk of infection with multiresistant bacteria:

    • Emergency Department
    • Surgery Department
    • Combustion Surgery Department
    • Intensive Care Unit
    • Oncology

3. Antibiotic susceptibility rates monitoring

Antimicrobial susceptibility testing with phenotypic methods is based on the measurement of the MIC (mg/L) and breakpoints to categorize bacteria and fungi as susceptible, intermediate or resistant.

The European Committee on Antimicrobial Susceptibility Testing (EUCAST) has harmonized antibiotic interpretive breakpoints throughout Europe. They have been or are now being implemented in most countries inside Europe and many countries outside it.

Everything needed to perform and interpret antimicrobial susceptibility testing is freely available from the EUCAST website:
https://www.eucast.org/
https://pubmed.ncbi.nlm.nih.gov/26089441/

 

4. Empirical antibiotic treatment

Because microbiological results do not become available for 24 to 72 hours, initial therapy for infection is often empiric and guided by the clinical presentation. It has been shown that inadequate therapy for infections in critically ill, hospitalized patients is associated with poor outcomes, including greater morbidity and mortality as well as increased length of stay.

Therefore, a common approach is to use broad-spectrum antimicrobial agents as initial empiric therapy.

Hospital-acquired infections are frequently related to the presence of invasive devices and procedures that result in loss of the normal barriers to infection, as is the case with intravascular catheter-associated bacteremia, ventilator-associated pneumonia, and catheter-associated urinary tract infections (UTIs). They are commonly caused by drug-resistant organisms, which are often endemic in hospitals because of the selection pressure from antimicrobial use. In selecting empiric antimicrobial therapy for such infections, clinicians should consider the following:

    • the site of infection and the organisms most likely to be colonizing that site (e.g., intravascular catheter-associated bacteremia is frequently a result of colonization and infection caused by staphylococci present on the skin)
    • prior knowledge of bacteria known to colonize a given patient (e.g., a nasal screening swab [currently conducted routinely by many hospitals before admitting patients to the intensive care unit] may indicate that the patient is colonized with MRSA)
    • the local bacterial resistance patterns or antibiograms available for important pathogens at most hospitals.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031442/
General Principles of Antimicrobial Therapy

I.3. Planning the laboratory process with AMR DetecTool

Possibilities and advantages of the device against the currently used diagnostic methods

The AMR DetecTool device can detect the most common resistance mechanisms of bacteria directly from the patient’s sample (blood culture, urine, rectal swab, bronchoalveolar lavage / tracheal aspirate), shortening the workflow for the detection of multidrug-resistant bacteria to 30 minutes.

Resistance mechanisms that can be detected:

    • ESBL: CTX-M MULTI
    • Carbapenemases: KPC, OXA, VIM, IMP, NDM
    • VAN A/B: vancomycin-resistant Enterococci
    • OXA-Ab: OXA-type carbapenemases in Acinetobacter sp.
    • 3GC: third-generation cephalosporin resistance

With the help of the Carba5 test, concrete antibiotics can be recommended as OXA, KPC, VIM, IMP and NDM enzyme types can be detected. OXA & KPC can be treated with meropenem + beta-lactamase inhibitor.

Integrating the device into the workflow

Integrate the AMRDetecTool after the gram stain, from the positive blood culture and after screening and microscopic test from the urine, before identification at the species level.

Specimen selection and collection

AMR DetecTool rapid tests need the same specimen as the currently used laboratory tests: blood culture, urine, rectal swab, and no required extra sampling.

I.4. Creating a communication plan

 

I.5. Meeting the significant stakeholders

 

I.6. Finalizing the communication plan

II. Implementation phase

III. Continuous operational and monitoring phase

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