Overview
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Antibiotics – miracle medicines
Antibiotic resistance – a critical global problem
The link between antibiotic use and resistance
Addressing antibiotic resistance
The role of antimicrobial stewardship
Prescribing and using antibiotics with care
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
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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
Urgent call to action
2. Spellberg, B. et al. Clinical Infectious Diseases 2008; 46 (2):155-64
3. Gottlieb, T and Nimmo, G. Medical Journal of Australia 2011; 194 (6): 281-3
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:
real people are affected
• Increased morbidity/mortality
Glen’s story
– 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
7. Glen’s story access at http://www.hha.org.au/ForHealthcareWorkers/education.aspx
8. Magiorakos, A. P., Srinivasan, A et al Clinical Infectious Diseases 2012; 18 (3); 268-81.
9. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-84
Antibiotic resistance:
a global problem…
Key findings:
• Very high rates of resistance
observed for common bacteria that
cause 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 antimicrobial
resistance (AMR).
10. 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
High prevalence of drug resistance
reported in clinically important pathogens
including serious hospital acquired skin
infections.
For example
• prevalence rates of 77.6% and 74.1% of
methicillin-resistant S. aureus reported in
Republic of Korea and Vietnam respectively.
• prevalence rates of 68–90% of gonorrhoea
infections with reduced susceptibility and
resistance to quinolones reported in Japan,
Malaysia and Singapore.
11. WHO 2015. Action agenda for antimicrobial resistance in the Western Pacific Region. Access at:
http://www.wpro.who.int/entity/drug_resistance/policy/en/ last accessed 8 September 2015
Antibiotic resistance 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
12. Mendes et al., Antimicrob. Agents Chemother. 2013
13. Xiao et al, Drug Resist Updat, 2011 (2009 data)
14. 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
15 Looke DF, Gottlieb T, Jones CA, Paterson DL Med J Aust. 2013 Mar 18;198(5):243-.
16. Harris P, Paterson D, Rogers B Med J Aust. 2015 Facing the challenge of multidrug-resistant gram-negative bacilli in Australia.
Mar 16;202(5):243-7.
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]
The link between use and 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.
17. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730
Antibiotic usage varies
Within the country there is variation in consumption of
antibiotics, not easily accounted for by case-mix.
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Overall antimicrobial usage rates (N=129) NAUSP 2014 *
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-the-national-antimicrobialutilisation-surveillance-program/
Antibiotic usage varies
Between hospitals consumption also varies.
Annual carbapenem usage by AIHW* peer group (FY2014-15)
*Australian Institute of Health and Welfare
19. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – unpublished data
Antibiotic use in Australian Hospitals
30-40% of hospitalised patients are prescribed
antibiotics20,21
The 2014 NAPS* Report indicates that around one quarter
of antibiotics prescribed in Australian hospitals are
prescribed inappropriately21
Australian hospitals dispense higher volumes of
antibiotics than some other countries22
*Hospitals that participate in NAPS are provided with data on the appropriateness of
their own prescribing patterns for local quality improvement.
20. Duguid M, Cruickshank M (eds). Antimicrobial Stewardship in Australian Hospitals. Sydney: ACSQHC, 2011
21. 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.
22. Antimicrobial use in Australian hospitals: 2014 report of the National Antimicrobial Utilisation Surveillance Program
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 – NAPS 2014
Adding to the problem …
Antibiotics are a limited resource
The dwindling development of antibiotics…
number of US FDA Antibiotic approvals23
Few new antibiotics
• majority developed pre 1970
• 3 new classes in 20 years
Global recognition that:
• new antibiotics are urgently
required
• need to conserve what we
have now
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23: 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
24. Spellberg B New antibiotic development: barriers and opportunities in 2012. APUA Clinical Newsletter 2012; 30(1):8-10
Antibiotic usage in our health service
• Insert local usage data if available
• Include information about
– Contributions to National Antimicrobial Usage
Surveillance Program (NAUSP)
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.
The National Antimicrobial Resistance (AMR) 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
25.
Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www.health.gov.au/amr
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Addressing antibiotic resistance:
a multidisciplinary, comprehensive approach
Prevent and manage infections
• Infection prevention and control
• Includes hand hygiene, standard and
transmission-based precautions, environmental
cleaning.
Prolong effectiveness of existing antibiotics
• Antimicrobial stewardship
Addressing antibiotic resistance is
everybody’s business.
Antimicrobial stewardship (AMS)
Principles:
• promote best clinical outcome for the treatment or prevention
of infection
• minimal toxicity to the patient
• minimal impact on resistance and other adverse events
• timely and optimal selection, dose and duration of an
antimicrobial.
Requires team work at all levels:
• “everybody's business"
• executive and clinical leadership
• clinical team (doctors, nurses, pharmacists, allied health)
• consumers.
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
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
27. National Safety & Quality Health Service Standards .Access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
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
28. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care
Standard. Access at www.safetyandquality.gov.au/ccs
Antimicrobial Use and Resistance in Australia
• The AURA Project will establish a national antimicrobial
usage and resistance surveillance system by June 2016.
• Working with existing programs, such as NAPS and NAUSP,
will enhance capacity for surveillance and build new systems
such as the National Alert System for Critical Antimicrobial
Resistances (NASCAR).
• The key objective is to increase access to data for action
against AMR.
• Funded by the Australian Government Department of Health.
http://www.safetyandquality.gov.au/national-priorities/amr-and-au-surveillance-project/
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
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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
– Local 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?
29. 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_Antibiotic15.pdf
Antibiotic Awareness Week 2015
• Coordinated by The Australian Commission on Safety and Quality in
Health Care
• National working group, “One Health” focus:
– Australian Government Department of Agriculture and Water Resources
– Australian Government Department of Health
– State and Territory Health 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
Antibiotics. Handle with Care.
The AMS Clinical Care Standard outlines evidenced-based approaches
for using antibiotics with care. Access at www.safetyandquality.gov.au/ccs
Antibiotic Awareness Week
What is happening in our health service ?
• Local activities, contacts
• Include information about local activities.
Fight antibiotic resistance:
take the pledge
• NPS MedicineWise 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
• Join the conversation - tag
@NPSMedicineWise or hashtag
#AntibioticResistance on social media
World Health Organization (WHO)
First World Antibiotic Awareness Week
Antibiotics: Handle with Care
Antibiotics are a precious resource and should be
preserved.
Aim of World Antibiotic Awareness Week:
• increase awareness of global antibiotic resistance
• encourage best practices among general public,
health workers and policy makers to avoid further
emergence and spread of antibiotic resistance.
• resources and more information available:
– WHO international http://www.who.int/drugresistance/en/
– Who Western Pacific Regional Office
http://www.wpro.who.int/topics/drug_resistance/en/
A global effort
Canada: Healthy Canadians Antibiotic
http://www.canada.ca/antibiotics
United States: Get Smart About Antibiotics
http://www.cdc.gov/GetSmart/
Europe: Antibiotic Awareness Day
http://ecdc.europa.eu/en/eaad/Pages/Home.aspx
Join the conversation
Monday 16 November
• Australian Antibiotic
Awareness Week
• #ABxAus
Wednesday 18 November
• A global Twitter chat involving
partner countries
• Organisations and experts
participating
• #AntibioticResistance
“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.”
30
Dr Margaret Chan
30. 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
• 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 stops 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.
• To preserve the miracle of antibiotics, whenever they are
used, antibiotics must be used with care.
Acknowledgements
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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
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Australian Group on Antimicrobial Resistance
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National Antimicrobial Utilisation Surveillance Program
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National Centre for Antimicrobial Stewardship
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European Centre for Disease Prevention and Control
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World Health Organization (WHO)
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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 web page:
www.safetyandquality.gov.au/aaw