Using antibiotics prudently

1
Using antibiotics prudently

• - Hospital Prescriber Presentation

Insert Name of presenter Insert Name of
hospital
2
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

3
Antibiotic resistance a patient safety issue
4
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.

Trends in antibiotic resistance (invasive
infections), 2002-2008. Source European
Antimicrobial Resistance Surveillance System
(EARSS), 2009.
5
Methicillin-resistant Staphylococcus aureus
(MRSA), blood and spinal fluid
2002 2007
Source European Antimicrobial Resistance
Surveillance System (EARSS), 2008.
6
Methicillin-resistant Staphylococcus aureus
(MRSA), EU, 2007 often high, but decreasing in
many countries
No. of countries
MRSA ()
? Country with a significant increase
(20052007) ? Country with a significant decrease
(20052007)
Source EARSS ECDC, 2009
7
Antimicrobial resistance in gram-negative
bacteria, EU, 2007 already high or increasing

• Country with a significant increase (2005-2007)
• ? Country with a significant decrease (2005-2007)

No. of countries
Source EARSS ECDC, 2009
Carbapenem-resistant Pseudomonas aeruginosa ()
No. of countries
3rd-gen. ceph.-resistant Escherichia coli ()
3rd-gen. ceph.-resistant Klebsiella pneumoniae ()
8
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)
Source European Surveillance of Antimicrobial
Consumption (ESAC), 2010. In ECDC Annual
Epidemiological Report 2010 in press.
9
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

1. Cosgrove SE, Carmeli Y. The impact of
antimicrobial resistance on health and economic
outcomes. Clin Infect Dis. 2003 Jun
136(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-resis
tant infections in a Chicago teaching hospital
implications for antibiotic stewardship. Clin
Infect Dis. 2009 Oct 1549(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 Feb115(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
Jul118(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
136(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 May22(5)387-94.
10
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.

11
Why inappropriate use of antibiotics contributes
to antibiotic resistance the why
12
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
May117(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
Nov41(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 Sep46(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 1549(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. 12.
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 Mar51(3)864-7.
13
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. 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 4136(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 Oct53(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 Sep24(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
May59(5)990-5.
14
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.

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
Nov30(5)724-7.
15
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).
Rates of nosocomial Clostridium difficile,
expressed per 1,000 patient-days, 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 Sep46(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
Sep24(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. 2000355(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 Jul29(1)60-6
discussion 7-8.

16
How prudent use of antibiotics can be promoted in
hospitals the how
17
Multifaceted strategies can address and decrease
antibiotic resistance in hospitals

• Antibiotic prescribing practices and decreasing
  antibiotic resistance can be addressed through
  multifaceted strategies including29-31
• 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 Sep24(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 Jul29(1)60-6
discussion 7-8.
18
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
  patients stay37-39

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 Sep24(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 Jul29(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
Jul156(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
Sep130(3)787-93.
19
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

20
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-resistan
  t 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

40. Singh N, Yu VL. Rational empiric antibiotic
prescription in the ICU. Chest. 2000
May117(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
Nov41(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 Sep46(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 Jul156(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
Sep24(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 Jul29(1)60-6 discussion 7-8.
21
European Antibiotic Awareness Day a campaign
to promote prudent use of antibiotics
22
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.

23
European Antibiotics Awareness DayPlanned local
activities

• Insert planned local activities, highlighting
  where involvement by the audience of this
  presentation would be welcome

24
THANK YOU!

• For more information on data sources and
  references, please visit
• http//antibiotic.ecdc.europa.eu
• insert national website