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’ 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://ecdc.europa.eu/en/eaad/Pages/Home.aspx
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: