Recommendation on prudent use of antimicrobial agents in human

medicine – Slovenian experiences

Intersectoral Coordination Mechanism

Prof. Milan Čižman, MD, Head

Implementation of the Council recommendation 2002/77/EC on the prudent

use of antimicrobial agents in human medicine in Slovenia

• Intersectoral coordination mechanism established in 2005

• National strategy prepared in 2006

• National action plan formulated in 2006

Agenda

• MRSA prevalence in Slovenia 2000-2006 – 21.4% to 7.1% - reduction of 67%

• Outpatient antibiotic use in Slovenia 2000 – 2007– 20.1 to 16.0 DDD/1000 inhab./day – reduction 20.3%

• Increase of VRE prevalence 2005-2006– <1 to 6%

• Recommendations – MRSA– antibiotic consumption in outpatients

www.rivm.ne/earss

Resistance levels (%) for invasive strains of S. aureus to methicillin (MRSA) in Slovenia and at

University Medical centre (UMC), Ljubljana, Slovenia

21,

4

19,

6

13,

8

12,

7

11,

8

10,

3

7,1

20,

50

33,

30

28,

30

14,

70

16,

70

7,3

0

11,

5

16

10

13

0

5

10

15

20

25

30

35

1998 1999 2000* 2001* 2002* 2003* 2004* 2005* 2006* 2007*Year

%

SloveniaUMC

MRSA in Slovenia /1

• PPS of hospital acquired infections (HAI) in Slovenian adult ICU, April 1997 – 6/8 (75% of adult ICUs)

• PPS of HAI in Slovenian adults ICU, October 2001 – 5/8 (60 % of adult ICUs)

• National PPS of HAI in acute care hospitals, October 2001 - 21/34 (62% of acute care hospitals)

Muzlovic I, et al. IDSA 2001.Klaus I, et al. J Hosp Infect 2003, 54: 149.

MRSA in Slovenia /2

• Comprehensive infection control program: MRSA cases acquired in hospitals decreased from 50% to 6.1% (1999-2002)

• Infection control measures: incidence of ICU – acquired MRSA decreased from 7.8 to 1.9 %.

• Legislation and regulation of infection control program in health care institutions (1999)*

• Audit of infection control implementations in health cares institutions (2006)**

Tomič V, et al. Arch Intern Med 2004, 164:2038Trampuž A. ICAAC 2001 K-1219*Official Journal of the R Slovenia. Uradni list RS. št. 74-3597/1999**Official Journal of the R Slovenia. Uradni list RS. št. 92/2006

Strategy for MRSA in Slovenia /1

• Active Surveillance Culture– Selective screening for MRSA in all patients at

risk for carriage on admission.

• Barrier precautions for patients – Contact isolation for patient with MRSA

• Promotion of hand hygiene – Use of alcohol–based hand rub

• Selective decolonization – eradication of MRSA carriage

Strategy for MRSA in Slovenia /2

• Improved communication (reporting) about patients with MRSA (MDROs) within and between health care facilities.

• Continuous education of HCW on appropriate hygiene procedures (hospitals, nursing homes).

• Use of hospital computer system to record MRSA carriers.

Strategy for MRSA in Slovenia /3Education

• Professionals – Postgraduate educational courses are organized

by Medical Faculty Ljubljana since 1984 (162 physicians and 290 nurses).

– National scientific meetings

• Patients – Newspapers, magazines, TV, leaflets

• Spread of informations to media and politicians.

Outpatient antibiotic use in Slovenia 1997-2007

Outpatient consumption of amoxicillin/clavulanate before and after restriction

0

0,5

1

1,5

2

1996 1998 2000 2002 2004 2006 2008 2010quartiles

DD

D/1

000

inha

bita

nts

AMC

pre-trend

post-trend

restriction

Outpatient consumption of fluoroquinolones before and after restriction

0

0,1

0,2

0,3

0,4

0,5

1996 1998 2000 2002 2004 2006 2008 2010quartiles

DD

D/1

00

0 in

ha

bita

nts

FQ

pre-trend

post-trend

restriction

Analysis of decreased outpatient antibiotic consumption in Slovenia

• The consumption decreased more for restricted than for non-restricted antibiotics:

27.7% vs 16.1% decrease (1999-2007)

• Positive correlation between antibiotic consumption and repeated media reports

• Negative correlation between antibiotic consumption and the number of rapid diagnostic tests (CRP, Streptococcal antigen tests)

0

5

10

15

20

25

30

35

40

45

2002 2003 2004 2005 2006

Res

ista

nce

(I+R

) %

0

200

400

600

800

1000

1200

1400

No

.of p

resc

rip

tion

s J0

1

Resistence of S. pneumoniae - children Resistence of S. pneumoniae - adults

No of prescriptions for J01 for children No of prescriptions for J01 for adults

Antibiotic prescriptions (J01) in children (0-14 years) and adults ( 15 years) and %penicillin-non-susceptible (I+R) S. pneumoniae, 2002-2006

CONCLUSION • Compliance to infection control guidelines for

MRSA control • Nation-wide awareness: HCW, lay public,

politicians• Enough single rooms, and staff• To control antibiotic consumption in outpatients

the combinations of restrictive and education measures are recommended

• Prudent use of rapid diagnostic tests may decrease the antimicrobial consumption in outpatients

• Higher antibiotic consumption and resistance rates in certain bacteria are observed in children