“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

1. Accessed from www.idsociety.org, from Spellberg, CID 2004 (modified)

Declining FDA approvals of new antibiotics in United States1

The “miracle” of antibiotics

2. Armstrong GL et al, JAMA 1999;281(1):61-66

• 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.

“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 resistanceAntibiotic 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 Asia-Pacific 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

AustraliaECOL: 12%KPNE: 15% New Zealand

ECOL: 11%KPNE: 10%

Hong KongECOL: 46%KPNE: 23%India

ECOL: 78%KPNE: 64%

IndonesiaECOL: 71%KPNE: 64%

Japan†ECOL: 17%KPNE: 11%

KoreaECOL: 37%KPNE: 40%

MalaysiaECOL: 36%KPNE: 45%

PhilippinesECOL: 47%KPNE: 23%

SingaporeECOL: 21%KPNE: 32%

TaiwanECOL: 91%KPNE: 75%

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)

China*ECOL: 54%KPNE: 41%

Thailand*ECOL: 55%KPNE: 50%

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

13. 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 between hospitalsEven within a country – huge inter-hospital variation in antibiotic consumption e.g. Meropenem use – 10-fold variation across 52 Australian hospitals

14. South Australian Infection Control Service. National Antimicrobial Utilisation Surveillance Program (NAUSP) 2012-13 Annual Report.

National Antimicrobial Utilisation Surveillance

Program (NAUSP) 2012-13 annual report14

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 narrow-spectrum 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 stewardshipAntimicrobial 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 An AMS program is in place 3.14.2 The clinical workforce prescribing

antimicrobials have access to endorsedTherapeutic Guidelines on antibiotic usage

3.14.3 Monitoring of antimicrobial usage andresistance is undertaken

3.14.4 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 hours5. Consider IV to oral switch 6. Seek advice for complex cases7. 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/npsmedicinewise.

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/campaign-materials/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