Preserving the Miracle
of
Antibiotics
[Insert name of presenter]
[Insert name of hospital]
Overview
• Antibiotic resistance
– a critical patient safety and public health issue
– the problem with resistant organisms
– the link to antibiotic use
• Appropriate use of antibiotics in our hospital
– Antimicrobial Stewardship
• Antibiotic Awareness Week 2012
– Preserving the miracle – use antibiotics appropriately
Importance of antibiotics
• Most significant impact on life expectancy in last 100 years (arguably) – ability
to prevent and treat infection
• Major factors: public health (sanitation), vaccination, antibiotics
Crude mortality rates for
all causes, noninfectious
causes and infectious
diseases over the period
1900-1996.
1. Armstrong GL et al, JAMA 1999;281(1):61-66
Antibiotics and other medical advances
• Other advances rely on ability to control
infection
–
–
–
–
–
–
–
Transplantation
Neonatal care
Chemotherapy for malignancy
Immunosuppression
Safe surgery
Safe obstetric care
Intensive care interventions
Emergence of antibiotic resistance
Antibiotic resistance threatens ability to control infection
2. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012
Resistance spreads rapidly
3. Centers for Disease Control and Prevention http://www.cdc.gov/hai/
Antibiotic resistance in 2012
• Worldwide problems with
resistant pathogens including
MRSA, VRE, Gram negative
organisms, HIV, TB and malaria4,5
• These problems affect us here in
Australia too
• Last line antibiotics
(carbapenems, fluoroquinolones,
3rd-gen cephalosporins) may no
longer be effective against some
common bacteria e.g. multiresistant E. coli infections causing
cystitis5
4. World Health Organization The evolving threat of antimicrobial resistance: Options for action 2012
5. Gottlieb T, Nimmo GR MJA 2011; 194(6): 281-283
Resistance in our region
• Gram negatives (E. coli, Klebsiella spp.)
– common infections e.g. UTI in community
– high rates resistance in our region
• ESBL-producing organisms = resistant to cephalosporins
6. Hawser SP et al. AAC 2009; 53(8):3280-3284
Antibiotic resistance locally
•
•
•
•
Which infections are we seeing ?
Insert hospital data
Numbers of cases
Example cases
Real people are affected
7. IDSA ‘Patient stories’ 2012 http://www.idsociety.org/Patient_Stories/
Impact of resistance
• Increased morbidity/ mortality
– Evidence across many pathogens
•
Untreatable infections
– Now being encountered
• Increased costs
– $18-29,000 US/ patient8
Antibiotic misuse drives antibiotic resistance
8. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-1184
High consumption is associated with
increased resistance
Countries with high penicillin consumption also have high rates of
penicillin resistance in pneumococci
Occurrence of penicillinnonsusceptible Streptococcus
pneumoniae (PNSP) versus
outpatient use of penicillins in
17 European countries.
9. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730
Consumption varies widely between
countries
Note: graph
represents per
capita
consumption
10. Goossens et al .Clin Infect Dis 2007; 44(8):1091-1095
Consumption varies between hospitals
Even within a country – huge inter-hospital variation in antibiotic consumption
e.g. meropenem use - 10-fold variation across 37 Australian hospitals
meropenem
doripenem
ertapenem
imipenem with cilastatin
median
Antimicrobial usage rate (DDD per 1000 OBDs)
70
60
National Antimicrobial
Utilisation Surveillance
Program (NAUSP)
2011-12 annual report11
50
40
30
20
10
0
P6 F3 A9 J8 W5 V5 G8 R9 G2 R3 O3 O2 I7 Z9 O7 D8 U2 M6 H7 F8 L6 L8 T3 L5 T4 D5 G5 B2 U6 U7 K0 R2 D6 O4 O5 L7 Z6
Hospital contributor code
11. South Australian Infection Control Service. National Antimicrobial Utilisation Surveillance Program
(NAUSP) 2011-12 Annual Report.
Antibiotic usage in our hospital
• Insert local usage data if available
Antibiotics are a limited resource
• Few new antibiotics being developed
• Most classes developed pre 1970
• Only 3 novel systemic classes in last 20 years
• Growing recognition globally that:
– new antibiotics are urgently required
– we need to conserve what we have
In summary....
• We have a problem !
– Growing rates of resistance
– Inappropriate use
– Decreasing pipeline of new
antibiotics
12. Turnidge J et al. MJA 2009: 191(7): 368-373
What can we do?
Preserve the miracle of antibiotics
by appropriate use.
13. Carlet J et al. Lancet 2011: 378(9788): 369-371
What is inappropriate antibiotic use?
• Prescribing unnecessarily
– e.g. for viral infections, prolonged prophylaxis
• Using broad spectrum agents when narrow
spectrum agents are more appropriate.
• Dose too high or too low
• Duration of treatment too long
• Not prescribing according to micro results
• Timing - omitting or delaying dose
“Appropriate use”?
• Prescribe according to current endorsed
•
•
•
•
•
Therapeutic Guidelines: Antibiotic
Check microbiology results
Review empiric antibiotic therapy at 48-72
hours
Seek infectious diseases/microbiology advice
early for complex cases (insert process for ID
consult here)
Use pharmacy expertise for dosing advice
(insert local processes here)
Use the MINDME Creed
14. Therapeutic guidelines: antibiotic. Version 14. 2010
Antimicrobial stewardship (AMS)
• Part of broader system for infection prevention and
control to minimise resistance
• Aim is to optimise use of antibiotics taking into account:
– Evidence of efficacy
– Toxicity
– Ecologic harm (effect on resistance)
• Requires team work at all levels:
– Executive and clinical leadership
– Prescribers, clinicians, pharmacists
Essential elements: treatment guidelines, formulary with
restrictions, selective susceptibility reporting of isolates, effective
audit and feedback to prescribers
National Safety & Quality Health Service Standards
Standard 3: Antimicrobial Stewardship Criterion
Actions required:
3.14.1 An antimicrobial stewardship program is in
place
3.14.2 The clinical workforce prescribing
antimicrobials have 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 the effectiveness
of antimicrobial stewardship
15. ACSQHC National Safety & Quality Health Service Standards www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
Antibiotic Awareness Week 2012
Preserve the miracle
• Antibiotic Awareness Week, 12-18 November,
2012
– A nationally coordinated campaign to promote
appropriate antibiotic use, supported by:
•
•
•
•
•
The Australian Commission on Safety and Quality in Health Care
NPS MedicineWise
Australasian College for Infection Prevention and Control
Australasian Society for Infectious Diseases
Australian Society for Antimicrobials
• An international effort: UK and Europe, USA, Canada
Antibiotic Awareness Week activities
• National resources
– For hospitals: Australian Commission on Safety and Quality in
Health Care
– For consumers and primary care, health professionals:
NPSMedicineWise
• 127 Australian hospitals participating in national
antibiotic survey
• Social media events (Facebook, Twitter)
• Media releases (ACSQHC, NPS MedicineWise)
• Events in hospitals all over Australia
• Insert local hospital activities?
Hospital resources
• Australian Commission on Safety and
Quality in Health Care
– ‘Antimicrobial Stewardship in
Australian Hospitals’
– Downloadable tools and resources
(example policies, guidelines,
templates, packet cards etc)
– Link to antimicrobial prescribing elearning modules
– Links to international websites
– Presentations
http://www.safetyandquality.gov.au/our-work/healthcareassociated-infection/antimicrobial-stewardship/
Resources for
Consumers and Health Professionals
• NPS MedicineWise
– Resources for consumers, health
professionals
– Facebook, Twitter conversations
planned for the week
– Antimicrobial prescribing e-learning
modules
www.nps.org.au
Our Hospital tools and activities to
promote appropriate use of antibiotics
• AMS committee (or other committee e.g. infection control,
drug & therapeutics committees) to coordinate activity
• Education
– prescribing guidelines
• Policy
– Formulary with restrictions and approval
• Access to expert prescribing advice
– ID, Micro, Pharmacy
• Audits and feedback
• Prescribing survey?
• Who to contact?
Key Messages
•
Resistance is a critical public health and patient safety issue
•
Resistant infections are harder to treat and are associated
with higher rates of morbidity and mortality
•
Inappropriate antibiotic use is a major driver of resistance
•
Antibiotics are a limited and precious resource
•
Up to 50% of antimicrobial prescribing in hospitals is
inappropriate
•
Antimicrobial Stewardship Programs and appropriate use of
antibiotics can contribute to reducing resistance and make a
difference to patient safety and quality of care
Want to know more ?
Australia
• Australian Commission on Safety and Quality in Health Care
(ACSQHC) www.safetyandquality.gov.au
• NPS MedicineWise www.nps.org.au
• State & territory health departments
International
• European Antibiotic Awareness Day
ttp://ecdc.europa.eu/en/eaad/Pages/Home.aspx
• Canadian Antibiotic Awareness Week
http://antibioticawareness.ca/
• United States Get Smart About Antibiotics Week
http://www.cdc.gov/GetSmart/campaignmaterials/week/index.html
Acknowledgements and References
• Australian Commission on Safety and Quality in Health Care
– AMS Jurisdictional Network
– Antibiotic Awareness Week working group members
• Australian Group on Antimicrobial Resistance
• National Antimicrobial Utilisation Surveillance Program
• Melbourne Health
– NHMRC Antimicrobial Stewardship partnership grant team
• European Centre for Disease Prevention and Control
References:
The presentation in it’s original version along with a complete list of references
can be downloaded from the Commission web page:
http://www.safetyandquality.gov.au/our-work/healthcare-associatedinfection/antimicrobial-stewardship/antibiotic-awareness-week-2012