Drug Resistant Streptococcus pneumoniae

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Drug Resistant Streptococcus pneumoniae
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the microbes are educated to resist penicillin
and a host of penicillin-fast organisms is bred
out which can be passed on to other individuals
and perhaps from there to others until they reach
someone who gets a
septicemia or a pneumonia which penicillin cannot
save. In such cases the thoughtless person
playing with penicillin treatment is morally
responsible for the death of the man who finally
succumbs to infection with the penicillin-resistan
t organism. I hope this evil can be averted.
Sir Alexander Fleming,
New York Times, June 26, 1945
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Importance of Pneumococcal Infections in the
U.S.

• 2000 CDC Active Bacterial Core Surveillance
  (ABCs)

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Drug ResistantStreptococcus pneumoniae

• Emerged in Spain and South Africa
• Emerged in the U.S. in the last decade
• Use of antibiotics for viral infections
• Threatening use of antibiotics for common
  infections

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Resistance and AntibioticPrescribing

• Risk factors for resistant S. pneumoniae are
• young age (lt 1 year)
• higher socioeconomic status
• day-care attendance
• recent receipt of antibiotics (2-5 times greater
  risk)

Pediatrics 199392761-7.
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Pneumococcal Carriage in Day Care Center
Outbreak, East Tennessee, 1996
Craig, Clin Infect Dis 1999291257-1264
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Penicillin Resistance in S. pneumoniae U.S.
1979-2003
vaccine
1979-1994 CDC Sentinel Surveillance Network
1995-2003 CDC Active Bacterial Core
Surveillance (ABCs) /Emerging Infections Program
2003 data are preliminary
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Trends in Pneumococcal Susceptibility, U.S,
1995-2000
CDC Active Bacterial Core Surveillance (ABCs)
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Invasive Pneumococcal Disease, Proportion of
Non-susceptible Isolates, Tennessee, 1999-2003
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Invasive Pneumococcal Disease, Tennessee,
1995-2003
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Evidence of Excessive Antibiotic Use in the US

• NAMCS data (1992)
• Antibiotics 2nd leading class of Rx in the US
• most for RTI (JAMA 1995273214-19)
• Antibiotic use in children
• URI 44
• Colds 46
• Bronchitis 75
• (JAMA 1998279875-77)

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UPDATE!

• NAMCS data (2000) Children lt 15
• Population-based antibiotic prescriptions
• decreased 40
• Visit-based antibiotic prescriptions
• decreased 29
• Declines coincide with increased media attention
• Antibiotic resistance has continued to increase
  through the 1990s

(JAMA 20022873096-3102)
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Antibiotic use in Tennessee

• In 2002, TN had the highest prescription rates in
  the country.
• Novartis Pharmacy Benefit Report 2002 Facts and
  Figures.
• In 2001, Tennessees utilization rates for
  -Penicillins,
• -Cephalosporins
• -Trimethoprims
• were over 20 higher than the national average.

Novartis Pharmacy Benefit Report 2001 Facts and
Figures.
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Oral Antibiotic Prescriptions, Knox County,
1996-1999
Perz, JAMA 20022873103-3109
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Changes in Prescribing From Year 1 to Year 3, per
Child-year
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Ratio of Prescriptions URI Visits, Knox County,
1996-1999
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Reasons for Antibiotic Use Conclusions from 8
Focus Groups

• Physician Concerns
• patient expects antibiotic
• diagnostic uncertainty
• time pressure

• Patient Concerns
• want clear explanation
• green nasal discharge
• need to return to work/child care

Antibiotic Prescription
Barden, Clin Pediatric 199837665-672
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Patient Satisfaction and Antibiotics

• Satisfaction predicted by
• time spent by MD explaining illness
• patient understanding of treatment choice
• Satisfaction not predicted by receipt of
  antibiotics

Hamm, J Fam Pract 19964356Mangione-Smith,
Pediatrics 1999103711-8
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Can Resistance Trends Be Reversed?

• Public health campaign in Iceland following
  dramatic increase in the rates of
  penicillin-resistant pneumococci from 2.3 to 20
  in 4 years
• Rates fell from peak of 20 in 1993 to 16.9 in
  1994
• Carriage rates of resistant strains among day
  care attendees dropped from 20 to 15 in same
  period JAMA 1996275175

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Principles of Judicious Antimicrobial
UseOtitis Media - Key Messages

• Episodes of otitis media should be classified as
  acute otitis media (AOM) or otitis media with
  effusion (OME)
• Antibiotics are not indicated for initial
  treatment of OME

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Principles of Judicious Antimicrobial
UseRhinitis and Sinusitis- Key Messages

• Rhinitis
• antibiotics should not be given for viral
  rhinosinusitis
• Sinusitis
• prolonged URI symptoms
• more severe URI symptoms (i.e. facial swelling,
  high fever)
• antibiotic treatment with the most
  narrow-spectrum agent

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Principles of Judicious Antimicrobial
UsePharyngitis- Key Messages

• Diagnose as group A strep
• Penicillin is the drug of choice in treating
  group A strep
• use erthromycin if penicillin allergic

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Principles of Judicious Antimicrobial UseCough
and Bronchitis- Key Messages

• Cough/bronchitis rarely needs antibiotics
• Antibiotic treatment for prolonged cough (gt10
  days) may be needed
• Mycoplasma pneumonia- use macrolide agent for
  children gt5

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Prevention - Pneumococcal Vaccination

• 23-valent polysaccharide vaccine (PPV)
• 60 effective in preventing bacteremic
  pneumococcal infection in immunocompetent adults
• 7-valent conjugate vaccine (PCV-7) for children
  age 3 -59 months
• gt95 effective in preventing invasive disease in
  young children

• Bartlett, Clin Infect Dis 200031347-382
• CDC, MMWR 200049(RR-9)1-34

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Receipt of PCV7 Among Children 19-35 Months,
U.S, 2002-2003
83.7
National Immunization Survey, Q3/2002-Q2/2003
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Appropriate Antibiotic Use Intervention Sites,
2002
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TennesseesAppropriate Antibiotic Use Campaign

• Mission
• To reduce inappropriate antibiotic use and the
  spread of antibiotic-resistant bacteria that
  cause many upper respiratory illnesses through
  state and local partnerships

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TAAUC History

• Created in the Spring of 2002 in response to TNs
• high levels of antibiotic resistance
• 2002-2003 Began developing partnerships and
  focused on educating health care providers and
  parents and relaying the programs key messages
• 2003-2004 Continued Year 1 activities, developed
  a coalition and partnerships, developed and
  produced program materials, and began media
  campaign development
• 2004-2005 Continuing Year 1 and Year 2
  activities, program expansion, development, etc.

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Campaign Goals

• Reduce inappropriate antibiotic use and the
  prevalence of antibiotic resistance in Tennessee
  by
• Increasing parental knowledge of appropriate
  antibiotic use
• Changing practitioners antibiotic prescribing
  behavior
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• Increasing community awareness of appropriate
  antibiotic use and resistance

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TAAUC Partners

• Bayer
• Roche
• TennCare
• Head Start
• Lamar Outdoor Advertising
• American Academy of Pediatrics (TN Unit)
• TN Radio Network

• Knox County Health Dept.
• Metropolitan Health Dept. of Nashville and
  Davidson County
• East TN Regional Office
• St. Thomas Hospital
• East Tennessee Childrens Hospital
• Bristol-Myers Squibb
• University of TN Medical Center
• Vanderbilt University
• Knox County Schools
• Vanderbilt Health Plan

• Blue Cross Blue Shield of TN
• Nashville Academy of Medicine
• Shaller Anderson of TN
• John Deer Health
• TN Pharmacists Association
• UT Medical Center
• GlaxoSmithKline
• Abbott Laboratories
• TN Academy of Family Physicians
• Pfizer
• Xantus
• Daiichi

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Program Components

• Provider Education
• Parent/Childcare Center Education
• Public Education

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TAAUC Billboard
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Conclusions

• Increasing antibiotic resistance threatens
  success of antibiotic treatment for common
  infections
• Many consumers use antibiotics inappropriately
• Decreased antibiotic use has been shown to
  reverse antibiotic resistant trends
• Physician and public education principles of
  appropriate use, educational materials,
  presentations mass media

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CDC Treatment Guidelines

• www.cdc.gov/drugresistance/community/technical.htm

TAAUC Websitewww.tennessee.gov/health