Antimicrobial Stewardship Program in Saudi Arabia; Pharma Middle East 2015 Dubai, UAE Antimicrobial Stewardship Program in Saudi Arabia; Experiences and Vision Future  Yousef A. Alomi, Bsc., Msc, BCPS, BCNSP, DiBA General Manager of General Administration of Pharmaceutical Care November 2015 yalomi@moh.gov.sa yalomi@gmail.com

Disclosure Yousef A. Alomi Reports No Relevant Financial Relationship Pharma Middle East 2015 Dubai, UAE Disclosure Yousef A. Alomi Reports No Relevant Financial Relationship

Learning Objectives Pharma Middle East 2015 Dubai, UAE Understand Antimicrobial Stewardship Program at MOH Saudi Arabia Know the Assessment Plan of Antimicrobial Stewardship Program How to Implement Antimicrobial Stewardship Program to all Middle East countries

Antimicrobial Stewardship Program “an ongoing effort by a health care institution to optimize antimicrobial use among hospitalized patients in order to improve patient outcomes, ensure cost-effective therapy, and reduce adverse sequelae of antimicrobial use (including antimicrobial resistance) Allerberger, F. and H. Mittermayer (2008). “Antimicrobial stewardship.” Clinical Microbiology and Infection 14(3): 197-199.

Three levels of demand were used sequentially until an antibiotic was dispensed or denied [4]: 1) Can I have something to relieve my symptoms?: 2) Can I have something stronger? 3) I would like to have antibiotic.

Saudi Pharmaceutical Journal (2014) 22, 550–554

Saudi Pharmaceutical Journal (2014) 22, 550–554

Saudi Pharmaceutical Journal (2014) 22, 550–554

Alumran et al. Health and Quality of Life Outcomes 2013, 11:39

The antimicrobial stewardship program in Gulf Cooperation Council (GCC) states: insights from a regional survey Journal of Infection Prevention October 8, 2015 Objectives: The purpose of the current study is to describe the prevalence and characteristics of antimicrobial stewardship programs (ASP) in Gulf Cooperation Council (GCC) states to explore opportunities and overcome barriers to effective ASP implementation. Methods: A cross-sectional questionnaire survey was used to evaluate the current status of ASP: major stewardship components, barriers of implementation and program impact in acute care hospitals of GCC states. Results: Forty-seven healthcare professionals responded from four GCC states, the majority from Saudi Arabia (81%). Twenty-nine (62%) participating hospitals had ASP in place. Of these established programs, 35 (75%) reported lack of funding and personnel as major barriers to program implementation. The top three objectives cited for the hospital ASP were to reduce resistance (72.3%), improve clinical outcomes (70.2%) and reduce costs (44.7%). The reported impact of existing ASP was reduction of inappropriate prescribing (68%), reduction of broad spectrum antibiotic use (63.8%), reduction of healthcare-associated infections (61.7%), reduction of length of stay or mortality metrics (59.6%), reduction in direct antibiotic cost (57.4%) and reduction of reported antibiotic resistance (55.3%). Conclusion: Survey participants from GCC states who have implemented ASP report significant impacts in the reduction of broad spectrum antibiotic use, hospital-acquired infection, inappropriate prescribing and antimicrobial resistance. These findings suggest a promising opportunity to enhance existing ASP through sharing of best practices and support the development of regional guidelines across GCC states.

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia. Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS1. BACKGROUND AND OBJECTIVES: Antimicrobial stewardship programs (ASPs) have shown to prevent the emergence of antimicrobial resistance associated with an inappropriate antimicrobial use. The primary objective of this study was to compare the prescribing appropriateness rate of the empirical antibiotic therapy before and after the ASP implementation in a tertiary care hospital. Secondary objectives include the rate of Clostridium difficile-associated diarrhea (CDAD), physicians' acceptance rate, patient's intensive care unit (ICU) course, total utilization using defined daily dose, and total direct cost of antibiotics. DESIGN AND SETTINGS: This is a comparative, historically controlled study. Adult medical ICU patients were enrolled in a prospective fashion under the active ASP arm and compared with historical patients who were admitted to the same unit before the ASP implementation. This study was approved by the institutional review board, and the need for informed consent was waived because the interventions and recommendations were evidence based and considered the standard of care. The study was conducted at KFSHRC, Riyadh. Ann Saudi Med. 2013 Nov-Dec;33(6):547-54.

Antimicrobial stewardship program implementation in a medical intensive care unit at a tertiary care hospital in Saudi Arabia. Amer MR, Akhras NS, Mahmood WA, Al-Jazairi AS1. METHODS: Adult medical ICU patients were enrolled under the active ASP arm if they were on any of the 5 targeted antibiotics (piperacillin/tazobactam, imipenem/cilastatin, meropenem, vancomycin, tigecycline), and had no official infectious disease consultation. The interventions were conducted via prospective audit and feedback. RESULTS: A total of 73 subjects were recruited, 49 in historical control and 24 in the active arm. The appropriateness of empirical antibiotics was improved from 30.6% (15/49) in the historical control arm to 100% (24/24) in the proactive ASP arm (P value < .05). For the ASP group, initially 79.1% (19/24) of the antibiotic uses were inappropriate and diminished by ASPs to 0% on the recommendations implementation. A total of 27 interventions were made with an acceptance rate of 96.3%. The rate of CDAD did not differ between the groups. A reduction in antibiotics utilization and direct cost were also noticed in the ASP arm. CONCLUSION: A proactive ASP is a vital approach in optimizing the appropriate empirical antibiotics utilization in an ICU setting in tertiary care hospitals. This study highlights the importance of such a program and may serve as a foundation for further ASP initiatives particularly in our region. Ann Saudi Med. 2013 Nov-Dec;33(6):547-54.

Skeleton of Committees Pharma Middle East 2015 Dubai, UAE Skeleton of Committees   Central antibiotics committee Regional antibiotic committee Hospital Antibiotic committee Primary Care Centres Antibiotic committee

Antimicrobial Stewardship Program Plan Pharma Middle East 2015 Dubai, UAE Antimicrobial Stewardship Program Plan 2014  Stage 1  Antibiotic Committee Central   Antibiotic Committee Region 20  Antibiotic Committee Peripheral 90 Hospital   Antibiotic adults Manual booklet and electronic   Antibiotic Training Courses Central   Antibiotic training courses region 20 

Antimicrobial Stewardship Program Plan 2015 Stage 2   Antibiotic Committee Peripheral additional 90 Hospital   Antibiogram Central   Antibiogram 20 Region  Antibiogram 90 Hospital   Antibiotic pediatrics Manual booklet and electronic   Review Antibiotic Adults Manual base on antibiogram   Antibiotic utilization   Antibiotic consumption   Antibiotic Training Courses Central   Antibiotic training courses region 20 Stewardship Antibiotics Residency Program (ASHP) 

Antimicrobial Stewardship Program Plan 2016 Stage 3   Antibiotic Committee Peripheral additional 60 Hospital   Antibiogram Central   Antibiogram 20 Region  Antibiogram 180 Hospital   Antibiotic pediatrics Manual booklet and electronic   Review Antibiotic Adults Manual base on antibiogram   Antibiotic utilization adults and pediatrics   Antibiotic consumption adults and pediatrics   Antibiotic Training Courses Central   Antibiotic training courses region 20 Follow Up Stewardship Antibiotics Residency Program (ASHP)  

Antimicrobial Stewardship Program Plan 2017 Stage 4   Antibiotic Committee 90 Private Hospital   Antibiogram Central   Antibiogram 20 Region adults and pediatrics   Antibiogram 250 Hospital adults and pediatrics   Review Antibiotic pediatrics Manual booklet and electronic   Review Antibiotic Adults Manual base on antibiogram   Antibiotic utilization adults and pediatrics  Antibiotic consumption adults and pediatrics   Antibiotic Training Courses Central   Antibiotic training courses region 20   Follow Up Stewardship Antibiotics Residency Program (ASHP)

Antimicrobial Stewardship Program Plan 2018 Stage 5  Antibiotic Committee additional 90 Private Hospital  Antibiogram Central   Antibiogram 20 Region adults and pediatrics   Antibiogram 250 Hospital adults and pediatrics   Antibiogram in 90 Private Hospital   Review Antibiotic pediatrics Manual booklet and electronic   Review Antibiotic Adults Manual base on antibiogram   Antibiotic utilization adults and pediatrics in MOH and Private   Antibiotic consumption adults and pediatrics in MOH and Private  Antibiotic Training Courses Central in MOH and Private  Antibiotic training courses region 20 in MOH and Private Follow Up Stewardship Antibiotics Residency Program (ASHP)  

Guideline for Establish Antimicrobial Stewardship at MOH hospitals Section I: Policy and procedure Section II: National antimicrobial guideline: Group A streptococcal Pharyngitis Acute Bacterial Rhinosinusitis Community Acquired Pneumonia Bacterial Meningitis Brain Abscess Infective endocarditis Urinary Tract Infection Osteomyelitis Diabetic Foot Infection Skin and Soft Tissue Infection Peritonitis Sexually Transmitted Disease Pelvic Inflammatory Disease Intra-abdominal Infection Brucellosis Tuberculosis Antiviral Infection Antifungal Infection Parasitic Infection Surgical Prophylaxis Appendix A: Guideline for blood culture collection Appendix B: Infection Control Appendix C: Skin test kits, Anaphylactic kits , Skin test procedure and anaphylaxis algorithm Appendix D: Antibiotics dosing monitoring Appendix E: Practical Approaches for Conversion IV antibiotics to Oral therapy Appendix F: Antibiogram Appendix G: Antimicrobial Consumption Appendix H: Formulary/ Pre-Authorization Restricted Forms Appendix I: Abbreviation Appendix J: Dose Adjustment for Renal Impairment

Guideline for Establish Antimicrobial Stewardship at MOH hospitals The antimicrobial stewardship team and administrative support Core members of antimicrobial stewardship: Infectious diseases physician ( Leader ) Clinical pharmacist with infectious diseases training (Coordinator) Clinical microbiologist An information system specialist An infection control professional hospital epidemiologist Administrative support: Hospital administration (necessary infrastructure) Medical staff leadership local providers ( e.g: nurses) Collaborated providers: Hospital infection control Pharmacy and therapeutics committees

Guideline for Establish Antimicrobial Stewardship at MOH hospitals Core strategies: Prospective audit with intervention and feedback Formulary restriction and preauthorization: Supplemental Antimicrobial Stewardship Strategies: Education Guidelines and clinical pathways Antimicrobial order forms Combination empirical therapy and de-escalation antimicrobial Conversion from parenteral to oral therapy Antimicrobial dosing Surveillance of antimicrobial resistance Computer Surveillance and Decision Support Monitoring of Process and Outcome Measurements

Policy This guideline only for adult Pharma Middle East 2015 Dubai, UAE Policy This guideline only for adult Antibiotics order form is controlled and guided method to all health provider(physician, pharmacist, clinical pharmacist and nurse during prescribing the antibiotics It is formatting as physician order Using of this order form only for community acquired infection.

Antimicrobial Stewardship Antibiotic Committees Infectious Diseases Team Antibiotics Physician order Form Antibiotics dosing monitoring Aminogylcoside, Vancomycin Switching IV antimicrobial to oral Dose adjustment for Renal Impairment Antibiotics Consumption Antibiogram

Monthly antibiotics consumption

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Antibiotics Committee (Central) 15 20 (Region) 250 (Peripheral) 80-100 (PCC) Antibiotics Manual Booklet Antibiotics Manual Electronic Antibiogram (Central) Antibiogram (Region) Antibiogram (Peripheral)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Antibiotics Consumption (Central) 20 (Region) 250 (Peripheral) 80-100 (PCC) Antibiotics Utilization Review Antibiotic Conference

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 2 Antibiotics Course (Central) 2-4 (Region) 250 (Peripheral) 80-100 (PCC) Therapeutic Drug Monitoring 20

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Decrease 20% Resistance Bugs (Central) (Region) (Peripheral) Will not increase Infection Rate

Stewardship Antibiotics Program Indicators 2014 2013 2012 No 1 Decrease 20-50% Antibiotics Cost Reduction (Central) (Region) (Peripheral) (PCC) 50% Privilege of Antibiotics Prescribing

Stewardship Antibiotics Program Indicators 2014 2013 2012 No 1 50% Antibiotics Policy Adherence (Central) (Region) (Peripheral) (PCC) Antibiotics Automatic Stop order

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Days of Therapy (DOT) (Central) (Region) (Peripheral) (PCC) Defined Daily Dose (DDD)

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Post Marketing Surveillance (Central) (Region) (Peripheral) (PCC) Drug Quality Reporting System

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 Antibiotic Medication Errors (Central) (Region) (Peripheral) (PCC) Antibiotic Adverse Drug Reaction

Antimicrobial Stewardship Program Indicators 2014 2013 2012 No 1 No of Mortality due to Infections (Central) (Region) (Peripheral) No of Parenteral Antibiotic (PCC)

Pharma Middle East 2015 Dubai, UAE Conclusion