Question 18

College answer

Syllabus topic/section:

2.1.3 Sepsis and Infections: Antimicrobial use in ICU: L1

Discussion: 

Overall, this question was answered well, with some candidates scoring very high marks. Some candidates spent a long time on part a) which was only worth 2 marks and candidates are reminded to focus their time according to the mark allocation and weighting.

Candidates who did well were aware of the National Safety and Quality Health Service National Standard and included both the purpose of an AMS team (the 4D’s being one of the common acronyms for this-but specifying the 4Ds was not required to score full marks) and its structure (multi-disciplinary review of antibiotics in ICU). In part b) candidates who did poorly only included a small number of advantages and disadvantages with minimal discussion about each one, despite this part being worth 8 marks.
 

Discussion

Principles: 

The four Ds mentioned in the examiner comments appear to originate from the paper by Doron & Davidson (2011) where the D words are:

The right Drug
The right Dose
The right Duration
The right De-escalation to a narrower spectrum antimicrobial

But that does not seem like it would be all the principles, and so perhaps something like this, integrating some of the Ds into a statement, would be better:

• Coordinated interventions intended to preserve the efficacy of available antibiotics:
  • Effective infection control to prevent transmission
  • Early source control
  • Guidelines for empiric and targeted therapy, including dose, shortest effective duration, and instructions for de-escalation
  • Culture-targeted reassessment of therapy 
  • Monitoring of adherence to these guidelines through antibiotic consumption and audit
  • Feedback and education to prescribers
  • Surveillance of antimicrobial resistance

"The principles" in this SAQ also appears to mean "structure of the AMS team"; possible staff on that committee could include:

• Medical specialists in "infectious diseases, intensive medicine, internal medicine, paediatrics, clinical pharmacology, surgery" (Richards, 2016);
• nurses;
• specialist pharmacists;
• microbiologists;
• members of management;
• members of the Infection Control Committee

b)

Advantages:

• Benefits would be maximal in the ICU:
  • Antibiotic use and infectious disease is prevalent in the ICU
  • Critically ill patients are the most vulnerable to adverse drug effects and resistant organisms
• Safety improvement:
  • Reduced antibiotic toxicity
  • Reduced MRO colonisation
• Reduced health care costs
  • Reduced use of expensive novel agents
  • Reduced length of ICU stay due to less MRO-induced infections
• Increased patient exposure to infections disease specialist attention
• Involvement of specialist pharmacists could improve the identification of adverse reactions and possible drug interactions, preventing morbidity
• Use of computer-assisted decision support for antibiotic prescribing could simplify prescribing
• Standardised order sets could improve empirical coverage, reducing missed infectious agents

Disadvantages:

• There is the possibility that antibiotic stewardship, with its emphasis on stopping or not starting antibiotics, could lead to patient harm from missed sepsis
• Delay imposed by the need to seek approval could lead to worse patient outcomes (as the timing of early antibiotics is thought to be important for reducing mortality)
• Manpower-expensive: increased referrals increase the workload of ID specialists
• Resource-expensive: pharmacists, physicians, administrators need to be recruited
• Resistance will emerge to the classes of drugs favoured by the stewards
• Antibiotic resistance will still develop in the community because of non-medical (eg. agricultural and veterinarian) antibiotic use
• Antibiotic stewardship may be unacceptable culturally in the closed model of ICU care
• May not improve clinical outcomes (eg. mortality) at the institution level
• No evidence that it decreases the incidence of adverse drug reactions.