Overview • • • Antibiotics are precious medicines Antibiotic resistance: a global and local problem The link between antibiotic use and resistance Addressing antibiotic resistance Antimicrobial stewardship (AMS) Antibiotic Awareness Week 2016 Whenever they are used, antibiotics must be used with care.
The ‘miracle’ of antibiotics • Discovery of penicillin revolutionised treatment of infectious disease • Increased life expectancy due to ability to prevent and treat infection Crude mortality rates for all causes, non infectious causes and infectious diseases over the period 1900 -1996. 1. Armstrong GL et al, JAMA 1999; 281(1): 61 -66
Antibiotics continue to save lives every day… Ability to control infection is critical to other advances in medicine including: – – – – Neonatal care Transplantation Chemotherapy Immunosuppression Complex and routine surgery Obstetric care Intensive care interventions
But…antibiotics are a limited resource Increasing antibiotic resistance Increased use of antibiotics Decreasing pipeline of new antibiotics 2. Spellberg, B. et al. Clinical Infectious Diseases 2008; 46 (2): 155 -64 3. Office of the Chief Scientist http: //www. chiefscientist. gov. au/2013/07/antibiotic-resistance-a-serious-threat/
Emergence of antibiotic resistance Antibiotic resistance threatens ability to control infection “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body. ” Sir Alexander Fleming, 1945 4. Sir Alexander Fleming, Nobel Lecture, December 1945 5. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012
Antibiotic resistance: a problem globally… 2014: WHO Global Report on Surveillance • • • Very high rates of resistance observed for common bacteria that cause healthcare associated and community-acquired infections in all WHO regions Significant gaps in surveillance Urgent need to strengthen collaboration on global surveillance to address antimicrobial resistance (AMR). May 2015 • World health assembly endorses global action plan to tackle AMR. September 2016 • 193 countries sign UN Declaration to take action on AMR, reaffirming their commitment to develop national action plans on AMR, based on the global action plan. 6. World Health Organization 2014. Antimicrobial Resistance: Global Report on Surveillance. http: //www. who. int/drugresistance/documents/surveillancereport/en / Last accessed 21/9/14 7. http: //www. who. int/antimicrobial-resistance/global-action-plan/en / 8. http: //www. who. int/mediacentre/news/releases/2016/commitment-antimicrobial-resistance/en /
…a problem in our region China* ECOL: 54% KPNE: 41% India ECOL: 78% KPNE: 64% Thailand* ECOL: 55% KPNE: 50% Malaysia ECOL: 36% KPNE: 45% Korea ECOL: 37% KPNE: 40% Hong Kong ECOL: 46% KPNE: 23% Singapore ECOL: 21% KPNE: 32% Japan† ECOL: 17% KPNE: 11% Philippines ECOL: 47% KPNE: 23% Taiwan ECOL: 91% KPNE: 75% Indonesia ECOL: 71% KPNE: 64% Resistance (%ESBL) in the Asia Pacific region 9. Mendes et al. , Antimicrob. Agents Chemother. 2013 10. Xiao et al, Drug Resist Updat, 2011 (2009 data) 11. Chong et al. , EJCMID, 2011 (2009 data) Australia ECOL: 12% KPNE: 15% New Zealand ECOL: 11% KPNE: 10%
…and a problem in Australia The National Antimicrobial Resistance (AMR) Strategy Responding to the threat of AMR 12 Seven objectives focused on: 1. Awareness, education 2. Antimicrobial stewardship 3. Surveillance 4. Infection prevention and control 5. International management 6. Research and development 7. Governance 12. Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www. health. gov. au/amr
Antimicrobial Use and Resistance in Australia (AURA) • Surveillance of antibiotic usage (volume, appropriateness) and resistance is the cornerstone of efforts to control AMR • Surveillance provides information on impact of usage patterns on development of resistant bacteria • Local surveillance is critical to informing local policy, guidelines and measuring effect of local interventions. • National surveillance can inform national response and prevention strategies • The national AURA project brings together a wide range of passive and targeted surveillance of antimicrobial resistance and usage in hospitals and the community • AURA 201615 provides a comprehensive picture of antimicrobial resistance, antimicrobial use and appropriateness of prescribing in Australia. Antimicrobial Use and Resistance in Australia (AURA) 2016: First Australian report on antimicrobial use and resistance in human health 13. http: //www. safetyandquality. gov. au/national-priorities/amr-and-au-surveillance-project/
AMR in Australia Some of the findings (AURA 2016) • • Enterobacteriaceae – strains of Escherichia coli that produce extended-spectrum -lactamases now a problem in community infections, often multidrug resistant. High rates of resistance in key Gram-positive organisms – Staphylococcus aureus – between 15. 8% and 17. 4% of isolates methicillin-resistant S. aureus (MRSA). Community MRSA strains now cause a significant proportion of infections in both the community and hospitals. – Enterococcus species – one of the highest rates in the world of vancomycin resistance in Enterococcus faecium. – Streptococcus pneumoniae – resistance (as defined for strains causing infections other than meningitis) was low (around 2%) for one key antimicrobial (benzylpenicillin), but high (21– 26%) for other key antimicrobials.
Antibiotic resistance locally What is happening in our health service • Which infections are we seeing? • What are our susceptibility and resistance patterns? – [Insert hospital data] – [Numbers of cases] – [Examples of cases]
Antibiotic use and antibiotic resistance Relationship between total antibiotic consumption and Streptococcus pneumoniae resistance to penicillin in 20 industrialised countries 14. Shaban RZ, Cruickshank M, Christiansen K & the Antimicrobial Resistance Standing Committee (2013 ), p. 6. National Surveillance and Reporting of Antimicrobial Resistance and Antibiotic Usage for Human Health in Australia. Antimicrobial Resistance Standing Committee, Australian Heath Protection Principal Committee: Canberra.
Antimicrobial Use and Resistance in Australia summary
International comparisons Antimicrobial use in Australian hospitals and other countries Sources: NAUSP (Australia), CIPARS (Canada), DANMAP (Denmark), ESPAUR (England), Neth. MAP (Netherlands), SAPG (Scotland), NORM (Norway), SWEDRES (Sweden)
Antibiotic usage in our health service • Insert local usage data if available • Include information about contributions to National Antimicrobial Usage Surveillance Program (NAUSP)
Antimicrobial stewardship (AMS) • A systematic approach to optimising use of antibiotics • Goals: ‒ ‒ improve patient outcomes improve patient safety reduce antimicrobial resistance reduce costs. • Part of broader system for infection prevention and control to minimise resistance • Requires teamwork at all levels: – – ‘everybody's business’ executive and clinical leadership clinical team (doctors, nurses, pharmacists, allied health) consumers 15. Mac. Gowan 1983 16. Nathwani D and Sneddon J. Practical Guide to Antimicrobial Stewardship. Access at http: //bsac. org. uk/news/practical-guide-to-antimicrobial-stewardship-in-hospitals /
What is inappropriate use? Inappropriate use includes: • Using broad-spectrum antibiotics (such as third generation cephalosporins, carbapenems) when narrow-spectrum antibiotics are effective • Prescribing too low or too high a dose of antibiotic • Not prescribing according to microbiology results • Continuing treatment for longer than necessary • Omitting doses or delayed administration Top reasons for inappropriate use – National Antimicrobial Prescribing Survey 2014
Essential strategies for effective AMS Essential strategies for all hospitals: • Implementing clinical guidelines consistent with Therapeutic Guidelines: Antibiotic • Establish formulary restrictions and an approval system • Reviewing/auditing antimicrobial prescribing with intervention and direct feedback • Selective reporting of susceptibility testing results
Clinical Care Standard for AMS What role do you play? Nine statements describing best practice for managing a patient who has, or is suspected of having, a bacterial infection, regardless of setting. • For consumers: Describes the care they can expect to receive • For clinicians: Provides support in the delivery of care the patient is expecting • For health services: Systems are in place to support clinicians in providing the care that is expected by the patient. 17. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Access at www. safetyandquality. gov. au/ccs
National Safety and Quality Health Service Standards, Standard 3: Antimicrobial Stewardship Criterion Actions required: 3. 14. 1 An AMS program is in place 3. 14. 2 The clinical workforce prescribing antimicrobials has access to endorsed therapeutic guidelines on antibiotic usage 3. 14. 3 Monitoring of antimicrobial usage and resistance is undertaken 3. 14. 4 Action is taken to improve effectiveness of your AMS program NSQHS Standard 3: is currently being revised and is under consultation. For planned pilot and implementation in 2017. AMS will remain a core component of Standard 3. 18. National Safety and Quality Health Service Standards , access at www. safetyandquality. gov. au/our-work/accreditation/nsqhss/
Antimicrobial stewardship in our hospital • Multidisciplinary, team approach • Local roles and responsibilities – Medicine, nursing, pharmacy – Consumer participation – Executive and clinical leaders • Local processes for stewardship – Include local processes for • • • seeking ID/micro consults guideline and formulary information pharmacy advice contacts other relevant information.
Our health service tools and activities to promote appropriate use of antibiotics • Responsible committees – e. g. infection control, drug and therapeutics committees • AMS team to coordinate activity • Education – Prescribing guidelines – Therapeutic Guidelines: Antibiotic – AMS Clinical Care Standard • Policy – Formulary with restrictions and approval • Access to expert prescribing advice – ID, micro, pharmacy • Monitoring, audit and feedback – appropriateness, usage, indicators • Who to contact? 19. Antibiotic Expert Groups. Therapeutic guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.
Antibiotic Awareness Week 2016 Antibiotics: Handle with Care • • World Antibiotic Awareness Week endorsed by the World Health Organization (WHO) Coordinated in Australia by the Australian Commission on Safety and Quality in Health Care, in partnership with – Australian Government Department of Health – Australian Government Department of Agriculture and Water Resources – State and Territory Health representatives – NPS Medicine. Wise – Australian Veterinary Association. • • Encourage best practices among general public, health workers and policy makers to avoid further emergence and spread of antimicrobial resistance Resources and links available at: http: //www. safetyandquality. gov. au/aaw
Antibiotic Awareness Week 2016 Antibiotics: Handle with Care Activities in our health service? • Include information about local activities • Provide details of local contacts for the week.
Remember… Antibiotics are a limited, precious resource • Antibiotics are a precious resource that could be lost • Antibiotic resistance is happening now – it is a worldwide problem that affects human and animal health • Antibiotic resistance happens when bacteria stop an antibiotic from working effectively – meaning some infections may be impossible to treat • Misuse of antibiotics contributes to antibiotic resistance • Few new antibiotics are being developed to help solve this problem Be part of the solution. Whenever you use antibiotics, use them with care.