Transcript Using Antibiotics Prudently

Using antibiotics prudently
Antimicrobial
Insert
name ofStewardship
presenter
The Welsh Perspective
Contents of this presentation
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Antibiotic resistance – a patient safety issue
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Situation in Europe
Drivers of antibiotic resistance
Consequences of antibiotic resistance
Why inappropriate use of antibiotics contributes
to antibiotic resistance
How prudent use of antibiotics can be promoted
in hospitals
European Antibiotic Awareness Day – a campaign
to promote prudent use of antibiotics
Antibiotic resistance
– a patient safety and public health
issue
Antibiotic resistance – a problem in
the present and the future
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Antibiotic resistance is an increasingly serious patient safety
and public health problem: resistant bacteria have become
an everyday concern in hospitals across Europe (figure 1)
The pipeline for new antibiotics is discouraging
Figure 1: European E. coli bacteraemia resistance rates 2009
hhttp://www.ecdc.europa.eu/en /activities/ surveillance/ EARSNet/database/Pages/map_reports.aspx
Use selects resistance
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Acquired resistance absent from bacteria
collected pre-1940
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Resistance repeatedly followed introduction of
new antibiotics
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Resistance greatest where use heaviest (figure 2)
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Resistant mutants selected in therapy
Low rates of antibiotic use =
Low resistance rates
Figure 2: Β-lactam use & resistance in S. pneumoniae across countries in Europe1
1. Bronzwaer et al Emerg Infect Dis. 2002; 8:278-82
Antibiotic resistance – a patient
safety issue for all hospitals
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The emergence, selection and spread of resistant
bacteria in hospitals is a major patient safety and
public health issue.
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Infections with antibiotic-resistant bacteria can result
in increased patient morbidity and mortality, as well as
increased hospital length of stay and cost of care.2-3
Antibiotic resistance frequently leads to a delay in
appropriate antibiotic therapy.4
Inappropriate or delayed antibiotic therapy in patients
with severe infections is associated with worse patient
outcomes and sometimes death.5-7
2. Cosgrove SE, Carmeli Y. The impact of antimicrobial resistance on health and economic outcomes. Clin Infect Dis. 2003 Jun 1;36(11):1433-7.
3. Roberts RR, Hota B, Ahmad I, Scott RD, 2nd, Foster SD, Abbasi F, et al. Hospital and societal costs of antimicrobial-resistant infections in a Chicago teaching hospital: implications for antibiotic
stewardship. Clin Infect Dis. 2009 Oct 15;49(8):1175-84.
4. Kollef MH, Sherman G, Ward S, Fraser VJ. Inadequate antimicrobial treatment of infections: a risk factor for hospital mortality among critically ill patients. Chest. 1999 Feb;115(2):462-74.
5. Ibrahim EH, Sherman G, Ward S, Fraser VJ, Kollef MH. The influence of inadequate antimicrobial treatment of bloodstream infections on patient outcomes in the ICU setting. Chest. 2000
Jul;118(1):146-55.
6. Lodise TP, McKinnon PS, Swiderski L, Rybak MJ. Outcomes analysis of delayed antibiotic treatment for hospital-acquired Staphylococcus aureus bacteremia. Clin Infect Dis.
2003 Jun 1;36(11):1418-23.
7. Alvarez-Lerma F. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired pneumonia Study Group. Intensive Care Med. 1996
May;22(5):387-94.
Antibiotics remain an invaluable but
finite resource
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Current evidence clearly demonstrates that the
inappropriate use of broad-spectrum antibiotics is
associated with the selection of antibiotic resistant
bacteria such as Extended-Spectrum Beta-Lactamase
(ESBL)-producing Gram-negative bacteria8
It is important to preserve antibiotics
In particular carbapenems (imipenem, meropenem,
ertapenem and doripenem) which are invaluable for the
treatment of infections due to multi-resistant gramnegative bacteria, including those with extendedspectrum b-lactamases.
Carbapenem-resistant Enterobacteriaceae remain rare
but are emerging (Figure 3)
8. Livermore DM and Hawkey PM. CTX-M: changing the face of ESBLs in the UK. Journal of Antimicrobial Chemotherapy, 2005; 56:451-454
Carbapenemase-producing
Enterobacteriaceae in England
Figure 3: Carbapenemase-producing Enterobacteriaceae referred to Antibiotic Resistance
Monitoring & Reference Laboratory, Health Protection Agency, England
http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1294740725984
Carbapenemases
Classification
Enzyme
Most Common Bacteria
Class A
KPC, SME, IMI
K. pneumoniae
Enterobacteriaceae
(rare reports in P. aeruginosa)
Class B
NDM, IMP, VIM
(metallo-blactamase)
Class D
P. aeruginosa
Enterobacteriaceae
OXA
Acinetobacter spp.
Acinetobacter spp.
Emerging Carbapenem Resistance in
Gram-Negative Bacilli
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Significantly limits treatment options for life-threatening
infections
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There are currently no new drugs for gram-negative
bacilli
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Emerging resistance mechanisms, carbapenemases are
mobile
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Prudent antimicrobial stewardship is essential
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Detection of carbapenemases and implementation of
infection prevention & control practices are also necessary
to limit acquisition and spread of resistance
Antibiotic resistance – a daily occurrence
in our hospital and community
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In Wales the most frequent infections where
resistance is an issue are
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E. coli bacteraemias (secondary care)
Coliform UTIs (primary care)
All-Wales resistance rates for
E. coli bacteraemias
Key:
3GC: Third generation cephalosporins
AMO: Amoxicillin
COA: Co-amoxiclav
CARB: Carbapenems
CXM: Cefuroxime
FQ: Fluoroquinolones
GEN: Gentamicin
PTZ: Piperacillin/tazobactam
Figure 4: All-Wales E. coli bacteremia resistance rates 2005-2010
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=20787
Hospital-level resistance rates for
E. coli bacteraemias
Table 1: Hospital-level E. coli bacteremia resistance rates 2010
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=20787
All-Wales resistance rates for
Community urinary coliforms
Key:
1GC: First generation cephalosporins
AMO: Amoxicillin
AMO/TRI: Combined resistance to both agents
AMO/TRI/FQ: Combined resistance to all 3 agents
COA: Co-amoxiclav
FQ: Fluoroquinolones
NIT: Nitrofurantoin
TRI: Trimethoprim
Figure 5: All-Wales E. coli bacteremia resistance rates 2005-2010
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=20787
Laboratory-level resistance rates for
community urinary coliforms
Table 2: Laboratory-level community urinary coliform resistance rates 2010
http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=20787
Why inappropriate use of antibiotics
contributes to antibiotic resistance
–“why” this should be important to you
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In-patients are at high risk of
antibiotic-resistant infections
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Studies show that misuse of antibiotics in hospitals is one
of the main factors that drive development of antibiotic
resistance.9-10
Patients in hospitals have a high probability of receiving
an antibiotic11 and up to 50% of all antibiotic use in
hospitals can be inappropriate.12-13
References:
9. Lesch CA, Itokazu GS, Danziger LH, Weinstein RA. Multi-hospital analysis of antimicrobial usage and resistance trends. Diagn Microbiol Infect Dis. 2001 Nov;41(3):149-54.
10. Lepper PM, Grusa E, Reichl H, Hogel J, Trautmann M. Consumption of imipenem correlates with beta-lactam resistance in Pseudomonas aeruginosa. Antimicrob Agents
Chemother. 2002 Sep;46(9):2920-5.
11. Ansari F, Erntell M, Goossens H, Davey P. The European surveillance of antimicrobial consumption (ESAC) point-prevalence survey of antibacterial use in 20 European hospitals in
2006. Clin Infect Dis. 2009 Nov 15;49(10):1496-504.
12. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients.
Cochrane Database Syst Rev. 2005(4):CD003543.
13. Willemsen I, Groenhuijzen A, Bogaers D, Stuurman A, van Keulen P, Kluytmans J. Appropriateness of antimicrobial therapy measured by repeated prevalence surveys. Antimicrob
Agents Chemother. 2007 Mar;51(3):864-7.
Misuse of antibiotics drives
antibiotic resistance
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Studies prove that misuse of antibiotics may cause
patients to become colonised or infected with antibioticresistant bacteria, such as meticillin-resistant
Staphylococcus aureus (MRSA), vancomycin-resistant
enterococci (VRE) and highly-resistant Gram-negative
bacilli.14-15
Misuse of antibiotics is also associated with an increased
incidence of Clostridium difficile infections.16-18
References:
14. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, gram-negative
bacilli, Clostridium difficile, and Candida. Ann Intern Med. 2002 Jun 4;136(11):834-44.
15. Tacconelli E, De Angelis G, Cataldo MA, Mantengoli E, Spanu T, Pan A, et al. Antibiotic usage and risk of colonization and infection with antibiotic-resistant bacteria: a
hospital population-based study. Antimicrob Agents Chemother. 2009 Oct;53(10):4264-9.
16. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst
Rev. 15. 2005(4):CD003543.
17. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp
Epidemiol. 2003 Sep;24(9):699-706.
18. Fowler S, Webber A, Cooper BS, Phimister A, Price K, Carter Y, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a
controlled interrupted time series. J Antimicrob Chemother. 2007 May;59(5):990-5.
What is misuse of antibiotics?
Misuse of antibiotics include:19
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Prescribing antibiotics unnecessarily
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Delaying antibiotic treatment in critically ill
patients;
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Using broad-spectrum antibiotics too generously,
or narrow-spectrum antibiotics incorrectly;
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Using lower or higher antibiotic dose than
appropriate for the specific patient;
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Inappropriate duration of antibiotic treatment - too
short or too long;
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Not streamlining antibiotic treatment according to
microbiological culture data results.
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Omitting or delaying doses of prescribed antibiotics
19. Gyssens IC, van den Broek PJ, Kullberg BJ, Hekster Y, van der Meer JW. Optimizing antimicrobial therapy. A method for
antimicrobial drug use evaluation. J Antimicrob Chemother. 1992 Nov;30(5):724-7.
Benefits of prudent use of antibiotics 1
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Prudent use of antibiotics can prevent the emergence and
selection of antibiotic-resistant bacteria.20-24
Figure 6: Rates of Vancomycin-resistant Enterococci in hospital before and after implementation of the
antibiotic management program compared with rates in National Nosocomial Infections Surveillance (NNIS)
System* hospitals of similar size28. *NNIS is now the National Healthcare Safety Network (NHSN).
References:
20. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients.
Cochrane Database Syst Rev. 2005(4):CD003543.
21. Lepper PM, Grusa E, Reichl H, Hogel J, Trautmann M. Consumption of imipenem correlates with beta-lactam resistance in Pseudomonas aeruginosa.
Antimicrob Agents Chemother. 2002 Sep;46(9):2920-5.
22 & 28. Carling P, Fung T, Killion A, Terrin N, Barza M. Favourable impact of a multidisciplinary antibiotic management program conducted during 7
years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
23. Bradley SJ, Wilson AL, Allen MC, Sher HA, Goldstone AH, Scott GM. The control of hyperendemic glycopeptide-resistant Enterococcus spp. on a
haematology unit by changing antibiotic usage. J Antimicrob Chemother.
24. De Man P, Verhoeven BAN, Verbrugh HA, Vos MC, Van Den Anker JN. An antibiotic policy to prevent emergence of resistant bacilli. Lancet.
2000;355(9208):973-8.
Benefits of prudent use of antibiotics 2
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Decreasing antibiotic use have also been shown to result in
lower incidence of Clostridium difficile infections.25-27
Figure 7: Rates of nosocomial Clostridium difficile, expressed per 1,000 patient-days, before and after
implementation of the antibiotic management program.29
References:
25. Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial
therapy for bacteremia. Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
26, 27, 29. Carling P, Fung T, Killion A, Terrin N, Barza M. Favourable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp
Epidemiol. 2003 Sep;24(9):699-706.
How prudent use of antibiotics can be
promoted in hospitals
And
How we are trying to make it easier for
you
Multifaceted strategies can address and
decrease antibiotic resistance in hospitals
• Antibiotic prescribing practices and decreasing
antibiotic resistance can be addressed through
multifaceted strategies (Antimicrobial
Stewardship) including:30-32
o Use of ongoing education
o Use of evidence-based hospital antibiotic
guidelines and policies
o Restrictive measures and consultations from
infectious disease physicians, microbiologists
and pharmacists
Rerefernces:
30. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev.
2005(4):CD003543.
31. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003
Sep;24(9):699-706.
32. Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial
therapy for bacteremia. Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
Measures that can decrease
antibiotic resistance
Prescribing Measures likely to decrease antibiotic resistance in
hospitals are described in the Start Smart – then Focus guidance
by the DH’s Advisory Committee on Antimicrobial Resistance and
Health Care Associated Infections (ARHAI) 33-35
START SMART:
Start prompt effective treatment in patients with life-threatening infection
Collect appropriate and early cultures before starting antibiotic therapy36.
Prescribe in accordance with local antibiotic policies/guidelines and resistance
patterns37
Document indication (s), route, dose and duration for antibiotic prescription
on prescription chart and in clinical notes and
For most surgical procedures, only single dose prophylaxis is recommended
Consult infection expert (s) and/or pharmacists if appropriate 33-35
References:
33, Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4):CD003543
34, Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
35 Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia.
Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
36. Rello J, Gallego M, Mariscal D, Sonora R, Valles J. The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med. 1997 Jul;156(1):196-200.
37. Beardsley JR, Williamson JC, Johnson JW, Ohl CA, Karchmer TB, Bowton DL. Using local microbiologic data to develop institution-specific guidelines for the treatment of hospital-acquired pneumonia.
Chest. 2006 Sep;130(3):787-93.
Measures that can decrease
antibiotic resistance
THEN FOCUS:
At 48 hours; review the patient and make a clinical
decision “the Antimicrobial Stewardship Decision” on
the need for on-going antibiotic therapy.
Does patient’s condition and/or culture results) necessitate:
1. Stop of antibiotic therapy (if no evidence of infection)
2. Switch from intravenous to oral therapy
3. Change: De-escalation/substitution/addition of agents
4. Continuation - review again at 72 hours OR
Document
Decision
5. Outpatient Parenteral Antibiotic Therapy (OPAT).
References:
33, Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4):CD003543
34, Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
35 Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia.
Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
DH-ARHAI Antimicrobial Stewardship Guidance –
Launch date: 18 November 2011
DH-ARHAI Antimicrobial Stewardship Guidance –
Launch date: 18 November 2011
Our hospital tools for prudent
antibiotic prescribing
• [Hospital antibiogram if available]
• [Hospital guidelines if available]
• [Antibiotic stewardship committee if it
exists]
• [Names of infectious diseases /
antibiotic experts]
Antibiotics – handle with care
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Misuse of antibiotics leads to resistance38-40
All hospital practitioners can play an active role in
reversing the trend of antibiotic-resistant bacteria:
– Take cultures before starting antibiotic therapy41
– Consult the hospital antibiotic expert42-44, [hospital
antibiotic guidelines and local antibiogram]
– Streamline antibiotic therapy based on culture
results45
References:
38. Singh N, Yu VL. Rational empiric antibiotic prescription in the ICU. Chest. 2000 May;117(5):1496-9.
39. Lesch CA, Itokazu GS, Danziger LH, Weinstein RA. Multi-hospital analysis of antimicrobial usage and resistance trends. Diagn Microbiol Infect Dis. 2001 Nov;41(3):149-54.
40. Lepper PM, Grusa E, Reichl H, Hogel J, Trautmann M. Consumption of imipenem correlates with beta-lactam resistance in Pseudomonas aeruginosa. Antimicrob Agents Chemother.
2002 Sep;46(9):2920-5.
41 & 45. Rello J, Gallego M, Mariscal D, Sonora R, Valles J. The value of routine microbial investigation in ventilator-associated pneumonia. Am J Respir Crit Care Med. 1997
Jul;156(1):196-200.
42. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev.
2005(4):CD003543
43. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003
Sep;24(9):699-706.
44.Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial
therapy for bacteremia. Clin Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
30
European Antibiotic Awareness Day
– a campaign to promote prudent
use of antibiotics
About
European Antibiotic Awareness Day
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European Antibiotic Awareness Day is marked across
Europe around 18 November.
European Antibiotic Awareness Day provides a platform
and support to national campaigns about prudent
antibiotic use in the community and in hospitals.
European Antibiotics Awareness Day:
Planned local activities
• [Insert planned local activities,
highlighting where involvement by the
audience of this presentation would be
welcome]
Acknowledgements
•
•
•
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Dr Robin Howe & Dr Maggie Heginbothom – Antimicrobial
Resistance Programme, Public Health Wales
European Centre for Disease Prevention & Control (ECDC)
Professor Brian Duerden – Previously Inspector of
Microbiology and Infection Control, Department of Health
Dr Cliodna McNulty – Head Primary Care Unit, Health
Protection Agency (HPA) & Chair Public Education, DH
Advisory Committee on Antimicrobial Resistance and
Healthcare Associated Infections (ARHAI)
Dr Diane Ashiru-Oredope – Pharmacist Lead, DH ARHAI
ARHAI EAAD 2011 Planning Group
THANK YOU!
•
For more information on data sources and
references, please visit:
o
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http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457
&pid=20618
http://www.dh.gov.uk/en/Publichealth/Antibioticresist
ance/index.htm
http://antibiotic.ecdc.europa.eu