Success of educational tools to control AMR in the community Roman Kolek Opolskie Voivodeship

GENERAL INFORMATION Region OPOLE in Poland and in Europe lubelskie podkarpackie śląskie małopolskie świętokrzyskie łódzkie mazowieckie opolskie dolnośląskie lubuskie wielkopolskie kujawsko -pomorskie warmińsko-mazurskie pomorskie podlaskie zachodniopomorskie 1044,4 thousand people (2,7% population of Poland) (0,2% population of European Union) 9412 sq km land (3% surface of Poland) (0,2% surface of European Union)

In National Health Fund (NFZ) of Opole Region, it was discovered that in the beginning of year 2007, amount of prescription of antibiotics dramatically increased – about 30-40% more than in similar period of year 2006. This fact caused, that issue of rationalization of prescribing antibiotics in primary care become very important for us.

Rationalisation of antibiotic therapy in primary care in the Opole region An average number of drug packs BNF Chapter 5 and ATC group „J” prescribed for an insured individual in 2005

Comparing data of year 2005, amount of antibiotics prescription in United Kingdom and in Poland especially in Opole Region, reveals that Polish general practitioners (GPs) tend to prescribe about 40% more antibiotics than their British colleagues. This suggests, that something is going wrong.

Rationalisation of antibiotic therapy in primary care in the Opole region An average number of antibacterial drugs packs for every 1000 of the populations in England and Region Opole in 2005

The first steps were taken to indicate the doctors’ bad habits and mistakes in their practice of issuing antibiotics prescriptions. A few local conferences were organized for small group of GPs, where we stressed these bad habits and showed differences between doctors’ routines in prescription of antibiotics. Specialists from National Program of Antibiotics Protection with Ms Professor Waleria Hryniewicz in charge, made the doctors familiar with new guidelines of using antibiotics in acute respiratory tract diseases.

191 GP-s from Opole Region took part in these trainings. All doctors involved interviewed their patients about their knowledge concerning using antibiotics, situation when antibiotics are needed, and what information from the doctor they want to get. After patients filled in adequate forms, some data base was created which we want to use to prepare educational leaflet for patients to provide them with more information about opportunities of non-antibiotic therapy.

An average amount of antibiotic course prescribed by GP’s in Opole counties for 100 doctors visit in time period between 01.11.2005 and 30.04.2006.

Average 14,48 courses/100 visit An average amount of antibiotic course prescribed by GP’s in their surgeries per 100 doctors visit in OOW NFZ in time period between 01.11.2005 and 30.04.2006. Average 14,48 courses/100 visit

An average amount of antibiotic course prescribed by all doctors for 1 patient under 6 years old in time period between 01.11.2005 and 30.04.2006.

Poster as a first component of campaign Posters inform parents and adult patients, that antibiotics are not remedy for common colds and virus infections.

In the end of January 2008 a further steep was made in our Program – due to kindness and support of Ms Prof. Hryniewicz, Rapid Staphylococcal Test for detect antigens S.pyogenes in a throat swab became available. 30 GPs took part in the second stage of the project.

Before using this test, doctors had to fill in Centor/Mc Issac scale form, and when results in this scale reached 2 and more, they started using this test. Of course in situation, when result was 4 points or more, application of antibiotic was necessary, and test was not important, but for their own experience, doctors keep using it.

Differences in amount of antibiotic prescriptions (J01 ATC) in period XI’2008-IV’2009 in compare with period XI’2006 – IV’2007 in Opole Region ATC Group Familly doctors with training - 2007 Familly doctors without training Doctors using Rapid Tests Other doctors J01AA Tetracyclines -42,37% -36,48% -50,90% -14,18% J01CA Broad-Spectrum Penicillines -12,88% -22,95% -23,02% 0,04% J01CE Penicillins sensitive B-laktamase 15,77% -22,53% 40,47% -8,43% J01CR Penicillins with inhibitors B-lactam -31,28% -24,01% -42,03% 14,54% J01DB Cefalosporins I gen. -37,15% -40,92% -45,26% -28,92% J01DC Cefalosporins II gen. -20,09% -18,17% -25,51% -10,16% J01EE Sulphonamides with Trimetoprim -33,06% -16,01% -29,73% -6,35% J01FA Makrolides -47,21% -35,82% -49,63% -22,04% J01FF Linkozamides -36,79% -25,42% -36,75% -1,52% J01GB Other aminoglicosides -38,53% -35,76% 9,39% -21,67% J01MA Fluorochinolones -16,99% -12,97% -27,91% -7,06% J01XE Nitrofuran 3,99% 3,15% 11,97% 12,69% Together -28,11% -25,72% -33,37% -7,83%

In the group of GPs who participated in courses there were significant differences in uses of amount and kinds of antibiotics groups through years mentioned: an increase in prescribing of penicillins sensitive B-lactamase (15,77% vs -22,53% in control group – without trening) decrease of co-amoxiclav (-31,28% vs -24,01% in control group and +14,54% in other doctors), tetracycline (-42,37% vs -36,48% in control group), trimethoprim and derivatives (-33,06 % vs -16,01% in control group), macrolides (-47,21% vs -35,82% in control group), quinolones (-16,99% vs -12,97% in control group).

Differences in number of patients aged 0-7 with prescriptions for antibiotics in year 2007-2009 in Opole Region ATC Group 2007 2008 2009 2009/2007 Together 137612 117746 115081 -16,37% J01AA Tetracyclines 195 137 83 -57,44% J01CA Broad-Spectrum Penicillines 20349 18922 18257 -10,28% J01CE Penicillins sensitive B-laktamase 2323 3083 2785 19,89% J01CR Penicillins with inhibitors B-lactamase 27583 22492 23325 -15,44% J01DB FIRST-GENERATION CEPHALOSPORINS 6560 5844 4749 -27,61% J01DC SECOND-GENERATION CEPHALOSPORINS 31746 27324 27931 -12,02% J01EE Sulphonamides with Trimetoprim 11295 9942 10101 -10,57% J01FA MAKROLIDES 32228 24752 22663 -29,68% J01FF LINKOZAMIDES 1856 1533 1364 -26,51% J01GB OTHER AMINOGLIKOSIDES 865 795 700 -19,08% J01MA FLUOROCHINOLONES 35 18 23 -34,29% J01XE NITROFURAN 2545 2892 3093 21,53%

The Question is : Whether the introduction of the rationalization and reduction of antibiotic therapy caused increased the number of infectious complications treated in hospitals, especially in children?

3.961 3.807

Conclusions (1) Reducing consumption of antibiotics in the pediatric population Opole Region did not increase hospital stay, and thus complications that could arise due to omission or delay the use of antibiotics in the treatment. Reducing the amount of antibiotic treatments recorded in the Opole Region is greater in the group of primary care physicians, who in 2007 and 2008 participated in training on the rationalization of antibiotic therapy.

Conclusions (2) Most greater reduction in number of those ordained antibiotics was observed in the group of doctors using rapid tests for detection of streptococcal antigens in throat swabs and even applying skills in this study Centor- Mc Isaac- scale; Safe for public health is to reduce the amount of antibiotics consumed you from rationalizing their use in accordance with the current state of medical knowledge and application in the proper way to mid-Public access diagnostic tools today

Conclusions (3) General practitioners have reduced prescribing antibiotics in response to research and policy initiatives. Further interventions for reduction of antibiotic prescription and more pre-prescription tests, would improve identification of patients’ needs and help to avoid various complications. These first conclusions showed, that courses given for GPs brought back information about their lifelong habits in comparison with modern medicine. It started positive change of their bad customs including long time antibiotic treatment, which will obviously result in resistance reduction of bacteria against antibiotics.

Thank you for your attention