Antimicrobial Stewardship Interventions: A Practical Guide
Antimicrobial stewardshipinterventions: a practical guide
Antimicrobial stewardshipinterventions: a practical guide
AbstractAntimicrobial resistance (AMR) is a global public health emergency. Antimicrobial stewardshipprogrammes have been identified as one of the core strategies to tackle AMR. How to selectthe most appropriate interventions for each setting however remains challenging. This practicalguide describes 10 commonly used stewardship interventions, which promote the optimaluse of antimicrobials at health care facilities. Administrators, health care leaders and front-lineclinicians learn about the most common interventions, the evidence behind them, as well asimportant implementation considerations, particularly for low-resource settings.ISBN 978-92-890-5626-7This title was initially published under ISBN: 978-92-890-5498-0 World Health Organization 2021Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGOlicence (CC BY-NC-SA 3.0 IGO; igo).Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided thework is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorsesany specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then youmust license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, youshould add the following disclaimer along with the suggested citation: “This translation was not created by the World HealthOrganization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall bethe binding and authentic edition: Antimicrobial stewardship interventions: a practical guide. Copenhagen: WHO Regional Officefor Europe; 2021”.Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of theWorld Intellectual Property Organization. sted citation. Antimicrobial stewardship interventions: a practical guide. Copenhagen: WHO Regional Office for Europe;2021. Licence: CC BY-NC-SA 3.0 IGO.Cataloguing-in-Publication (CIP) data. CIP data are available at http://apps.who.int/iris.Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests forcommercial use and queries on rights and licensing, see http://www.who.int/about/licensing.Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures orimages, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from thecopyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solelywith the user.General disclaimers. The designations employed and the presentation of the material in this publication do not imply theexpression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or areaor of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps representapproximate border lines for which there may not yet be full agreement.The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed orrecommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, thenames of proprietary products are distinguished by initial capital letters.All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, thepublished material is being distributed without warranty of any kind, either expressed or implied. The responsibility for theinterpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use.Address requests about publications of the WHO Regional Office for Europe to:PublicationsWHO Regional Office for EuropeUN City, Marmorvej 51DK-2100 Copenhagen ØDenmarkAlternatively, complete an online request form for documentation, health information, or for permission to quote ortranslate, on the Regional Office website (http://www.euro.who.int/pubrequest).Design and layout: 4PLUS4.dk
nWhere to start?1Interventions prior to or at the time of prescription2816202632Clinician educationPatient and public educationInstitution-specific guidelines for the management of commoninfectionsCumulative antibiogramsPrior authorization of restricted antimicrobialsDe-labeling of spurious antibiotic allergies37Interventions after prescription38445054Prospective audit and feedbackSelf-directed antibiotic reassessments by prescribing clinicians(antibiotic timeouts)Antibiotic dose optimizationAntibiotic duration58Bibliography
AcknowledgmentsThis guide was prepared by Marisa Holubar (WHO Collaborating Centre forAntimicrobial Resistance and Stewardship, Stanford University School of Medicine),Elisabeth Robilotti (Memorial Sloan Kettering Cancer Center), and Stan Deresinski(WHO Collaborating Centre for Antimicrobial Resistance and Stewardship, StanfordUniversity School of Medicine), under the technical guidance of Saskia Nahrgang(WHO Regional Office for Europe).Input and review were provided by Ketevan Kandelaki (WHO Regional Office forEurope), Danilo Lo Fo Wong (WHO Regional Office for Europe), and Onur Karatuna(European Committee on Antimicrobial Susceptibility Testing (EUCAST) DevelopmentLaboratory).This document was produced with the financial assistance of theEuropean Union. The views expressed herein can in no way betaken to reflect the official opinion of the European bial resistanceAccess Watch Reserve [classification system]Clinical and Laboratory Standards Institutecentral nervous systemintensive care unitpenicillinWorld Antimicrobial Awareness Week
IntroductionIntroduction: Antimicrobial resistance (AMR) is a global public healthemergency. AMR is the ability of a microorganism to survive and resistexposure to antimicrobial drugs, threatening the effectiveness of successfultreatment of infection.There are different types of antimicrobials, which work against different typesof microorganisms, e.g. antibacterials or antibiotics against bacteria, antiviralsagainst viruses, antifungals against fungi, etc.Antimicrobials are life-saving drugs and their discovery is among themost important scientific advances of the 20th century. There is, however,accumulating data demonstrating that antimicrobial misuse is widespreadin all health care settings. The misuse of antimicrobials in human health careis one of the key modifiable drivers of the emergence of AMR. Antimicrobialstewardship in this practical guide refers to coordinated interventions designedto promote the optimal use of antibiotic agents, including the decision to usethem, drug choice, dosing, route, and duration of administration.Objective: This practical guide describes some commonly used stewardshipinterventions, which promote the optimal use of antimicrobials at health carefacilities. Although evidence to support these interventions is primarily fromstudies conducted in high-income countries, this guide highlights ways toadapt these interventions to resource-limited settings.Target audience: The target audience are administrators and health careleaders who are new to antimicrobial stewardship and are planning to implementone or more interventions in their health care setting. Clinicians interested inantimicrobial stewardship may also use this document as a reference.Scope: There are 10 interventions in this practical guide, six of which occur priorto or at the time of prescription and four of which occur afterwards. They arelisted in Table 1 and there is a summary sheet for each intervention. Althoughthis list is not comprehensive, the selected interventions are those that arecommonly deployed, and their impact has been assessed in the medicalliterature.vii
Table 1. List of 10 interventions in this compilationInterventions prior to or at thetime of prescriptionInterventions after prescription1. Clinician education7. Prospective audit and feedback2. Patient and public education8. Self-directed antibiotic reassessments (antibiotics timeouts)3. Institution-specific guidelines forthe management of commoninfections9. Dose optimization4. Cumulative antibiograms10. Duration optimization5. Prior authorization of restrictedantimicrobials6. De-labeling of spurious antibioticallergiesRelevance to clinicians: Front-line clinicians play a vital role in protecting the powerof antimicrobials. In the OpenWHO online course, “Antimicrobial Stewardship: Acompetency-based approach”1, it was illustrated how clinicians can improve theirantibiotic prescribing by using the clinician-patient encounter as a framework. Thesesteps in clinical decision-making, depicted in Fig. 1, will be familiar to clinicians.Although the timing may differ in the outpatient and inpatient settings, the generalflow of decision-making is similar. The interventions reviewed in this practical guidetarget different stages in the clinician-patient encounter.1viiiRead more: Antimicrobial Stewardship: A competency-based approach [website]. In: OpenWHO/courses.Geneva: World Health Organization; 2016–2021 ed 24 February 2021).
Fig. 1. Steps in clinical decision-makingInterventions prior to or atthe time of a ecisionsPatienteducationInitial evaluationInterventions aftera prescriptionDatareviewSubsequent evaluationExamples of how to use the practical guide are:as a reference when planning to implement an antimicrobial stewardshipintervention; andz as a tool for educating colleagues and clinicians at your institution aboutantimicrobial stewardship.zBarriers to antimicrobial stewardship: The barriers to appropriateantimicrobial prescribing are numerous and complicated. However,antimicrobial stewardship interventions can overcome these obstacles andbe highly effective. The summary of each intervention calls attention to someof the barriers and how programmes can successfully overcome them. Somecommonly cited barriers are:zzzzzzzzzzclinician knowledge deficits regarding the optimal use of antibiotics;opposition from clinicians to antimicrobial stewardship;limited access to reliable clinical diagnostic or microbiologic testing;limited or unreliable access to quality-assured antimicrobials;fear that withholding antimicrobials, and especially antibiotics will lead topoor outcomes;limited or lack of communication between health care providers;limited infrastructure and/or administrative support for antimicrobialstewardship programmes or interventions;limited access to data, including antimicrobial prescribing trends, at a facility,and of data regarding the prevalence of AMR in the community;limited public/patient acceptance of antimicrobial stewardship; andpublic access to antimicrobials, such as antibiotics, without prescriptions inthe community.ix
Where to start?This depends on your institution’s resources.If your facility has limited access to microbiologic data, consider the followinginterventions:clinician educationz patient and public educationz institution-specific guidelines for the management of common infectionsz duration optimization.zIf your facility has access to timely and accurate microbiology results from amicrobiology laboratory, also consider:zzcumulative antibiogramsself-directed antibiotic reassessments (antibiotic timeouts).If your facility employs clinical pharmacists, consider:zdose optimization.If your facility is planning to or has established an antimicrobial stewardship teamwith dedicated time to review patient cases, consider:prior authorization of restricted drugsz prospective audit and feedbackz de-labeling of antibiotic allergies .zx
Interventions prior to orat the time of prescription1
Clinician educationOngoing clinical education by physicians is essential for the provision of optimalpatient care. It is crucial for policy-makers and health care administrators toprovide opportunities for physicians to address information gaps through clinicaleducation and continuing professional development. New treatments, optimaldiagnostic tools and strategies, and practicing the right prescribing behaviours– all with the focus on patient care and safety – remain the cornerstones ofexcellence in clinical practice and are essential for successful antimicrobialstewardship. Clinical education can occur in many formats, all of which offerdifferent advantages for stewardship training but incur different costs.Rationale for implementing the interventionz The intervention is essential for maintaining knowledge of up-to-date practicesand guidelines for the use of antimicrobials.z Clinician education enhances awareness of local, regional and global threats fromAMR.z Attention to ongoing clinical training is an important aspect of patient safety inhealth care services delivery.Diverse educational materials can be used to address different prescriber learningstyles. Stewardship education can be accomplished in a variety of settings. Newprogrammes or stewardship initiatives with limited resources should leverageexisting open access material to create meaningful clinical education opportunitiesfor prescribers (Fig. 2).2
Fig. 2. Diverse educational resources employed in continuing medicaleducationLearning stylesProblem-based learning,case-based learning,team-based learningLearning settingsWorkshops, discussion sessions,simulation activitiesLearning resourcesOpenWHO (1)MEDtube (2)CDC’s Antibiotic StewardshipTraining Series (3)PrerequisitesEngaged clinicians are needed, who are interested in maintaining up-to-dateclinical education, for their own knowledge and to encourage peers.Strong leadership is needed to support prioritization and to ensure protectedtime for clinicians to engage in continuing education and professionaldevelopment. Leadership can also help by incentivizing human resources tomaintain up-to-date clinical knowledge.Supporting evidencez In a study by Doron & Davidson (4), a significantly greater decrease inannual prescription rates for antibiotics occurred in the educationalintervention group vs the control group and the effect was sustained duringa subsequent four month follow-up period. The educational interventionsincluded lectures, didactic meetings, email memos and telephonecounselling by an expert.z In a study by Regev-Yochay et al. (5), educational interventions, such asgroup meetings, workshops, seminars, and practice campaigns, resultedin a decrease in the total antibiotic prescription rates in children treated byphysicians who attended those educational interventions, compared tocontrol physicians (observed in the first intervention year).z In a study by Weiss et al. (6), the distribution and presentation of userfriendly educational materials (guidelines) to physicians and dentists inQuebec significantly reduced antibiotic prescribing compared with the restof Canada.3
z Behavioural interventions were shown to reduce inappropriate prescribing inmultiple settings. In primary care, peer comparison and accountable justificationreduced inappropriate antibiotic prescriptions for acute respiratory tract infections,most of which are viral (7,8).When should you choose this intervention and for whichsettings is it appropriate?zClinical education is appropriate to all clinical practice settings and alllevels of training.zFacilities with limited resources can develop clinical educational materialon a limited number of institutionally relevant stewardship topics.zClinical education is often combined with other stewardship interventions to provide an in-depth rationale for certain approaches (e.g. trainingin pharmacokinetics/pharmacodynamics) enhances understanding ofantimicrobial prophylaxis).Risks/costsRisks/costs include:z a lack of time to pursue continuing professional development;z a lack of available educational materials for a broad audience;z concerns about local applicability of mass educational programmes; andz psychological barriers of individual clinicians towards engaging in some of theeducational interventions (e.g. the fear of not knowing enough).4
Examples of educational exercises1. On the occasion of the annual World Antimicrobial Awareness Week (18-24November), organize an educational event addressing the prudent use ofantibiotics targeted at one or more of the following types of audience: (I)(II)(III)(IV)physicians (junior and/or senior)health care professionals in generalstudentspatients.You can use this opportunity to conduct a questionnaire among the targetgroups in order to assess their level of awareness about AMR, hand hygieneand antibiotic stewardship practices. These data could be used in the futurefor research purposes or to establish an ongoing clinical education agenda.2. Within your clinical practice, discuss team cases involving antimicrobialtreatment that you encountered which posed diagnostic or treatmentchallenges. In your presentation try to include:(I)(II)(III)(IV)(V)(VI)Signs and symptomsLaboratory resultsImaging performedTreatment (especially current guidelines)Outcomes and follow-upProphylaxisEncourage the presentation of cases by different team members on aregular basis. Make it a recurring session of meetings and discussions.Consider interdisciplinary case conferences which may include discussionwith other departments within your institution (e.g. case conference on jointpulmonary/critical care and infectious diseases).3. Organize mini-review seminars with your clinical team to discuss recentupdates on treatment guidelines for infections related to your department.Encourage all team members (e.g. nurses, physicians, students) to beinvolved in planning the content and delivering information updates atregular intervals (quarterly/annually).NOTE: Formal (surveys) and informal (comments from attendees) feedback should be part of theroutine evaluation of clinical education exercises to assess the utility of educational offerings for thetarget audience. Information from these surveys can be reviewed with leadership in order to ensureappropriate resource allocation.5
References1. OpenWHO [website]. Geneva: World Health Organization; 2016-2021 (https://openwho.org/).2. MEDtube [website] (https://medtube.net/).3. CDC’s Antibiotic Stewardship Training Series [website]. In: CDC TRAIN. Atlanta:Centers for Disease Control and Prevention (https://www.train.org/cdctrain/training plan/3697).4. Doron S, Davidson LE. Antimicrobial stewardship. Mayo Clin Proc. 2011;86(11):1113–23. doi: 10.4065/mcp.2011.0358.5. Regev-Yochay G, Meir R, Dagan R, Roizin H, Morag B, Hetman S, et al. Reductionin antibiotic use following a cluster randomized controlled multifaceted intervention: the Israeli judicious antibiotic prescription study. Clin Infect Dis. 2011;53(1):33–41. doi: 10.1093/cid/cir272.6. Weiss K, Blais R, Fortin A, Lantin A Gaudet M. Impact of a multipronged education strategy on antibiotic prescribing in Quebec, Canada. Clin Infect Dis.2011;53(5):433–9. doi: 10.1093/cid/cir409.7. Persell SD, Doctor JN, Friedberg MW, Meeker D, Friesema E, Cooper A, et al. Behavioral interventions to reduce inappropriate antibiotic prescribing: a randomizedpilot trial. BMC Infect Dis. 2016;16:373.8. Meeker D, Linder JA, Fox CR, Friedberg MW, Persell SD, Goldstein NJ, et al, Effect of Behavioral Interventions on Inappropriate Antibiotic Prescribing AmongPrimary Care Practices: A Randomized Clinical Trial. JAMA, 2016. 315(6): p. 562-70.doi:10.1001/jama.2016.0275.6
WHO/Yoshi Shimizu7
Patient and public educationPatients and the public should be educated about the proper use, administration,storage and disposal of antimicrobials, such as antibiotics, so they can becomeallies in the fight against AMR. This education can take two explicit forms: 1) masseducation campaigns which inform the public, such as informational messagingabout influenza and the fact that antibiotics do not treat viral infections; and2) direct clinician to patient education targeting a specific medical condition. Bothtypes of education increase overall public awareness of AMR and work to counterthe rampant misinformation and misconceptions about antibiotics in the publicsphere.Rationale for implementing the interventionAMR is a global problem. The solution requires individual, local, national andinternational solutions. Collective awareness of this problem by patients and thepublic at large is an important part of stemming the tide of AMR.Prerequisitesz Human resources: Clinical and non-clinical personnel need time to develop andimplement a communication strategy at a specific institution. It is helpful if thosecharged with patient/public education missions can assess what the patients/public already know about AMR and adapt messaging accordingly (e.g. accessto community survey data or national antimicrobial utilization trends can enhancetargeted messaging to certain populations). Consider integrating messaging aboutAMR with other local health education campaigns (e.g. importance of vaccines,food safety and hand hygiene).8
z Technical/Implementation resources: Free material accessible on the Internetmay need to be adapted to the local context. For example, teams may needresources to adapt materials for specific patient populations (e.g. pediatric/adolescent patients, parents; patients with different languages). Higher-ordertechnical support to develop visual or multimedia material is an advantagebut not a necessity. Web-based content, including the use of social media,may be utilized, including materials developed by WHO, such as thosededicated to World Antimicrobial Awareness Week (WAAW) (see linksbelow).z Support of leadership: Dedicated commitment from the administrativeleadership, regarding the importance of AMR messaging to patients and thepublic, can vastly extend the reach of your message.Relevant literaturez General information is available on public awareness and responsibility inthe judicious use of antibiotics (1).z The problem that there is limited public knowledge about antibiotics andAMR is global and affects the full spectrum of patients, from pediatric toadult care (2-4).z Communicating your message about AMR is complex and needs to bedone in the context of other important and related health messaging (5).z Training and involvement can be supported by multiple participants in thehealth care system (6).z Online pledges can increase public and health care professionalengagement with the problem of AMR (7).9
Consider the message you would like to sharePublic education on antimicrobial use can take many forms. It is important toprovide a consistent, easily understood, evidence-based message about appropriate antimicrobial use that is also supported by all stakeholders involvedin your educational campaigns (e.g. local leaders, patient advocates, community members, physicians, nurses). Examples of key concepts on which youmay focus your education campaigns, and which have been included in manystewardship initiatives, include:zzzzzzzzHow do antibiotics work?What types of diseases and conditions can antimicrobials treat?How does antibiotic resistance develop?When should I take antibiotics?Why is it important to follow instructions on the duration and dosage ofantibiotic therapy?What should I do with leftover antibiotics?How are antibiotics used outside of human medicine?What else can I do to reduce my risk for diseases that antibiotics cannotreduce? (e.g. importance of vaccines for vaccine-preventable diseases)Each patient visit is an opportunity to touch on one of these important aspectsof AMR education. Encourage patients to ask questions and clarify what theydo not understand. Create a safe space for sharing their doubts and worriesconcerning the use or avoidance of antibiotics.10
Examples of WHO campaigns and other useful interactivematerialsWorld Antimicrobial Awareness Week (8)Hand Hygiene Day, 5 May. An example of WHO campaign “Save lived: CleanYour hands” (9)World Immunization Week 2019 (10)Messages for the general public regarding AMR (11)An interactive website with awareness activities produced for WorldAntibiotic Awareness Week (12)Superbugs: the game to play on smartphone or tablet (13)A comic book in Spanish “Superheroes against Superbugs: AntimicrobialResistance” (14)YouTube video: Stop the superbugs (15)Educating patients about antibiotic use (16) WHO/Yoshi Shimizu11
When should you choose this intervention and for whichsettings is it appropriate?zHospitals vs ambulatory care: Patients often stay in the hospital for along enough time to allow you to have more opportunities to engage ineducational interventions and reinforce your message. Patients seen inthe ambulatory care setting may be less ill, and more focused on the bigpicture rather than acute medical conditions, and thus more attuned toaccept educational information. Additionally, ambulatory patients mayhave a better-established relationship with clinicians, making it easierfor them to receive AMR information and repeat messaging. Patientsare often accompanied by their families in both settings which may helpimprove retention of the message.zAcademic setting: Students can be great educators for patients. Theyoften have more time available to dedicate to one-on-one education.Furthermore, engaging in such educational activities helps to consolidate students’ knowledge, develop skills and language necessary fordoctor-patient communication as well as build up self-confidence whencontributing to crafting pro-health behaviours in the community.zWaiting rooms: These can serve as useful spaces for providing healthcare information while a patient awaits an appointment and are excellentvenues to leverage the use of technology to enhance your message.Risks/costsz Patient education is time-consuming and requires repeat messaging.z Information acquisition may vary across a population based on willingness toaccept ideas about AMR and baseline knowledge of basic scientific concepts.z Certain information about AMR may cause anxiety (e.g. colonization with bacteriaproducing extended-spectrum beta-lactamases) or fear of stigmatization (amongmarginalized populations, such as refugees or immigrants).12
References1. Ancillotti M, Eriksson S, Veldwijk J, Fahlquist JN, Andersson DI, GodskesenT. Public awareness and individual responsibility needed for judicious use ofantibiotics: a qualitative study of public beliefs and perceptions. BMC PublicHealth. 2018;18(1): 1153. doi.org/10.1186/s12889-018-6047-8.2. Bert F, Gualano MR, Gili R, Scaioli G, Lovato E, Angelillo IF, et al. Knowledgeand attitudes towards the use of antibiotics in the paediatric age group: amulticenter survey in Italy. Eur J Public Health. 2017;27(3):506–12.doi: 10.1093/eurpub/ckw209.3. Kamata K, Tokuda Y, Gu Y, Ohmagari N, Yanagihara K. Public knowledge andperception about antimicrobials and antimicrobial resistance in Japan: A national questionnaire survey in 2017. PLoS One. 2018;13(11):e0207017.doi: 10.1371/journal.pone.0207017.4. Mazinska B, Struzycka I, Hryniewicz W. Surveys of public knowledgeand attitudes with regard to antibiotics in Poland: Did the European Antibiotic Awareness Day campaigns change attitudes? PLoS One.2017;12(2):e0172146. doi: 10.1371/journal.pone.0172146.5. Rush L, Patterson C, McDaid L, Hilton S. Communicating antimicrobial resistance and stewardship in the national press: Lessons from sepsis awarenesscampaigns. J Infect. 2019;78(2):88–94. doi: 10.1016/j.jinf.2018.09.001.6. Childs-Kean LM, Briggs HL, Cho JC. All aboard!: Involvement of medical andpharmacy trainees in antimicrobial stewardship. Infect Control Hosp Epidemiol. 2018;40(2):1–6. doi: 10.1017/ice.2018.332.7. Chaintarli K, Ingle SM, Bhattacharya A, Ashiru-Oredope D, Oliver I, GobinM. Impact of a United Kingdom-wide campaign to tackle antimicrobial resistance on self-reported knowledge and behaviour change. BMC PublicHealth. 2016;16(1):393.doi: 10.1186/s12889-016-3057-2.8. World Antimicrobial Awareness Week (WAAW) [website]. Geneva: WorldHealth Organization; 2021 -awareness-week; accessed 5 February 2021).9. SAVE LIVES: Clean Your Hands 5 May 2019 [website]. Geneva: World HealthOrganization, 2019 s/clean-hands/5may2019/en/, accessed 5 February 2021).10. World Immunization Week 2019 [website]. Geneva: World Health Organization, 2019 week/2019, accessed 5 February 2021).13
11. Key messages to the general public. In: European Antibiotic Awareness Day[website]. Stockholm: European Centre for Disease Prevention and Control, ormedkey-messages/key-messages-general-public, accessed 5 February 2021).12. Antibiotics handle with care, World Antibiotic Awareness Week 2019 [website].Rome, Paris and Geneva: Food and Agriculture Organization of the United Nations, World Organization for Animal Health, and World Health Organization, ss-week/activities/en, accessed 5February 2021).13. Superbugs the mobile game. In: Longitude Prize [website] London: Nesta, 58Vicitoria Embankment, 2019 ce/superbugs, accessed 5 February 2021).14. Superheroes Against Superbugs: An
Feb 24, 2021 · ix Fig. 1. Steps in clinical decision-making Examples of how to use the practical guide are: z as a reference when planning to implement an antimicrobial stewardship intervention; and z as a tool for educating colleagues and clinicians at your institution about antimicrobial stewardship. Barriers to a
Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129
A Hospital Pharmacist’s Guide to Antimicrobial Stewardship Programs Greater New York Hospital Association United Hospital Fund — Antimicrobial Stewardship Toolkit - Best Practices from the GNYHA/UHF Antimicrobial Stewardship Collaborative National Quality Pa
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Antimicrobials, Aspergillus fumigatus, Antimicrobial Peptides 1. Introduction 1.1. Antimicrobial Peptides and Proteins It is notable that antimicrobial peptides particularly cationic ones play a signifi-cant role within the natural immunity of animal defences against topical and general microbes altogether species of life. These antimicrobial .
Antimicrobial Peptides 2 ANTIMICROBIAL PEPTIDES OFFERED BY BACHEM Ribosomally synthesized antimicrobial peptides (AMPs) constitute a structurally diverse group of molecules found virtually in all organisms. Most antimicrobial peptides contain less than 100 amino acid residues, have a net positive charge, and are membrane active. They are major
A PRACTICAL PERSPECTIVE: STEWARDSHIP FOSTERING RESPONSIBLE LONG-TERM WEALTH CREATION Introduction: Stewardship in a nutshell How can a business thrive and sustain growth while enhancing the wealth of its stakeholders and the well-being of the societies in which it operates? This, in essence, is the question stewardship aims to answer.
Virology 15 Mycology 17 Parasitology 17 Interpretation of Viral Diagnostic Tests 19 Antimicrobial Formulary 23 Antimicrobial Costs 25 Antimicrobial Concepts and Tips 27 Antimicrobial Restrictions and . identification and susceptibility testing on most comm
Tulang tergolong jaringan ikat yang termineralisasi (Ardhiyanto, 2011), termasuk jaringan ikat khusus (Lesson et al, 1995). Komposisi dalam jaringan tulang terdiri dari matrik organik dan matrik inorganik (Nanci, 2005). Sel-sel pada tulang antara lain osteoblast, osteosit, osteoklas dan sel osteoprogenitor. Osteoblast ditemukan dalam lapisan .
