Antibiotic Stewardship in Hospitals and Primary Care: the Slovenian - - PowerPoint PPT Presentation

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Antibiotic Stewardship in Hospitals and Primary Care: the Slovenian Experience Prof Bojana Beovic, MD, PhD University Medical Centre Ljubljana Slovenia 1 16 es JNI, Nancy , du 10 au 12 juin 2015 Dclaration de liens d intrt avec les

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Antibiotic Stewardship in Hospitals and Primary Care: the Slovenian Experience

Prof Bojana Beovic, MD, PhD University Medical Centre Ljubljana Slovenia

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16es JNI, Nancy, du 10 au 12 juin 2015

Déclaration de liens d’intérêt avec les industries de santé en rapport avec le thème de la présentation (loi du 04/03/2002) :

Consultant ou membre d’un conseil scientifique Conférencier ou auteur/rédacteur rémunéré d’articles ou documents: Pfizer, MSD, Alkaloid, Astellas, AstraZeneca, Sandoz Prise en charge de frais de voyage, d’hébergement ou d’inscription à des congrès ou autres manifestations Investigateur principal d’une recherche ou d’une étude clinique

OUI NON OUI NON OUI NON OUI NON

L’orateur ne souhaite pas répondre

Intervenant : Bojana Beović Titre : Prof

16es Journées Nationales d’Infectiologie, Nancy du 10 au 12 juin 2015

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A Little Bit of Geography…

France: 63.5 Mio Inhabitants Slovenia: 2.1 Mio Inhabitants

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Antibiotic Stewardship is…

  • To choose the most effective antibiotic therapy
  • To minimize adverse events
  • To minimize the development of antibiotic

resistance

  • At minimal cost

McGowan&Gerding, New Horiz 1996; 4: 370-6. ANTIBIOTIC STEWARDSHIP

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Aspects of Antibiotic Stewardship

  • Non-governemental initiatives: national,

international

  • EU state-driven projects/programs
  • National activities
  • University-based initiatives
  • Regional activities
  • Hospital-based activities
  • Industry…
  • projects
  • programs
  • recommendations
  • legislation
  • structures
  • campaigns
  • research…

 restriction  education  structural changes… Public Patients Physician Pharmacists Nurses IT… (management)…

OWNERSHIP TYPE OF ACTIVITY ACTIVITY THE TARGET GROUP

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„(antimicrobial) AND stewardship“ in PubMed

200 400 600 800 1000 N of publications > 10 years 5 to 10 years last 5 years

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Do the Interventions Work?

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Do the Interventions Work?

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Interventions are effective in reducing antimicrobial consumption and / or reducing antimicrobial resistance.

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Translational Medicine… is a discipline that aims to improve the health of individuals and

the community by "translating" findings into diagnostic tools, medicines, procedures, policies and education.

http://en.wikipedia.or

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Determinants of Hospital (Outpatient?) Antibiotic use

  • Sociocultural aspects
  • Socioeconomic aspects
  • Organisational policies
  • Knowledge
  • Attitudes

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Huscher MEJL, Grol RPTM, van der Meer JW. Lancet ID, 2010; 10: 167-75.

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Some Facts on Health-care System in France and in Slovenia

3,3 2,5

1 2 3 4

France Slovenia

N of licensed medical doctors per 1000 Inh

6,3 4,5

2 4 6 8

France Slovenia

N of hospital beds per 1000 Inh

16,8 17,1

5 10 15 20

France Slovenia

Hospital discharge rate per 1000 Inh

11,6 9,4

5 10 15

France Slovenia

Health-care expenditure in % GDP https://data.oecd.org/health.htm

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  • Legislation
  • Infrastructure
  • Local strategy
  • Monitoring of outcomes
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Did the Recommendations Have Any Impact?

Report on the implementation 2003 (REPORT FROM THE COMMISSION TO THE COUNCIL, 22.12.2005)

  • Almost all countries have national systems for surveillance of antimicrobial use and antibiotic consumption
  • The majority of Member States co-ordinate actions to improve prescribing practices.
  • Sixteen countries have measures in place to enforce regulations for prescription-only use of systemic antimicrobial agents.
  • Most countries have nationally accepted guidelines on appropriate use of antimicrobials for at least some conditions/syndromes
  • Twenty-two countries have a national programme for hospital hygiene and infection control in place, only about half of the

countries have legal requirements or recommendations about the number of infection control nurses per hospital bed

  • In all countries education is provided by non-sponsored continuing education, and in almost all of them also through sponsoring

by the pharmaceutical industry

  • All but six countries have performed a lay public campaign in some format in the past five years
  • Twenty Member States, two EEA countries, and Bulgaria reported to have an intersectoral mechanism in place and five countries

are about to create it. One Member State did not report to create such a mechanism.

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Legislation on Antibiotic Stewardship in Slovenia

  • Establishment of the intersectorial mechanisms (National antibiotic

committee) 2005: ID physicians, clinical microbiologists, pharmacists, veterinarians, IT, a MoH representative

  • By-laws on antimicrobial consumption surveillance and responsible use
  • f antibiotics 2011:
  • antimicrobial consumption surveillance is mandatory
  • antimicrobial stewardship programmes are mandatory in each hospital
  • audits of antimicrobial stewardship programmes by ICM (since 2013)

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Official Journal of Slovenia 2011; 21: 1022-5.

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Infrastructure in Slovenian Hospitals

  • Mandatory AS programme
  • Antimicrobial committee / drug committe or at least
  • ne dedicated person with additional training in AS

(in small hospitals)

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Local Strategies in Slovenian Hospitals: Audits in 10 Hospitals, Major Findings

(2013-2015)

  • The physicians do not receive information on antimicrobial resistance and consumption in the hospital:

4/10

  • Poor adherence to guidelines: 7/10
  • Indication for antibiotics not in the records: 6/10
  • Poor adherence to antibiotic surgical prophylaxis guidelines: 7/8
  • No de-escalation: 4/10
  • Combination of antibiotics in-appropriate: 5/10
  • Missing antibiotic prescribing improvement plan: 4/10
  • No guidelines for prescribing „CIA“ antibiotics: 6/10
  • In-appropriate duration of therapy: 7/10
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Recommendations for Antimicrobial Use in Outpatients and Inpatients in Slovenia (1998 – 2013)

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http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx

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1.55 2.17

http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx

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In-hospital Antibiotic Consumption: F vs SI

  • The French hospitals (2007): 41.1 DDD/100 patient-

days

  • Slovenian hospitals (2007): 50 DDD/100 patient-days

Why: Less hospital beds in Slovenia?

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Amadeo B, et al. J Antimicrob Chemother 2011; 66: 434-42. www.anbico.si

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Antibiotic Consumption in General and University Hospitals in Slovenia in DDD/100 patient-days

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10 20 30 40 50 60 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Tetraciklini (J01A) Sulfonamidi in trimetoprim (J01E) Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F) Kinolonske protimikrobne učinkovine (J01M) Drugi beta-laktamski antibiotiki (J01D) Druge protimikrobne učinkovine (J01X) Betalaktamski antibiotiki, penicilini (J01C)

All hospitals included from 2003 onwards

www.anbico.com

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Antibiotic Consumption in General and University Hospitals in Slovenia in DDD/1000 admissions

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50 100 150 200 250 300 350 400 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Tetraciklini (J01A) Sulfonamidi in trimetoprim (J01E) Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F) Kinolonske protimikrobne učinkovine (J01M) Drugi beta-laktamski antibiotiki (J01D) Druge protimikrobne učinkovine (J01X) Betalaktamski antibiotiki, penicilini (J01C) Aminoglikozidni antibiotiki (J01G) Amfenikoli (J01B)

All hospitals included from 2003 onwards

www.anbico.si

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Antibiotic Consumption in General and University Hospitals in Slovenia in DDD/1000 admissions

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50 100 150 200 250 300 350 400 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Tetraciklini (J01A) Sulfonamidi in trimetoprim (J01E) Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F) Kinolonske protimikrobne učinkovine (J01M) Drugi beta-laktamski antibiotiki (J01D) Druge protimikrobne učinkovine (J01X) Betalaktamski antibiotiki, penicilini (J01C) Aminoglikozidni antibiotiki (J01G) Amfenikoli (J01B)

All hospitals included from 2003 on

www.anbico.si

INTENSIFICATION OF TREATMENT

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Strategies in Ambulatory Antibiotic Use in Slovenia

  • Education of family physicians during the specialisation curriculum
  • Education of family physicians provided by Slovenian Medical

Association, ICM at the MoH, Health Insurance Institute)

  • Restricted prescribing of some antibiotics by the Health Insurance

Institute (proposed by professionals)

  • Antibiotic pocket-books

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http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx

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31.1 14.5

http://ecdc.europa.eu/en/activities/surveillance/ESAC-Net/Pages/index.aspx

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Ambulatory Antibiotic Consumption in Slovenia in DDD/1000 Inh/day (DID)

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5 10 15 20 25 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Tetraciklini (J01A) Sulfonamidi in trimetoprim (J01E) Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F) Kinolonske protimikrobne učinkovine (J01M) Drugi beta-laktamski antibiotiki (J01D) Druge protimikrobne učinkovine (J01X) Betalaktamski antibiotiki, penicilini (J01C) Aminoglikozidni antibiotiki (J01G)

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Ambulatory Consumption of Co-amoxiclav in Slovenia in DID

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1 2 3 4 5 6 7 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

www.anbico.si

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Ambulatory Consumption of Co-amoxiclav in Slovenia in DID

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1 2 3 4 5 6 7 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

www.anbico.si Čižman M, et al. J Glob Antimicrob Resist 2015

Restriction of co-amoxiclav prescribing, if the indication was not recognized as appropriate, the physician is fined.* *Level and trend change p< 0.001

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Ambulatory Consumption of Macrolides in Slovenia in DID

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0,00 0,50 1,00 1,50 2,00 2,50 3,00 3,50 4,00 4,50 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Telithromicin (J01FA15) Roksitromicin (J01FA06) Miokamicin (J01FA11) Midekamicin (J01FA03) Klindamicin (J01FF01) Klaritromicin (J01FA09) Eritromicin (J01FA01) Diritromicin (J01FA13) Azitromicin (J01FA10)

www.anbico.si

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Ambulatory Consumption of Macrolides in Slovenia in DID

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0,00 0,50 1,00 1,50 2,00 2,50 3,00 3,50 4,00 4,50 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Telithromicin (J01FA15) Roksitromicin (J01FA06) Miokamicin (J01FA11) Midekamicin (J01FA03) Klindamicin (J01FF01) Klaritromicin (J01FA09) Eritromicin (J01FA01) Diritromicin (J01FA13) Azitromicin (J01FA10)

www.anbico.si Čižman M, et al. J Glob Antimicrob Resist 2015

Restriction of macrolides introduced because of high resistance of pneumococci* *decrease after intervention was not significant

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Ambulatory Consumption of Fluoroquinolones in Slovenia in DID

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0,00 0,20 0,40 0,60 0,80 1,00 1,20 1,40 1,60 1,80 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 Pefloksacin (J01MA03) Ofloksacin (J01MA01) Norfloksacin (J01MA06) Moksifloksacin (J01MA14) levofloksacin (J01MA12) Ciprofloksacin (J01MA02)

Restriction of fluoroquinolones* *level and trend change <0.001

www.anbico.si Čižman M, et al. J Glob Antimicrob Resist 2015

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Antibiotic Resistance: France vs Slovenia (2013)

5 10 15 20 25 30

  • E. coli resistant

to 3rd gen cephalosporins

  • E. coli resistant

to fluoroquinolones

  • K. pneumoniae

resistant to 3rd gen cephalosporins

  • K. pneumoniae

non-susceptible to carbapenems

  • P. aeruginosa

resistant to ceftazidime

  • P. aeruginosa

resistant to carbapenems MRSA

  • S. pneumoniae

non-susceptible to penicillin

  • S. pneumoniae

resistant to macrolides

  • E. faecium

resistant to vancomycin

% resistance, sterile samples

France Slovenia

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EARS-net. http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/table_reports.aspx

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Conclusions: Can Slovenia Serve as an Example

  • Good control of antibiotic prescribing in the community, less success in the hospital sector
  • Relatively high resistance rates (poor health-care resources, fewer hospital beds, less

effective infection control?)

  • Country-wide antibiotic stewardship activities easier to perform in small countries

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