Recommendation on prudent use of antimicrobial agents in human medicine – Slovenian experiences...
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Recommendation on prudent use of antimicrobial agents in human
medicine – Slovenian experiences
Intersectoral Coordination Mechanism
Prof. Milan Čižman, MD, Head
Implementation of the Council recommendation 2002/77/EC on the prudent
use of antimicrobial agents in human medicine in Slovenia
• Intersectoral coordination mechanism established in 2005
• National strategy prepared in 2006
• National action plan formulated in 2006
Agenda
• MRSA prevalence in Slovenia 2000-2006 – 21.4% to 7.1% - reduction of 67%
• Outpatient antibiotic use in Slovenia 2000 – 2007– 20.1 to 16.0 DDD/1000 inhab./day – reduction 20.3%
• Increase of VRE prevalence 2005-2006– <1 to 6%
• Recommendations – MRSA– antibiotic consumption in outpatients
www.rivm.ne/earss
Resistance levels (%) for invasive strains of S. aureus to methicillin (MRSA) in Slovenia and at
University Medical centre (UMC), Ljubljana, Slovenia
21,
4
19,
6
13,
8
12,
7
11,
8
10,
3
7,1
20,
50
33,
30
28,
30
14,
70
16,
70
7,3
0
11,
5
16
10
13
0
5
10
15
20
25
30
35
1998 1999 2000* 2001* 2002* 2003* 2004* 2005* 2006* 2007*Year
%
SloveniaUMC
MRSA in Slovenia /1
• PPS of hospital acquired infections (HAI) in Slovenian adult ICU, April 1997 – 6/8 (75% of adult ICUs)
• PPS of HAI in Slovenian adults ICU, October 2001 – 5/8 (60 % of adult ICUs)
• National PPS of HAI in acute care hospitals, October 2001 - 21/34 (62% of acute care hospitals)
Muzlovic I, et al. IDSA 2001.Klaus I, et al. J Hosp Infect 2003, 54: 149.
MRSA in Slovenia /2
• Comprehensive infection control program: MRSA cases acquired in hospitals decreased from 50% to 6.1% (1999-2002)
• Infection control measures: incidence of ICU – acquired MRSA decreased from 7.8 to 1.9 %.
• Legislation and regulation of infection control program in health care institutions (1999)*
• Audit of infection control implementations in health cares institutions (2006)**
Tomič V, et al. Arch Intern Med 2004, 164:2038Trampuž A. ICAAC 2001 K-1219*Official Journal of the R Slovenia. Uradni list RS. št. 74-3597/1999**Official Journal of the R Slovenia. Uradni list RS. št. 92/2006
Strategy for MRSA in Slovenia /1
• Active Surveillance Culture– Selective screening for MRSA in all patients at
risk for carriage on admission.
• Barrier precautions for patients – Contact isolation for patient with MRSA
• Promotion of hand hygiene – Use of alcohol–based hand rub
• Selective decolonization – eradication of MRSA carriage
Strategy for MRSA in Slovenia /2
• Improved communication (reporting) about patients with MRSA (MDROs) within and between health care facilities.
• Continuous education of HCW on appropriate hygiene procedures (hospitals, nursing homes).
• Use of hospital computer system to record MRSA carriers.
Strategy for MRSA in Slovenia /3Education
• Professionals – Postgraduate educational courses are organized
by Medical Faculty Ljubljana since 1984 (162 physicians and 290 nurses).
– National scientific meetings
• Patients – Newspapers, magazines, TV, leaflets
• Spread of informations to media and politicians.
Outpatient consumption of amoxicillin/clavulanate before and after restriction
0
0,5
1
1,5
2
1996 1998 2000 2002 2004 2006 2008 2010quartiles
DD
D/1
000
inha
bita
nts
AMC
pre-trend
post-trend
restriction
Outpatient consumption of fluoroquinolones before and after restriction
0
0,1
0,2
0,3
0,4
0,5
1996 1998 2000 2002 2004 2006 2008 2010quartiles
DD
D/1
00
0 in
ha
bita
nts
FQ
pre-trend
post-trend
restriction
Analysis of decreased outpatient antibiotic consumption in Slovenia
• The consumption decreased more for restricted than for non-restricted antibiotics:
27.7% vs 16.1% decrease (1999-2007)
• Positive correlation between antibiotic consumption and repeated media reports
• Negative correlation between antibiotic consumption and the number of rapid diagnostic tests (CRP, Streptococcal antigen tests)
0
5
10
15
20
25
30
35
40
45
2002 2003 2004 2005 2006
Res
ista
nce
(I+R
) %
0
200
400
600
800
1000
1200
1400
No
.of p
resc
rip
tion
s J0
1
Resistence of S. pneumoniae - children Resistence of S. pneumoniae - adults
No of prescriptions for J01 for children No of prescriptions for J01 for adults
Antibiotic prescriptions (J01) in children (0-14 years) and adults ( 15 years) and %penicillin-non-susceptible (I+R) S. pneumoniae, 2002-2006
CONCLUSION • Compliance to infection control guidelines for
MRSA control • Nation-wide awareness: HCW, lay public,
politicians• Enough single rooms, and staff• To control antibiotic consumption in outpatients
the combinations of restrictive and education measures are recommended
• Prudent use of rapid diagnostic tests may decrease the antimicrobial consumption in outpatients
• Higher antibiotic consumption and resistance rates in certain bacteria are observed in children