I.

SCOPE & PURPOSE

1. The Manual of Procedures for Implementing Antimicrobial Stewardship Programs in Hospitals, 2016,
by the Department of Health, Philippines, requires all hospitals to have a hospital antimicrobial policy as
a stand against antimicrobial resistance and commitment towards appropriate antimicrobial use through
effective stewardship.

2. The goal of the policy is to optimize the use of antimicrobials for infections, through restriction and
monitoring, so that each patient receives the safest, most rational, and cost-effective antimicrobial agent,
subsequently minimizing the likelihood of antibiotic resistance.

3. This policy is mandatory and applies to all hospital staff involved in prescribing, dispensing,
administering of antimicrobials, and monitoring of response. Failure to comply may result in disciplinary
action. Both the pay floors and service wards are included in this policy.

II. STANDARDS FOR PRUDENT ANTIMICROBIAL PRESCRIBING AND USE

1. A history of allergy to relevant agents should always be sought and documented.

2. Do not start antimicrobial therapy without clear clinical justification. Antimicrobials should be used
after a treatable infection has been recognized or there is a high degree of suspicion of infection. In
general, colonization or contamination should not be treated. Patients who receive antimicrobial therapy
are at increased risk of colonization and infection with multi-resistant pathogens. Patients should not be
subjected to this increased risk without reasonable evidence of infection or established prophylactic
benefit.

3. Antimicrobials should be used for prophylaxis only when its benefit has been established and
prescribed in accordance with guidelines. Majority of surgical procedures require only a single dose of
perioperative prophylaxis. Long-term prophylaxis should be given only if clear clinical indication exists
(e.g. post-splenectomy).

4. Before starting antimicrobial therapy, every effort should be made to collect relevant specimens for
microbiological investigations.

5. Effective treatment must be started promptly (i.e., as soon as possible) in patients with life-
threatening infection. Treatment delay is associated with increased morbidity and mortality.

6. Antimicrobial therapy should be used solely as an adjunct in cases where surgery or wound
management is the primary intervention. The presence of foreign bodies has a profound effect on the
activity of antimicrobial agents and it is often necessary to remove the foreign material to cure an
infection in its vicinity (e.g. prosthetic heart valve or joint implant). Similarly, drainage of infected
abscesses or empyema and debridement of necrotic tissue is critical to successful outcomes.

7. The choice of antimicrobial should be guided by the result of the culture and susceptibility profile of
the identified causative pathogen, if it is known.

8. Empiric therapy must be governed by the hospital antibiotic guidelines if available, or local society
clinical practice guidelines (e.g. PSMID) or government-based guideline (e.g.DOH - National Antibiotic
Guidelines(NAG).Clinical guidelines are developed in accordance with local pathogen epidemiology &
antimicrobial sensitivity patterns, and recommend antimicrobial agents selected for target site
penetration and evidence-based clinical efficacy. If guidelines are not followed for clinical reasons, the
reason should be clearly documented.

9. Narrow-spectrum antimicrobial agents should be prescribed in preference to broad- spectrum agents

where appropriate. Broad-spectrum agents cause the most collateral damage to non-pathogenic normal
flora, which form an integral component of the host defense against infection by competing with
pathogens for nutrients and producing antibiotic secretions. Broad-spectrum agents also apply selection
 pressure to colonizing bacteria increasing the risk of colonization by antimicrobial-resistant strains, which
could subsequently cause difficult to treat infection.

10. Broad-spectrum empirical antimicrobial therapy may be indicated in certain circumstances. Examples
are listed below.

a. Life-threatening infection or presenting with septic shock

b. Immunocompromised hosts
c. Suspected or confirmed poly-microbial infection (e.g. intraabdominal infection, pneumonia)
d. Recent exposure to broad spectrum antimicrobials or failure of first-line therapy with narrow-
spectrum antimicrobial
e. Infections with high risk of multidrug-resistant pathogens (e.g. recent contact with a healthcare
environment or exposure to antimicrobials)
f. Laboratory-confirmed multi-drug resistant pathogen

11. Empirical antimicrobials must be reviewed at 48 hours. A review of the patient’s clinical status and
results from investigations (e.g. microbiological, laboratory and/or radiology) should be performed; and
an antibiotic plan developed to either :

• Stop antibiotics
• Switch to oral treatment
• De-escalate to a narrow-spectrum antimicrobial if a causative organism is identified and
antimicrobial sensitivity data are available
• Antibiotics continued and reviewed after a further 24 hours; or • Initiate outpatient-based
parenteral antimicrobial therapy

12. Targeted therapy should be used in preference to broad-spectrum antimicrobials unless there is a
clear clinical reason (for example, mixed infections or life-threatening sepsis). The prescription of broad-
spectrum antimicrobials should be reviewed as soon as possible and promptly de-escalated to narrow-
spectrum agents when sensitivity results become available. If therapy was not de-escalated, the reason
should be clearly documented.

13. Document all prescriptions for antimicrobial therapy in the medical notes and drug chart/prescription,
including the indication for treatment, the drug, dose, route of administration, date for review and
intended duration (start and stop date). Review of antimicrobial therapy by medical colleagues following
transfer of care is facilitated by clear documentation of the reason for initiating prescribing and the original
intended course length.

14. The timing, regimen, dose, route of administration and duration of antimicrobial therapy shall be
regularly reviewed and optimized. In general, antimicrobial courses must be reviewed daily.

15. Antimicrobial therapy must be prescribed at an appropriate dose, as recommended in the clinical
guideline. The dose must be appropriate for the patient’s weight, renal and hepatic function, site of
infection, causative pathogen and pharmacokinetic and pharmacodynamic properties of the
antimicrobial.

16. Antimicrobials should be given orally rather than intravenouslyin accordance to the IV-to-PO switch
guideline. The intravenous prescription should be reviewed after 48 hours as a minimum.

17. Antimicrobial treatment should be stopped as soon as clinically and/or microbiologically indicated. A
stop date or review date should be recorded by the prescriber on the order sheet. In general, antimicrobial
courses should be reviewed within 5 days.

18. All antimicrobial prescriptions may be dispensed by the pharmacy for a treatment period of up to 7
days, after which an antimicrobial stop procedure will be enforced. If there is a need to extend
antimicrobial therapy for more than 7 consecutive days, the Seventh Day Antimicrobial Form must be
completed and approved by the designated approver in the hospital. Pharmacists are required to confirm
 authorization before dispensing beyond 7 days (see Seventh Day Automatic Stop Order Procedure and
Seventh Day Antimicrobial Form).

19. Antimicrobials not in the Phil National Formulary (PNF) essential drug list or hospital formulary must
not be prescribed without authorization by the Pharmacy and Therapeutics Committee (PTC). All
formulary antimicrobials have been reviewed by the PTC for cost-effectiveness, safety and the propensity
to cause resistance. All new antimicrobials must be approved via the appropriate channels before being
included in the formulary.

20. In compliance with PhilHealth Circular No. _____, all physicians are advised to prescribe antimicrobials
listed in the Philippine National Formulary (PNF) Essential Drug List of 2017. If a physician insists on
prescribing non-PNF antimicrobials, the physician must justify such prescription to the patient, and explain
to the patient that by doing so, the patient may end up getting their PhilHealth benefit disallowed.

21. Restricted antimicrobials must not be prescribed without authorization. (See MECHANICS—list of
permitted, monitored, and restricted antimicrobials)

These may only be prescribed upon completion of the Restricted Antimicrobial Order Form with the
expressed authorization of the designated approver in the hospital. Pharmacists are required to confirm
authorization before dispensing restricted antimicrobials (see 2018 Implementing Guidelines on the
Antimicrobial Restriction, Monitoring, Surveillance and Utilization Policyand Restricted Antimicrobial
Order Form)

22. Monitored antimicrobials are subjected to prospective clinical audit, followed by immediate and direct
feedback to the prescriber (if necessary) by the Antimicrobial Stewardship (AMS) Program. This multi-
disciplinary team effort ensures the appropriateness of prescribing and optimizes treatment for the
individual patient. (See MECHANICS—list of permitted, monitored, and restricted antimicrobials)

23. Staff administering systemic antimicrobial agents must query any prescription that does not state a
stop/review date (duration) and indication on the drug chart with the medical team. Any prescription
continuing beyond the stop/review date must also be queried. Continue to administer the antimicrobial
while awaiting review.

24. Clinical pharmacists in inpatient and outpatient settings must support prudent prescribing/ use of
antimicrobials by:

• Reviewing antimicrobial prescriptions for appropriateness and guideline compliance – any

concerns must be raised urgently with the clinicians caring for the patient.

• Requesting a stop/review date (duration) and an indication is recorded on the medical record
as part of every antimicrobial prescription. If the stop/review date or duration and indication
are not documented on the medicine chart or in the notes, contact the prescriber and request
this information and then endorse the drug chart accordingly. Inform the prescriber that the
standard is to include a stop/review date and indication every time an order for an antimicrobial
agent is made. If the prescriber is unavailable, write in the notes requesting a stop/review date
and indication be written on the drug chart and in the medical notes.

• Provide patient counselling on appropriate antimicrobial administration and use.

III.PRUDENT PRESCRIBING INITIATIVES

1. A formulary of antimicrobials. This is a list of antimicrobials which are approved for use within the
hospital. The formulary will indicate the antimicrobials that will be subject to restrictions. The formulary
will be maintained by the PTC in collaboration with the AMS Committee and Infection Control Committee.

2. The National Antibiotic Guidelines (NAG).These are available from the Department of Health (DOH)
website and cover the prophylaxis and treatment of most common infections and important conditions
 for which antimicrobials are used. A digital copy of the NAG is available in the hospital portal, and provided
to all clinical departments.

3. Hospital Clinical Pathways. These provide standardized guidance to clinicians for the timely and
appropriate treatment of infections, especially for common infections and syndromes.

4. A scheduled program of education on the appropriate use of antimicrobials for healthcare staff, who
are in contact with patients on antibiotics. The AMS Committee will be responsible for provision of this
standard Training Course on AMS through an education program certified or recognized by the DOH.

5. Surveillance and monitoring of antimicrobial use and resistance in accordance with the Manual of
Procedures for Implementing Antimicrobial Stewardship Programs In Hospitals (2016), the Philippines
Antimicrobial Use Surveillance Methods Guide, and the Antimicrobial Resistance Surveillance Program
(ARSP).

6. Hospital Antibiogram to inform the development of hospital-specific antimicrobial guidelines and

selection of appropriate empiric antimicrobial therapy. This is published every year.

7. Medicine management policy defines the appropriate procedures for the purchase, storage,
prescribing, dispensing, counselling, administration and disposal of medicines, including antimicrobials.

8. Policy on liaising with pharmaceutical industry to prevent inappropriate interaction between

pharmaceutical industry representatives and hospital staff that may negatively influence prescribing
behavior and formulary selection.

IV. DEFINED ROLES and RESPONSIBILITESOF ANTIMICROBIAL STEWARDSHIP (AMS)

1. The attending physician, either the resident or fellow, or his duly designated clerk or intern, shall fill
up the official form (i.e. Antimicrobial Utilization Form). This form should contain relevant information
that contains the patient’s clinical summary including the working diagnoses and identified site/s of
infection, and pertinent laboratory examinations, including the important microbiological test results.

2. A prescribed or ordered antimicrobial, under the restricted category, may be given by the nurse on
duty for 24 hours after the initial dose. Subsequent doses and administration will be subject to the
approval of the infectious disease section (EXCEPT FOR CRITICALLY-ILL/SEPTIC SHOCK PATIENTS)

3. For critically-ill and septic shock patients, pre-authorization referral before use of restricted
antimicrobials is NOT necessary to prevent delay of administration BUT is required to do so within 24
hours.

4. Subsequent doses of antimicrobials after 24 hours will be based on the recommendations stipulated
in the Antimicrobial Usage Form thus close coordination with the nurse on duty and the pharmacy
department is very important. The assigned attending physician, either the resident or fellow for the unit
must be able to give the recommendations within 24 hours upon receipt of the referral.

5. An automatic stop order on every antimicrobial agent will be given on Day 7 of its administration. A
reminder of this instruction will be placed and written by the Clinical Pharmacist 2 days before the
completion date (day 5 antimicrobial). Extended use of the antimicrobial agent is subject to the approval
of the attending physician, either the resident or fellow,.

6. In the event of a 2nd consultation for another antimicrobial request, the patient is to be referred to
the ID Specialist of choice of the AP. However, for the following conditions tabulated below DIRECT
REFERRAL to the Infectious Diseases Service is RECOMMENDED:
 Organism-based Condition-based

MRSA PDR organisms S. aureus bacteremia

MDR Pseudomonas ESBL Infective endocarditis

aeruginosa Enterobacteriacae
Osteomyelitis
Fluconazole-
MDR A.baumanii resistant candida Septic arthritis

Deep-seated infections (abscess, empyema)

Necrotizing skin infections
Prosthesis and implant infections

V. ANTIMICROBIAL STEWARDSHIP PROGRAM WORKFLOW

A. 24-hour Authorization (see APPENDIX 1)

1. To be applied to all restricted antimicrobials

2. Clinical pharmacist or ward nurse will inform the attending physician, either the resident or fellow and
Pharmacist of a prescribed restricted antimicrobial.

3. The 1st dose of the restricted antimicrobial will be administered by the unit nurse without waiting for
the approval from the attending physician, either the resident or fellow.

4. The attending physician, either the resident or fellow will see the patient, review course and make
recommendations before the scheduled 2nd day. An optional follow-up visit to the patient may be done
upon the discretion of the physician.

5. attending physician, either the resident or fellow approval is required before any further doses will be
administered after the 1st day.

6. Pharmacist will ensure restricted antimicrobials will be reviewed during the regular AMS rounds.

7. Unit nurse or clinical pharmacist will remind the attending physician, either the resident or fellow 48
hours before the 7th antibiotic day automatic stop order, unless new recommendations have been made
by the attending physician, either the resident or fellow.

B. Regular AMS Rounds

a. The pharmacist will conduct daily rounds on all monitored and restricted antimicrobials in
their respective wards. The pharmacist may provide recommendations on the optimization of
the dose of antimicrobials (based on the patients age, weight, creatinine clearance), and
monitor and prevent drug-drug interactions.
b. During rounds, the attending physician, either the resident or fellow will review monitored
and restricted antimicrobials due for 7th-day automatic stop orders.
c. The pharmacists will prepare the list of patients up for review by the attending physician,
either the resident or fellow.
d. Monitored antimicrobials(see APPENDIX 2)

i. The 1st dose of the monitored antimicrobial will be administered by the unit nurse without prior
approval from the attending physician, either the resident or fellow.
ii. attending physician, either the resident or fellow will review monitored antimicrobials during the regular
AMS rounds.
 iii. Unit nurse or clinical pharmacist will remind the attending physician, either the resident or fellow 48
hours before the schedule 7th day automatic stop order for the prescribed antimicrobial.

iv. Automatic stop order will be enforced unless new recommendations have been made by the attending
physician, either the resident or fellow.

e. All other antimicrobials

i. All other antimicrobial prescriptions will be administered by the unit nurse without prior approval
from the attending physician, either the resident or fellow.

C. 7th-day Automatic Stop Order (see APPENDIX 3)

a. This applies to ALL antimicrobials.

b. Unit nurse or clinical pharmacist will remind the attending physician 48 hours before the
scheduled 7th-day automatic stop order of their prescribed antimicrobial.
c. Antimicrobials will be stopped automatically unless the patient’s case has been referred and
reviewed by the attending physician, either the resident or fellow with recommendations.

D. IV-to-PO Switch

a. Automatic review for IV-to-PO switch at 48 hours will be made by the AMS Pharmacist in
consultation with the attending physician, either the resident or fellow.
b. Antimicrobials can be switched when patient fits the criteria stated in the IV-to-PO switch data
form (see Appendix 4).

VI. DECKING SCHEDULE OF CONSULTANTS (Adult and Pediatric Infectious Diseases)

A. Consultant of the Section of Infectious Diseases will be decked to the program every week.

B. If an antimicrobial which requires approval will be prescribed between changes in deck (i.e.
antimicrobial prescribed at 10 pm of the last day of the 1st week), the consultant assigned for the following
week will be the one notified to approve the use of the prescribed drug.
APPENDIX 1
APPENDIX 2
APPENDIX 3
APPENDIX 4