Transcript grand-round-ik-141016-v1 - Continuous Learning, Education

Ildiko Kustos
Medical Microbiology Consultant
COCH
14 Oct 2016
Modern medical practice relies on the
widespread availability of effective
antimicrobials to prevent and treat
infections in humans
 Penicillin 1928 Sir Alexander Fleming
 Antibiotics were first prescribed in 1940s
 1970s: the battle of the bugs versus the
drugs was over.
1967 William H Stewart US Surgeon General
“it is time to close the book on infectious
diseases”
 The Government de-emphasized bacterial
research and the drug industry, sensing a
saturated market, shifted resources
elsewhere.
 Resistance has eventually been seen to all
abx that have been developed
 Diverse mechanisms have been
demonstrated
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UK Prime Minister
commissioned a review on
antimicrobial resistance to
address the growing
global problem of drugresistant infections.
Report from 2014
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Rapid emergence of resistant bacteria is
occurring worldwide
Bacterial infections are getting a threat again
‘Antibiotic crisis’ has been attributed to:
◦ Overuse and misuse of antimicrobials
◦ Lack of new drug development by the pharmaceutical
industry
CDC declared in 2013 that the human race is now
in the ‘post-antibiotic era’ that could have
‘catastrophic consequences’
C. Lee Ventola MS: The Antibiotic Resistance Crisis P&T 2015;
40(4): 277-283
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Significant threat to patient safety
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worse outcomes
longer hospitalizations
Significantly higher mortality rates
greater healthcare expenditures
Poor outcomes are multifactorial
◦ ?greater severity of underlying illness
◦ delays in initiation of effective therapy
◦ lack of effective antimicrobial therapy
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new infectious diseases have been discovered
nearly every year over the past 30 years
there have been very few new antibiotics
developed
encourage development of new drugs
looking after the current supply of antibiotics
is equally important.
◦ better hygiene measures to prevent infections
◦ prescribing fewer antibiotics
◦ making sure they are only prescribed when needed
Threat
Report 2013
CDC
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Each year in the US at least 2 million people
become infected with multi-resistant bacteria
at least 23,000 people die each year as a
direct result of these infections.
Many more people die from other conditions
that were complicated by an antibioticresistant infection
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The threats are ranked in categories: urgent,
serious, and concerning
assessed the threats according to seven
factors (associated with resistant infections):
health impact
economic impact
how common the infection is
a 10-year projection of how common it could
become
◦ how easily it spreads
◦ availability of effective antibiotics
◦ and barriers to prevention
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Infections classified as urgent threats include:
◦ carbapenem-resistant Enterobacteriaceae (CRE)
 9,000 infections/year in US, 600 deaths
◦ drug-resistant gonorrhea
 820,000 gonococcal infection / year
 246,000 drug resistant gonorrhoea infection
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188,600 resistance to tetracycline
11,480 reduced susceptibility to cefixime
3,280 reduced susceptibility to ceftriaxone
2,460 redcued susceptibility to azithromycin
◦ Clostridium difficile
 250,000 C. difficile infections/ year
 14,000 deaths
2002
2012
700
600
655
500
574
400
419
300
200
311
310
2008
2009
100
0
2010
2011
2012
90
80
78
70
70
60
47
50
37
40
32
30
20
7
10
0
TMP
NIT
CIP
GEN
TAZ
MER
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Multidrug-resistant Acinetobacter
Drug-resistant Campylobacter
Fluconazole-resistant Candida
Extended spectrum β-lactamase producing
Enterobacteriaceae (ESBLs)
Vancomycin-resistant Enterococcus (VRE)
Multidrug-resistant Pseudomonas aeruginosa
Drug-resistant non-typhoidal Salmonella
Drug-resistant Salmonella Typhi
Drug-resistant Shigella
Methicillin-resistant Staphylococcus aureus (MRSA)
Drug-resistant Streptococcus pneumoniae
Drug-resistant tuberculosis
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Vancomycin-resistant Staphylococcus aureus
(VRSA)
Erythromycin-resistant Group A
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Clindamycin-resistant Group B Streptococcus
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Streptococcus
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Chief Medical Officer has warned that antibiotic
resistance could bring a return to the hospital
conditions of the 19th century
It was said that the problem was a "ticking time-bomb"
It should be added to the government's National Risk
Register, alongside terrorist threats
There are no new classes of antibiotics in the pipelines
across the world (and there are very few in
development)
Drug resistance is growing in part because doctors are
prescribing antibiotics in cases where they are not
necessary
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1. Overuse
As early as 1945 Sir A Fleming raised alarm regarding
antibiotic overuse (New York Times 6/26/45)
Misuse of penicillin could lead to propagation of mutant forms
of bacteria that would resist the new miracle drug.
Ca.14 % of Staph strains isolated in a London hospital had
developed resistance to penicillin by 1946
 Epidemiological studies: direct relationship between antibiotic
consumption and emergence of resistant strains (Nature,
2013; 495(7440): 141
 Selective pressure
 Over the counter antibiotic prescriptions
 Patient demands
 Not completing prescribed courses
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2. Inappropriate prescribing
Studies have shown that indication, choice or
duration of antibiotic treatment is incorrect in
30-50% of cases (Luyt et al, Crit Care 2014,
14(8): 480
Subinhibitory and subtherapeutic antibiotic
concentrations can promote the development
of antibiotic resistance
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3. Extensive agricultural usage
Antibiotics used as growth supplements in
livestock
Estimated 80% of antibiotics used in animals
in the US
Improve animal health, produce larger yields,
and higher quality products
Abx used in livestock ingested by humans
when consuming food
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4. environmental usage
Agricultural use affect the environment as
antibiotics are excreted in urine and stool by
animals
Tetracyclines and streptomycin used for
spraying fruit trees
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Number of new antibiotics has declined since 1980s
Most of these drugs are in two classes (beta-lactams and quinolones)
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Technical difficulties – bacterial evolution is uncertain
– development of resistance is unpredictable
Antibiotics are used for short term treatment –
ecomonically not good investment
Withhold of new antibiotics in reserve for only the
worst cases
Complex regulatory procedures, changes in rules,
absence of clarity, differences in clinical trial
requirements among countries
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The importance of AMR has been recognised
globally for many years.
◦ The first ‘World Health Assembly (WHA) AMR
resolution’ was agreed in 1998 and urged Member
States to take action to address AMR.
◦ The need to accelerate progress has been
acknowledged by both the WHO and European
Commission.
◦ The ‘2001 WHO Global Strategy for Containment of
AMR’, the ‘2011 EU AMR Strategic Action Plan’ and
the ‘2012 EU Council Conclusions’ have all helped
to provide a renewed focus on the area
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WHO Antimicrobial resistance fact sheet 2016
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Antimicrobial resistance is a complex problem
Affects all of the society
Driven by many interconnected factors
Single, isolated interventions have limited impact
Coordinated action is required
All countries need national action plans on AMR
Greater innovation and investment are required in
research and development of new antimicrobial
medicines, vaccines and diagnostic tools.
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Published 2016
Includes 28 recommendations regarding implementation of AMS
Program
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Preauthorisation of abx prescription
Prospective audit and feedback
Facility specific clinical practice guidelines
Antibiotic stop orders on prescriptions
Computerized clinical decision support
Suggest against antibiotic cycling
Monitoring and adjustment programs for aminoglycosides
Implement programs to increase appropriate use of oral abx and timely transition
from IV to oral abx
Selective reporting of abx
Development of anti biograms
Rapid viral testing for respiratory pathogens
PCT measurements on ICUs
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sets out UK actions to address the key
challenges to AMR
The overarching goal of the Strategy is to
slow the development and spread of AMR.
It focusses activities around 3 strategic aims:
◦ improve the knowledge and understanding of AMR,
◦ conserve and steward the effectiveness of existing
treatments,
◦ stimulate the development of new antibiotics,
diagnostics and novel therapies
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1. improving infection prevention and control practices
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2. optimising prescribing practice
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3 improving professional education, training and public
engagement
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4 developing new drugs, treatments and diagnostics
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5 better access to and use of surveillance data
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6 better identification and prioritisation of AMR research
needs
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7 strengthened international collaboration
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‘European Antibiotic Awareness Day’ (since 2008) to raise
awareness among health professionals and the public
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GP toolkit – ‘Treat Antibiotics Responsibly, Guidance and
Education Tool’ (TARGET) (developed by HPA)
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‘Start Smart then Focus’ launched in 2011to provide
guidance on antibiotic stewardship in hospitals
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To improve prescribing, a number of measures relating to
usage and choice of antibiotics were developed as part of
the ‘Quality, Innovation, Productivity and Prevention’ (QIPP)
programme in the NHS.
Number of initiatives to promote the responsible use of
antibiotics in the veterinary sector
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AMS Committee had been set up in 2011
AMS Program had been initiated 2011
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Antimicrobial Stewardship: Definition
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“optimal selection, dosage, and duration of antimicrobial
treatment that results in the best clinical outcome for the
treatment or prevention of infection with minimal toxicity to
the patient and minimal impact on subsequent resistance”
A multi-faceted approach to influence antimicrobial
prescribing, institution-wide to improve outcomes, prevent
resistance and minimize excessive cost
IDSA Guidelines. Clin Infect Dis 2007;44:159
Antibiotic guidelines
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Narrow-spectrum agents for empirical treatment (where
appropriate)
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Minimize the use of 3rd gen cephalosporins,
clindamycin, carbapenems, fluoroquinolones
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Give guidance on dosage, duration, for iv to oral switch.
Daily review of drug prescriptions by ward Pharmacists
Microbiology ward rounds / MDT
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Daily Critical care rounds
Daily follow up of patients with positive blood cultures
Weekly Haematology MDT
Weekly CDT Ward Round
Weekly Orthopaedic ward round
Trust wide point prevalence antibiotic audits
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Percentage of patients on antibiotics: Comparison of North West Hospitals:
Point prevalence audit Spring 2010
45
39
40
37
35
35
30
30
30
32
31
30
32
30
26
25
%
22
23
22
23
26
23
20
15
10
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% patients receiveing antibiotic therapy
te
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Percentage of Patients on Antibiotic Therapy at different Trusts
45.0%
40.0%
35.0%
30.0%
25.0%
20.0%
15.0%
10.0%
5.0%
0.0%
Trust
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50 antibiotics per month
Data collected by antibiotic Pharmacists
Data obtained from Medical notes and MediTech
As specified by PHE the review include documented evidence of:
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Stop
IV to oral switch
Change antibiotic
Continue antibiotic
OPAT
This information can either be documented in the medical notes
or electronically on EP system incl:
◦ Antibiotic stopped / changed / restarted / dose adjustment etc on EP
◦ Change in Stop / review date
◦ Change in plan for therapeutic drug monitoring plan e.g. change
vancomycin level
Month 2016
Documented review of antibiotic
prescription
(Medical notes OR EP)
April
82%
May
86%
June
88%
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Reduction in antibiotic consumption per 1,000
admissions
There are three parts to this indicator:
◦ Total antibiotic consumption per 1,000 admissions - as
measured by Defined Daily Dose (DDD)
◦ Total consumption of carbapenem per 1,000 admissions
- as measured by Defined Daily Dose (DDD)
◦ Total consumption of piperacillin-tazobactam per 1,000
admissions - as measured by Defined Daily Dose (DDD)
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Baseline period/date 2013/14
◦ (discussions regarding 2015/16 baseline figures)
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Reduction of 1% or more in total antibiotic
consumption against the baseline
Reduction of 1% or more in carbapenem usage
against the baseline
Reduction of 1% or more in piperacillin-tazobactam
usage against the baseline
Each of the indicators is worth 25% of part 4a
with an additional 25% to be paid for submission of
consumption data to PHE for years: 2014/15 to
2016/17.
Data will be collected quarterly
Data will be reported to the commissioner annually
900,000
838639
800,000
700,000
760601
674615
600,000
500,000
400,000
300,000
200,000
100,000
0
2013/14
2014/15
13% increase in 2014/15
10% increase in 2015/16
2015/16
80000
70000
60000
50000
40000
30000
20000
63719
67704
2014/15
2015/16
49412
10000
0
2013/14
29% increase in 2014/15
7% increase in 2015/16
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meropenem
ertapenem
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1200
20000
18000
1000
16000
14000
800
12000
10000
17787
8000
6000
4000
10383
600
400
12186
1109
640
672
2013/14
2014/15
200
2000
0
0
2013/14
2014/15
2015/16
15% increase in 2014/15
46% increase in 2015/16
2015/16
5% increase in 2014/15
65% increase in 2015/16
450000
400000
411167
419789
2015/16
2016/17
350000
300000
250000
200000
150000
100000
50000
0
2% increase compared to 2015/16 (Q1+Q2)
700
9000
8000
600
500
611
512
7000
8310
6925
6000
400
5000
300
4000
3000
200
2000
100
1000
0
0
2015/16
ERTAPENEM
2016/17
19% increase compared to 2015/16
2015/16
MEROPENEM
2016/17
16.6% decrease compared to 2015/16
35000
30000
31574
29946
25000
20000
15000
10000
5000
0
2015/16
2016/17
5% decrease compared to 2015/16 (Q1+Q2)
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Microbiology input in patients positive blood
cultures and other significant results
Daily review of patients on Critical Care
?microbiology review of patients on
meropenem
?microbiology review of patients on Tazocin
>7 days
Antibiotic reports
Written consultation system for all doctors on
Meditech
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Review antibiotics on ward rounds
Review antibiotics (and document) within 72
hrs
Stop unnecessary antibiotics
Review culture results
Narrow the spectrum if possible
Switch to oral antibiotics if clinically
appropriate
Contact microbiology if any concerns