Overview Antibiotics are precious lifesaving medicines Antimicrobial resistance

Overview • • • Antibiotics are precious life-saving medicines Antimicrobial resistance is both a global and local problem The link between antibiotic use and resistance Addressing antimicrobial resistance in Australia Antimicrobial stewardship (AMS) Antibiotic Awareness Week 2017.

Antibiotic Awareness Week in Australia Aims to encourage best practices among the general public, health workers and policy makers to avoid further emergence and spread of antimicrobial resistance.

What is antimicrobial resistance? • Antimicrobial resistance (AMR) occurs when bacteria, parasites, viruses or fungi change to protect themselves from the effects of antimicrobial drugs designed to destroy them. • This means previously effective antimicrobial drugs (e. g. antibiotics) used to treat or prevent infections may no longer work. • The World Health Organization (WHO) has identified AMR as ‘one of the biggest threats to global health’.

Why are antibiotics and antimicrobial resistance important? • Antibiotics decreased mortality from infections caused by resistant bacteria − Currently, antibiotics reduce post-operative infection rates to below 2. 0% − Without effective antibiotics, this could increase to around 40% to 50%. Up to 30% of these patients could die from resistant bacterial infections • Modern medicine, especially surgery and cancer treatments, depends on effective antibiotics to minimise the risk of infection − The risk of mortality without access to effective antibiotics may make some treatments and surgical procedures too risky to continue • Antimicrobial resistance could cause significant loss of life • Antimicrobial resistance results in substantial financial cost for patients and healthcare systems.

How has antimicrobial resistance developed? • • • Antimicrobial resistance is a natural phenomenon Overuse, misuse and inappropriate use of antibiotics The delivery of more complex health care requiring longer use of antibiotics Prolonged hospitalisation The implications of surgical procedures undertaken overseas Resistant pathogens can now spread easily − during hospitalisation if infection prevention is poor − potential for cross-border transmission through increased travel.

Source: Centers for Disease Control and Prevention

Antibiotic use is related to antimicrobial resistance Relationship between total antibiotic consumption and Streptococcus pneumoniae resistance to penicillin in 20 industrialised countries. Source: The Antimicrobial Resistance Standing Committee (2013) National Surveillance and Reporting of Antimicrobial Resistance and Antibiotic Usage for Human Health in Australia.

Decline in antibiotic production • Very few antibiotics have been developed in the last 20 years • Most ‘new’ antibiotics are variations of existing antibiotics • Only 5 novel classes have been developed in the last 20 years, e. g. 1 for TB. Source: Butler M, Blaskovich M, Cooper M. Antibiotics in the clinical pipeline in 2013. J. Antibiot 2013; 66: 571 -591.

Antimicrobial Resistance requires a global response In May 2015, the World Health Assembly adopted a Global Action Plan on Antimicrobial Resistance, which outlines five key objectives to: 1. Improve awareness and understanding of antimicrobial resistance 2. Strengthen the knowledge and evidence base 3. Reduce the incidence of infection 4. Optimise the use of antimicrobial medicines 5. Develop the economic case for sustainable investment. https: //amr-review. org

Australia’s response to antimicrobial resistance In June 2015, the Australian Government released its first National Antimicrobial Resistance Strategy 2015– 2019 to guide the response to the threat of antimicrobial misuse and resistance. Objectives: 1. Communication, education and training 2. Antimicrobial stewardship 3. Surveillance 4. Infection prevention and control 5. National research agenda 6. Strengthen international partnerships 7. Clear governance arrangements.

Australia’s response to antimicrobial resistance • In Australia, antimicrobial resistance also affects aged care homes and the community. High levels of antibiotic use in the community (which includes primary and aged care) is a growing concern • Australia is better placed than many countries to respond to antimicrobial resistance through having: - The Antimicrobial Use and Resistance in Australia Surveillance System – AURA Surveillance System - The National Alert System for Critical Antimicrobial Resistances – CARAlert - The Australian Government’s National Antimicrobial Resistance Strategy 2015 -2019 - Initiatives developed and implemented from Australia’s states and territories, and the private sector.

Surveillance of Antimicrobial Use and Resistance in Australia (AURA) The AURA Surveillance System: • Coordinates the integration of data from a range of sources on antimicrobial use and antimicrobial resistance • Contributes significantly to the development and implementation of health strategies to respond to, monitor and prevent antimicrobial resistance in Australia.

Surveillance of Antimicrobial Use and Resistance in Australia (AURA) The AURA National Coordination Unit is responsible for the AURA Surveillance System. It partners with multiple organisations to inform strategies for local, state and territory and national health system. National Neisseria Network National Notifiable Diseases Surveillance System Org. TRx

AURA 2017 Key Findings – Antibiotic use in the Community • Australia has very high usage of antibiotics in the community. In 2015, 46% of individual Australians received an antibiotic • In 2015 antibiotics were most commonly dispensed for very young people and older people, with: − 51% of those aged 0– 4 years − 60% of those aged 65 years or over, and − 76% of those aged 85 years or over being supplied at least one antibiotic • Between 1 January and 31 December 2015, 30% of Medicine. Insight patients (just under 1 million people) were prescribed systemic antibiotics.

Prescribing for Upper Respiratory Tract Infection (RTI) • A lot of prescribing is for respiratory tract infections • Seasonal variation is driven by viruses – which do not respond to antibiotics • Data shows that 60% of patients who present with RTI will be prescribed antibiotics. Marked seasonal variation in agents used for RTI

Patient impact of antimicrobial resistance infections • Catheter-related bloodstream infections are avoidable – following best-practice guidelines can achieve rates close to zero • MRSA bacteraemia – can be contracted in many ways. Can cause multiple organ dysfunction syndrome • Preventing infections is everybody's business (whole of hospital) • Prolonged hospital stay. Watch Glen’s Story here

Antimicrobial resistance locally – What is happening in our health service • Which infections are we seeing? [Insert surveillance data] • What are our susceptibility and resistance patterns? • [Insert hospital data] • [Numbers of cases] • [Examples of cases] • Are there local antimicrobial resistance issues? • What are local rates of MRSA, C diff? • Do you have access to a local antibiogram?

Local example of a resistant bacterial infection • This is a placeholder for a local example of a patient who experienced a resistant bacterial infection at your healthcare facility • Insert a case study (optional) • You may want to detail the: − − − diagnosis and the method of diagnosis bacterium that was resistant to the preferred antibiotic medications used to treat the bacterial infection time, resources and people involved to treat the infection impact on the patient, the patient’s life and patient’s family immediate, medium or long-term health implications (if any).

Monitoring of Critical Antimicrobial Resistances (CARAlert)

Critical Antimicrobial Resistances (CAR) • Organisms which are resistant to ‘last-line’ antibiotics • 1, 064 notifications March 2016–March 2017 • 70% of all CARs were from the 3 most populous states: − New South Wales (34%) − Victoria (21%) − Queensland (15%) • Only 2 reports received from the Northern Territory and 5 from Tasmania Examples • Carbapenem-resistant Enterobacteriaceae – few treatment options • Reduced-susceptibility Neiserria gonorrhoea – 2 nd most common CAR

Aggregate Hospital Antibiotic Use 2015 Factors that are likely to have contributed to reduced use include: • Increased capacity of local, state and territory, and national AMS programs • Changes in clinical practice • More effective adoption of recommendations in Therapeutic Guidelines: Antibiotic.

Antibiotic Use in Australian Hospitals 2015 • 30 to 40% of inpatients are receiving an antibiotic on any given day • Cephazolin is the most common antibiotic used • 916 DDD / 1, 000 bed days − Accounts for multiple antibiotics per patient − Difference between DDD and patient doses • The most common indications for prescribing antimicrobials were: 1. Surgical prophylaxis (15. 5%) 2. Community-acquired pneumonia (10. 5%) 3. Medical prophylaxis (7. 6%) 4. Sepsis (5. 7%) 5. Urinary tract infection (5. 0%).

Understanding Variation • There is marked variation in use of antibiotics − between states − between hospitals • different sizes • within the same size • The reasons for this are not well understood • Also marked variation in community dispensing of antibiotics − The first Atlas included information on community antibiotic use.

Number of PBS prescriptions dispensed for amoxycillin-clavulanate per 100, 000 people, age standardised, by local area, 2013– 14 Source: Australian Atlas of Healthcare Variation

Local Antibiotic Use • Insert local antibiotic use data (if available) • Include information about your contributions to National Antimicrobial Usage Surveillance Program (NAUSP) • Insert NAUSP data.

Appropriateness of prescribing at our hospital • Does your healthcare facility audit appropriateness of prescribing? • What tools are used (eg. NAPS, jurisdictional resource) • If participating in NAPS, insert your healthcare facilities: − insert NAPS results here − results compared to national results − how the your facility’s NAPS results have contributed to your AMS program.

Appropriateness of prescribing at our hospital • Local data to be added here • Visit the NAPS portal – https: //www. naps. org. au • Consider including time-series data.

Appropriateness of prescribing at our hospital • Visit the NAPS portal – https: //www. naps. org. au • Consider including time-series data • Example tables from NAPS or NAUSP

Why is inappropriate use important? Top reasons for inappropriate use – National Antimicrobial Prescribing Survey 2015 May increase risk of adverse effects, including: • • • AMR (current and future patients) Antimicrobial allergy Spectrum too broad Antimicrobial not indicated Treatment failure Incorrect dose or frequency Clostridium difficile Incorrect duration Increased health care costs. Spectrum too narrow Incorrect route

Addressing AMR: Antimicrobial stewardship (AMS) • A systematic approach to optimising the use of antimicrobials • Goals: ‒ improve patient outcomes / patient safety ‒ reduce antimicrobial resistance ‒ reduce costs. • AMS works hand-in-hand with infection prevention and control strategies • Requires teamwork at all levels: − ‘everybody's business’ − executive and clinical leadership − clinical team (doctors, nurses, pharmacists, allied health) − consumers.

Essential elements for AMS Programs • • Structure, governance and people Executive and clinical leadership AMS committee and Multidisciplinary AMS team Expert advice from − infectious diseases experts − microbiologists − pharmacists • Education and training − prescribers, pharmacists, nurses − consumers • Information technology resources.

Essential strategies for AMS Programs • Multidisciplinary efforts • Implementing clinical guidelines consistent with Therapeutic Guidelines: Antibiotic • Establishing formulary restrictions and an approval system • Reviewing/auditing antimicrobial prescribing with intervention and direct feedback to prescribers • Selective reporting of susceptibility testing results • Monitoring antimicrobial use and outcomes, and reporting to clinicians and management.

Commission Resources for AMS (New edition 2018)

Consumer information

Improving antimicrobial use with the AMS Clinical Care Standard Describes best-practice in antibiotic prescribing: 1. Urgent treatment of severe infection 2. Appropriate investigations collected (preferably before antibiotics) 3. Information given to patient about diagnosis 4. Prescribing as per Therapeutic Guidelines: Antibiotic (or other local guidelines) 5. Information given to patient about treatment 6. Documentation of treatment plan in the record 7. Narrowing of broad-spectrum empiric treatment when appropriate 8. Investigations reviewed in a timely way 9. Surgical prophylaxis in accordance with guidelines

Therapeutic Guidelines: Antibiotic A quick note… • Always use the most current version – Currently version 15, 2014) • Check hospital intranet • A ‘go to’ reference, especially where there are limited local guidelines • Learn more – www. tg. org. au – click ‘Products’, then ‘Antibiotic’

Antimicrobial Stewardship in our healthcare facility Insert information on your AMS service: • • • Structure, governance – who is responsible? Who leads AMS activities? Who is on your local AMS team? What AMS activities are undertaken? What AMS activities are you / your department involved in?

Local Antibiotic Awareness Week Activities Insert information on AAW in your health service: • Join the conversation on social media: • Hashtags #Antibiotic. Resistance / #AAW 2017 • @ACSQHC and @NPSMedicine. Wise • Local activities and contact people • Include information about local activities

Key messages about antibiotics and antimicrobial resistance • Antimicrobial resistance occurs when an organism evolves and develops resistance to an antimicrobial that should inhibit or destroy it • Antimicrobial resistance is reducing the effectiveness of antimicrobials to treat infections • Antimicrobial resistance is happening now • Few new antimicrobials are being developed • The misuse, overuse, and inappropriate use of antimicrobials contributes to antimicrobial resistance • Antimicrobial stewardship works hand in hand with prevention and control strategies to help address antimicrobial resistance.