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Antimicrobial Stewardship
Reflections on International Efforts
Professor Barry Cookson
Division of Infection and Immunity,
Univ. College London
ECDC AMR Strategy
Infection
Prevention &
Control
Antimicrobial
Stewardship
New Diagnostics,
Antibiotics and
Treatments
AMR & AB
Usage
Surveillance
Training/
Prioritisation
of R&D &
Education:
Professio- Interventions:
Organisational
nals &
International & Behavioural
Public
Collaboration
Seven Key Areas
7) strengthened international collaboration with a wide
range of governmental and non-governmental
organisations, international regulatory bodies and others to
influence opinion, galvanise support, and mobilise action to
deliver the scale of change needed globally.
8 components of WHO Regional
Strategy
• Combined strategy on HAI and AMR and link to patient safety
• Strengthen surveillance of HAI and combine AMR
• Improve use of standardized surveillance methods and indicators,
and process & progress indicators
• Standardize guidelines and tools for infection control and
prevention in health care settings, including AM drug use.
• Move from individual projects to national programmes
• Foster partnership with professional groups
• Review research agenda, training needs and gaps
• Political commitment, advocacy, resources
Pittet et al, Considerations for a WHO European strategy….
The Lancet Infectious Diseases 2005; 5: 242-250.
Sally Davies
UK Representative
WHO Executive 2014
AMR Strategy Champion?
Liam Donaldson
WHO Patient Safety
Kenneth Calman
Clinical Governance & Total Quality Management
The Healthcare Associated Infection and related
AMR paradox: high burden but little action
• Complex issue:
with no immediate, easy solution
• Requires multi disciplinary approaches:
never easy
• Control and Prevention seen as costly
• Diffuse issue:
Individual or Institutional or “Public Health” problem?
Why the increased profile in the “00”s?
• A Patient Safety Issue at last
– WHO Global Patient Safety Alliance
• Hand Hygiene
• Surgical Site Infection
• Antimicrobial Resistance (never progressed!)
– DG SANCO funded European project Improving Patient
Safety in Europe (IPSE)
• International community & media views changed as a
result of SARS & the Pandemic Flu threat
• Crying wolf no longer: Armageddon organisms are
evident globally
“EUROPE”
• 17 Old Member States (MS)
• 10 New MS
• EEA: European Economic Area adds
Iceland, Liechtenstein and Norway
• EFTA: European Free Trade Association
Switzerland, Iceland, Liechtenstein and Norway
• EU acceding countries: Croatia April 2013
See European Economic Area
http://en.wikipedia.org/wiki/European_Free_Trade_Associa
tion#Current_members
“In England (~2005) we make hospital acquired infection
(HAI) rates publically available by named hospital”
After the initial shock around Europe:
in 2012 6/28 European countries are doing this!
Publication of hospital specific HAI infection rates
Cookson et al, J Hosp Infect 2011: 79; 260-264
Vive la Différence
EU Directorate (SANCO) group suggested possibility of different
systems:
• Confidential within the health care institution, not public
health authorities e.g. individual surgical team infection rates.
• Confidential benchmarking within surveillance networks with
publication of anonymised or aggregated results e.g.
surveillance of surgical site infections.
• Disclosure to public health authorities e.g. early warning of
notifiable nosocomial events.
• Public reporting of agreed indicators e.g. composite structure
and process indicators or HAI rates e.g. France, England
Consensus standards and performance indicators for
healthcare associated infection in Europe
Cookson et al, J Hosp Infect 2011: 79; 260-264
Topic
Agree
Modify
Neutral
Disagree
Organisation
85%
9%
4%
1%
Control
79%
7%
2%
2%
Surveillance
79%
11%
1%
2%
Education
79%
14%
1%
3%
15%
11%
2%
2%
5%
3%
Resources
79%
Overall Averages 80%
Seven Key Areas
2) optimising prescribing practice through
implementation of antimicrobial stewardship
programmes that promote rational
prescribing and better use of existing
and new rapid diagnostics
Behaviours of patients and doctors
(Agricultural, Aquaculture, Vets use: science, politics
and economic hurdles: overwhelmingly
important!)
ECDC Activities
(Council Recommendation
2002/77/EC)
• 2013 !!! Exploring misuse of antimicrobial
agents in human medicine across whole
chain of stakeholders : prescribers, pharmacists and
patients. Sales of antimicrobial agents without a
prescription (SCORE 2002-03)
• 2014: Antibiotic Prescribing & Resistance in European
Children (ARPEC)
• 2014-15: Follow up review of EC Recommendations
Seven Key Areas
1) improving infection prevention and control
practices in human (and animal health), both
through enhanced dissemination & implementation
of best practice & better use of data and diagnostics
5) better access to and use of surveillance data
..facilitate greater data consistency &
standardisation across the system & encourage
improved data linkage
Relevant DG SANCO
EU Networks
HELICS
EARSS:
Hospitals in Europe Link European Antimicrobial ESAC: European
Surveillance of
for Infection Control
Resistance Surveillance
through Surveillance
Antimicrobial
2000
Scheme
unofficial
Consumption
1993
2002
ECDC
Embedded in Improving
Patient Safety in Europe
HELICS
(IPSE) 2005
2008
C section (n= 12 124)
HELICS-associated national networks (2000-2003)
10
SSI
rate 9
per
8
100
op. 7
6
5
4
3
2
1
0
A
B
C
D
Anonymised
Countries
E
F
Large differences are found between
countries
• in rates of HAIs,
• in distribution of rates
• in the characteristics of the infections
This is attributable to:
Differences in definition interpretation/data collection?
Differences in recruitment?
 Difference in Antibiotic Rx & other medical policies?
 Difference in the quality of care?
Healthcare-Associated Infections
surveillance Network (HAI-Net)
• Coordination Groups (European experts)
and contact points in participating countries
• Modules:




Surgical site infections: 16 countries
HAI in intensive care units: 14 countries
Point prevalence survey: 30 countries
HAI in long-term care (HALT-2, outsourced): 24
countries
 Surveillance of C. difficile infections, pilot: 14 countries
 Concordance of definitions, Validation studies
Need post discharge
Five Countries Reporting Hip Prosthesis
Infections to ECDC have shown reduced infection rate
trends between 2004-06
Source: HELICS-SSI, ECDC Annual Epidemiological Report 2008
Methicillin-resistant Staphylococcus aureus
EU 2005- 2007
No. of countries
EARSS-ECDC
0
10
20
30
MRSA (%)
40
50
 2 Countries with a significant increase (2005–2007)
 8 Countries with a significant decrease (2005–2007)
Alcohol hand rub consumption in acute care hospitals, ECDC PPS
2011-2012
Structure and process indicators:
percentage of single room beds
Austria
Belgium
Bulgaria
Croatia
Cyprus
Czech Republic
Denmark
Estonia
Finland
France
Germany
Greece
Hungary
Iceland
Ireland
Italy
Latvia
Lithuania
Luxembourg
Malta
Netherlands
Norway
Poland
Portugal
Romania
Slovakia
Slovenia
Spain
Sweden
UK-England
UK-Northern Ireland
UK-Scotland
UK-Wales
*Poor data representativeness
0
20
40
60
80
100
N of single room beds*100 /Total beds
Single room beds in participating hospitals (%): median = 11.1%
Source: ECDC, 2012 (ECDC PPS data as of 23/11/2012)
Prevalence of antimicrobial use in acute care hospitals, ECDC PPS
2011-2012
*Poor PPS data representativeness
Seven Key Areas
3) improving professional education, training and
public engagement
2013
COMPETENCY 1: Infection Prevention &Control
COMPETENCY 2: Antimicrobial resistance & antimicrobials
COMPETENCY 3: Prescribing antimicrobials
COMPETENCY 4: Antimicrobial Stewardship
COMPETENCY 5: Monitoring and learning
https://www.gov.uk/government/publications/antimicrobial-prescribing-andstewardship-competencies
Training
HALT
eBug
Seven Key Areas
4) developing new drugs, treatments and diagnostics
(and infection prevention and control interventions)
6) better identification and prioritisation of AMR
research needs e.g. new drugs, improved rapid or point-ofcare diagnostic tests for humans (& animals).
Relevant DG R&D Projects
HARMONY (1999-2001) incl MRSA typing network
 


Harmonisation of Antibiotic Resistance measurement, 
Methods of typing Organisms and ways of using these  

and other tools to increase the effectiveness of Nosocomial
infection control
ARPAC (2002-2005) Very useful papers
Antibiotic Resistance Prevention and Control
ARMed (2002-2006)
Antibiotic Resistance in Mediterranean Countries
MOSAR (2007-2012)
Mastering hOSpital Antimicrobial Resistance in Europe

• BURDEN 2008-2013 Very useful data
Burden of Resistance and Disease in Europe
• IMPLEMENT 2008-2013 (www site?)
Implementing Strategic Bundles for Infection Prevention
& Management.
• PROHIBIT 2008-2013
Analyses existing guidelines and IPC practices
• SATURN 2010-2015
Impact of Specific Antibiotic Therapies on the
prevalence of hUman host ResistaNt bacteria
• R-GNOSIS 2011-2016
Studies in Multidrug-resistant GNRs
Other Ongoing Projects
• " Routine diagnostic tool for urinary tract infections caused by
extended spectrum beta lactamase and
carbapenamase producing bacteria" (ROUTINE)
• "Rapid identification of respiratory tract infections
(RID-RTI)
• "Development of a handheld antibacterial drug
resistance diagnostic device using nanowire technology"
(NANOMAL)
• "Automated next generation sequencing for
diagnostic microbiology“ (PATHSEEK),
HORIZON 2020
• HEALTH.2013.2.3.1-1: Drugs and vaccines for
infections that have developed or are at the risk
of developing significant anti-microbial resistance.
• HEALTH.2013.2.3.1-2: Stratified approaches to
antibacterial and/or antifungal treatment
A “Perfect Storm”
Companies withdrawing from antimicrobial market as:
•
•
•
•
New drug development expensive
Resistance, not just side effects, a huge challenge
Patient numbers often relatively small & regimens short
Patents short-lived
Founded
in 2007
Spreading the
costs of R&D
IMI New Drugs for Bad Bugs (ND4BB)
initiative
COMbatting BACterial resistance in Europe (COMBACTE) €194.6m
“CLIN-Net”: large clinical trials
“LAB-Net”: microbial surveillance for trial site selection
– Studies : Novel antibiotic vs skin and respiratory infections
New human immunoglobulin monoclonal antibody
against S. aureus alpha toxin
Molecular basis of the bacterial cell wall permeability
(TRANSLOCATION)
€29.3m
– Explore how to stop the Gram negative bacteria ejecting antimicrobials
Trans Atlantic Task Force Recommendations
Future Collaborations (1)
Trans Atlantic Task Force Recommendations
Future Collaborations (2)