Antimicrobial Stewardship
i.e. an organised antimicrobial management program in line with therapeutic guidelines and local incidence of antimicrobial-resistant pathogens
Infection Control
i.e. prevention of the spread of antibiotic resistant organisms particularly in healthcare settings according to national / international standards
Principles of antimicrobial use
The Antimicrobial Creed
M Microbiology guides therapy wherever possible
I Indications should be evidenced-based
N Narrowest spectrum therapy required
D Dosage individualised to the patient and appropriate to the site and type of infection
M Minimise duration of therapy
E Ensure oral therapy is used where clinically appropriate
Antibiotic Therapies
Prophylactic therapy: aims to prevent
infection when there is a significant
clinical risk of infection developing
Empirical therapy: treats an
established infection when the
causative agent has not been
identified
Directed therapy: treats an
established infection when the
pathogen has been identified
Prophylactic therapy
aims to prevent infection when there is a
significant clinical risk of infection developing
- restrict to when evidence of efficacy or when consequences of infection would be associated with significant morbidity or mortality
- base antimicrobial choice on the likely pathogen
- use a single perioperative dose sufficient to achieve adequate intraoperative tissue concentration at the time contamination is most likely
Empirical therapy
treats an established infection when the
causative agent has not been identified
- restrict to when clear indication for therapy and likely clinical benefit
- obtain specimens for laboratory diagnosis
- base antimicrobial choice on the likely pathogen and antimicrobial susceptibility
- review empirical therapy at 48 to 72 hours
- obtain laboratory diagnostic and antimicrobial susceptibility information
Directed therapy
treats an established infection when the pathogen
has been identified
- critically evaluate laboratory results to distinguish infection from colonisation or contamination
- direct therapy in accordance with clinical guidelines using the most effective, least toxic and narrowest spectrum drug available
- use a single drug unless combination therapy is required for efficacy
- optimise antimicrobial dosage, and monitor blood concentrations for drugs with a narrow therapeutic index
- use oral therapy when clinically appropriate
- keep duration of therapy as short as possible
Key Elements of bpacNZ Antimicrobial Stewardship Guidelines
Recommendations for Organisations (NZ AMR Group, DHBs (Health NZ))
- Antimicrobial Stewardship Programmes
- Antimicrobial Stewardship Teams
- Antimicrobial Stewardship Interventions
Communication (NZ AMR Group, DHB AMR Teams, PHARMAC)
Laboratory Testing (NZ AMR Group, DHB AMR Teams, ESR)
Recommendations for Prescribers and other Healthcare Providers
- selecting the most appropriate antimicrobial agent
- prescribing the shortest effective course
- the most appropriate dose
- route of administration
New Antimicrobials (NZ AMR Group, DHB AMR Teams, PHARMAC and Medsafe)
Principles of Infection Control
The SPREAD OF INFECTION within health care requires three elements:
• A source of infecting organisms (bacteria, viruses, fungi);
• A susceptible host;
• A route of transmission of the organism from one person / site to another
Source: The source may be patients, staff or visitors and may include persons with obvious acute
illness, or those who are asymptomatic or colonised by the infectious agent. Another source may be the
patient’s own microbiota. Other potential sources are objects in the environment that are contaminated,
including health care equipment.
Host (patient): The patient’s resistance to pathogenic micro-organisms varies. Some patients may be
immune to or able to resist colonisation by an infectious agent, others may simply be colonised and
become asymptomatic carriers, where others will develop a clinical disease. Persons with underlying
disease such as diabetes, lymphoma, leukaemia, or treated with certain antimicrobial agents,
corticosteroids, irradiation or immunosuppressive agents are particularly prone to infection. Extremes of
age, chronic debilitating disease, shock, coma, traumatic injury or surgical procedures, presence of
invasive devices can also make an individual more susceptible to infection.
Transmission: Micro-organisms can be transmitted by a variety of routes and the same micro-organism
may be transmitted by more than one route. There are four main routes of transmission:
Contact, Droplet, Infected food or drink, vectors
Term for chain of infection
The spread of microbes from source to a susceptible host
Some basic principles apply dependent on the route of spread of the micro-organism and include:
- In the prevention of infection by contact the following measures are important:
• Effective hand hygiene is the single most important measure in the prevention of the spread of
infection;
• Health care staff should wear suitable gloves and other protective clothing whenever there is any
possibility of direct contact with infected blood, body fluids or contaminated material;
• Strict adherence to principles of aseptic technique will minimise the likelihood of contamination during
the insertion and management of invasive devices and other clinical procedures such as wound care. - In the prevention of infection by inanimate objects and the environment in the health care setting the
following measures are important:
• Effective environmental cleaning and good housekeeping techniques together with appropriate
cleaning, disinfection and sterilization of medical equipment;
• Appropriate segregation and disposal of healthcare waste and contaminated laundry. - In the prevention of infection by food and drink the following measures are important:
• Provision of adequate hand washing facilities, especially when handling or preparing food;
• Strict adherence to food hygiene regulations;
• Healthcare environments are subject to strict controls to minimise the risk of Legionella pneumophila;
• Food handlers suffering from septic conditions of the skin or gastro-intestinal infections MUST be
excluded from work until proven to be microbiologically free from infection. - In the prevention of spread of infection by the airborne route the following measures are important:
• Adequate un-crowded housing;
• Segregating infected patients to minimise the risk of cross-infection. This is usually in single rooms in
hospital or by use of a separate waiting room in a GP surgery;
• Vaccination / immunisation programmes where appropriate. - In the prevention of infection by vectors the following measures are important:
While most people readily associate rats and mice with risks to health, the part played by cockroaches
and other insects is not always appreciated. They have been implicated in the transmission of infection in
food stores and food preparation areas as well as in the home. Therefore, adequate measures for pest
control in food preparation areas in the health care setting must be implemented.
NZS 8143.3:2008 Infection Prevention and Control Standards
Standard 1: There is a managed environment, which minimises the risk of infection to consumers,
service providers, and visitors. This shall be appropriate to the size and scope of the service.
Standard 2: There are adequate human, physical, and information resources to implement the
infection control programme and meet the needs of the organisation.
Standard 3: Documented policies and procedures for the prevention and control of infection reflect
current accepted good practice and relevant legislative requirements and are readily available and are
implemented in the organization. These policies and procedures are practical, safe, and
appropriate/suitable for the type of service provided.
Standard 4: The organisation provides relevant education on infection control to all service providers,
support staff, and consumers.
Standard 5: Surveillance is carried out in accordance with agreed objectives, priorities, and methods
that have been specified in the infection control programme.
Standard 6: Acute care and surgical hospitals will have established and implemented policies and
procedures for the use of antibiotics to promote the appropriate prudent prescribing in line with
accepted guidelines. The service can seek guidance from clinical microbiologists or infectious disease
physicians.
Standard Infection Control Precautions (SICPs)
SICPs are the basic infection prevention and control measures necessary to reduce the risk of
transmitting infectious agents from both recognised and unrecognised sources of infection.
There are 10 elements of SICPs: (only know first 4)
- Patient placement
- Hand hygiene
- Respiratory and cough hygiene
- Personal protective equipment
- Patient Placement/Assessment for Infection Risk
Patients must be promptly assessed for infection risk on arrival at the care area, e.g.
inpatient/outpatient/care home, (if possible, prior to accepting a patient from another care area) and
should be continuously reviewed throughout their stay. This assessment should influence placement
decisions in accordance with clinical/care need
- Hand Hygiene
Hand hygiene is considered one of the most important ways to reduce the transmission of
infectious agents that cause healthcare associated infections (HCAIs).
Clinical hand-wash basins (HWBs) must:
• be used for that purpose only and not used for the disposal of other liquids
• have mixer taps, no overflow or plug and be in a good state of repair
• have wall mounted liquid soap and paper towel dispensers.
- Respiratory and Cough Hygiene
Respiratory and cough hygiene is designed to minimise the risk of cross-transmission of known or suspected respiratory illness (pathogens):
- Personal Protective Equipment (PPE)
Before undertaking any procedure, staff should assess any likely exposure to blood and/or other
body fluids, non-intact skin or mucous membranes and wear personal protective equipment (PPE)
that protects adequately against the risks associated with the procedure.
Transmission Based Precautions (TBPs)
Transmission based precautions (TBPs) are additional measures (to SICPs) required when caring for
patients/ individuals with a known or suspected infection such as COVID-19. TBPs are based upon the
route of transmission and include:
a) Contact precautions: Used to prevent and control infections that spread via direct contact with the
patient or indirectly from the patient’s immediate care environment (including care equipment). This is
the most common route of infection transmission. COVID-19 can be spread via this route.
b) Droplet precautions: Used to prevent and control infections spread over short distances (at least 3
feet/1 metre) via droplets (>5μm) from the respiratory tract of individuals directly onto a mucosal
surfaces or conjunctivae of another individual. Droplets penetrate the respiratory system to above the
alveolar level. COVID-19 is predominantly spread via this route and the precautionary distance
has been maintained at 2 metres in care settings.
c) Airborne precautions: Used to prevent and control infection spread without necessarily having close
patient contact via aerosols (≤5μm) from the respiratory tract of one individual directly onto a mucosal
surface or conjunctivae of another individual. Aerosols penetrate the respiratory system to the alveolar
level. COVID-19 can spread via this route when Aerosol Generating Procedures (AGPs) are undertaken
Global Action Plan on Antimicrobial Resistance
In 2015, the WHO published a Global Action Plan on Antimicrobial Resistance to provide a
framework for governments around the world to develop their own national strategies to combat
antimicrobial resistance
Antimicrobial Resistance Action Plan
In 2017, New Zealand published its national Antimicrobial Resistance Action Plan which contains
5 key objectives covering: Awareness and Understanding; Surveillance and Research; Infection
Prevention and Control; Antimicrobial Stewardship; Governance, Collaboration and Investment
who developed Antimicrobial Stewardship Guidelines, and
Infection Prevention and Control Standards
New Zealand has also developed Antimicrobial Stewardship Guidelines, and Infection Prevention and Control Standards
Standard Infection Control Precautions COVID 19
Following the advent of the COVID-19 pandemic, additional Transmission Based Precautions (TBPs) are used in addition to Standard Infection Control Precautions (SICPs) when caring for patients or individuals with a known or suspected infection such as COVID-19
