Overview
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Antibiotic resistance – a global issue
The link between antibiotic use and resistance
Addressing antibiotic resistance
The role of antimicrobial stewardship
Actions for Antibiotic Awareness Week
– 7 ways to improve antibiotic use
Wherever they are used, antibiotics must be used responsibly
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
“Anne Miller, 90, first patient who was saved
by penicillin”
In 1999, the New York Times published an article about Anne Sheafe Miller….
“…who made medical history as the first patient ever saved by penicillin…died
on May 27 in Salisbury, Conn. She was 90…..”
• March 1942 - Mrs Miller was near death, suffering from a streptococcal
infection. Doctors had tried everything available (sulfa drugs, blood
transfusions, surgery). All treatments failed.
•Desperate, doctors obtained a tiny amount of what was still an obscure,
experimental drug and injected Mrs Miller with it.
•Her hospital chart (now an exhibit at the Smithsonian Institution), registered a
sharp overnight drop in temperature, and by the next day she was rapidly
recovering. Mrs Miller's life was saved by antibiotics.
•Penicillin also saved the lives of all those previously felled by bacterial
infections with streptococci, staphylococci and pneumococci, and the lives of an
untold number of servicemen and civilians wounded in World War II.
2. Saxon W, New York Times, June 9, 1999
Antibiotics continue to save lives,
every day…
• Ability to control infection is critical to other
advances in medicine
–
–
–
–
–
–
–
Neonatal care
Transplantation
Chemotherapy
Immunosuppression
Complex and routine surgery
Obstetric care
Intensive care interventions
But…….Antibiotics
are a limited resource
We have…..
 Growing rates of
resistance
 Increased use of
antibiotics
 Decreasing pipeline of
new antibiotics
3. Spellberg, B. et al. Clinical Infectious Diseases 2008; 46 (2):155-64
Emergence of antibiotic resistance
“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
The issue of antibiotic resistance was recognised
early in the ‘antibiotic era’. It threatens our ability to
control infection.
4. Sir Alexander Fleming, Nobel Lecture, December 1945
Emergence of antibiotic resistance
Antibiotic resistance threatens ability to control infection
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/
Impact of resistance
• Increased morbidity/ mortality
– Evidence across many
pathogens
•
Untreatable infections
– Now being encountered
• Increased costs9
– $18-29,000 US/patient
– Excess length of stay 6.4 – 12.7
days/patient
Real people are affected
7. IDSA ‘Patient stories’ 2013 http://www.idsociety.org/Patient_Stories/
8. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-1184
AMR is a problem globally……
Key findings:
• Very high rates of resistance observed for
common bacteria that cause common
health care associated and community
acquired infections (for example urinary
tract, pneumonia) in all WHO regions
• Significant gaps in surveillance
• Urgent need to strengthen collaboration
on global surveillance as the foundation of
global strategies to address AMR.
9. World Health Organization 2014 Antimicrobial Resistance: Global Report on surveillance.
http://www.who.int/drugresistance/documents/surveillancereport/en/ Last accessed 21/9/14
……a problem in our region…..
China*
ECOL: 54%
KPNE: 41%
India
Thailand*
ECOL: 78%
ECOL: 55%
KPNE: 64%
KPNE: 50%
Malaysia
ECOL: 36%
KPNE: 45%
Korea
ECOL: 37%
KPNE: 40%
Hong Kong
ECOL: 46%
KPNE: 23%
Singapore
ECOL: 21%
KPNE: 32%
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)
Japan†
ECOL: 17%
KPNE: 11%
Philippines
ECOL: 47%
KPNE: 23%
Australia
ECOL: 12%
KPNE: 15%
Taiwan
ECOL: 91%
KPNE: 75%
New Zealand
ECOL: 11%
KPNE: 10%
….and a problem here in Australia
We need to act now!!
13. Turnidge J et al. MJA 2009: 191(7): 368-373
14. Looke DF, Gottlieb T, Jones CA, Paterson DL Med J Aust. 2013 Mar 18;198(5):243-4.
Antibiotic resistance: 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]
The link between
antibiotic use and antibiotic 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.
15. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730
Antibiotic usage varies between hospitals
Even within a county there is inter-hospital variation in antibiotic consumption
e.g. Meropenem use – 10-fold variation across 64 Australian hospitals
other carbapenems combined
80
70
National Antimicrobial
Utilisation Surveillance
Program (NAUSP)
2013-14 annual report14
60
50
40
30
20
10
0
M7
F3
K3
P6
W5
D8
V5
A9
J8
K7
T5
I7
H7
N5
G3
K4
O3
R3
D3
S3
G2
F8
H9
T4
L8
Z9
T3
M6
U2
W7
U6
R8
L5
G5
W6
E4
G9
O2
D5
Q8
K2
G6
Y6
O7
E7
L6
L3
D2
U7
B2
Q3
C5
W9
O5
L7
P8
C2
N9
R4
V4
F7
O4
Z6
P4
Antimicrobial usage rate (DDD per 1000 OBDs)
meropenem
Contributor code
16. South Australian Infection Control Service. National Antimicrobial Utilisation Surveillance Program
(NAUSP) 2013-14 Annual Report.
Adding to the problem ….
Antibiotics are a limited resource
• Few new antibiotics
• Majority developed pre 1970
• 3 new classes in 20 years
Global recognition that:
• new antibiotics are urgently
required
• we need to conserve what
we have
The dwindling development of antibiotics…
Number of US FDA Antibiotic approvals18
19
17: Adapted from Spellberg B et al. The epidemic of antibiotic resistant infections: A call to action for the medical
community from the Infectious Diseases Society of America. Clin Inf Dis 2008;48:155-64
A great deal of antibiotic use is
inappropriate
There is evidence to suggest that 25 - 50% of antibiotic prescribing in
Australian Hospitals is inappropriate19
This includes;
• Unnecessary prescription of antibiotics, such as for viral
infections (colds) or for prolonged prophylaxis
• Using broad-spectrum antibiotics (such as third
generation cephalosporins, carbapenems) when narrowspectrum antibiotics are effective
• Prescribing too low or too high a dose of antibiotic
• Continuing treatment for longer than necessary
• Not prescribing according to microbiology results
• Omitting doses or delayed administration
19 . Duguid M and Cruickshank M. Antimicrobial Stewardship in Australian Hospitals . 2011
Antibiotic usage in our health service
• Insert local usage data if available
• Include information about local participation in
the National Antimicrobial Prescribing Survey
2013/14 if participating, insert relevant results
What can be done to address
antimicrobial and antibiotic resistance ?
Two complementary arms
• Infection prevention and control
• Antimicrobial stewardship
Addressing Antibiotic Resistance
in our health service.
• Infection prevention and control
– Hand hygiene
– Standard and transmission based precautions
– Environmental cleaning
– Aseptic technique
– Workforce immunisation
• Antimicrobial stewardship
NSQHS 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 have access to
endorsed Therapeutic Guidelines on
antibiotic usage
3.14.3
Monitoring of antimicrobial usage &
resistance is undertaken
3.14.4
Action is taken to improve
effectiveness of your AMS program
20. National Safety & Quality Health Service Standards .Access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
Antimicrobial stewardship (AMS)
Optimising use of antibiotics
• Aim to:
– Maximise best outcomes
– Minimise harm to the individual
– Minimise ecologic harm to wider community
• Requires team work at all levels:
– Executive and clinical leadership
– The clinical team (doctors, nurses, pharmacists, allied health)
– Consumers
Antimicrobial stewardship (AMS)
• an inter-professional effort, across the
continuum of care
• timely and optimal selection, dose and duration
of an antimicrobial
• promotes best clinical outcome for the
treatment or prevention of infection
• minimal toxicity to the patient
• minimal impact on resistance and other
adverse events
21. Nathwani D and Sneddon J Practical Guide to Antimicrobial Stewardship
Essential strategies for effective AMS
Antimicrobial Stewardship
in our Hospital
• Local processes for stewardship
– Include local processes for seeking ID/micro consults
and pharmacy advice, guideline and formulary
information, contacts, any other relevant information.
Our Health service 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
• Audit and feedback
• Who to contact?
Therapeutic Guidelines: Antibiotic
A quick note…
• Current Version 14 being
revised
• Version 15 available
November 2014
• http://www.tg.org.au
Antibiotic Awareness Week 2014
• Coordinated by The Australian Commission on Safety and
Quality in Health Care
• National working group, “One Health” focus:
– Australian Department of Agriculture, Australian
Department of Health, State and Territory Health
department representatives, NPS MedicineWise,
Australian Veterinary Association
• Supported by:
– Australasian College for Infection Prevention and Control
– Australasian Society for Infectious Diseases
– Australian Society for Antimicrobials
– Society of Hospital Pharmacists of Australia
Australian Commission on Safety and Quality in Health Care
No action today, no cure tomorrow*
7 Actions YOU can take
1. Obtain cultures before starting therapy
2. Use Therapeutic Guidelines: Antibiotic22
3. Document indication and review date
4. Review and reassess antibiotics at 48 hours
5. Consider IV to oral switch
6. Seek advice for complex cases
7. Educate consumers about antibiotic use
What else can you do to improve antibiotic use ?
22. Therapeutic Guidelines: Antibiotic. Version 14. 2010
*adopted from WHO World Health Day 2011
Antibiotic Awareness Week
What is happening in our health service ?
• Local activities, contacts
• Include information about local activities.
NPS MedicineWise
Take the health professional pledge
• Visit nps.org.au/antibiotics
to access resources for
health professionals and
consumers.
• Become an antibiotic
resistance fighter: take the
health professional pledge.
• Join the conversation on
twitter
@NPSMedicineWise or
facebook.com/npsmedicine
wise.
A global effort
• European Antibiotic Awareness
Day
http://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/c
ampaignmaterials/week/index.html
Join the conversation
Follow us on Twitter @ACSQHC
Monday 17 November
• Australian Antibiotic
Awareness Week
• #ABXAus
Tuesday 18 November
• #AntibioticDay
• A global twitter chat involving
partner countries
• Organisations and experts
participating
“Never underestimate the
importance of consumer
groups and civil society in
combating antimicrobial
resistance. They are
important movers,
shakers, and front-line
players, especially in this
age of social media”.
23. 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
Remember….
Antibiotics are a limited, precious resource
• Antibiotic resistance is a growing, global problem
• Antibiotic resistance is an issue in our hospitals and in our
communities, for all of us who prescribe or use antibiotics
• Resistant infections are harder to treat and are associated
with higher rates of mortality and morbidity
• Inappropriate use of antibiotics promotes resistance
• Few new antibiotics are being made available
• To conserve the antibiotics we have, antibiotics must always
be used responsibly
• If we don’t all take action today ……. there may be no
cure tomorrow…
Acknowledgements and References
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Australian Commission on Safety and Quality in Health Care
– Antibiotic Awareness Week working group members
– AMS Jurisdictional Network
– AMS Advisory Committee
Australian Group on Antimicrobial Resistance
National Antimicrobial Utilisation Surveillance Program
NHMRC/ Melbourne Health Centre for Antimicrobial Stewardship
European Centre for Disease Prevention and Control
World Health Organization (WHO), World Health Day Campaign 2011
http://www.who.int/world-health-day/2011/en/index.html.
References available at www.safetyandquality.gov.au/aaw2014
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 web page: www.safetyandquality/aaw2014