Antibiotic policy to prevent resistance development

1
Antibiotic policy to prevent resistance
development

• Inga Odenholt
• Associate professor
• Department of Infectious Diseases, Malmö
• Lund University, Sweden

2
(No Transcript)
3
Antibiotic Resistance -THE RESULT OF A GLOBAL
FAILURE
4
Antibiotic resistance
New treatment options
5
Introduction of New Antibiotic Classes
Oxazolidinones
Trimetoprim
Streptogramins
Quinolones
Lincosamides
Chloramphenicol
Cephalosporins
Tetracyclines
Macrolides
Glycopeptides
Aminoglycosides
Penicillins
Sulphonamides
1930s 1940s 1950s
1960s 1970s 1980s 1990s
2000s
6
How to combat the increasing resistance?
7
STRAMA
Swedish Strategic programme for The Rational use
of Antimicrobial Agents and Surveillance of
Resistance
www.strama.org
8
How it all started

• Increasing incidence of Pc-resistant pneumococci
  (PRP) in Southern Sweden from 2 to 8-15 in
  early 1990s
• Deterring international experiences
• Who is responsible for action?
• Discussion between competent authorities and
  professional organizations resulted in the
  formation of a national network for the combat of
  antibiotic resistance (1994)

9
STRAMA National Group Swedish Medical
Association Swedish Institute for Infectious
Disease Control National Board of Health and
Welfare Medical Products Agency National
Corporation of Swedish Pharmacies Swedish
Society for Hospital Hygiene and Infection
Control The Swedish Federation of County
Councils Corporation of County Medical Officers
Swedish Association of Local Authorities The
Swedish Network of Pharmacoepidemiology
National Veterinary Institute The Swedish Board
of Agriculture
10
STRAMA Primary objectives 1.To create a
cross-sectorial national forum to - share
information - formulate national strategies -
support an initiate research activities -
collaborate with media 2. To stimulate the
formation of regional STRAMA - groups in
every county
11
STRAMA 1995-1999 Voluntary basis 2000-2002
Supported by the Swedish Government with 320.000
EUR yearly 2003 Funding increased to 800.000 EUR
12

• Examples of Goals for STRAMA (out-patients)
• 1. To follow the usage of antibiotics and the
• pattern of resistance at the national/regional
  levels
• 2. To implement therapeutic guidelines and
• intervention programmes
• 3. To give feed-back to prescribers
• 4. Cooperation with media
• In order to reduce inappropriate antibiotic
  use

13
Antibiotic consumption on a national
levelSwedish Diagnosis-Antibiotic Prescribing
study 2000 and 2002
14

• Five counties, 1.3 mil inhabitants
• chosen to reflect the countrys antibiotic
  utilisation
• 140 primary care centres, 600 GPs
• One week in November
• Recruitment through local STRAMA groups
• Anonymous

15
(No Transcript)
16
Antibiotics for urinary tract infections in the
2000 and 2002 STRAMA Diagnosis-antibiotic
prescribing study
17
Antibiotic consumption on a regional level
Tetracyclins
Amoxicillin
Penicillin V
Cephalosporins
Macrolids
18
Antibiotics age group 0-6 years, municipalities
in Sweden with the highest and lowest
consumption, 2002.
19
Resistance pattern
20
Feed-back to the prescribers
Consumption of fluoroquinolones in 4 districts
Uppsala County The effect of prescriber
feed-back and educational outreach
(DDD/1000 inhabitants/day)
21
Consumption of fluoroquinolones in 4 districts
Uppsala County The effect of prescriber
feed-back and educational outreach
(DDD/1000 inhabitants/day)
22
Conclusions

• Knowing the national and regional use of
  antibiotics and the national and regional
  resistance pattern
• Interventions e.g. Therapeutic guidelines,
  education on a local level
• Continuous efforts have led to changes in
  prescribing patterns (e. g. reduced use of
  quinolones in uncomplicated UTI, decreased use of
  of antibiotics in total 20 in 8 years)

23
Treatment guidelines
24
STRAMA in hospitals The point-prevalence study

• During 2 weeks in November 2003 and 2004 all
  patients in appr. 80 of the hospitals in Sweden
  were registered
• 54 hospitals were included
• 434 departments
• 13536/11 348 patients
• 30.9/31.8 of the patients were treated with
  antibiotics

25
The point-prevalence study

• The aims of the study were to describe the use of
  antibiotics in Swedish hospitals
• Indications/Diagnoses
• Choice of antibiotics. Correct or not?
• Dose
• Community-acquired or nosocomial infections
• Infections related to foreign-body devices

26
Diagnoses   Central nervous system Ophthalmic
infections Mouth and throat Upper respiratory
tract Bronchitis Pulmonary infections Cardiovascul
ar system Gastrointestinal upper Gastrointestinal
lower Gastrointestinal transmissible
diseases Liver/bile duct/pancreas/spleen Skin and
soft tissue Bone and joint Urinary bladder,
cystitis Kidney, pyelonephritis, febrile urinary
tract infection Genitalia Sepsis Indication not
specified Indication unclear
27
The point-prevalence study

• Of all patients in the hospitals, antibiotic
  treatment was initiated
• In 17 due to community-acquired infections
• In 9 due to nosocomial infections
• In 6 as prophylaxis

28
Percentage of antibiotic treated patients per
speciality PPS 2003 och 2004.
2003 tot 4178 treated of 13 536 patients
2004 tot 3622 treated, of 11 348 ipatients
90
PPS 2003
80
PPS 2004
70
60
50
Andel behandlade/inneliggande patienter
40
30
20
10
0
ögon
urologi
geriatrik
onkologi
hudklinik
neurologi
akutklinik
kardiologi
hematologi
kärlkirurgi
barnkirurgi
gynekologi
handkirurgi
njurmedicin
lungmedicin
reumatologi
barnmedicin
neurokirurgi
thoraxkirurgi
allm kirurgi
med rehab
plastikkirurgi
endokrinologi
neonatalavd
neuro rehab
barnhabilitering
BB/förlossning
infektionsklin
öron-näsa-hals
gastroenterologi
Alla specialiteter
allm internmed
ortopedisk kirurgi
transplantations kirurgi
29
What antibiotics were used?
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
Too much quinolones and cephalosporins!
34
CID, 200438 (suppl 4) 341-345
35
SANT-study
Swedish Antibiotic Nursing home Trial
36
Aims of the study

• To describe and evaluate the treatment of
  infections in elderly patients in nursing homes

37
Results of the registration

• 58 nursing homes with 2752 patients
• 890 infection registrations
• Mean age of 86 years.
• Appr. 2/3 were women

38
Results

• 43 of the patients had received antibiotics the
  past 3 months
• 33 had had the same infection the past 3 month
• Urinary tract infections was the most common
  diagnosis (60 ). Thereafter skin- and soft
  tissue infections (15 ), pneumonia (15 ) and
  others
• (10 ).
• In 86 of all registered infections antibiotics
  were initiated

39
Treatment of UTIs

• 89 of the patients received antibiotics
• gt50 of the patients had got a UTI diagnosis the
  past 3 month and gt 50 had received antibiotics
  the past 3 month

40
What did we learn?

• Earlier studies have shown that appr. 50 of
  patients in nursing homes have asymptomatic
  bacteriuria
• A majority of these patients receive antibiotics,
  which is not recommended

41
Hospital-acquired infections
42
(No Transcript)
43
(No Transcript)
44
Asymptomatic patients with or without indwelling
catheters should not be treated with antibiotics
45
Antibiotic prophylaxis
46
(No Transcript)
47
(No Transcript)
48
(No Transcript)
49
Too long prophylaxis!

• One dose before
• Transurethral prostate resection
• Transrectal prostate core biopsy
• Surgery with bowel substitute
• Opening of the urinary tract, i.e. radical
• prostatectomy

50
Conclusions

• Too much quinolones and cephalosporins in the
  hospitals
• Too much quinolones on not recommended
  indications (e.g. lower UTIs in women)
• Too much antibiotic treatment for urinary tract
  infections in asymptomatic patients
• Too much antibiotic treatment for urinary tract
  infections in patients with catheters
• Too long prophylaxis in surgery

51
If we stop using one antibiotic, can the
resistance trend be reversed?
52
(No Transcript)
53
Consumption of Trimethoprim in Kronoberg 1998-Jan
2005
54
A difficult balance
The best interests of the individual
The global need for effective antibacterial
treatment
Appropriate antibacterial prescribing
Butler C et al. JAC 2001 48435440
55
Thank you for your attention