EAAD2010 POWER POINT

Report
Using antibiotics prudently
- Hospital Prescriber Presentation
[Insert Name of presenter]
[Insert Name of hospital]
Contents of this presentation
• Antibiotic resistance – a patient safety issue
– Situation in Europe
– Drivers of antibiotic resistance
– Consequences of antibiotic resistance
• Why inappropriate use of antibiotics contributes to
antibiotic resistance – the “why”
• How prudent use of antibiotics can be promoted in
hospitals – the “how”
• European Antibiotic Awareness Day – a campaign to
promote prudent use of antibiotics
2
Antibiotic resistance
– a patient safety issue
3
Antibiotic resistance –
a problem in the present and the future
• Antibiotic resistance is an increasingly serious public health problem:
resistant bacteria have become an everyday concern in hospitals
across Europe.
Proportion of resistant isolates (%)
30
20
10
0
2002
2003
2004
2005
2006
2007
2008
Penicillin-non susceptible S. pneumoniae (EU pop.-weighted average)
Erythromycin-resistant S. pneumoniae (EU pop.-weighted average)
Fluoroquinolone-resistant E. coli (EU pop.-weighted average)
Third-gen. cephalosporin-resistant E. coli (EU pop.-weighted average)
4
Trends in antibiotic resistance (invasive infections), 2002-2008. Source: European Antimicrobial Resistance
Surveillance System (EARSS), 2009.
Methicillin-resistant Staphylococcus aureus
(MRSA), blood and spinal fluid
2002
2007
No data
<1%
1-5%
5-10%
10-25%
25-50%
>50%
Source: European Antimicrobial Resistance Surveillance System (EARSS), 2008.
5
No. of countries
Methicillin-resistant Staphylococcus aureus (MRSA), EU,
2007: often high, but decreasing in many countries
MRSA (%)
 Country with a significant increase (2005–2007)
 Country with a significant decrease (2005–2007)
Source: EARSS & ECDC, 2009
6
Antimicrobial resistance in gram-negative bacteria, EU,
2007: already high or increasing
No. of countries
 Country with a significant increase (2005-2007)
 Country with a significant decrease (2005-2007)
Source: EARSS & ECDC, 2009
No. of countries
Carbapenem-resistant Pseudomonas aeruginosa (%)
3rd-gen. ceph.-resistant Escherichia coli (%)
7
3rd-gen. ceph.-resistant Klebsiella pneumoniae (%)
Total outpatient antibiotic use in EU Member
States, Iceland and Norway, 2008
* Total use, i.e. including inpatients (CY, GR, LT).
** Reimbursement data, i.e. not including over-the-counter sales without a prescription (ES)
*** Data from 2007 (MT)
8
Source: European Surveillance of Antimicrobial Consumption (ESAC), 2010. In: ECDC Annual
Epidemiological Report 2010: in press.
Antibiotic resistance –
A patient safety issue for all hospitals
• The emergence, selection and spread of resistant bacteria
in hospitals is a major patient safety issue.
– Infections with antibiotic-resistant bacteria can result in increased
patient morbidity and mortality, as well as increased hospital length
of stay.1-2
– Antibiotic resistance frequently leads to a delay in appropriate
antibiotic therapy.3
– Inappropriate or delayed antibiotic therapy in patients with severe
infections is associated with worse patient outcomes and sometimes
death.4-6
9
1. Cosgrove SE, Carmeli Y. The impact of antimicrobial resistance on health and economic outcomes. Clin Infect Dis. 2003 Jun 1;36(11):1433-7.
2. 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.
3. 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.
4. 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.
5. 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.
6. Alvarez-Lerma F. Modification of empiric antibiotic treatment in patients with pneumonia acquired in the intensive care unit. ICU-Acquired neumonia Study Group. Intensive Care Med. 1996 May;22(5):387-94.
Antibiotic resistance –
a daily occurrence in our hospital
• In our [country / hospital] the most frequent resistant
infections are the following [insert appropriate data where
available].
• These infections have resulted in [insert data on additional
days of hospitalisation, morbidity, mortality, and costs
where available].
10
Why inappropriate use of antibiotics contributes to
antibiotic resistance
– the “why”
11
In-patients are at high risk of antibiotic-resistant
infections
• Misuse of antibiotics in hospitals is one of the main factors
that drive development of antibiotic resistance.7-9
• Patients in hospitals have a high probability of receiving an
antibiotic10 and 50% [adapt to national figure where
available] of all antibiotic use in hospitals can be
inappropriate.11-12
7. Singh N, Yu VL. Rational empiric antibiotic prescription in the ICU. Chest. 2000 May;117(5):1496-9.
8. 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.
9. 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.
10. 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.
11. 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.
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
12 12.
Mar;51(3):864-7.
Misuse of antibiotics drives antibiotic resistance
• Studies prove that misuse of antibiotics may cause patients
to become colonised or infected with antibiotic-resistant
bacteria, such as meticillin-resistant Staphylococcus aureus
(MRSA), vancomycin-resistant enterococci (VRE) and
highly-resistant Gram-negative bacilli.13-14
• Misuse of antibiotics is also associated with an increased
incidence of Clostridium difficile infections.15-17
13
13. 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.
14. 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.
15. 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.
16. 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.
17. 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 can include any of the following18:
• When antibiotics are prescribed unnecessarily;
• When antibiotic administration is delayed in critically ill
patients;
• When broad-spectrum antibiotics are used too generously, or
when narrow-spectrum antibiotics are used incorrectly;
• When the dose of antibiotics is lower or higher than
appropriate for the specific patient;
• When the duration of antibiotic treatment is too short or too
long;
• When antibiotic treatment is not streamlined according to
microbiological culture data results.
14
18. 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
• Prudent use of antibiotics can prevent the emergence and selection of
antibiotic-resistant bacteria.19-23
• Decreasing antibiotic use have also been shown to result in lower
incidence of Clostridium difficile infections.24-26
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 size.27
*NNIS is now the National Healthcare Safety Network (NHSN).
15
Rates of nosocomial Clostridium difficile, expressed per 1,000 patientdays, before and after implementation of the antibiotic management
program.28
19, 24. 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.
20. 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.
21, 25, 27, 28. 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.
22. 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.
23. 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.
26. 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.
How prudent use of antibiotics can be promoted in
hospitals
– the “how”
16
Multifaceted strategies can address and
decrease antibiotic resistance in hospitals
• Antibiotic prescribing practices and decreasing antibiotic
resistance can be addressed through multifaceted
strategies including:29-31
 Use of ongoing education
 Use of evidence-based hospital antibiotic guidelines and
policies
 Restrictive measures and consultations from infectious
disease physicians, microbiologists and pharmacists
29. 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.
30. 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.
31. 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.
17
Measures that can decrease antibiotic resistance
Measures that guide antibiotic prescribing are likely to decrease antibiotic
resistance in hospitals.32-34 Such measures include:
 Obtaining cultures
Take appropriate and early cultures before initiating empiric antibiotic therapy,
and streamline antibiotic treatment based on the culture results35
 Monitoring local antibiotic resistance patterns
Being aware of local antibiotic resistance patterns (antibiograms) enables
appropriate selection of initial empiric antibiotic therapy36
 Consulting specialists
Involve infectious disease physicians, microbiologists and pharmacists in your
decisions about antibiotic therapy during your patient’s stay37-39
18
32, 37. 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
33, 38. 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.
34, 39. 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.
35. 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.
36. 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.
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]
19
Antibiotics – handle with care
• Misuse of antibiotics leads to resistance40-42
• All hospital practitioners can play an active role in
reversing the trend of antibiotic-resistant bacteria:
– Take cultures before starting antibiotic therapy43
– Consult the hospital antibiotic expert44-46, [local antibiogram, and
hospital antibiotic guidelines]
– Streamline antibiotic therapy based on culture results47
20
40. Singh N, Yu VL. Rational empiric antibiotic prescription in the ICU. Chest. 2000 May;117(5):1496-9.
41. 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.
42. 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.
43, 47. 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.
44. 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
45. 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.
47.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.
European Antibiotic Awareness Day
– a campaign to promote prudent use of
antibiotics
21
About
European Antibiotic Awareness Day
• 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.
22
European Antibiotics Awareness Day:
Planned local activities
• [Insert planned local activities, highlighting where
involvement by the audience of this presentation would be
welcome]
23
THANK YOU!
• For more information on data sources and references,
please visit:
– http://antibiotic.ecdc.europa.eu
– [insert national website]
24

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