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CHAPTER 4: ANTIMICROBIAL STEWARDSHIP (AMS) PROTOCOL
Antimicrobial stewardship is to optimize clinical outcome while minimizing unintended consequences of
antibiotic use, which include the development of resistant organism and antibiotic toxicity.
Objectives
1. To achieve appropriate use of antimicrobials especially misuse and over-use of antibiotics
2. Combating antimicrobial resistance
3. Improve patient outcomes and safety
4. Reduce healthcare costs
ROLE OF ANTIMICROBIAL STEWARDSHIP TEAM
1. To enhance the antimicrobial policy and implementation of formulary restriction & approval system
2. To perform the regular audit of antimicrobial prescribing and feedback to prescribers.
3. Provision of continuous education to healthcare professionals on rationale antimicrobial prescribing and
the threat of antimicrobial resistance.
4. Facilitate evaluation of antimicrobial stewardship activities focusing but not limiting to process measures
and outcome measures, as well as antimicrobial resistance trend.
STRUCTURE AND ROLE OF ANTIMICROBIAL STEWARDSHIP COMMITTEE
Antimicrobial Stewardship Committee is authorized and approved by Hospital administration.
According to IDSA/SHEA guidelines, the core member of the committee consists of:
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STRATEGY AND IMPLEMENTATIONS OF AMS TEAM ACTIVITIES
▪ Assess the motivations of the teams being referred
▪ Ensure the accountability and leadership of the stewardship plan and management by having senior
member of ASP team leading the activities
▪ Establish trust between ASP stewards and the antibiotic prescribers by effective communications
▪ Effective interventions via antimicrobial review methods. The review does not just include on
appropriateness of antibiotic usage, but other measures such as;
⮚ Requirements on need of therapeutic drug monitoring
⮚ Potential conversion from IV to oral route
⮚ Review on antibiotics related adverse effects
⮚ Specific review on need of novel agents
⮚ Review on pharmacokinetics/pharmacodynamics (PK/PD) of the antimicrobial use
⮚ Potential drug-drug interactions
⮚ Treatment or prophylaxis indications
⮚ Use of investigations or options for biomarkers
⮚ Interpretation of microbiology findings
▪ Identify key measurements for improvement
▪ Set up regular meetings for continuous antibiotic stewardship education and seminars
▪ Enrolling non-medical counterparts to be part of antimicrobial stewards within their disciplines
▪ Collaborate with various teams in scientific research and antimicrobial audit projects
▪ Easy access to antibiotics guidelines and local antibiograms such as antibiotic digital apps or
pocketbook, and leaflets
AMS INTERVENTIONS
▪ During clinical stewardship review, a range of point of care stewardship interventions are carried out.
These provide direct and timely feedback to the prescribers as well as opportunity to educate clinical
staff on appropriate prescribing.
▪ Appropriate prescriptions are evaluated based on;
1. Indication for the antibiotics
2. Choice of agents
3. Dose
4. Duration of therapy
5. Route of administration; IV vs oral, bolus vs infusion
6. Empirical vs targeted therapy
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7. Likelihood of ongoing infection or not
8. Need for escalation, de-escalation or stopping therapy
AMS STRATEGIES
The core strategies consist of formulary restriction and approval system as described above, and Prospective
Audit & feedback
PROSPECTIVE AUDIT & FEEDBACK
This is performed by pharmacists, targeting on the predetermined antimicrobial prescriptions of (e.g
Carbapenem and Vancomycin) in selected adult wards.
Targeted prescription is reviewed and referred to ID/AMS team if fulfilling referral criteria.
Methodology
1. Prospective audit and feedback mechanism
2. 72-H STOP Vancomycin
▪ This is performed by targeting on the prescriptions of Carbapenem and Vancomycin in selected
adult wards
▪ Targeted prescription is reviewed by pharmacists and referred to ID/AMS team if fulfilling referral
criteria
▪ ID team will review the referred patient in the respective ward
▪ Decisions and recommendations to continue or stop will be documented in patient clinical notes
▪ Pharmacists will follow up with prescribers on ID team antibiotic input (for carbapenem)
▪ Pharmacy will stop antibiotic supply if does not meet indication criteria after ID review (for
vancomycin)
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ANTIMICROBIAL ORDER TOOLS
In HCTM, all medications including antimicrobials are prescribed by doctors via computerized physician online
electronic prescribing. The electronic prescribing system is set up so that antimicrobials are dispensed at a
limited duration of 3 to 5 days to prompt prescription review by the clinician on indication and duration of
therapy. Each prescription is screened by pharmacy staffs according to hospital policy before dispensing.
Dedicated Antimicrobial Prescription Charts are used In General Intensive Care Unit (GICU) (See appendix)
The prescription of the restricted antimicrobials have to be justified with a paper form of Jawatankuasa
Terapeutik Dan Ubat-ubatan (JKTU) Form, submitted to the Pharmacist. endorsed with signature and stamp
of the prescribing specialist as proof of consent. The aim of introducing stricter policy for drug supply is to
ensure appropriate use of these antimicrobials within the institution which could eventually lead to antimicrobial
resistance.
However, commonly used antimicrobials such as Amoxicillin/clavulanic acid are allowed to be kept as
floorstock in wards with approval by pharmacist and such list is to be revised 6 monthly. Meanwhile in selected
intensive care units e.g. GICU, NICU and BMT ward, broad-spectrum antimicrobials like carbapenems are
also kept as floorstock at controlled amount. This is to achieve time of first dose as soon as possible in sepsis
management among critically ill patients.
ANTIMICROBIAL DOSE OPTIMIZATION
Antimicrobials are commonly prescribed in standard doses for adults. Nonetheless, antimicrobials’ dosing
regimens can be individualized and prescribed at optimal dose with consideration of pharmacodynamic and
pharmacokinetic properties to improve clinical outcomes and minimizing antimicrobial resistance according
to latest evidence available. The use of pharmacodynamics to design antibiotic dosing regimens such as
the extended and continuous infusion of beta-lactams and vancomycin are applied mainly in GICU ward for
indicated patients only under the supervision of intensive care team (Refer to Appendix – HCTM GICU
Antibiotic continuous infusion protocol).
Dose optimization integrated into the drug-review process and adjusted according to organ function
especially in renal insufficiency, guided by available references but not limited to. References that are
commonly referred as dosing guide in HCTM UKM are Lexicomp, Micromedex, The Renal Drug Handbook
by Taylor & Francis Group, Stanford Heath Care Antimicrobial Dosing Reference Guide etc.
THERAPEUTIC DRUG MONITORING (TDM) SERVICE
The main objective of providing clinical pharmacokinetic services is utilization of information on the serum
drug concentrations to manage a patient’s medication regimen as well as to optimize clinical outcome.
List of patients that were prescribed selected antimicrobials with narrow therapeutic range such as
Vancomycin, Gentamicin and Amikacin are screened from the pharmacy prescribing system daily during
working days. Blood samplings for drug concentration are ordered by clinician including pharmacists after
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assessment as indicated. Assays for serum drug concentration will be performed by in-house biochemical
laboratories. Interpretation of antimicrobials concentration and regime modification are done accordingly,
considering drugs’ pharmacokinetic profile and patient clinical condition with the guide of local TDM protocol
which will be reviewed every 3 years.
IV TO ORAL SWITCH
Intravenous-to-oral conversion as a key stewardship measure to optimize antibiotics use with numerous
benefits for patients such as shortening the length of hospital stay, eliminating adverse effects associated
with IV therapy, increasing patient comfort and mobility as well as lowering healthcare costs.
Oral switch can be considered after intravenous therapy of 48 hours or even earlier with evaluation of
microbiology results and assessment of patients’ response to treatment.
A patient must meet all the criteria below before switching to oral antimicrobial:
● Display signs of clinical improvement with T<38°C with >24 hours AND
● Able to tolerate oral therapy AND
● No sign of sepsis AND
● No high risk or deep seated infection.
Choice of oral regime is selected based on current parenteral regime, drug bioavailability, site of infection
and microbiology evidence, according to reference such as but not limited to National Antimicrobial
Guidelines.
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APPENDIX (1)
HCTM GICU VANCOMYCIN CONTINUOUS INFUSION PROTOCOL
*Patient must use central line or dedicated peripheral line for vancomycin infusion
*Applied only for GICU patient, once transfer out to switch to intermittent infusion Advantage of
Continuous Vancomycin Infusion in ICU:
● Continuous infusion vancomycin is associated with a 53% reduction in the odds of acute kidney
injury
● 2.6-fold higher odds of pharmacokinetic target attainment when compared with intermittent
infusion which results in less variability in serum vancomycin concentrations, and requires less
therapeutic drug monitoring
● Reduce Cost by reducing the frequency of level taken and amount of preparation
● demonstrated higher CNS to serum ratios than intermittent dosing.
● more sustain level in pleural fluid than intermittent infusion
● Require a lower total daily dose than vancomycin intermittent infusion
Loading Dose
If the patient has recently received vancomycin without level within last 2 days to send levels prior to
commencing, if: Serum level < 6umol/l - load as above
6-10 umol/L - load 500mg in 100ml 5% glucose infuse over 1 hour.
10-19 umol/L - DO NOT LOAD but go to continuous infusion (see maintenance)
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Maintenance Dose
Commence immediately after the loading dose. Prescribed on the REGULAR section of the drug chart. The
prescription MUST include the infusion concentration and infusion rate. Maintenance dose should be
adjusted to achieve CSS (Concentration of Steady State) 12- 17 umol/L (17 - 25 mg/ml). For Deep Seated
and Severe infection can target up to 19 umol/L (28 mg/ml)
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Converting from Intermittent Dosing to Continuous Dosing:
● Patients who are therapeutic on intermittent dosing do not require a loading dose
● Patients on continuous infusion vancomycin therapy may accumulate vancomycin and therefore
may require lower total daily doses compared to intermittent therapy
● If patients therapeutic on intermittent dosing
○ Add up total daily vancomycin dose
○ Reduce by 10-15%
○ Round to the nearest 250 mg (this will be the starting dose of continuous infusion)
● If patients are sub-therapeutic or supra-therapeutic on intermittent dosing
○ Refer Pharmacist for dose adjustment
Converting from Continuous Dosing to Intermittent Dosing:
● if level not therapeutic while on continuous infusion or kidney impair: Refer Pharmacist
● If therapeutic on continuous infusion vancomycin to convert total daily dose to 15-25% increment
as:
● The first dose should be given immediately after stopping the continuous infusion. A serum
vancomycin level must be checked before the administration of the second intermittent dose
COMPATIBILITIES
Vancomycin solution has a low pH that may cause chemical or physical instability when it is
mixed with other compounds. Mixing with alkaline solutions should be avoided.
The following drugs have been reported to be incompatible with vancomycin: -
APPENDIX (2)
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HCTM GICU BETA-LACTAM CONTINUOUS INFUSION
PROTOCOL
Advantages: ( Nordin)
● Beta-lactams exhibit time-dependent bactericidal activity, Continuous Infusion (CI) significantly
increases the likelihood of maintaining serum levels above the MIC
● Higher likelihood of attaining PK/PD targets than intermittent infusion
● cost-effective
● Lower risk for adverse drug reactions (i.e. nephrotoxicity, neurotoxicity), which are often peak-
dependent.
*If multiple antibiotics are used as empirical to choose one as the potential targeted for continuous
infusion
Converting from Continuous infusion to intermittent infusion: To start Regular dose as per CrCl as
soon as infusion stop.
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APPENDIX (3)
HCTM Formulary Smartphone
application
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CHAPTER 5 SURGICAL ANTIMICROBIAL PROPHYLAXIS (SAP)
PRINCIPLE
Surgical antibiotic prophylaxis (SAP) is a practice aiming to prevent or reduce the incidence of
postoperative infection including surgical site infection (SSI).1 The WHO’s ‘Global Guidelines for The
Prevention SSI of 2016’, and the ‘CDC Prevention Guideline for The Prevention of Surgical Site Infection
2017’ had no specific recommendation on the type and dosage of antibiotic for SAP perioperatively.1,2 In
UKMMC, the SAP practice is recommended to be based on ‘Surgical Prophylaxis Review (2018)’. This
review provides information on the need for prophylaxis, choice, dose, route, and timing and duration of
the antimicrobial.3 The aim of the review is to ensure rational, safe, and effective SAP practice including
avoiding the use of antimicrobials when not required. However, other infection control practices,
improvement in operating room ventilation, sterilization methods, barriers, and surgical technique is of
similar importance.
Apart from surgical risk, there are various factors affecting the prevalence of SSI including infection control
measures in the operating theatre, surgical technique, and perioperative preparation. The use of SAP is
also justified in high-risk patients such as patients with immunocompromised and poor nutritional status,
presence of concurrent remote infections, micro-organisms colonization, and recent surgical procedure.
The benefits of SAP are mainly related to the consequence of the severity of SSI,4,5 hence reducing
mortality and morbidity and, hospital stay and cost. In another hand, SAP also comprises a portion of
hospital pharmacy budgets. Therefore, an appropriate choice is also of utmost importance.
ANTIMICROBIAL IN SURGICAL ANTIBIOTIC PROPHYLAXIS
Antimicrobial prophylaxis is indicated for most clean-contaminated and contaminated procedures, and
certain clean procedures, considering the infection risk and morbidity. Patient-related factors such as
obesity, immunosuppression, diabetes, poor nutritional status, microorganism colonization, and concurrent
remote infections should also be considered in the selection for SAP. The selection of SAP should be
selected according to the risk of patient colonization with multidrug-resistant microorganisms.
Antimicrobials are considered as a treatment when their use is in contaminated procedures or infection.
The choice and dosage should be prescribed according to the target specificity and sensitivity.
CHOICE OF ANTIMICROBIAL
The prophylaxis is not meant to target all possible microorganisms but only the most common, according
to the surgical procedure(s). Many antimicrobials are similar in terms of target spectrum, efficacy, toxicity,
and ease of administration. In view of prophylactic antimicrobials being broad-spectrum may alter the
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bacteriology of opportunistic infection, it is very important that its benefits should outweigh the probability
of adverse drug reaction, super-infection, or development of resistance. In our institution, Amoxicillin/
Clavulanic acid is the commonest choice of SAP. As most postoperative infections are due to the patient's
skin flora comprising Staphylococcus aureus and coagulase-negative staphylococci, beta-lactams e.g.
penicillins and cephalosporins are the commonest choices for SAP.6 The choice of an SAP in patients with
a history of allergy to penicillins may not be straightforward as the use of cephalosporins may be
contraindicated due to the concern of cross-reaction. Nevertheless, the status of allergy warrants further
assessment before resorting to alternative choices which can be less efficacious.6
Hospitalised patients may be colonized with bacterial floral that include multi-resistant bacteria such as
methicillin-resistant staphylococci. Unnecessary use of vancomycin selects for vancomycin-resistant
enterococci (VRE), vancomycin-intermediate Staphylococcus aureus (VISA), and vancomycin-resistant
Staphylococcus aureus (VRSA). It is good clinical practice for patients to bathe or shower prior to surgery;
either plain soap or an antimicrobial soap may be used for this purpose. The aim is to ensure that the skin
is as clean as possible and to reduce the bacterial load, especially at the site of the incision. In nasal
carriers of Staphylococcus aureus, decolonization with mupirocin ointment with or without chlorhexidine
gluconate body wash is recommended for the prevention of infection.7
TIMING OF ADMINISTRATION
There are multiple factors that may influence the effectiveness of the SAP; the underlying condition(s) of
the patient, the pharmacokinetics of the antimicrobial used, and the duration of the procedure. To ensure
successful prophylaxis, the antimicrobial has to be of the appropriate choice, in an effective concentration,
and the administration should be timed and completed before exposure to contamination.
The WHO recommends administration of SAP not more than 120 minutes prior to skin incision and CDC
recommends the exact time for SAP administration prior to incision should be determined by the half-life of
the antimicrobial.1,2 Practically, the administration of SAP should be as closest as possible to the time of
surgical incision.
REDOSING
If surgery lasts <4 h and no significant blood loss occurs, a single dose of SAP is sufficient.2,8 However, as
shown in Table 1, redosing of SAP is recommended when the duration of the procedure exceeds two half-
lives of the antimicrobial, or if there is excessive blood loss during the procedure to maintain the activity
throughout the duration of the procedure.2 The serum levels of antimicrobial are reduced by blood loss and
fluid replacement, especially in the first hour of surgery when its concentrations are high. It is difficult to
predict the precise effects of blood loss and fluid replacement. Therefore, the redosing will depend on the
particular antibiotic used, the time and rate of blood loss, and fluid replacement. Redosing should be
considered after intraoperative blood loss of more than 1.5L in adults or 25mL/kg in children.
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DURATION
According to CDC, the prescription of SAP should be discontinued after the incision is closed in clean and
clean-contaminated surgeries.2 However, in clinical practice many SAPs are continued up to or more than
24 hours postoperatively. There is no additional benefit in prolonging antibiotic prophylaxis compared to a
single dose.1,2,8,9 In fact, it may contribute to the emergence of antimicrobial resistance and financial waste.
The extended use of antimicrobials after procedures is discouraged unless indicated as treatment.1,2,10
Table 1. The half-life of and proposed redosing interval of antibiotic
Adapted from PPUKM Surgical Prophylaxis Review (2018).3 *Redosing according to prolonged
procedures.
PROCESS MEASURE
In our institution, the performance of the SAP practice is measured as part of the annual point prevalence
survey. The number of patients receiving surgical antibiotic prophylaxis according to hospital guidelines
and the total number of surgical patients receiving antibiotic prophylaxis was recorded by the pharmacist.
The total number of surgeries that require prophylaxis and the duration of SAP used is also recorded and
audited.
In general, prescribing has been shown to be influenced by several factors, including the prescriber, patient
and clinical demand. Diagnostic uncertainty also plays an important role in overprescribing of SAP.11 It has
been proven that Antimicrobial stewardship (AMS) programs is recommended as a key intervention in
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reducing the burden of healthcare-associated infections and costs. In order to achieve appropriate SAP
practice, a multifaceted strategy is suggested, combining hospital administrative, physician, and patient.
The publication of guidelines and recommendations, educational sessions on appropriate prescribing,
educational sessions on the diagnosis and management of infections, and audits or reviews of prescribing
data are strategies that may improve the practices of SAP.
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SURGICAL ANTIMICROBIAL PROPHYLAXIS
INFECTION CONTROL
Surgical antibiotic prophylaxis (SAP) is one of the established
components of Surgical Site Infection (SSI) prevention.
AIM
The main aim is to prevent or reduce the incidence of surgical site
infection (SSI) and to ensure appropriate antimicrobial prophylaxis,
including avoiding the use of antimicrobials when not required.
ANTIMICROBIAL
Antimicrobial prophylaxis is indicated for most clean-contaminated and
contaminated procedures, and certain clean procedures, considering
the infection risk and morbidity. It is not to target all possible
microorganisms but only the most common, according to the surgical
procedure(s).
TIME
The administration should be not more than 120 minutes prior to skin
incision and the exact time should be determined by the half-life of the
antimicrobial.
DURATION
A single dose of antimicrobial of choice appropriately recommended
prior to skin incision for procedure that last <4 h with no significant
blood loss.
Redosing is recommended if the duration exceeds two half-lives of the
antimicrobial, or if there is excessive blood loss aim to maintain the
activity of the antimicrobial throughout the duration of the procedure.
Figure 1. Surgical antimicrobial prophylaxis at a glance.
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REFERRENCES
1. Ministry of Health Malaysia. Policies & Procedures on Infection Prevention and Control. 3rd
edition. Vol. 3rd edition, Infection Control Unit Medical Care Quality Section Medical
Development Division Ministry of Health Malaysia. 2019.
Hand Hygiene
1. Ministry of Health Malaysia. Poster of How to Handrub?. Infection Control Unit Medical Care
Quality Section Medical Development Division Ministry of Health Malaysia. 2021
2. Ministry of Health Malaysia. Poster of How to Handwash?. Infection Control Unit Medical Care
Quality Section Medical Development Division Ministry of Health Malaysia. 2021
Management of Spillage
1. Poster of Spillage Management PPUKM HCTM. Infection Control Unit PPUKM HCTM_2016
2. Poster of Disinfectant Tablets for Spillage. Infection Control Unit, UKMMC_2016
Isolation Room
1. healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_part_d_isolation_rooms
Enteral nutrition
1. ASPEN Safe Practices for Enteral Nutrition Therapy
(https://www.researchgate.net/publication/309706255)
2. Community Infection Prevention Control Policy for Care Home settings, CH 07 Enteral tube
feeding October 2020 Version 3.00
3. Community Infection Prevention Control Policy for Domiciliary Care staff, DC 03 Enteral tube
feeding April 2021 Version 2.00
4. Enteral Feeding and Infection Control in Adults Policy version 7, Issued 10/05/2021
5. Guidelines for enteral feeding in adult hospital patients, M Stroud, H Duncan, J Nightingale, Gut
2003;52 (Suppl VII) : vii1–vii12 (www.gutjnl.com)
6. Infection control in enteral feed and feeding systems in the community (British Journal of Nursing
(Mark Allen Publishing), October 2012)
7. Preventing infections in people having treatment or care at home or in the community, 1 March
2012 (www.nice.org.uk)
Parenteral Nutrition
1. Ayers P, Adams S, Boullata J, Gervasio J, Holcombe B, Kraft MD, Marshall N, Neal A, Sacks G, Seres
DS, Worthington P. American Society for Parenteral and Enteral Nutrition. A.S.P.E.N. parenteral
nutrition safety consensus recommendations. JPEN J Parenter Enteral Nutr. 2014 Mar-Apr;38(3)
296-333. doi:10.1177/0148607113511992. PMID: 24280129.
2. Pittiruti M, Hamilton H, Biffi R, MacFie J, Pertkiewicz M. ESPEN guidelines on parenteral nutrition:
central venous catheters (access, care, diagnosis and therapy of complications). Clinical nutrition.
2009 Aug 1;28(4):365-77.
3. AmericanSociety of Health-System Pharmacists. ASHP Guidelines on Compounding Sterile
Preparations. Am J Health-Syst Pharm. 2014;71:145–66.
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4. Manual For Sterile Preparation, MOH 2021
Intravascular catheter related infections
1. The Prevention of Intravascular Catheter-Related Infections. Retrieved 12/09/2019. Official copy at
http://unchealthcare-uncmc.policystat.com/policy/7113270/. Copyright © 2019 UNC Medical Center
2. Infusion Nurses Society. (2021). Infusion therapy: Standards of practice.
3. https://www.cdc.gov/infectioncontrol/pdf/guidelines/bsi-guidelines-H.pdf
4. Hill, S., Moureau, N.L. (2019). Right Securement, Dressing, and Management. In: Moureau, N. (eds)
Vessel Health and Preservation: The Right Approach for Vascular Access. Springer, Cham.
https://doi.org/10.1007/978-3-030-03149-7_9
5. Grissinger M. (2011). Capping intravenous tubing and disinfecting intravenous ports reduce risks of
infection. P & T : a peer-reviewed journal for formulary management, 36(2), 62–76.
Central vascular related infection
1. MOH Manual Central Venous Catheter Care Bundle Compliance Surveillance 2016.
2. https://www.cdc.gov/hai/bsi/clabsi-resources.html
3. https://www.cdc.gov/infectioncontrol/guidelines/BSI/index.html
4. https://www.cdc.gov/nhsn/psc/bsi/
Nicu
1. Bankhead R, Boullata J, Brantley S, Corkins M, Guenter P, Krenitsky J, Lyman B, Metheny NA, Mueller
C, Robbins S, Wessel J. ASPEN enteral nutrition practice recommendations. Journal of Parenteral and
Enteral Nutrition. 2009 Mar;33(2):122-67
2. Boullata JI, Carrera AL, Harvey L, Escuro AA, Hudson L, Mays A, McGinnis C, Wessel JJ, Bajpai S, Beebe
ML, Kinn TJ, Klang MG, Lord L, Martin K, Pompeii-Wolfe C, Sullivan J, Wood A, Malone A, Guenter P
ASPEN Safe Practices for Enteral Nutrition Therapy Task Force, American Society for Parenteral and
Enteral Nutrition. ASPEN Safe Practices for Enteral Nutrition Therapy. JPEN J Parenter Enteral Nutr.
2017;41:15–103
3. Centers for Disease Control and Prevention. Breastfeeding. Guidelines and Recommendations –
Proper Storage and Preparation of Breast
Milk. https://www.cdc.gov/breastfeeding/recommendations/handling_breastmilk.htmAccessed
March 2022.
4. Centers for Disease Control and Prevention. Healthcare-Associated Infections (HAIs). Best Practices
for Environmental Cleaning in Healthcare Facilities: in Resource-Limited Settings.
https://www.cdc.gov/hai/prevent/resource-limited/cleaning-procedures.html. Accessed March
2022
5. Hand Hygiene: Why, How & When? – World Helath Organization.
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Unit, Medical Care Quality Section, Medical Development Division, Ministry of Health Malaysia. ISBN:
978-967-2173-79-3
7. Steele C. Best Practices for Handling and Administration of Expressed Human Milk and Donor Human
Milk for Hospitalized Preterm Infants. Front Nutr. 2018; 5:76. doi:10.3389/fnut.2018.00076
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Common IV Drugs in NICU HCTM that SHOULD NOT infuse through filter:
1. Albumin:
http://www.adhb.govt.nz/newborn/Guidelines/Blood/BloodProducts/Blood%20product-
%20albumin.htm
2. IVIG: https://www.starship.org.nz/guidelines/blood-products-immunoglobulin-ivig-newborn-
services/
3. Insulin:
https://www.slhd.nsw.gov.au/RPA/neonatal/content/pdf/Medications_Neomed/Insulin_for_hy
perglycaemia_Neomedv1.2_full_20170620.pdf
4. https://www.starship.org.nz/guidelines/insulin-neutral-for-the-newborn-intensive-care
5. AmphoB & Ampholip: Product insert
6. Ibuprofen: NICU consensus as infuse using Canafusion Ca-500 pump
Operation Room
1. Operation Theatre Quality and Prevention of Surgical Site Infections, A.M. Spangnolo, G. Ottria, D.
Amicizia, F. Perdelli, M.L. Cristina. J Prev Med Hyg 2013; 54(3): 131-137
2. Policies & Procedures on Infection Prevention and Control, 3rd Edition 2019, Medical Care Quality
Section, Medical Development Division, Ministry of Health Malaysia.
3. Berry & Khon’s Operating Room Technique,13th Edition,Nancy marie Phillips:248-299
4. Manual Panduan Perawatan ,Jabatan Perkhidmatan Kejururawatan Hospital Universiti Kebangsaan
Malaysia ,Hospital Censelor Tuanku Muhriz.
Mortuary
1. Policies & Procedures on Infection Prevention and Control, MOH, 3rd Edition 2019
2. Guidelines For Handling Dead Bodies Of Suspected/ Probable/Confirmed Covid-19, MOH, Annex 20,
3. Managing Infection Risks When Handling The Deceased, HSE, UK, 2018
4. Managing Health And Safety Risks In New Zealand Mortuaries, OSH, NZ, 2000
Hematology oncology
1. https://www.cdc.gov/hai/settings/outpatient/basic-infection-control-prevention-plan-
2011/index.html
2. Ariza-Heredia, E. J., & Chemaly, R. F. (2018). Update on infection control practices in cancer
hospitals. CA: a cancer journal for clinicians, 68(5), 340–355. https://doi.org/10.3322/caac.21462
3. MOH Systemic Protocol 3rd Edition 2016
4. Chemo Protocol, Cell Therapy Centre, UKMMC (2013).
5. Infusion Nursing Society Standards of Practice, 2021
6. Oncology Nursing Society Access Devices Guidelines
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Section f : Occupational safety and health care worker
1. Ministry of Health Malaysia. Policies & Procedures on Infection Prevention and Control. 3rd edition.
Vol. 3rd edition, Infection Control Unit Medical Care Quality Section Medical Development Division
Ministry of Health Malaysia. 2019.
2. Linda Tietjen. Infection Prevention Guidelines for Healthcare Facilities with Limited Resources. Vol.
372, Jhpiego. 2013. 1–75 p.
3. CDC. Recommendation of the Immunization Practices Advisory Committee (ACIP). Inactivated
hepatitis B virus vaccine. [Internet]. Vol. 31, MMWR. Morbidity and mortality weekly report. 1982. p.
317-322,327-328. Available from:
https://www.embase.com/search/results?subaction=viewrecord&id=L12683001&from=export
4. Iuliano AD, Roguski KM, Chang HH, Muscatello DJ, Palekar R, Tempia S, et al. Estimates of global
seasonal influenza-associated respiratory mortality: a modelling study. Lancet.
2018;391(10127):1285–300.
5. World Health Organization. Influenza ( Seasonal ) Ask the expert : Influenza Q & A. Who [Internet].
2018;2020(November 2018):1–5. Available from: https://www.who.int/news-room/fact-
sheets/detail/influenza-(seasonal)
6. Requirements UH. Visa Type Hajj and Umrah Health Requirements. 2005;
Section G : Antimicrobial Stewardship
1. Blot S, Koulenti D, Akova M, et al. Does contemporary vancomycin dosing achieve therapeutic targets
in a heterogeneous clinical cohort of critically ill patients? Data from the multinational DALI study.
Crit Care. 2014;18(3):R99
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