Overview

• Antibiotics are precious medicines

• Antibiotic resistance: a global and local problem

• The link between antibiotic use and resistance

• Addressing antibiotic resistance

• Antimicrobial stewardship (AMS)

• Antibiotic Awareness Week 2016

Whenever they are used, antibiotics must be used with care.

The ‘miracle’ of antibiotics

1. Armstrong GL et al, JAMA 1999;281(1):61-66

• Discovery of penicillin revolutionised treatment of infectious disease

• Increased life expectancy due to ability to prevent and treat infection

Crude mortality rates for

all causes, non infectious

causes and infectious

diseases over the period

1900-1996.

Antibiotics continue to

save lives every day…

Ability to control infection is critical to other

advances in medicine including: – Neonatal care

– Transplantation

– Chemotherapy

– Immunosuppression

– Complex and routine surgery

– Obstetric care

– Intensive care interventions

But…antibiotics

are a limited resource

Increasing antibiotic resistance

Increased use of antibiotics

Decreasing pipeline of new

antibiotics

2. Spellberg, B. et al. Clinical Infectious Diseases 2008; 46 (2):155-64

3. Office of the Chief Scientist http://www.chiefscientist.gov.au/2013/07/antibiotic-resistance-a-serious-threat/

Emergence of antibiotic resistance Antibiotic resistance threatens ability to control infection

4. Sir Alexander Fleming, Nobel Lecture, December 1945

5. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012

“It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.”

Sir Alexander Fleming, 1945

Resistance spreads rapidly

6. Centers for Disease Control and Prevention http://www.cdc.gov/hai/

Antibiotic resistance:

a problem globally…

7. World Health Organization 2014 . Antimicrobial Resistance: Global Report on Surveillance.

http://www.who.int/drugresistance/documents/surveillancereport/en/ Last accessed 21/9/14

8. http://www.who.int/antimicrobial-resistance/global-action-plan/en/

9. http://www.who.int/mediacentre/news/releases/2016/commitment-antimicrobial-resistance/en/

2014: WHO Global Report on Surveillance • Very high rates of resistance observed for common

bacteria that cause health care associated and community acquired infections in all WHO regions

• Significant gaps in surveillance

• Urgent need to strengthen collaboration on global surveillance to address antimicrobial resistance (AMR).

May 2015 • World health assembly endorses global action plan to

tackle AMR.

September 2016 • 193 countries sign UN Declaration to take action on

AMR, reaffirming their commitment to develop national action plans on AMR, based on the global action plan.

Resistance (%ESBL)

in the Asia Pacific

region

Australia ECOL: 12% KPNE: 15%

New Zealand ECOL: 11% KPNE: 10%

Hong Kong ECOL: 46% KPNE: 23%

India ECOL: 78% KPNE: 64%

Indonesia ECOL: 71% KPNE: 64%

Japan† ECOL: 17% KPNE: 11%

Korea ECOL: 37% KPNE: 40%

Malaysia ECOL: 36% KPNE: 45%

Philippines ECOL: 47% KPNE: 23%

Singapore ECOL: 21% KPNE: 32%

Taiwan ECOL: 91% KPNE: 75%

10. Mendes et al., Antimicrob. Agents Chemother. 2013

11. Xiao et al, Drug Resist Updat, 2011 (2009 data)

12. Chong et al., EJCMID, 2011 (2009 data)

China* ECOL: 54% KPNE: 41%

Thailand* ECOL: 55% KPNE: 50%

…a problem in our region

…and a problem in Australia

The National Antimicrobial Resistance (AMR)

Strategy13

Responding to the threat of AMR

Seven objectives focused on:

1. Awareness, education

2. Antimicrobial stewardship

3. Surveillance

4. Infection prevention and control

5. International management

6. Research and development

7. Governance

.

13. Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www.health.gov.au/amr

Impact of resistance:

real people are affected

14. Glen’s story access at http://www.hha.org.au/ForHealthcareWorkers/education.aspx

15. Magiorakos, A. P., Srinivasan, A et al Clinical Infectious Diseases 2012; 18 (3); 268-81

16. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-84

• Increased morbidity and mortality

– evidence across many pathogens

• Pan drug-resistant infections – now being encountered

• Increased costs – $18-29 000 US/patient

– Excess length of stay 6.4-12.7 days/patient

Glen’s story

Antimicrobial Use and Resistance in Australia

(AURA)

• Surveillance of antibiotic usage (volume, appropriateness) and

resistance is the cornerstone of efforts to control AMR

• Surveillance provides information on impact of usage patterns on

development of resistant bacteria

• Local surveillance is critical to informing local policy, guidelines and

measuring effect of local interventions

• National surveillance can inform national response and prevention

strategies

• The national AURA project brings together a wide range of passive

and targeted surveillance of antimicrobial resistance and usage in

hospitals and the community

• Incorporates the new National Alert System for Critical Antimicrobial

Resistance (CARAlert)

• AURA 201619 provides a comprehensive picture of antimicrobial

resistance , antimicrobial use and appropriateness of prescribing in

Australia.

Antimicrobial Use and Resistance in Australia (AURA) 2016: First Australian report on

antimicrobial use and resistance in human health

17. http://www.safetyandquality.gov.au/national-priorities/amr-and-au-surveillance-project/

Antimicrobial Use and Resistance in Australia (AURA)

Surveillance System

PBS NAPS

NPS MedicineInsight

AGAR

NNDSS NNN OrgTRx

Private Path (SNP)

NAUSP

AMR in Australia

Some of the findings (AURA 2016) • Enterobacteriaceae – strains of Escherichia coli that produce

extended-spectrum -lactamases now a problem in community

infections, often multidrug resistant.

• High rates of resistance in key Gram-positive organisms

– Staphylococcus aureus – between 15.8% and 17.4% of

isolates methicillin-resistant S. aureus (MRSA). Community

MRSA strains now cause a significant proportion of infections

in both the community and hospitals.

– Enterococcus species – one of the highest rates in the world

of vancomycin resistance in Enterococcus faecium.

– Streptococcus pneumoniae – resistance (as defined for

strains causing infections other than meningitis) was low

(around 2%) for one key antimicrobial (benzylpenicillin), but

high (21–26%) for other key antimicrobials.

CARAlert Priority Organism List

Antibiotic resistance locally

What is happening in our health service

• Which infections are we seeing?

• What are our susceptibility and resistance

patterns?

– [Insert hospital data]

– [Numbers of cases]

– [Examples of cases]

Antibiotic use and antibiotic resistance Relationship between total antibiotic consumption and Streptococcus

pneumoniae resistance to penicillin in 20 industrialised countries

18. Shaban RZ, Cruickshank M, Christiansen K & the Antimicrobial Resistance Standing Committee (2013), p. 6.

National Surveillance and Reporting of Antimicrobial Resistance and Antibiotic Usage for Human Health in Australia.

Antimicrobial Resistance Standing Committee, Australian Heath Protection Principal Committee: Canberra.

Antimicrobial Use and Resistance in

Australia summary

International comparisons

Antimicrobial use in Australian hospitals and other countries

Sources: NAUSP (Australia), CIPARS (Canada), DANMAP (Denmark), ESPAUR (England), NethMAP (Netherlands), SAPG (Scotland), NORM (Norway), SWEDRES (Sweden)

Antibiotic use in Australian hospitals

• 30-40% of hospitalised patients are prescribed antibiotics.19,20

• The 2014 NAPS* Report indicated that around one quarter of

antibiotics prescribed in Australian hospitals were prescribed

inappropriately.20

• More than 40% of prescriptions in hospitals for antimicrobials to

prevent infection after surgery were inappropriate, due to incorrect

duration, incorrect dose or dosing frequency.

• Australian hospitals dispense higher volumes of antibiotics than

some other countries.21

*Hospitals that participate in NAPS are provided with data on the appropriateness of

their own prescribing patterns for local quality improvement.

19. Duguid M, Cruickshank M (eds). Antimicrobial Stewardship in Australian Hospitals. Sydney: ACSQHC, 2011

20. Australian Commission on Safety and Quality in Health Care (2015). Antimicrobial prescribing practice in Australian hospitals: results of the 2014

National Antimicrobial Prescribing Survey, ACSQHC, Sydney.

21. Antimicrobial use in Australian hospitals: 2014 report of the National Antimicrobial Utilisation Surveillance Program

Antibiotic usage varies Within Australia there is variation in consumption of

antibiotics, not easily accounted for by case-mix .

22. Antimicrobial use in Australian hospitals: 2014 annual report of the National Antimicrobial Utilisation Surveillance

Program http://www.safetyandquality.gov.au/publications/antimicrobial-use-in-australian-hospitals-2014-report-of-

the-national-antimicrobial-utilisation-surveillance-program/

Overall antimicrobial usage rates (N=129) NAUSP 2014*

Antibiotic usage varies Consumption also varies between hospitals Annual carbapenem usage by Australian Institute of Health and Welfare peer group (financial year 2014-15)

23. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – Annual report 2014-2015

Antibiotic usage varies Consumption also varies between hospitals

Annual ceftriaxone usage by Australian Institute of Health and Welfare peer group

(financial year 2015-16)

24. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – Annual report 2014-2015

Antibiotic usage in our health service

• Insert local usage data if available

• Include information about contributions to National

Antimicrobial Usage Surveillance Program (NAUSP)

What is inappropriate use?

Inappropriate use includes:

• Using broad-spectrum antibiotics (such

as third generation cephalosporins,

carbapenems) when narrow-spectrum

antibiotics are effective

• Prescribing too low or too high a dose

of antibiotic

• Not prescribing according to

microbiology results

• Continuing treatment for longer than

necessary

• Omitting doses or delayed

administration

Top reasons for inappropriate

use – National Antimicrobial

Prescribing Survey 2014

What about antibiotic appropriateness in

our health service?

• Insert local prescribing data, including:

Participation in the National Antimicrobial Prescribing

Survey, results and trends over time, if relevant.

Antimicrobial stewardship (AMS)

• A systematic approach to optimising use of antibiotics

• Goals: ‒ improve patient outcomes

‒ improve patient safety

‒ reduce antimicrobial resistance

‒ reduce costs.

• Part of broader system for infection prevention and control to minimise resistance

• Requires teamwork at all levels: – ‘everybody's business’

– executive and clinical leadership

– clinical team (doctors, nurses, pharmacists, allied health)

– consumers

25. MacGowan 1983

26. Nathwani D and Sneddon J. Practical Guide to Antimicrobial Stewardship.

Access at http://bsac.org.uk/news/practical-guide-to-antimicrobial-stewardship-in-hospitals/

Essential strategies for effective AMS

Essential strategies for all hospitals:

• Implementing clinical guidelines consistent

with Therapeutic Guidelines: Antibiotic

• Establish formulary restrictions and an

approval system

• Reviewing/auditing antimicrobial prescribing

with intervention and direct feedback

• Selective reporting of susceptibility testing

results

Clinical Care Standard for AMS

What role do you play?

Nine statements describing best practice

for managing a patient who has, or is

suspected of having, a bacterial infection,

regardless of setting.

• For consumers: Describes the care

they can expect to receive

• For clinicians: Provides support in the

delivery of care the patient is expecting

• For health services: Systems are in

place to support clinicians in providing

the care that is expected by the patient.

27. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Access at www.safetyandquality.gov.au/ccs

National Safety and Quality Service Standards,

Standard 3:

Antimicrobial Stewardship Criterion

28. National Safety and Quality Health Service Standards , access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/

Actions required:

3.14.1 An AMS program is in place

3.14.2

The clinical workforce prescribing antimicrobials has access to endorsed therapeutic guidelines on antibiotic usage

3.14.3

Monitoring of antimicrobial usage and resistance is undertaken

3.14.4

Action is taken to improve effectiveness of your AMS program

NSQHS Standard 3: is currently being revised and is under consultation.

For planned pilot and implementation in 2017. AMS will remain a core component of Standard 3.

Antimicrobial stewardship

in our hospital

• Multidisciplinary, team approach

• Local roles and responsibilities – Medicine, nursing, pharmacy

– Consumer participation

– Executive and clinical leaders

• Local processes for stewardship – Include local processes for

• seeking ID/micro consults

• guideline and formulary information

• pharmacy advice

• contacts

• other relevant information.

Evidence for antimicrobial stewardship

Clinical and Economic Outcomes from the Implementation of Hospital-based

Antimicrobial Stewardship Programs: A Systematic Review and Meta-Analysis.

Karanika S et al., 2016

• Review and meta-analysis examined 26 studies to examine the clinical and economic

outcomes of AMS programs. Author conclusions: “Hospital ASPs [Antimicrobial Stewardship Programs] result in significant decrease in antimicrobial consumption

and cost, and the benefit is higher in the critical care setting. Infections due to specific antimicrobial-resistant

pathogens and the overall hospital length of stay are improved as well.”

Current evidence on hospital antimicrobial stewardship objectives: a systematic

review and meta-analysis. Schuts EC et al, 2016.

• Review and meta-analysis that sought to assess whether antimicrobial stewardship

objectives had any effects in hospitals and long-term care facilities on four predefined

patients' outcomes: clinical outcomes, adverse events, costs, and bacterial resistance

rates. Author conclusions: “Findings of beneficial effects on outcomes with nine antimicrobial stewardship objectives suggest they

can guide stewardship teams in their efforts to improve the quality of antibiotic use in hospitals”.

29. Karanika S, Paudel S, Grigoras C, Kalbasi A, Mylonakis E.. Clinical and Economic Outcomes from the Implementation of

Hospital-based Antimicrobial Stewardship Programs: A Systematic Review and Meta-Analysis. Antimicrobial Agents and

Chemotherapy. 2016 [epub].

30. Schuts EC, Hulscher MEJL, Mouton JW, Verduin CM, Stuart JWTC, Overdiek HWPM, et al. The Lancet Infectious

Diseases.16(7):847-56.

Our health service tools and activities to

promote appropriate use of antibiotics

• Responsible committees – e.g. infection control, drug and therapeutics committees

• AMS team to coordinate activity

• Education – Prescribing guidelines

– Therapeutic Guidelines: Antibiotic

– AMS Clinical Care Standard

• Policy – Formulary with restrictions and approval

• Access to expert prescribing advice – ID, micro, pharmacy

• Monitoring, audit and feedback – appropriateness, usage, indicators

• Who to contact?

31. Antibiotic Expert Groups. Therapeutic guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.

Therapeutic Guidelines: Antibiotic

A quick note…

• Check hospital intranet

• Current Version 15

– released November 2014

• Learn more

– www.tg.org.au

– click ‘Products’, then ‘Antibiotic’

– summary of new information and major changes for version 15: www.tg.org.au/uploads/PDFs/Whats_New_in_Antibiotic15.pdf

Consumer information

Antibiotic Awareness Week 2016

Antibiotics: Handle with Care

• World Antibiotic Awareness Week endorsed by the World Health Organization (WHO)

• Coordinated in Australia by the Australian Commission on Safety and Quality in Health Care, in partnership with

– Australian Government Department of Health

– Australian Government Department of Agriculture and Water

Resources

– State and Territory Health representatives

– NPS MedicineWise

– Australian Veterinary Association.

• Encourage best practices among general public, health workers and policy makers to avoid further emergence and spread of antimicrobial resistance

• Resources and links available at: http://www.safetyandquality.gov.au/aaw

Antibiotic Awareness Week 2016

What is happening in our health service?

• Local activities, contacts

• Include information about local activities.

Australian Commission

on Safety and Quality in Health Care resources

Antibiotics: Handle with Care.

Fight antibiotic resistance:

take the pledge

• NPS MedicineWise is asking consumers and health professionals to take the pledge to fight antibiotic resistance

• Health professionals are encouraged to have (the sometimes difficult) conversations with patients when antibiotics are not appropriate

• Visit nps.org.au/aaw to download resources to use throughout AAW 2016

• Join the conversation - hashtag #AntibioticResistance or tag @ACSQHC and @NPSMedicineWise on social media

A global effort Canada: Healthy Canadians Antibiotic

http://www.canada.ca/antibiotics

United States: Get Smart About Antibiotics

http://www.cdc.gov/GetSmart/

Europe: Antibiotic Awareness Day

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

United Kingdom

http://antibioticguardian.com/

Join the conversation

Monday 14 November • Australian Antibiotic

Awareness Week

• #ABxAus

Friday 18 November • A global Twitter chat involving

partner countries

• Organisations and experts participating

• #AntibioticResistance

“Never underestimate the

importance of consumer

groups and civil society in

combating antimicrobial

resistance. They are

important movers, shakers,

and front-line players,

especially in this age of

social media.” Dr Margaret Chan

32

32. Dr Margaret Chan, Keynote address at the conference on Combating antimicrobial resistance: time for action Copenhagen, Denmark 14 March 2012 .

http://www.who.int/dg/speeches/2012/amr_20120314/en/ Last accessed 22/9/14

Remember…

Antibiotics are a limited, precious resource

• Antibiotics are a precious resource that could be lost

• Antibiotic resistance is happening now – it is a worldwide problem that

affects human and animal health

• Antibiotic resistance happens when bacteria stop an antibiotic from

working effectively – meaning some infections may be impossible to

treat

• Misuse of antibiotics contributes to antibiotic resistance

• Few new antibiotics are being developed to help solve this problem

Be part of the solution. Whenever you use antibiotics, use

them with care.

Acknowledgements • Australian Commission on Safety and Quality in Health Care

– Antibiotic Awareness Week working group members

– AMS Jurisdictional Network

– AMS Advisory Committee

– Antimicrobial Use and Resistance in Australia - AURA

• Australian Group on Antimicrobial Resistance

• National Antimicrobial Utilisation Surveillance Program

• National Centre for Antimicrobial Stewardship

• European Centre for Disease Prevention and Control

• World Health Organization (WHO)

• References available at www.safetyandquality.gov.au/aaw

This presentation is intended to be used by health professionals, and reasonable care has been taken to ensure that

the information is correct at the date of creation. It is intended to be used in its original version.

The original version along with a complete list of references can be downloaded from the Commission webpage:

www.safetyandquality.gov.au/aaw