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Preserving the Miracle of Antibiotics

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1 Preserving the Miracle of Antibiotics
[Insert name of presenter] [Insert name of hospital]

2 Overview Antibiotic resistance
a critical patient safety and public health issue the problem with resistant organisms the link to antibiotic use Appropriate use of antibiotics in our hospital Antimicrobial Stewardship Antibiotic Awareness Week 2012 – Preserving the miracle – use antibiotics appropriately This presentation will cover: The problem of antibiotic resistance today That it is a critical patient safety and public health issue How extensive the problem is The link between the antibiotic use and the development of resistance. The role of antimicrobial stewardship in supporting the appropriate use of antibiotics Information on antibiotic awareness week in Australia and internationally and the focus on preserving the miracle of antibiotics while there is still time

3 Importance of antibiotics
Most significant impact on life expectancy in last 100 years (arguably) – ability to prevent and treat infection Major factors: public health (sanitation), vaccination, antibiotics Crude mortality rates for all causes, noninfectious causes and infectious diseases over the period The most significant impact on increasing life expectancy in the last 100 years has been the ability to prevent infection through improvements in public health, such as sanitation, and vaccinations and to treat infection with antibiotics. Mortality rates from non infectious diseases has remained fairly constant whilst dying from infectious diseases has decreased markedly, although more recently this is starting to increase. 1. Armstrong GL et al, JAMA 1999;281(1):61-66

4 Antibiotics and other medical advances
Other advances rely on ability to control infection Transplantation Neonatal care Chemotherapy for malignancy Immunosuppression Safe surgery Safe obstetric care Intensive care interventions Advances in modern medicines such as transplantation, neonatal care, cancer treatments, safe surgery and obstetric care and ICU interventions all rely on effective antibiotics to control infection. Without antibiotics these therapies will be endangered.

5 Emergence of antibiotic resistance
Antibiotic resistance threatens ability to control infection The time it takes for bacteria to develop resistance is decreasing. Start of line = time of antibiotic discovery, End of line = when resistance reported More recently the time between discovery and development of resistance has become much shorter Note – why is the line for Vancomycin so long ? In many hospitals the use of Vancomycin has been restricted. 2. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012 5

6 Resistance spreads rapidly
Once resistance develops it spreads rapidly. This graph from the Center of Disease Control in the US demonstrates how quickly resistant strains of MRSA, VRE and fluoroquinolone resistant Pseudomonas aeruginosa have spread. 3. Centers for Disease Control and Prevention

7 Antibiotic resistance in 2012
Worldwide problems with resistant pathogens including MRSA, VRE, Gram negative organisms, HIV, TB and malaria4,5 These problems affect us here in Australia too Last line antibiotics (carbapenems, fluoroquinolones, 3rd-gen cephalosporins) may no longer be effective against some common bacteria e.g. multi-resistant E. coli infections causing cystitis5 This slide summarise the state of antibiotic resistance in 2012. Worldwide there are problems with resistant pathogens such as MRSA, VRE, Gram negative organisms as well as HIV , Tb and Malaria. Australia is not isolated from these problems. There are concerns that last line antibiotics such as carbapenems, fluorquinolones and 3rd and 4th generations cephalosporins may no longer be effective against some common infections such as multi-resistant E coli urinary tract infections. Note: the report from the World Health Organisation provides a comprehensive summary of the global state of resistance, including in our region, and outlines some of the options to address the problem not only in human health care but in other areas. 4. World Health Organization The evolving threat of antimicrobial resistance: Options for action 2012 5. Gottlieb T, Nimmo GR MJA 2011; 194(6): 7

8 Resistance in our region
Gram negatives (E. coli, Klebsiella spp.) – common infections e.g. UTI in community – high rates resistance in our region ESBL-producing organisms = resistant to cephalosporins Resistance is high in our region with many countries having high levels of resistant Gram negative bacilli such as E Coli and Klebsiella species that cause common infections such as urinary tract infections. This slide shows the emergence of extended spectrum beta lactamase producing Gram negative bacilli in the Asia Pacific region. These organisms are resistant to cephalosporins. Australia – on first look it appears that we are doing quite well, however it is important to remember that: This slide does not give the full picture of resistance in Australia, Australia is still working on the development of a comprehensive surveillance system. This is an emerging and growing problem in Australia As Australians continue to travel overseas it is likely that the rates will follow trends seen in other countries. 6. Hawser SP et al. AAC 2009; 53(8):

9 Antibiotic resistance locally
Which infections are we seeing ? Insert hospital data Numbers of cases Example cases Note: Users should insert local hospital data into this slide. If a hospital antibiogram is available, use that. If not, give examples of infections from resistant pathogens that have occurred. Examples might include: central line associated bacteraemia, catheter associated urinary tract infections, surgical site infections. Consider including information about increased length of stay and negative outcomes for patients.

10 Real people are affected
No one is immune from the risk of infection with a multi-resistant pathogen as David Ricci found out. David’s case recently featured on the Four Corners Program “Rise of the Superbugs”. How many of you have treated a patient infected with a multi-resistant organism? How many of you know someone who has been infected with a multi-resistant pathogen? 7. IDSA ‘Patient stories’ 2012 10

11 Antibiotic misuse drives antibiotic resistance
Impact of resistance Increased morbidity/ mortality Evidence across many pathogens Untreatable infections Now being encountered Increased costs $18-29,000 US/ patient8 Antibiotic misuse drives antibiotic resistance Patients infected with resistant pathogens are more likely to have treatment failures, recurrent infections and delayed recovery. A two fold higher death rate has been reported amongst patients with antimicrobial- resistant infections. There is also a significant cost related to the treatment of resistant infections. And in Australia there are cases reported of infections with multi-resistant organisms that are untreatable with antibiotics. 8. Roberts RR et al. Clinical Infectious Diseases 2009; 49:

12 High consumption is associated with increased resistance
Countries with high penicillin consumption also have high rates of penicillin resistance in pneumococci Occurrence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP) versus outpatient use of penicillins in 17 European countries.  Here we see the occurrence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP) plotted against outpatient use of penicillins in 17 European countries. DID = defined daily doses per 1,000 inhabitants.  This clearly demonstrates the relationship of usage with development of penicillin resistance – as usage has increased so has resistance . 9. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11): 12

13 Consumption varies widely between countries
Note: graph represents per capita consumption This graph show the difference in per capita consumption of antibiotics in outpatient/community setting in the US and 27 European countries. Australia is positioned in the middle with usage over twice that of the Netherlands. 10. Goossens et al .Clin Infect Dis 2007; 44(8): 13

14 Consumption varies between hospitals
Even within a country – huge inter-hospital variation in antibiotic consumption e.g. meropenem use - 10-fold variation across 37 Australian hospitals National Antimicrobial Utilisation Surveillance Program (NAUSP) annual report11 Even within a country there is huge inter-hospital variation in consumption of antibiotics (not easily accounted for by case-mix). There is a 10-fold variation in meropenum use across 37 Australian hospitals. Hospitals are mostly large tertiary institutions. Axis label: DDD per 1000 OBDs = Defined Daily Doses per 1000 Occupied Bed Days Note – in addition to high consumption, there is evidence to suggest that up to 50% of antibiotic prescribing in Australian Hospitals is not in accord with guidelines (see Antimicrobial Stewardship in Australian Hospitals , 2011 ) 11. South Australian Infection Control Service. National Antimicrobial Utilisation Surveillance Program (NAUSP) Annual Report. 14

15 Antibiotic usage in our hospital
Insert local usage data if available Note: This information should be available from the Pharmacy Department or local pharmacy contractor/supply service. If comprehensive data is not readily available, consider choosing one broad spectrum agent as an example.

16 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 To add to the problem of increased resistance and consumption, few new antibiotics are being developed. only three novel antibiotic classes have been developed in the last 20 years. although new antibiotics are urgently needed it is expected that few will be developed in the next 10 years. there is a need to conserve what we have.

17 In summary.... We have a problem ! Growing rates of resistance
Inappropriate use Decreasing pipeline of new antibiotics In summary we have a problem: There are growing rates of resistance to antibiotics in our hospitals and the community There are few new antibiotics being developed What antibiotics we do have we are not using appropriately 12. Turnidge J et al. MJA 2009: 191(7):

18 Preserve the miracle of antibiotics by appropriate use.
What can we do? Preserve the miracle of antibiotics by appropriate use. As antibiotic resistance increases and the development of new agents declines it is critical that we use antimicrobials wisely and judiciously. It is our responsibility to preserve the miracle of antibiotics. 13. Carlet J et al. Lancet 2011: 378(9788):

19 What is inappropriate antibiotic use?
Prescribing unnecessarily e.g. for viral infections, prolonged prophylaxis Using broad spectrum agents when narrow spectrum agents are more appropriate. Dose too high or too low Duration of treatment too long Not prescribing according to micro results Timing - omitting or delaying dose Antibiotics are used inappropriately when: They are prescribed unnecessarily such as for viral infections (colds), or for prolonged prophylaxis Broad spectrum antibiotics such as third generations cephalosposrins, carbapenems are used when a narrow spectrum antibiotic such as benzyl penicillin is effective When the dose given is too low (and there is treatment failure) or too high Treatment is continued for longer than necessary because courses are not time limited or no one remembers to cancel them. Antibiotics are not prescribed according to micro results. Doses are not given or administration is delayed. This effects ALL of us who prescribe, dispense or administer antibiotics – we ALL can play a part in making sure they are used appropriately and preserved for use in those infections where choice of therapy is limited.

20 “Appropriate use”? Prescribe according to current endorsed Therapeutic Guidelines: Antibiotic Check microbiology results Review empiric antibiotic therapy at hours Seek infectious diseases/microbiology advice early for complex cases (insert process for ID consult here) Use pharmacy expertise for dosing advice (insert local processes here) Use the MINDME Creed How can we use antibiotics appropriately? Prescribe in accordance with the latest edition of Therapeutic Guidelines:Antibiotic Use microbiology results to improve antibiotic choice, streamline therapy to agent with a narrow spectrum Review empiric therapy at 48 – 72 hours . Convert to targeted therapy when the pathogen and its susceptibilities are known. Seek advice from clinical microbiology or infectious diseases physician early for complex cases. Consult a clinical pharmacist for advice on optimising the antibiotic doses. Follow the MINDME Antimicrobial Prescribing Creed 14. Therapeutic guidelines: antibiotic. Version

21 Antimicrobial stewardship (AMS)
Part of broader system for infection prevention and control to minimise resistance 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 Antimicrobial management or stewardship programs have been developed in response to the need to reduce unnecessary and inappropriate antibiotic use. They are part of a broader system for infection prevention and control to minimize resistance An AMS program alone is not sufficient to control resistance. To be effective a program needs to be established in conjunction with a comprehensive infection prevention and control program that includes hand hygiene, standard and transmission based precautions and cleaning and disinfection. Antimicrobial stewardship (AMS) is a systematic approach to optimising the use of antibiotics taking into account: Evidence of efficacy Toxicity of the drug Ecological harm – the effect on resistance or development of Clostridium difficile infection. Successful AMS requires executive support and clinical leadership as well as team work between prescribers, pharmacists and nurses. Essential elements of an AMS program include: Use of treatment guidelines that take into account local microbiological susceptibility patterns An antibiotic formulary that includes restricting board spectrum and later generation antimicrobials to patients in whom use is clinically justified. Selective reporting of susceptibility testing consistent with hospital treatment guidelines Monitoring and auditing antibiotic usage. Reviewing antibiotic prescribing with intervention and feedback to prescribers

22 National Safety & Quality Health Service Standards Standard 3: Antimicrobial Stewardship Criterion
Actions required: An antimicrobial stewardship program is in place The clinical workforce prescribing antimicrobials have access to endorsed Therapeutic Guidelines on antibiotic usage Monitoring of antimicrobial usage and resistance is undertaken Action is taken to improve the effectiveness of antimicrobial stewardship From January 2013 all hospitals and day procedure services undergoing accreditation will be assessed against the National Safety and Quality Health Service Standards. Standard 3 is the Standard for “Preventing and Controlling Healthcare Associated Infections” . There is an Antimicrobial Stewardship Criterion that forms part of the Standard. Hospitals are required to: Have an AMS program in place Provide access to endorsed Therapeutic Guidelines on antibiotic usage Monitor their antimicrobial usage and resistance; and Take action to improve the effectiveness of their AMS program 15. ACSQHC National Safety & Quality Health Service Standards

23 Antibiotic Awareness Week 2012 Preserve the miracle
Antibiotic Awareness Week, November, 2012 A nationally coordinated campaign to promote appropriate antibiotic use, supported by: The Australian Commission on Safety and Quality in Health Care NPS MedicineWise Australasian College for Infection Prevention and Control Australasian Society for Infectious Diseases Australian Society for Antimicrobials An international effort: UK and Europe, USA, Canada This is the first year that Australia has joined with other developed countries in holding a range of activities in November to raise the awareness of antibiotic resistance and the importance of conserving antibiotic use . Australia’s campaign is coordinated by the Australian Commission on Safety and Quality in Health Care, and supported by NPS MedicineWise Australasian College for Infection Prevention and Control Australasian Society for Infectious Diseases Australian Society for Antimicrobials

24 Antibiotic Awareness Week activities
National resources For hospitals: Australian Commission on Safety and Quality in Health Care For consumers and primary care, health professionals: NPSMedicineWise 127 Australian hospitals participating in national antibiotic survey Social media events (Facebook, Twitter) Media releases (ACSQHC, NPS MedicineWise) Events in hospitals all over Australia Insert local hospital activities? There are a range of activities occurring in Australia. The Australian Commission on Safety and Quality have a range of resources for hospitals to use. NPS Medicine wise have resources for consumers and health professionals and their Facebook page encouraging consumers to sign up to be resistance fighters. There will be media releases and Twitter feeds throughout the week and events occurring in hospitals across the country.

25 Hospital resources Australian Commission on Safety and Quality in Health Care ‘Antimicrobial Stewardship in Australian Hospitals’ Downloadable tools and resources (example policies, guidelines, templates, packet cards etc) Link to antimicrobial prescribing e-learning modules Links to international websites Presentations In addition to materials promoting Antibiotic Awareness Week the Commission provides a range of resources to assist hospitals implement AMS. The Commission publication - Antimicrobial Stewardship in Australian Hospitals summarises current evidence about AMS programs and their implementation in hospitals includes strategies and sample resources is available to download in full from the Commission website Individual tools and resources can also be downloaded There is a link to antimicrobial prescribing e-learning modules which were developed by the Commission in collaboration with NPS MedicineWise.

26 Resources for Consumers and Health Professionals
NPS MedicineWise Resources for consumers, health professionals Facebook, Twitter conversations planned for the week Antimicrobial prescribing e-learning modules NPS MedicinesWise provide a range of materials for consumers and health professionals that support the safe and effective use of antimicrobials, including the antimicrobial prescribing e-learning modules, which prescribers and pharmacists are encouraged to complete.

27 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 Prescribing survey? Who to contact? For hospitals to complete

28 Key Messages Resistance is a critical public health and patient safety issue Resistant infections are harder to treat and are associated with higher rates of morbidity and mortality Inappropriate antibiotic use is a major driver of resistance Antibiotics are a limited and precious resource Up to 50% of antimicrobial prescribing in hospitals is inappropriate Antimicrobial Stewardship Programs and appropriate use of antibiotics can contribute to reducing resistance and make a difference to patient safety and quality of care In summary: Antibiotic resistance is a critical patient safety as well as a public health issue Infections with resistant organisms are harder to treat and are associated with higher rates of morbidity and death Inappropriate and overuse of antibiotics is a major driver of resistance Up to 50% of antimicrobial prescribing in Australian hospitals is considered inappropriate Antibiotics are a precious resource that needs to be protected by using them appropriately. AMS programs as part of the broader systems in a hospital for infection prevention and control and can help to reduce the emergence to resistance, improve patient safety and reduce unnecessary healthcare and societal costs 28

29 Want to know more ? Australia
Australian Commission on Safety and Quality in Health Care (ACSQHC) NPS MedicineWise State & territory health departments International European Antibiotic Awareness Day ttp:// Canadian Antibiotic Awareness Week United States Get Smart About Antibiotics Week If you want to know more about Antibiotic Awareness Week and resources to promote the week or support antimicrobial stewardship visit the sites listed.

30 Acknowledgements and References
Australian Commission on Safety and Quality in Health Care AMS Jurisdictional Network Antibiotic Awareness Week working group members Australian Group on Antimicrobial Resistance National Antimicrobial Utilisation Surveillance Program Melbourne Health NHMRC Antimicrobial Stewardship partnership grant team European Centre for Disease Prevention and Control References: The presentation in it’s original version along with a complete list of references can be downloaded from the Commission web page:

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