1

Drug Resistant Streptococcus pneumoniae

2

“… the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out which can be passed on to other individuals and perhaps from there to others until they reach someone who gets a

septicemia or a pneumonia which penicillin cannot save. In such cases the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.” Sir Alexander Fleming,

New York Times, June 26, 1945

3

Importance of Pneumococcal Infections in the U.S.

1st3,300Meningitis

2nd60,000Bloodstream infection

1st7 millionOtitis Media

1st135,000Pneumonia

RankCases per

YearType of Infection

2000 CDC Active Bacterial Core Surveillance (ABCs)

4

Drug ResistantStreptococcus pneumoniae

• Emerged in Spain and South Africa

• Emerged in the U.S. in the last decade

• Use of antibiotics for viral infections

• Threatening use of antibiotics for common infections

5

Resistance and AntibioticPrescribing

• Risk factors for resistant S. pneumoniae are:– young age (< 1 year)– higher socioeconomic status– day-care attendance– recent receipt of antibiotics (2-5 times greater

risk)

Pediatrics 1993;92:761-7.

6

Pneumococcal Carriage in Day Care Center Outbreak, East

Tennessee, 1996

05

101520253035404550

MDRSP Serotype 14 Other Serotypes

Per

cent

car

rier

s

DCC-ADCC-BDCC-CPediatrics practice

Craig, Clin Infect Dis 1999;29:1257-1264

7

Penicillin Resistance in S. pneumoniae U.S. 1979-2003

0

5

10

15

20

25

30

1979 1982 1985 1988 1991 1994 1997 2000 2003

Year

Pere

cen

t o

f is

ola

tes Intermediate

Fully Resistant

1979-1994: CDC Sentinel Surveillance Network

1995-2003: CDC Active Bacterial Core Surveillance (ABCs) /Emerging Infections Program

Sentinel ABCs

vaccine

2003 data are preliminary

8

0102030

Pen Ery Oflox /Levo

Tet

Antibiotic

Per

cen

t

no

nsu

scep

tib

le

1995 1996 1997 1998 1999 2000

CDC Active Bacterial Core Surveillance (ABCs)

Trends in Pneumococcal Susceptibility, U.S, 1995-2000

9

0%

10%

20%

30%

40%

50%

60%1999

2000

2001

2002

2003

1999

2000

2001

2002

2003

1999

2000

2001

2002

2003

1999

2000

2001

2002

2003

Davidson Hamilton Knox Shelby

Invasive Pneumococcal Disease, Proportion of Non-susceptible Isolates,

Tennessee, 1999-2003

10

0

20

40

60

80

100

120

1995 1996 1997 1998 1999 2000 2001 2002 2003

Rate

per

100,0

00)

children 0-4 years adults 65 and older

Invasive Pneumococcal Disease, Tennessee, 1995-2003

11

• NAMCS data (1992):– Antibiotics 2nd leading class of Rx in the US

• most for RTI(JAMA 1995;273:214-19)

• Antibiotic use in children: – URI: 44%– Colds: 46%

– Bronchitis: 75% (JAMA 1998;279:875-77)

Evidence of Excessive Antibiotic Use in the US

12

• NAMCS data (2000): Children < 15– Population-based antibiotic prescriptions

• decreased 40%

– Visit-based antibiotic prescriptions • decreased 29%

– Declines coincide with increased media attention

– Antibiotic resistance has continued to increase through the 1990’s

(JAMA 2002;287:3096-3102)

UPDATE!

13

Antibiotic use in Tennessee

• In 2002, TN had the highest prescription rates in the country.

Novartis Pharmacy Benefit Report: 2002 Facts and Figures.

• In 2001, Tennessee’s utilization rates for -Penicillins,

-Cephalosporins

-Trimethoprims

were over 20% higher than the national average.Novartis Pharmacy Benefit Report: 2001 Facts and Figures.

14

Oral Antibiotic Prescriptions, Knox County, 1996-1999

0

20

40

60

80

100

120

140

160

180

200

Knox Davidson Hamilton Shelby

Rate

per

100 P

ati

en

t-years

Year 1 Year 2 Year 3

Perz, JAMA 2002;287:3103-3109

15

Changes in Prescribing From Year 1 to Year 3, per Child-year

16

Ratio of Prescriptions : URI Visits, Knox County, 1996-1999

0.0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1.0

1.1

1.2

1.3

Knox Davidson Hamilton Shelby

Rati

o

Year 1 Year 2 Year 3

17

Patient Concerns• want clear explanation• green nasal discharge• need to return to

work/child care

Physician Concerns• patient expects

antibiotic• diagnostic uncertainty• time pressure

Barden, Clin Pediatric 1998;37:665-672

Antibiotic Prescription

Reasons for Antibiotic Use: Conclusions from 8 Focus Groups

18

Hamm, J Fam Pract 1996;43:56Mangione-Smith, Pediatrics 1999;103:711-8

Satisfaction predicted by:

– time spent by MD explaining illness

– patient understanding of treatment choice

Satisfaction not predicted by receipt of antibiotics

Patient Satisfaction and Antibiotics

19

• Public health campaign in Iceland following dramatic increase in the rates of penicillin-resistant pneumococci from 2.3% to 20% in 4 years

• Rates fell from peak of 20% in 1993 to 16.9% in 1994

• Carriage rates of resistant strains among day care attendees dropped from 20% to 15% in same period

JAMA 1996;275;175

Can Resistance Trends Be Reversed?

20

• Episodes of otitis media should be classified as acute otitis media (AOM) or otitis media with effusion (OME)

• Antibiotics are not indicated for initial treatment of OME

Principles of Judicious Antimicrobial Use:

Otitis Media - Key Messages

21

Principles of Judicious Antimicrobial Use:

Rhinitis and Sinusitis- Key Messages

• Rhinitis:– antibiotics should not be given for viral

rhinosinusitis • Sinusitis:

– prolonged URI symptoms– more severe URI symptoms (i.e. facial swelling,

high fever)– antibiotic treatment with the most narrow-

spectrum agent

22

Principles of Judicious Antimicrobial Use:

Pharyngitis- Key Messages

• Diagnose as group A strep

• Penicillin is the drug of choice in treating group A strep– use erthromycin if penicillin allergic

23

Principles of Judicious Antimicrobial Use:

Cough and Bronchitis- Key Messages

• Cough/bronchitis rarely needs antibiotics

• Antibiotic treatment for prolonged cough (>10 days) may be needed– Mycoplasma pneumonia- use macrolide agent

for children >5

24

• 23-valent polysaccharide vaccine (PPV)– ~60% effective in preventing bacteremic

pneumococcal infection in immunocompetent adults

• 7-valent conjugate vaccine (PCV-7) for children age 3 -59 months– >95% effective in preventing invasive

disease in young children

Bartlett, Clin Infect Dis 2000;31:347-382CDC, MMWR 2000;49(RR-9):1-34

Prevention - Pneumococcal Vaccination

25

8.415.5

59.1

93.7

0102030405060708090

100

1 2 3+ 3+ HiB

Number of doses

Vac

cin

e co

vera

ge,

%

National Immunization Survey, Q3/2002-Q2/2003

83.7

Receipt of PCV7 Among Children 19-35 Months, U.S, 2002-2003

26

Appropriate Antibiotic Use Intervention Sites, 2002

LA County

Federally Funded programs (N=27)

27

• Mission– To reduce inappropriate antibiotic use and the

spread of antibiotic-resistant bacteria that cause many upper respiratory illnesses through state and local partnerships

Tennessee’sAppropriate Antibiotic Use

Campaign

28

TAAUC History• Created in the Spring of 2002 in response to TN’s

high levels of antibiotic resistance

• 2002-2003: Began developing partnerships and focused on educating health care providers and parents and relaying the program’s key messages

• 2003-2004: Continued Year 1 activities, developed a coalition and partnerships, developed and produced program materials, and began media campaign development

• 2004-2005: Continuing Year 1 and Year 2 activities, program expansion, development, etc.

29

Campaign Goals

Reduce inappropriate antibiotic use and the prevalence of antibiotic resistance in Tennessee by:

• Increasing parental knowledge of appropriate antibiotic use

• Changing practitioner’s antibiotic prescribing behavior

 • Increasing community awareness of appropriate

antibiotic use and resistance

30

TAAUC Partners

Knox County Health

Dept.

Metropolitan Health

Dept. of Nashville and

Davidson County

East TN Regional Office

St. Thomas Hospital

East Tennessee

Children’s Hospital

Bristol-Myers Squibb

University of TN

Medical Center

Vanderbilt University

Knox County Schools

Vanderbilt Health Plan

• Blue Cross Blue

Shield of TN

• Nashville Academy of

Medicine

• Shaller Anderson of

TN

• John Deer Health

• TN Pharmacists

Association

• UT Medical Center

• GlaxoSmithKline

• Abbott Laboratories

• TN Academy of Family

Physicians

• Pfizer

• Xantus

• Daiichi

• Bayer

• Roche

• TennCare

• Head Start

• Lamar Outdoor Advertising

• American Academy of

Pediatrics (TN Unit)

• TN Radio Network

31

Program Components

• Provider Education

• Parent/Childcare Center Education

• Public Education

32

TAAUC Billboard

33

• Increasing antibiotic resistance threatens success of antibiotic treatment for common infections

• Many consumers use antibiotics inappropriately

• Decreased antibiotic use has been shown to reverse antibiotic resistant trends

• Physician and public education: principles of appropriate use, educational materials, presentations & mass media

Conclusions

34

35

CDC Treatment Guidelines

www.cdc.gov/drugresistance/community/technical.htm

TAAUC Website

www.tennessee.gov/health