Republic
of
the Philippines
Department
of
Health
OFFICE OF THE SECRETARY
JAN
17
21119
ADMINISTRATIVEORDER
Now-1879'
20194002
SUBJECT: Implementing
Guidelines on
the PhilippineAntimicrobialStewardship
(AMS)
Program for Hospitals
I. BACKGROUNDAntimicrobial resistance (AMR)
is a
significant public health threat thatcauses major health
and
economic consequences both in human
and
veterinary health.
It
claims lives, prolongs illnesses, increases healthcare costs
and
financial burden,adversely affects trade,
as
well
as
threatens national
and
global security. In thePhilippines, the Antimicrobial Resistance Surveillance Program
(ARSP)
found veryalarming resistance rates among various pathogens.In 2009, the Health Facilities Development Bureau (HFDB) formerly NationalCenter for Health Facilities Development (NCHFD)
of
the Department
of
Health(DOH) published the National Standards
in
Infection Control for Healthcare Facilities
to
strengthen infection prevention
and
control (IPC) programs nationwide and preventthe occurrence
of
healthcare-associated infections (HAI) among patients.
It also
provided guidelines for the hospital management, service providers and support staff on the provision
of
quality services
at
various aspects
of
work and service delivery points
in
the hospital.The Office
of
the President issued
in
2014 the Administrative Order
(AO) No.42
entitled “Creating an Inter-Agency
Committee
for
the
Formulation andImplementation
of
a National
Plan
to
Combat Antimicrobial Resistance
in
thePhilippines”
to
bring together
all
key partners across many sectors towardsidentifying
and
implementing concrete efforts and plans
to
mitigate and control AMR.The Department
of
Health (DOH) led the finalization
of
“The
Philippine Action
Plan
to
Combat Antimicrobial Resistance:
One
Health Approach” through the Inter-Agency Committee
on
AMR (ICAMR) which was launched during the
15’t
PhilippineAMR Summit in
2015.
Stipulated in the action plan are the country strategies thatfocus on the following core
areas:
leadership and governance; surveillance
and
laboratory capacity; access
to
essential medicines
of
assured quality; awareness
and
promotion; infection prevention and control; rational antimicrobial use amonghumans and animals; and research
and
development.
In
response
to
the prevailing epidemiologic trends
of
infectious diseases,
AO
No. 2016-0002 entitled “National Policy on Infection Prevention and Control inHealthcare Facilities” was issued by HFDB
to
further provide guidance
and
strengthen the implementation
of
IPC
programs across hospitals. The
A0
No. 2016-
0002
outlines
14
priority areas
of
IPC
programs
to
be established in
healthcare?
Building
1,
San
Lazaro Compound,
Rizal
Avenue,
Sta.
Cruz,
1003
Manila
0
Trunk Line 651-7800 Local
1113, 1108,
1
135
/
DirectLine:
711—9502;
711-9503
Fax:
743-1829
0 URL:
http://www.doh.gov.ph' e-mail: ftduqueféidohiiovph
é;
Kr
II.III.
facilities. Included in the list is the institutionalization
of
an AntimicrobialStewardship (AMS) Program that aims
to
strengthen the knowledge, attitude and practices
of
involved stakeholders on rational prescribing, dispensing and use
of
antimicrobials;
and, to
improve patient outcomes by decreasing infections caused
by
resistant organisms.The World Health Organization (WHO) defined AMS
as
a multidisciplinary,multi-intervention, coordinated approach to improve the appropriate use
of
antimicrobials by promoting the selection
of
the optimal antimicrobial drug regimen
to
ensure that the right choice
of
antibiotic, right route
of
administration, right dose,right time, and right duration
of
treatment are strictly observed
to
minimize harm
to
the patients.
To set
the standards on the implementation
of
the AMS program inhospitals, the DOH hereby issues this
Order.
OBJECTIVESGeneral
Objective:This Order aims
to
define the overall framework and strategic directions
to
implement the Philippine Antimicrobial Stewardship (AMS) Program in all hospitalsnationwide towards improving the use
of
antimicrobials, mitigating, and preventingthe emergence
of
antimicrobialresistance (AMR) in the Philippines.Specific Objectives:The implementation
of
the Philippine AMS Program aims
to:
1.
Promote rational and optimal antimicrobial therapy;
2.
Effect positive behaviour and institutional changes towards ensuring the optimaluse antimicrobials by the prescribers, dispensers, other healthcare professionals,and patients in the hospitals;
3.
Establish multidisciplinary leadership and commitment, clinical governance andaccountability
in
antimicrobial management and control ensuring thatinterventions are sustainable and well-supported with necessary technical andfinancial resources;
4.
Create
an
environment where healthcare professionals are supported with toolsand systems
to
implement antimicrobial management;
SCOPE
AND
COVERAGE
This Order
shall
be applicable
to all
Level
1,
2, and
3
hospitals in thePhilippines, both in the public and private sector.
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IV.
DEFINITIONOF TERMS
1.
Antimicrobial Resistance
(AMR)
—
is
the defense mechanism developed by
a
microorganism (including bacteria, viruses
and
some parasites) to an antimicrobialdrug
to
which it was previously sensitive. AMR, which
is a
consequence
of
theuse or misuse
of
an
antimicrobial agent, ensues when
a
microorganism mutates or acquires
a
resistant
gene.
Resistant organisms withstand attack by antimicrobial or antiparasitic agents
so
that standard treatments become ineffective, allowinginfections
to
persist and spread.AMR
Surveillance
—
is the tracking
of
changes in microbial populations which permits the early detection
of
resistant strains
of
public health performanceresulting in the prompt notification
and
investigation
of
outbreaks.
Antibiogram
—
is
an overall profile
of
antimicrobial susceptibility testing results
of
a
specific microorganism
to a
battery
of
antimicrobial drugs.
Antimicrobial Resistance
Surveillance
Program
(ARSP)
—
is a
laboratory- based surveillance system in selected hospital sentinel sites that determines thecurrent status and developing trends
of
resistance
of
selected bacteria to specificantimicrobials, with the Research Institute for Tropical Medicine (RITM)
as
theDOH national reference laboratory.
Antimicrobial Stewardship
(AMS)
—
refers
to a
multidisciplinary, multi-intervention, coordinated approach
to
improve the appropriate use
of
antimicrobials by promoting the selection
of
the optimal antimicrobial drugregimen
to
ensure the right choice
of
antibiotic, right route
of
administration, rightdose, right time, and right duration
to
minimize harm
to
the patient
and
future patients.
Antimicrobial
Use (AMU) Surveillance
—
is
the act
of
tracing how and whyantimicrobials are being used
and
misused by patients andhealthcare providers.
Automatic Stop-order
—
refers
to
the method
of
appropriately limiting theduration
of
antimicrobial usage which can be employed for the use
of
empiric or therapeutic antimicrobials.De-escalation
Therapy
—
refers
to
the method
of
narrowing the spectrum
of
anempiric antimicrobial regimen which includes adjusting
an
empiric antibioticregimen on the basis
of
culture results and other
data; and,
discontinuing empirictherapy
if
testing subsequently fails
to
demonstrate evidence
of
an
infectious process.Dose
Optimization
—
refers
to
the method
of
ensuring that specific characteristics
of
the drug
(e.g.,
concentration or time-dependent killing, toxicities), theinfectious agent
(e.g.,
minimum inhibitory concentration), the patient
(e.g.,
weight, renal function), and the site
of
infection
are all
taken into account in thetreatment.
/:
_
NW
10.
Emerging
Infectious Diseases (EIDs)
—
are newly identified, previouslyunknown, or drug-resistant infections whose incidence in human has increasedwithin the past two decades or whose incidence threatens
to
increase in the near
future.
11
InfectionControl Committee(ICC)
—
refers to a body that provides a forum for multidisciplinary input cooperation and information sharing tasked
to
ensureoverall implementation
of
infection control strategies by formulating and updatinginfection control policies, guidelines and procedures. Representation includesmanagement, physicians, and other healthcare workers from clinicalmicrobiology, pharmacy, sterilizing service,housekeeping and training services.
12.
Infection Prevention and Control
(IPC)
—
refers
to
the discipline whichcomprises measures, practices, protocols and procedures
all
aimed
at
preventing
and
controlling the development
of
new infections acquired in healthcare settings.
13.
Intravenous
to
Oral Antimicrobial Therapy
Switch
—
refers
to
the method
of
changing from intravenously administered antimicrobials
to
orally administeredantimicrobials used for antimicrobial agents with which similar concentrations areachieved whether administered intravenously or orally.
14.
National Antibiotic
Guidelines
Committee
(NAGCom)
—
is a
technicalcommittee
at
the DOH composed
of
specialists on infectious diseases created
to
develop antibiotic guidelines for health facilities aiming
to
provide information onthe treatment
of
choice/ recommendations for selected pathogen-specificconditions based on recent evidences
of
clinical effectiveness, adverse effects,cost and patterns
of
resistance,
and,
necessary dosing
and
monitoring guidelinesfor specific antimicrobials.
15.
National External Quality
Assessment Scheme (NEQAS)
—
refers
to
theexternal evaluation
of
a
laboratory’s performance using proficiency panels whichaims
to
evaluate the effectiveness
of
the quality assurance program.
16.
Philippine National Formulary
(PNF)
—
refers
to
the list
of
medicines prepared
and
periodically updated by the DOH that satisfy the priority health care needs
of
the population
and
which
are
selected based on evidence
of
their efficacy, safetyand comparative cost-effectiveness. This serves
as
the national reference for quality
and
rational selection
of
the medicines which are vital in achieving the best health outcomes.
17.
Pharmacy and Therapeutics Committee
(PTC)
—
is
the primary multi-disciplinary body
of
the hospital or government health unit that governs issuesrelated
to
medicines such
as
evaluation, selection, rational use and other relatedmatters.
18.
Point-of-care
(POC)
Interventions
—
are interventions that occur at the wardlevel with the treating medical team, often soon after empirical therapy has beeninitiated. These provide direct feedback
to
the prescriber at the time
of
prescription or laboratory diagnosis, and provide
an
opportunity
to
educateclinical staff on appropriateprescribing.4
n
fir“
VI.
GENERALGUIDELINES
1.
The national AMS program for hospitals shall be created
as
part
of
the overallcomprehensive National Action Plan
to
Combat AMR, pursuant to
A0
42
series
of
2014. The program shall be headed by the Pharmaceutical Division (PD)
of
theDOH Central Office in partnership with the Health Facilities and ServicesRegulatory Bureau (HFSRB) and the Health Facility Development Bureau(HFDB).The AMS program shall be based on six core elements stated in the implementingguidelines, namely:
(1)
leadership;
(2)
policies, guidelines, and pathways; (3)AMR and antimicrobialuse (AMU) surveillance;
(4)
action;
(5)
education;
and (6)
performance evaluation. These shall provide a systematic approach
to
optimizethe use
of
antimicrobials within the facility reducing adverse consequences
of
antimicrobial use which include AMR, toxicity and unnecessary healthcare
costs.
The AMS Program shall be part
of
the overall initiatives in improving patientsafety; quality
of
care;
national policy for infection prevention and control;management
of
emerging infectious diseases; and the current hospital licensingstandards
of
the DOH.All hospitals shall establish
an
effective and efficient AMS program that involves
a
multidisciplinary, multi-intervention and coordinated strategy
to
optimize theuse
of
antimicrobials. This shall be led by an AMS Committee in partnership withthe Pharmacy
and
Therapeutics Committee (PTC), the Infection ControlCommittee (ICC) and the Patient Safety Committee
to
enable
a
holistic andcoordinated approach in implementing AMS strategies. In cases where it cannot be instituted due
to
variations across the health facilities depending on availableresources and expertise, hospitals are granted with flexibility where
to
place theAMS program considering existing hospital management structure,
as
long
as
accountabilities
are
clear and outputs
are
delivered.
.
An AMS Steering Committee composed
of
experts from key professionalsocieties and representatives
from
relevant DOH units
shall
be created
to
developthe AMS Manual
of
Procedures
(MOPS)
and oversee the conduct
of
monitoring
and
evaluation
of
the AMS program implementation in
all
hospitals.The DOH shall identify hospitals which shall serve
as
training hubs that shall provide infrastructure for multi-professional skills training
and
education on AMS programs in hospitals.
IMPLEMENTING
GUIDELINESThe hospitals shall be governed by the six
(6)
AMS core pillars:
A.
Leadership
1.
The Chief
of
Hospital and designated members
of
the hospital administrationshall be responsible
and
accountable in implementing AMS in their facility
and shall ensure leadership and management support through but not limitedto the following:
a.
Dedicating sufficient funding and resources for AMS-related activities;
b.
Allowing the
staff
to contribute
to
the AMS goals
of
the hospital through participation in the hospital stewardship program;
0.
Supportingtraining and continuous education;
(1.
Ensuring accountability from
all
levels and across relevant clinicaldepartments through continuous monitoring
of
performance;
and,
e.
Building
an
enabling environment
to
support AMS-related activities such
as
setting up an information technology (IT) system
to
monitor antibioticuse or antibiotic alert systems
2.
The Chief
of
Hospital shall create
a
governance structure through an issuancethat shall define the different roles
and
responsibilities,
and
job descriptions
of
all
hospital staff in stewardship-related activities and other relevant initiativeson infection prevention and control.
3.
The AMS Committee shall be composed
of
an infectious disease specialist(IDS), medical microbiologist, AMS clinical pharmacist, representatives fromthe AMS Team, clinicians fiom key medical and surgical departments, andmembers
of
the hospital management,
to
include members
of
other relatedgroups such
as
the PTC and
ICC.4.
The AMS Team shall be composed
of
an
Infectious Disease Specialists (IDS)(Levels
2 and
3
hospitals), AMS-trained physician (Level
1
hospitals), AMSClinical Pharmacist, and an Administrative
Staff.B.
Policies, Guidelines,
and ClinicalPathways
1.
All hospitals shall have
an
antibiotic policy
to
promote rational prescribingand dispensing practices.
2.
All hospitals
shall
adopt or adapt
to
their local context the National AntibioticGuidelines
to
guidethe clinicians in the management
of
infectious diseases.
3.
The AMS Committee, together with the PTC and
ICC, shall
be responsible for the development, implementation
and
revisions
of
the hospital antimicrobial policy, standard guidelines and pathways, with the support and commitmentfrom the hospitals administration.
4.
The policy, guidelines, and pathways shall be reviewed regularly and updated
as
needed
to
determine
if
these
are still
effective based on the hospital’s AMR rates
and
antimicrobialuse
data.
C.
Surveillanceof
AMU
and AMR
1.
The AMS Committee shall ensure the regular Antimicrobial Use (AMU)monitoring which shall be reported
to
DOH-PD annually and
to
relevanthospital departments
as
well.
/V
M
{(7
All hospitals
shall
conduct AMR surveillance and develop annual institutionalantibiogram (through the AMS Committee and the microbiology laboratory)for reportable pathogens which shall be identified in the AMS MOPs defined by the Antimicrobial Resistance Surveillance Program (ARSP) at least once ayear, which shall be submitted annually
to
the Research Institute for TropicalMedicine (RITM). For hospitals without an on-site microbiology laboratory,microbiological culture and sensitivity results shall be obtained from externallaboratories for their own
set
of
patients
so
they can develop their ownantibiogram.The microbiology laboratory
of
the hospital shall participate and pass both the National External Quality Assessment Scheme (NEQAS) for microbiologyand the Antimicrobial Resistance Surveillance Program BacteriologyLaboratory Accreditation for PhilHealth reimbursement
of
selectantimicrobials in the Philippine National Formulary (PNF).The hospital management shall strengthen the capacity for laboratorysurveillance that shall allow monitoring
of
antimicrobial susceptibility patterns
and
detection
of
resistant pathogens.
D.
Action
1.
The hospital
shall
employ
a
comprehensive combination
of
persuasive andrestrictive interventional strategies which shall be listed
in
the AMS MOPs
to
safeguard and ensure the optimal use
of
all
antimicrobials used within thefacility. These may include antimicrobial restriction
and
pre-authorization,seventh day automatic stop order, audit
and
feedback, and point-of-care (POC)interventions such
as
dose optimization, streamlining or de-escalation
of
antimicrobialtherapy and intravenous
to
oral antimicrobial therapy switch.All antimicrobials prescribed and used for admitted patients within thehospital shallbe subjected
to
the interventions
of
the AMS program.E.
Education
1.
The
PD
shall disseminate the AMS
MOPS to all
levels
of
hospital
care.2.
All hospitals shall aim
to
provide training and continuous education
to
healthcare
staff,
who are in contact with patients on antibiotics. These includenot only the prescribers
(i.e.
attending physicians), nurses, clinical pharmacists, microbiologists, and midwives, but
also
medical students and paramedical staff under training
to
ensure that the transfer
of
basic andadvanced scientific knowledge and skills on the proper use
of
antibioticsoccurs
at
an early
stage.
The AMS Committee shall ensure that the above-mentioned hospital personnel attend the standard Training Course on AMS through an education program certified or recognized by the DOH.
WOW
4.
Hospitals, especially the teaching and training institutions, shall also developtraining modules with clear learning outcomes and competencies on AMScovering microbiology, prevention and control
of
infectious diseases, clinical pharmacology, hospital pharmacy and patient communication skills and the prudent use
of
antibiotics.
5.
AMS Practitioners shall continually update themselves on the newestdevelopments in the area
of
microbiology, infectious disease management
and
prevention, pharmacotherapy, and AMS practice.
6.
All hospitals shall ensure that systems
are
in place for patient education
and
counselling on how
to
take their prescribed antimicrobials correctly and useantimicrobials responsibly.
7.
The DOH shall identify public
and
private hospitals which shall serve
as
theAMS training hubs and forge
a
partnership based on the existing rules andregulations. These institutions
shall:
a.
Facilitate and organize the conduct
of
the AMS training
b.
Manage the administrative matters related
to
the conduct
of
the activityincluding the management and disbursement
of
funds, andcoordination with the participants
c.
Perform secretariat functionswhich
are,
but not limited
to:
i.
Preparation and organization
of
programme (based on the DOH prescribed content)
ii.
Selection and invitation
of
resource persons
iii.
Provision
of
logistical support
iv.
Documentation
of
issues raised during the training program
v.
Coordination with the DOH AMR secretariat for the pre-
and
post-training activities (including the preparation
of
necessaryreports)
d.
Submit sub-allotment utilization/liquidation report
to
the DOH-PD (for public training hubs only)F.
Performance Evaluation
1.
An AMS SteeringCommittee (ASC) shall be created
to
oversee the conduct
of
monitoring and evaluation
of
the AMS program
and
provide relevantevidence-based recommendations
to
the DOH.
2.
The AMS Committee
of
all
hospitals shall submit
to
the DOH PD an annualAMS program monitoring report based on the tool developed (Annex
A)
for tracking
of
progress
of
the AMS Program.
f
8
AK?
VII. ROLES
AND
RESPONSIBILITIES
A.
Department of Health Central
Office
1.
Pharmaceutical
Division (PD)
a.
Facilitate the development
of
the AMS
MOPS
which shall stipulate thedetails
of
the AMS implementation in the hospitals.
b.
Lead the overall monitoring
of
the implementation
of
the AMS program inhospitals in partnership with the HFDB and HFSRB.c. Provide technical assistance on the implementation
of
the program throughthe dissemination
of
the AMS
MOPS
and participation in the training
r011-
outs.
d.
Convene and provide technical
and
administrative support
to
the NAGCom in the updating
of
the national antibiotic guidelines and ASC informulatingtheir AMS program recommendations.
e.
Provide technical assistance on AMU surveillance and interpretantimicrobial consumption data submitted by the hospitals and publishannual report.
f.
Collect
and
analyze monitoring and evaluationreports from hospitals.
2.
Disease
Preventionand Control Bureau
(DPCB)
a.
Identify DOH-accepted Clinical Practice Guidelines
of
infectious diseasesthat are
of
public health importance for adoption
of
the hospitals.
b.
Inform the relevant agencies on the updated treatment guidelines
of
therespective public health programs.
c.
Develop standards and protocols on managing emerging infectiousdiseases (EIDs) in partnership with
EB,
HFDB and RITM.
3.
Epidemiology
Bureau
(EB)
a.
Provide technical assistance on epidemiology and surveillance for hospital-acquired infections
(HA1), and
AMR.
b.
Serve
as
the national collaborating center for the reported AMR cases inhospitals which include diseases
of
public health importance and these pathogens being monitored through the ARSP.
4.
Field
Implementation and Coordination Team (FICT)
a.
Ensure adherence
of
all
hospitals
to
the guidelines
of
the AMSimplementation.
/y
N)
('7
.
Health
Facility Development
Bureau
(HFDB)
a.
Participate in the monitoring
of
AMS implementation in hospitals in partnershipwith the PD and HFSRB.
b.
Ensure that AMS program is aligned
to
the National Infection Preventionand Control Policy
and,
the overall quality
of
care and patient safety.
.
Health
Facilities
and
Services
RegulatoryBureau
(HFSRB)
a.
Ensure that the institutionalization and effective implementation the AMS program,
and
integration
of
the AMS program and reporting
of
AMR surveillance data are part
of
the licensing and re-licensing requirements
of
hospitals.
b.
Ensure that ICC and PTC in hospitals are functional
as
part
of
theminimum licensing requirements
and
compliant with the DOH program policies on antimicrobial resistance.
0.
Perform corresponding regulatory actions for hospitals that will deviatefrom the timeline (Annex
B)
of
AMS institutionalization in their facilities.
.
Food
and DrugAdministration
(FDA)
a.
Ensure the safety, efficacy, and quality
of
antimicrobials available in themarket.
b.
Advocate the standards on the good storage and distribution practices
of
antimicrobials within the hospital
to
ensure that their quality and integrityaremaintained.
c.
Evaluate the reports received from the hospitals on antimicrobials thatresulted
in
failure
of
therapy.
.
Philhealth
a.
Ensure reimbursement
of
antimicrobials listed in the PNF.
.
Research Institute for Tropical
Medicine
(RITM)
a.
Oversee the implementation
of
ARSP
in
hospitals.
b.
Monitor generation
of
data on AMR patterns in the hospitals.
0.
Provide technical assistance in maintaining AMR surveillance.
(1.
Generate
and
disseminates countrywideARSP data.
Wm{B
“M“
B. DOI-I
Regional
Offices
1.
Ensure that
all
antimicrobials are rationally prescribed, dispensed and used by
all
healthcare professional and patients by practicing AMS at all levels
of
healthcare towards successfully combattingAMR in the region.
2.
Provide technical support on the AMS implementation
to
the hospitals in their respective regions.
3.
Furnish the DOH PD feedback report on the status
of
hospitals implementingthe AMS program.C.
Hospitals
1.
Chief of Hospital or
Medical
Director
together with the members
of
thehospital administration
shall:
a.
Ensure that
a
local framework for AMS program
is
in place.
b.
Dedicate sufficient funding
and
resources for AMS-related activities for the operations
of
the AMS
Team.
c.
Establish
an
enabling environment
to
support AMS-related activities.
(1.
Allow staff
to
contribute
to
the AMS goals
of
the hospital through participation in the hospital AMS program.
e.
SupportAMS-related training
and
continuous education.
f.
Ensure accountability from
all
levels and across relevant clinicaldepartments through continuous monitoring
of
performance.
2.
AMS
Committee
a.
Develop
and
maintain antimicrobial policies, forrnulary, and clinical practice guidelines for antimicrobialtreatment and prophylaxis.
b.
Supervise the overall implementation, monitoring
of
the effectiveness
and
championing the efforts
to
improve the hospital’s AMS program andinitiatives with direct accountability
to
the
PD.
0.
Ensure the availability
of
resources for the sustainability
of
the AMS program.
(1.
Collaborate with the Pharmacy and Therapeutics Committee (PTC) andInfection Control Committee (ICC) in promoting rational use
of
medicines.
W11
e.
Provide feedback
to
prescribers and conduct educational activities for medical, nursing and pharmacy
staff
on antimicrobial prescribing andAMS principles.
f.
Monitor antimicrobial usage
and
resistance.
3.
AMS
Team
a.
Implement the AMS strategies and perform AMS interventions as needed.
b.
Develop
and
review standard treatment guidelines and prescribing policies.
0.
Regularly collect, analyze and report the progress
of
the AMS program
to
the hospital AMS Committee, administrators, and
DOH.d.
Educate healthcare
staff
on appropriate antimicrobial prescribing andresistance.
e.
Identify
and
design systems/processes to facilitate appropriateantimicrobial
use.
f.
Provide expert advice on the development
of
policies related
to
appropriateuse
of
antimicrobials and control
of
AMR in the hospital.
4.
ICC and PTC
d.
Maintain the antimicrobial policies and formulary, and ensure that theyremain current
and
adhered
to.
Develop, maintain and disseminate the hospital program.Lead in the creation
of
evidence-based treatment and surgical prophylaxisguidelines that are incorporated into the antimicrobial policy.Monitor the process and outcomemeasures
of
antimicrobial policies.
5.
Microbiology
Laboratory Department
a.
Ensure the timely identification
of
pathogens
and
the quality performance
of
routine antimicrobial susceptibility testing.Provide microbiological expertise in the development and review
of
standard treatment guidelines and forrnularyrestrictions.Participate
in
the evaluation
of
AMU and AMR surveillance.Assist in infection prevention
and
control
efforts.
AX;
VIII.
IX.XI.
MONITORING
AND EVALUATION
A.
The DOH
PD
through the ASC shall be responsible for the implementation andmonitoring
of
the AMS program in hospitals.
B.
The
HFDB
and HFSRB shall ensure that the health facilities
are
compliant withthe prescribed standards necessary for the fulfilment
of
licensing and re-licensingrequirements
of
hospitals.
C.
The monitoring
and
evaluation
of
the AMS program in hospitals shall bedocumented which shall always be available for public health purposes.FUNDING SOURCEThe budget for the national implementation
of
the AMS program shall be derivedfrom the funds
of
the DOH
PD
and the resources provided by development partner organizations. The hospitals shall incorporate in their annual budget plan line itemsrelated
to
the AMS implementation and ensure the sustainability
of
the program.
REPEALIN
G CLAUSEAll previous Orders inconsistent in part or in whole
to
this Administrative Order
are
hereby rescinded or amended accordingly.
EFFECTIVITY
This Order
shall
take effect immediately.FRANC CO
.
DUQUE
III,
MD, MSc
Se
etary
of
Health
13
me
“
V
ANNEXA
Republic
of
the Philippines
Department
of
Health
OFFICE OF THE SECRETARY
ANTIMICROBIAL
STEWARDSHIP (AMS)
MONITORINGTOOLFOR
HOSPITALS Name
of
Hospital:
Region/Province:
Address: Date of Visit:Time
started:
A.
Leadership
1.
Is
there an
existing
hospital
policy for
the implementation
of
the
Antimicrobial
Stewardship
(AMS)
program?
_
Yes
_
No
If yes,
when
was
the
AMS
hospital
policy signed? (dd
/
mm/yyyy):
If
no,
when
does
the hospital
aim to
issue
a policy?
2.
Which of
the
following
handlesthe
AMS
program
in
your
hospital?
_
Antimicrobial
Stewardship
Committee
_
Infection Control Committee
(ICC)
_
Pharmacy
and
Therapeutics
Committee
(PTC)
_
Others
(please
specify):*Requestfor the
organizationalstructure ofthe
AMS
program
within thefacility.
The AMS
Committee may be independent
or
lodged with
either
the
ICC
or
the
PTC.
3.
Are
the
roles and
responsibilities
of
the hospitalstaff
involved in
the stewardship-related
activities
stated
in
the
policy?
_
Yes
_
No,
why not?
4. Is
there
a
trained
AMS
team at your hospital?
_
Yes
_
No,
why not?
*Note: The
'AMS
team’
must
be composed
ofmore
than one
staffmember
who
supports
clinical decisions to ensure
appropriateantimicrobial
use.
5.
Is
there
a physician
identified
as a
leader
for
AMS
activities
atyour hospital?
_
Yes,
who leads?
_No
6.
Are
there
sufficient funding
and resources
for AMS-related activities in
your hospital?
_
Yes
_
NoIf
yes,
how
much?
If
no,
what resourcesare
lacking?
7. Is
there an
IT
system
being utilized to
support
AMS-related activities in
your hospital?
_
Yes
_
NoIf
yes,
please
identify
the software
/
5
being used by
your
hospital:
9°
Kindly
listthe
challenges
encountered
by
your hospital
in
establishingthe
AMS
program.
B.
Policy,Guidelines and ClinicalPathways
9.
Does
your hospitalimplementan antibiotic
policy to
promote rationalantimicrobial prescribingand dispensing
practices?
__
Yes
,
__
N0
/\/
*If
yes,
request
for
a copy
of the
policy.
{LL
{
10.
Does
your hospitalkeep
a
softand hard
(if
downloaded)
copy of
the
National Antibiotic Guidelines?
_
Yes
_
N
o
11.
Does
your hospitalhave
facility-specific
treatment recommendationsbased on
local
antimicrobialsusceptibility
to
assistwithantimicrobialselection
for common clinical
conditions?
_
Yes
__
No12.
Does
your hospital
follow clinical
pathway/s
in
treating
infections
and syndromes?
_
Yes
_
N
o
If yes,
please
identify
the
infections and
syndromes beingaddressed
by
these
clinical pathways:
13.
Does
the
facility have
an approved hospitalformulary
list?
_Yes
_
N
0,
why not?
*If
yes,
request
for
a copy
of
the
hospitalformulary
list.
C.
Antimicrobial
Use
and
Antimicrobial Resistance Surveillance
14.
Has
your
facility
producedan antibiogram
in
the past year?
_
Yes
_
No15.
Who
interprets your hospitalantibiogram?
16. Is
the antibiogram
accessible to all
healthcare
staff?
_
Yes
_
No17. Is
there
a
platform
for
the monitoring
of
antimicrobialuse
(AMU)
in
your hospital?
_
Yes
_
No
If yes,
please
identify
the
tool being used for
AMU
surveillance:
18. Is
there
a
pharmacistresponsible
for
ensuringappropriate antimicrobialuseat your
facility?
_
Yes
__
No19.
Does
your hospitalconductanalysis
of
the antibiogramand
AMU
data?
_Yes
_
NoIf
yes,
pleasedescribethe methodology
of analysis: (Does the hospital
correlate
the
laboratorydata
on
resistant pathogens
with
AMU?)20. Do
you
imposerestricted antimicrobial
list?
_Yes
_
N0,
why not?
D.
Action
21.
Which of
the
following
AMS
interventions
does
your hospitalimplement?
Check all applicable:
_
Antimicrobial
restriction
and
pre-authorization
_
Seventh day
automaticstop order
_
Dose
optimization
_
Streamlining
or
de—escalation
of
antimicrobialtherapy
_
lV-to-PO
antimicrobialtherapy
switch
_
Audit
and
Feedback
_
Others, please specify:22. Does
your
facility have a
written
policy
that requires prescribers
to
document
an
indication
in
the
medical
record or duringorder entry
for all
antimicrobial prescriptions?
_Yes
_
No,
why
not?
*If
yes,
request
for
a copy
of the
policy.23. Is
it
routine practice
for specified
antimicrobialagents
to be
approved
by a
physician prior
to use in
your hospital?
_No
Yes j
Page
2
of3
Kb
g
,7
24.
Is
there
a formal
procedure
for a physician,
pharmacist,or other staff member
to
reviewthe appropriateness
of
anantimicrobialwithinor after 48 hours
from
the
initial
order?
_Yes
__
No
25. Does
your hospitalmonitor
if
the indication
is
captured
in
the
medical
record
for all
antimicrobial prescriptions?
_
Yes
_
No
26. Are
the results
of
antimicrobialaudits or reviewscommunicatedregularlywith prescribers?
_
Yes,
howregular?
.
No
27. Does
your hospitalconduct
AMS-related
trainingsand seminars
to all Its staff?
_Yes
_
No
28. Does
your hospital promote collaborationamong
its
healthcare professionals?
_
Yes
_
N
o
29. Does
your hospital
organize activities
that
will
strengthen the
knowledge of
the patients
and
caregivers
in on
rational
use
of antimicrobials?
_
Yes
_
No30.
Which of
the
following
doesyour hospital
use to
disseminate
AMS-related
informationwithinthe
facility? Please check
anddescribe
all applicable:
_
Posters
_
Newsletters
_
Leaflets
/
pamphlets
__
Television
_
Others, please specify:
F.
Performance
Evaluation
31. How
often
does
your hospitalevaluate
its
AMS
programs?
_
Annually
_
Biannually
_
Quarterly
_
Others, please specify:
32.
Have you
developed
an
annual report
on
antimicrobialstewardship
in
the pastyear?
Yes
_
N
o
NOTES: Nameof Interviewer and Designation Nameof Interviewee and DesignationTime finished:
AWN“
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