الفهرس 
Carbapenem resistance EnterobacteralsOnly 14 pages are availabe for public view
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Abstract
Carbapenem resistant Enterobacterals (CRE) colonization has been recognized as a major public health threat, on the other hand infections caused by these organisms cause significant morbidity and mortality. There are numerous drug resistance mechanisms in gram-negative bacteria (GNB); β lactamase genes carried on mobile genetic elements are a key mechanism for the rapid spread of antibiotic-resistant GNB globally. CDC recommended screening for CRE colonization and\or infection for better control, clinical laboratory and standards institute stated the modified carbapenem inactivation method (mCIM) for screening for CRE and stated EDTA carbapenem inactivation method (eCIM) to differentiate between Metallo β lactamases and other types of CRE when mCIM is positive. chromogenic agar is a sensitive, specific and rapid media used for screening but not approved by CLSI yet.
With the emergence of carbapenemase-producing Enterobacterals as well as multi-drug resistant Pseudomonas aeruginosa and Acinetobacter baumannii, colistin has become a last-resort agent. As a result, the evolution of colistin resistance in multidrug-resistant bacteria is a major clinical and public health problem.
Many interventions have been demonstrated to beat that spread, one of which is the antimicrobial stewardship programs on the international, national and facility levels. One of the major pillars of the antimicrobial stewardship programs is the perioperative antibiotic surgical prophylaxis (PAP) which is critical to preventing the emergence of bacterial resistances e.g. CPE, which are a well-known threat to hospitalized patients. On the other hand, it is critical to preventing surgical site infections (SSIs), which are the second most common healthcare-associated infection and complicate approximately 5% of surgical procedures each year, according to the Centers for Disease Control (CDC).
In our study, we conducted improvement project with the use of FOCUS PDCA method to implement and find the impact of ASP on antibiotics usage and antimicrobial resistance with special emphasis on carbapenem resistant and colistin resistant Enterobacterals. For finding the problem we worked on three parameters which are:
1) Rates of antimicrobial resistance& its increase which was identified through screening of patients doing clean and clean contaminated surgeries for carbapenem resistant Enterobacterals and colistin resistant Enterobacterals (through culture on chromagar media, mCIM test, IMP-IMP EDTA test and colistin E test), antibiogram, and rates of multiple drug resistant organisms (MDR).
2) Antibiotics Use & Misuse of which was identified through point prevalence for antibiotic usage
3) Assessing behavioral effect on infection rates and antimicrobial resistance rates through infection control compliance assessment, SSI rates and base line behavioral assessment.
After Organizing the team and committee formation we Clarified how the process works according to WHO toolkit for antibiotic stewardship program implementation, then we used SWOT analysis, fish bone analysis (Ishikawa diagram) and Pareto chart to Understand the root causes of the problem.
from the previous steps we identified the strategic goals, made gap analysis for the program implementation steps according to pre-identified standards and barriers in implementing the program to select area for improvement. then we started Plan phase where the selected areas of improvement were plotted and a Gantt chart was done to define the stages of implementation with timeline. After that a detailed action plan was done in the Do phase.
In Check phase, efficacy of the project was checked by comparing the interventions results through the same tools used in identifying the problem and assessment of the program according to WHO and CDC tool kits for core elements assessment and program assessment. Finally in the Act phase we re-identified the areas of improvement, barriers in implementation and recommended actions and solutions, also mentioned changes that should be standardized and stabilized and recommended another PDCA cycle again for the actions that we failed to achieve.
In our study we implemented almost all of the stewardship core elements and infection control compliance increased from 69% to 94% beside an increase in the cumulative usage of access group from 15.3% to 28.8% with a decrease in the Cumulative usage percent for carbapenems from 35.4% before ASP to zero percent after ASP implementation. Also, a significant decrease in the rates of MDR organisms from 33.6% to 28.3% occurred, A significant decrease in rates of Pseudomonas species from 17.3% to 11% and in MDR Pseudomonas species from 9.6% to 4.7% besides a significant decrease in the ESBL rates of Klebsiella species (other than pneumoniae) from 5.3% to 2.1%.
Sensitivity of some antibiotics significantly increased towards gram positive and gram-negative species while other sensitivity of other antibiotics significantly increased due to abuse of antibiotics in the hospital and community as well.
On screening of 60 patients before ASP and 60 patients after ASP (swabs from SSI of clean and clean contaminated surgeries) and Enterobacterals isolates were then cultured on chromagar media to screen for their resistance to carbapenems, and were subjected to mCIM and IMP-EDTA tests to screen for carbapenemase production and type, as well as their screening for colistin resistance by colistin E test, no significant change was observed mostly due to the short duration of the study.
Carbapenem resistant Enterobacterals (CRE) colonization and infection is a major public health threat and causes significant morbidity and mortality. ASP is one of the main pillars designed to fight antimicrobial resistance. In our study we found a great positive impact on antimicrobial resistance and antimicrobial consumption in surgical prophylaxis without affection of patient sequela. Preauthorization combined with training, monitoring and reporting were effective in the implementation of the ASP but greater results would have happened if the study duration was longer.
Pharmacy recommendations:
1. Tracking antibiotics dispensing methods as regarding site and time.
2. Calculating amounts of antibiotics dispensed for clean and clean-contaminated surgeries versus number of surgeries done via defined daily dose (DDD).
3. Proper documentation of antibiotics indications.
4. Apply forms of Egyptian drug authority to track antibiotic usage and calculate DDD, review dates, de-escalation protocols.
5. Implement IV to oral shift protocol.
6. Implement pharmacy information technology system and activate antibiotics dispensing control module e.g. automatic stop orders and list of restricted antibiotics.
Recommendations to improve ASP implementation:
7. Make antibiogram for each unit separately to identify areas of weakness and narrow the spectrum of resistance screening.
8. Repeating of the post-intervention screening for carbapenem resistant Enterobacteriaceae after ensuring that there is no interfering factor on the results.
9. MRSA screening for all patients undergoing clean and clean-contaminated surgeries.
10. Expand types of surgeries exposed for targeted surveillance to get more accurate results.
11. Find sources of fund for the program.
12. National banning of purchasing antibiotics without medical prescription.