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Overview - BMJ Quality & Safety · Crude mortality rates for all causes, non infectious causes and...
Transcript of Overview - BMJ Quality & Safety · Crude mortality rates for all causes, non infectious causes and...
Overview
• 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
1. Armstrong GL et al, JAMA 1999;281(1):61-66
• 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.
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
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
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
• Increased morbidity/mortality
– 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
Glen’s story
Antibiotic resistance:
a global problem…
10. World Health Organization 2014 Antimicrobial Resistance: Global Report on surveillance.
http://www.who.int/drugresistance/documents/surveillancereport/en/ Last accessed 21/9/14
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).
...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
Resistance (%ESBL)
in the Asia Pacific
region
Australia ECOL: 12% KPNE: 15% New Zealand
ECOL: 11% KPNE: 10%
Hong Kong ECOL: 46% KPNE: 23% India
ECOL: 78% KPNE: 64%
Indonesia ECOL: 71% KPNE: 64%
Japan† ECOL: 17% KPNE: 11%
Korea ECOL: 37% KPNE: 40%
Malaysia ECOL: 36% KPNE: 45%
Philippines ECOL: 47% KPNE: 23%
Singapore ECOL: 21% KPNE: 32%
Taiwan ECOL: 91% KPNE: 75%
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)
China* ECOL: 54% KPNE: 41%
Thailand* ECOL: 55% KPNE: 50%
Antibiotic resistance in our region
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.
…and a problem here in Australia
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
17. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730
Occurrence of penicillin-
nonsusceptible Streptococcus
pneumoniae (PNSP) versus
outpatient use of penicillins in
17 European countries.
Antibiotic usage varies Within the country there is variation in consumption of antibiotics, not easily accounted for by case-mix. .
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-antimicrobial-
utilisation-surveillance-program/
Overall antimicrobial usage rates (N=129) NAUSP 2014 *
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
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
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
The dwindling development of antibiotics…
number of US FDA Antibiotic approvals23
24
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) Strategy25
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
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
27. National Safety & Quality Health Service Standards .Access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
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
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
• 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.” Dr Margaret Chan
30
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
• 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
• National Centre for Antimicrobial Stewardship
• European Centre for Disease Prevention and Control
• World Health Organization (WHO)
• 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