Overview Antibiotics are precious medicines Antibiotic resistance a
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
Resistance spreads rapidly 6. Centers for Disease Control and Prevention http: //www. cdc. gov/hai/
Antibiotic resistance: a problem globally… 2014: WHO Global Report on Surveillance • • • Very high rates of resistance observed for common bacteria that cause health care 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. 7. World Health Organization 2014. Antimicrobial Resistance: Global Report on Surveillance. http: //www. who. int/drugresistance/documents/surveillancereport/en / Last accessed 21/9/14 8. http: //www. who. int/antimicrobial-resistance/global-action-plan/en / 9. 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 10. Mendes et al. , Antimicrob. Agents Chemother. 2013 11. Xiao et al, Drug Resist Updat, 2011 (2009 data) 12. 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) 13 Strategy Responding to the threat of AMR . 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 13. Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www. health. gov. au/amr
Impact of resistance: real people are affected • Increased morbidity and mortality – evidence across many pathogens • Pan drug-resistant infections – now being encountered • Increased costs – $18 -29 000 US/patient – Excess length of stay 6. 4 -12. 7 days/patient 14. Glen’s story access at http: //www. hha. org. au/For. Healthcare. Workers/education. aspx 15. Magiorakos, A. P. , Srinivasan, A et al Clinical Infectious Diseases 2012; 18 (3); 268 -81 16. Roberts RR et al. Clinical Infectious Diseases 2009; 49: 1175 -84 Glen’s story
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 • Incorporates the new National Alert System for Critical Antimicrobial Resistance (CARAlert) • AURA 201619 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 17. http: //www. safetyandquality. gov. au/national-priorities/amr-and-au-surveillance-project/
Antimicrobial Use and Resistance in Australia (AURA) Surveillance System PBS NAUSP NAPS NPS Medicine. Insight Private Path (SNP) Org. TRx AGAR NNDSS NNN
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.
CARAlert Priority Organism List
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 18. 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 use in Australian hospitals • 30 -40% of hospitalised patients are prescribed antibiotics. 19, 20 • The 2014 NAPS* Report indicated that around one quarter of antibiotics prescribed in Australian hospitals were prescribed inappropriately. 20 • More than 40% of prescriptions in hospitals for antimicrobials to prevent infection after surgery were inappropriate, due to incorrect duration, incorrect dose or dosing frequency. • Australian hospitals dispense higher volumes of antibiotics than some other countries. 21 *Hospitals that participate in NAPS are provided with data on the appropriateness of their own prescribing patterns for local quality improvement. 19. Duguid M, Cruickshank M (eds). Antimicrobial Stewardship in Australian Hospitals. Sydney: ACSQHC, 2011 20. Australian Commission on Safety and Quality in Health Care (2015). Antimicrobial prescribing practice in Australian hospitals: results of the 2014 National Antimicrobial Prescribing Survey, ACSQHC, Sydney. 21. Antimicrobial use in Australian hospitals: 2014 report of the National Antimicrobial Utilisation Surveillance Program
Antibiotic usage varies Within Australia there is variation in consumption of antibiotics, not easily accounted for by case-mix . Overall antimicrobial usage rates (N=129) NAUSP 2014* 22. Antimicrobial use in Australian hospitals: 2014 annual report of the National Antimicrobial Utilisation Surveillance Program http: //www. safetyandquality. gov. au/publications/antimicrobial-use-in-australian-hospitals-2014 -report-of-thenational-antimicrobial-utilisation-surveillance-program/
Antibiotic usage varies Consumption also varies between hospitals Annual carbapenem usage by Australian Institute of Health and Welfare peer group (financial year 2014 -15) 23. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – Annual report 2014 -2015
Antibiotic usage varies Consumption also varies between hospitals Annual ceftriaxone usage by Australian Institute of Health and Welfare peer group (financial year 2015 -16) 24. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – Annual report 2014 -2015
Antibiotic usage in our health service • Insert local usage data if available • Include information about contributions to National Antimicrobial Usage Surveillance Program (NAUSP)
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
What about antibiotic appropriateness in our health service? • Insert local prescribing data, including: Participation in the National Antimicrobial Prescribing Survey, results and trends over time, if relevant.
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 25. Mac. Gowan 1983 26. Nathwani D and Sneddon J. Practical Guide to Antimicrobial Stewardship. Access at http: //bsac. org. uk/news/practical-guide-to-antimicrobial-stewardship-in-hospitals /
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. 27. 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 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. 28. 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.
Evidence for antimicrobial stewardship Clinical and Economic Outcomes from the Implementation of Hospital-based Antimicrobial Stewardship Programs: A Systematic Review and Meta-Analysis. Karanika S et al. , 2016 • Review and meta-analysis examined 26 studies to examine the clinical and economic outcomes of AMS programs. Author conclusions: “Hospital ASPs [Antimicrobial Stewardship Programs] result in significant decrease in antimicrobial consumption and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant pathogens and the overall hospital length of stay are improved as well. ” Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Schuts EC et al, 2016. • Review and meta-analysis that sought to assess whether antimicrobial stewardship objectives had any effects in hospitals and long-term care facilities on four predefined patients' outcomes: clinical outcomes, adverse events, costs, and bacterial resistance rates. Author conclusions: “Findings of beneficial effects on outcomes with nine antimicrobial stewardship objectives suggest they can guide stewardship teams in their efforts to improve the quality of antibiotic use in hospitals”. 29. Karanika S, Paudel S, Grigoras C, Kalbasi A, Mylonakis E. . Clinical and Economic Outcomes from the Implementation of Hospital-based Antimicrobial Stewardship Programs: A Systematic Review and Meta-Analysis. Antimicrobial Agents and Chemotherapy. 2016 [epub]. 30. Schuts EC, Hulscher MEJL, Mouton JW, Verduin CM, Stuart JWTC, Overdiek HWPM, et al. The Lancet Infectious Diseases. 16(7): 847 -56.
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? 31. Antibiotic Expert Groups. Therapeutic guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.
Therapeutic Guidelines: Antibiotic A quick note… • Check hospital intranet • Current Version 15 – released November 2014 • Learn more – www. tg. org. au – click ‘Products’, then ‘Antibiotic’ – summary of new information and major changes for version 15: www. tg. org. au/uploads/PDFs/Whats _New_in_Antibiotic 15. pdf
Consumer information
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 What is happening in our health service? • Local activities, contacts • Include information about local activities.
Australian Commission on Safety and Quality in Health Care resources Antibiotics: Handle with Care.
Fight antibiotic resistance: take the pledge • NPS Medicine. Wise is asking consumers and health professionals to take the pledge to fight antibiotic resistance • Health professionals are encouraged to have (the sometimes difficult) conversations with patients when antibiotics are not appropriate • Visit nps. org. au/aaw to download resources to use throughout AAW 2016 • Join the conversation - hashtag #Antibiotic. Resistance or tag @ACSQHC and @NPSMedicine. Wise on social media
A global effort Canada: Healthy Canadians Antibiotic http: //www. canada. ca/antibiotics United States: Get Smart About Antibiotics http: //www. cdc. gov/Get. Smart/ Europe: Antibiotic Awareness Day http: //ecdc. europa. eu/en/eaad/Pages/Home. aspx United Kingdom http: //antibioticguardian. com/
Join the conversation Monday 14 November “Never underestimate the importance of consumer groups and civil society in combating antimicrobial resistance. They are Friday 18 November important movers, shakers, • A global Twitter chat involving and front-line players, partner countries especially in this age of • Organisations and experts social media. ” participating • Australian Antibiotic Awareness Week • #ABx. Aus • #Antibiotic. Resistance Dr Margaret Chan 32. Dr Margaret Chan, Keynote address at the conference on Combating antimicrobial resistance: time for action Copenhagen, Denmark 14 March 2012. http: //www. who. int/dg/speeches/2012/amr_20120314/en / Last accessed 22/9/14 32
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.
Acknowledgements • Australian Commission on Safety and Quality in Health Care – Antibiotic Awareness Week working group members – AMS Jurisdictional Network – AMS Advisory Committee – Antimicrobial Use and Resistance in Australia - AURA • Australian Group on Antimicrobial Resistance • National Antimicrobial Utilisation Surveillance Program • National Centre for Antimicrobial Stewardship • European Centre for Disease Prevention and Control • World Health Organization (WHO) • References available at www. safetyandquality. gov. au/aaw This presentation is intended to be used by health professionals, and reasonable care has been taken to ensure that the information is correct at the date of creation. It is intended to be used in its original version. The original version along with a complete list of references can be downloaded from the Commission webpage: www. safetyandquality. gov. au/aaw
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