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Overview
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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
• 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.
1. Armstrong GL et al, JAMA 1999;281(1):61-66
Antibiotics continue to
save lives every day…
Ability to control infection is critical to other
advances in medicine including:
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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
“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
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
Antibiotic resistance:
a problem globally…
2014: WHO Global Report on Surveillance
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Very high rates of resistance observed for common
bacteria that cause healthcare 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
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World health assembly endorses global action plan
to tackle AMR.
September 2016
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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.
6. World Health Organization 2014 . Antimicrobial Resistance: Global Report on Surveillance.
http://www.who.int/drugresistance/documents/surveillancereport/en/ Last accessed 21/9/14
7. http://www.who.int/antimicrobial-resistance/global-action-plan/en/
8. http://www.who.int/mediacentre/news/releases/2016/commitment-antimicrobial-resistance/en/
…a problem in our region
China*
ECOL: 54%
KPNE: 41%
India
ECOL: 78%
KPNE: 64%
Thailand*
ECOL: 55%
KPNE: 50%
Malaysia
ECOL: 36%
KPNE: 45%
Korea
ECOL: 37%
KPNE: 40%
Hong Kong
ECOL: 46%
KPNE: 23%
Singapore
ECOL: 21%
KPNE: 32%
Japan†
ECOL: 17%
KPNE: 11%
Philippines
ECOL: 47%
KPNE: 23%
Taiwan
ECOL: 91%
KPNE: 75%
Indonesia
ECOL: 71%
KPNE: 64%
Resistance (%ESBL)
in the Asia Pacific
region
9. Mendes et al., Antimicrob. Agents Chemother. 2013
10. Xiao et al, Drug Resist Updat, 2011 (2009 data)
11. Chong et al., EJCMID, 2011 (2009 data)
Australia
ECOL: 12%
KPNE: 15%
New Zealand
ECOL: 11%
KPNE: 10%
…and a problem in Australia
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The National Antimicrobial Resistance (AMR) Strategy
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
12. Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www.health.gov.au/amr
Antimicrobial Use and Resistance in Australia
(AURA)
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Surveillance of antibiotic usage (volume, appropriateness)
and resistance is the cornerstone of efforts to control AMR
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Surveillance provides information on impact of usage patterns
on development of resistant bacteria
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Local surveillance is critical to informing local policy,
guidelines and measuring effect of local interventions.
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National surveillance can inform national response and
prevention strategies
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The national AURA project brings together a wide range of
passive and targeted surveillance of antimicrobial resistance
and usage in hospitals and the community
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AURA 201615 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
13. http://www.safetyandquality.gov.au/national-priorities/amr-and-au-surveillance-project/
AMR in Australia
Some of the findings (AURA 2016)
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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.
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
14. 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 usage in our health service
• Insert local usage data if available
• Include information about contributions to National
Antimicrobial Usage Surveillance Program (NAUSP)
Antimicrobial stewardship (AMS)
• A systematic approach to optimising use of antibiotics
• Goals:
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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:
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‘everybody's business’
executive and clinical leadership
clinical team (doctors, nurses, pharmacists, allied health)
consumers
15. MacGowan 1983
16. Nathwani D and Sneddon J. Practical Guide to Antimicrobial Stewardship.
Access at http://bsac.org.uk/news/practical-guide-to-antimicrobial-stewardship-in-hospitals/
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
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.
17. 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 Health Service Standards,
Standard 3:
Antimicrobial Stewardship Criterion
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.
18. National Safety and Quality Health Service Standards , access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/
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
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seeking ID/micro consults
guideline and formulary information
pharmacy advice
contacts
other relevant information.
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?
19. Antibiotic Expert Groups. Therapeutic guidelines: Antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.
Antibiotic Awareness Week 2016
Antibiotics: Handle with Care
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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
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Australian Government Department of Health
Australian Government Department of Agriculture and Water
Resources
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State and Territory Health representatives
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NPS MedicineWise
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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
Antibiotics: Handle with Care
Activities in our health service?
• Include information about local activities
• Provide details of local contacts for the week.
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.