“No action today, no cure tomorrow” adopted from WHO World Health Day 2011
Overview
•
•
•
•
•
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 2013 –
7 days, 7 ways to improve antibiotic use in our hospital
Antibiotics are a limited resource
• We have…..
– Growing rates of resistance
– Inappropriate use
– Decreasing pipeline of new antibiotics
Declining FDA
approvals of new
antibiotics in
United States1
1. Accessed from www.idsociety.org, from Spellberg, CID 2004 (modified)
The “miracle” of antibiotics
• Discovery of penicillin by Sir Alexander Fleming and its subsequent
development by Florey & Chain revolutionised treatment of infectious disease
• Life expectancy has ↑ due to ability to treat infection
Crude mortality rates for
all causes, noninfectious
causes and infectious
diseases over the period
1900-1996.
2. 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.
3. 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 for malignancy
Immunosuppression
Safe surgery
Safe obstetric care
Intensive care interventions
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/
“The Red Plague”
• Refers to emerging resistance in
Gram negative organisms (E.
coli, Klebsiella spp.)
• Cause common infections e.g.
UTI in community
• High rates of resistance in AsiaPacific region
• Some strains pan-drug resistant
7. Looke DF, Gottlieb T, Jones CA, Paterson DL Med J Aust. 2013 Mar 18;198(5):243-4.
Real people are affected
8. IDSA ‘Patient stories’ 2013 http://www.idsociety.org/Patient_Stories/
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
9. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-1184
Resistance (%ESBL) in the Asia Pacific 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%
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%
Resistance in Australia
gains public attention…
We need to act now!!
Antibiotic resistance locally
• 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 resistance and antibiotic use
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.
13. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730
Antibiotic usage varies between hospitals
Even within a country – huge inter-hospital variation in antibiotic consumption
e.g. Meropenem use – 10-fold variation across 52 Australian hospitals
Antimicrobial usage rate (DDD per 1000 OBDs)
meropenem
ertapenem
doripenem
imipenem with cilastatin
70
60
National Antimicrobial
Utilisation Surveillance
Program (NAUSP)
2012-13 annual report14
50
40
30
20
10
M7
F3
P6
K3
J8
A9
W5
R9
G8
K7
T5
I7
R3
O3
Z9
O2
G3
H7
U2
F8
H9
D8
T4
L8
T3
O7
G2
Q8
L6
W7
G5
U7
W6
D3
E4
L5
D6
B2
N9
H4
L3
R2
U6
E7
P8
C5
O5
C2
L7
Z6
O4
P4
0
Hospital contributor code
14. South Australian Infection Control Service. National Antimicrobial Utilisation Surveillance Program
(NAUSP) 2012-13 Annual Report.
What is inappropriate use ?
• 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
• Continuing treatment for longer than necessary
• Not prescribing according to microbiology results
• Omitting or delaying administration of doses
• Prescribing intravenous therapy when oral therapy is
known to be effective and clinically safe
• Not taking antibiotics as prescribed
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 short…we have a problem !
– Growing rates of resistance
– Inappropriate use
– Decreasing pipeline of new
antibiotics
15. Turnidge J et al. MJA 2009: 191(7): 368-373
Addressing Antibiotic Resistance
in Australia – “One Health”
• Involves cooperation between human health
professionals, veterinarians, farmers, policy makers from
health and agriculture and other related experts to
develop strategies to contain antibiotic resistance
• National work has commenced to progress a “One
Health” approach in Australia, through an Antimicrobial
Resistance Prevention & Containment Strategy.
Addressing Antibiotic Resistance
in our hospital
• Infection prevention and control
– Hand hygiene
– Standard and transmission based precautions
– Environmental cleaning
– Aseptic technique
– Workforce immunisation
• Antimicrobial stewardship
Antimicrobial stewardship (AMS)
• 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
NSQHS Standards, Standard 3:
Antimicrobial Stewardship Criterion
Actions required:
3.14.1
3.14.2
3.14.3
3.14.4
An AMS program is in place
The clinical workforce prescribing
antimicrobials have access to endorsed
Therapeutic Guidelines on antibiotic usage
Monitoring of antimicrobial usage and
resistance is undertaken
Action is taken to improve the
effectiveness of AMS
16. ACSQHC National Safety & Quality Health Service Standards www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
Antimicrobial Stewardship in our
Hospital
• Local processes for stewardship
– Include local processes for seeking ID/micro consults
and pharmacy advice, any other relevant information.
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
• Who to contact?
Antibiotic Awareness Week 2013
• Coordinated by The Australian Commission on
Safety and Quality in Health Care
• National working group comprises members from:
– NPS MedicineWise, Australian Pesticides and Veterinary
Medicines Authority, Department of Agriculture, State and
Territory Health department representatives, 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
Seven Actions
Antibiotic Awareness Week
1. Obtain cultures before starting therapy
2. Use Therapeutic Guidelines: Antibiotic17
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 patients about antibiotic use
What else can you do to improve antibiotic use ?
Visit www.safetyandquality.gov.au/aaw2013
17. Therapeutic Guidelines: Antibiotic. Version 14. 2010
Remember…. Antibiotics are a
limited and precious resource
• Antibiotic resistance is a global problem - in our hospitals
and in our communities – and an issue for prescribers
and users of antibiotics
• Resistant infections are harder to treat and are
associated with higher rates of mortality and morbidity
• Inappropriate use of antibiotics drives resistance
• There are few new antibiotics being made available
• Antibiotics must always be used responsibly
• If we don’t all take action today, there may be no cure
tomorrow…
Antibiotic Awareness Week
in our Hospital
• Local activities processes for stewardship
– Include information about local activities.
• National Antimicrobial Prescribing Survey 2013
– Include information about local participation in the
survey, and local contact details
Australian Commission on Safety and
Quality in Health Care
• NO ACTION TODAY, NO CURE
TOMORROW !*
– *Adopted from WHO World Health
Day, 2011 campaign to address AMR
• National Antimicrobial Prescribing
Survey
– Online prescribing survey conducted
by the NHMRC/Melbourne Health
AMS Research Group, supported by
the Commission
– Option for benchmarking analysis
– Can be accessed via the Commission
webpage www.safetyandquality/AAW2013
NPS MedicineWise
• Visit nps.org.au/antibiotics
to access resources for
health professionals and
consumers.
• Become an antibiotic
resistance fighter: take the
health professional pledge.
• Paint your ward purple –
wear a ‘Resistance Fighter’
t-shirt and spread the word.
• 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
Acknowledgements and References
• Australian Commission on Safety and Quality in Health Care
– AMS Jurisdictional Network
– Antibiotic Awareness Week working group members
– AMS Advisory Committee
• Australian Group on Antimicrobial Resistance
• National Antimicrobial Utilisation Surveillance Program
• NHMRC/ Melbourne Health Antimicrobial Stewardship Research Group
• 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.
This presentation is endorsed only when presented in it’s original version.
The original version along with a complete list of references can be
downloaded from the Commission web page: www.safetyandquality/AAW2013