Antibiotic policy to prevent resistance development
Antibiotic policy to prevent resistance development
Inga Odenholt
Associate professor
Department of Infectious Diseases, Malmö
Lund University, Sweden
Antibiotic Resistance--THE RESULT OF A GLOBALTHE RESULT OF A GLOBAL
FAILURE FAILURE
Antibiotic Resistance--THE RESULT OF A GLOBALTHE RESULT OF A GLOBAL
FAILURE FAILURE
Antibiotic Antibiotic resistanceresistance New treatment New treatment
optionsoptions
Sulphonamides
Tetracyclines
PenicillinsAminoglycosides
Macrolides
Glycopeptides
Streptogramins
Chloramphenicol
Quinolones
Trimetoprim
Lincosamides
1930´s 1940´s 1950´s 1960´s 1970’s 1980´s 1990´s 2000´s
Oxazolidinones
Introduction of New Antibiotic Classes
Cephalosporins
How to combat the increasing resistance?
How to combat the increasing resistance?
STRAMASTRAMASwedish Strategic programme for The Rational use of Antimicrobial Agents and Surveillance of Resistance
www.strama.org
How it all startedHow 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)
STRAMA National GroupSTRAMA 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
STRAMASTRAMA Primary objectivesPrimary 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
STRAMASTRAMA
1995-1999 Voluntary basis
2000-2002 Supported by the Swedish Government with 320.000 EUR yearly
2003 Funding increased to 800.000 EUR
Examples of Goals for Examples of Goals for STRAMA (out-patients)STRAMA (out-patients)
1. To follow the usage of antibiotics and thepattern of resistance at the national/regional levels
2. To implement therapeutic guidelines andintervention programmes
3. To give feed-back to prescribers
4. Cooperation with media
In order to reduce inappropriate antibiotic use
Antibiotic consumption on a Antibiotic consumption on a national levelnational level
Swedish Diagnosis-Swedish Diagnosis-Antibiotic Prescribing study Antibiotic Prescribing study
2000 and 20022000 and 2002
• Five counties, 1.3 mil inhabitants– chosen to reflect the country’s antibiotic
utilisation
• 140 primary care centres, 600 GPs• One week in November• Recruitment through local STRAMA
groups• Anonymous
Antibiotics for urinary tract infections in the 2000 and 2002 STRAMA Diagnosis-
antibiotic prescribing study
0%
20%
40%
60%
80%
100% No treatmentReferralOn treatmentOthersQuinolonesTrim+sulfaTrimetoprimCefalosporinesTetracyclinesFosfomycinNitrofurantoinPivmecillinam
Antibiotics in the county of Skåne
År
1999 2000 2001 2002 2003 2004 2005
DD
D / 1
00
0 in
v o d
ag
0
1
2
3
4
5
6
TetracyclinsAmoxicillin Penicillin V Cephalosporins Macrolids
Antibiotic consumption on a regional level
0
200
400
600
800
1000
1200
Antibiotics age group 0-6 years, municipalities in Sweden with the highest and lowest consumption, 2002.
The resistance of E. coli in Sweden
0
5
10
15
20
25
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
År
% r
esis
ten
s
Ampicillin
Trimethoprim
Quinolones
Cefadroxil
Mecillinam
Nitrofurantoin
Resistance pattern
Consumption of fluoroquinolones in 4 districts Uppsala County The effect of prescriber feed-back and educational outreach (DDD/1000 inhabitants/day)
00,20,40,60,8
11,21,41,61,8
1995
1996
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)
00,20,40,60,8
11,21,41,61,8
199519961997
ConclusionsConclusions
• 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)
Treatment guidelines
STRAMA in hospitals The point-prevalence study
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
• 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
The point-prevalence studyThe point-prevalence study
Diagnoses Central nervous systemOphthalmic infectionsMouth and throatUpper respiratory tractBronchitisPulmonary infectionsCardiovascular systemGastrointestinal upperGastrointestinal lowerGastrointestinal transmissible diseasesLiver/bile duct/pancreas/spleenSkin and soft tissueBone and jointUrinary bladder, cystitisKidney, pyelonephritis, febrile urinary tract infectionGenitaliaSepsisIndication not specifiedIndication unclear
• 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
The point-prevalence studyThe point-prevalence study
Percentage of antibiotic treated patients per speciality; PPS 2003 och 2004. 2003: tot 4178 treated of 13 536 patients2004: tot 3622 treated, of 11 348 ipatients
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
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PPS 2004
What antibiotics were used?What antibiotics were used?
Antibiotic used for treatment and prophylaxis
0
100
200
300
400
500
600
700
800
900
1000
Cephalosporins Isoxazolyl-pc Quinolones Ampicillin Penicillins Tetracyclins
No o
f ter
apie
s Treatment
Prophylaxis
PPS 2003 Urology, spectrum of used antimicrobials
0
2
4
6
8
10
12
Num
ber o
f DDD
Community aquired Hospital aquired
PPS 2003 Urology
Treatment diagnoses
0
5
10
15
20
25
30
Cystitis Fever Cl difficilecolitis
Genital Lower GI-tract Upper GI-tract Skin / softtissue
Pneumonia Pyelitis Septicemia Others
Num
ber o
f the
rapi
es
Therapy, 62 Prophylaxis, 37
Too much quinolones and cephalosporins!
Too much quinolones and cephalosporins!
CID, 2004;38 (suppl 4): 341-345
SANT-study
Swedish Antibiotic Nursing home Trial
Aims of the studyAims of the study
•To describe and evaluate the treatment of infections in elderly patients in nursing homes
Results of the registrationResults of the registration
• 58 nursing homes with 2752 patients
• 890 infection registrations
• Mean age of 86 years.
• Appr. 2/3 were women
ResultsResults• 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
Treatment of UTIsTreatment of UTIs
• 89 % of the patients received antibiotics
• >50% of the patients had got a UTI diagnosis the past 3 month and > 50% had received antibiotics the past 3 month
0
5
10
15
20
25
30
35
%
• 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
What did we learn?What did we learn?
Hospital-acquired infectionsHospital-acquired infections
Percent hospital-acquired infections in relation to all admitted patients in some Swedish counties
0,0
2,0
4,0
6,0
8,0
10,0
12,0
Jönköpings län, 808 Skåne län, 2116 Sweden, 11348
%
Postoperative infections
Device-related HAI
C. difficile enterocolitis
Other HAI
HAI from other hospitals
All
PPS 2003 Hospital acquired infections, foreign devices, 299 st
0
20
40
60
80
100
120
CNS Hart /vascular
Cystitis Upper GI-tr Skin / softtissue
Liver / bile Bone / joint Pneunonia Pyelonefritis Septicemia Others
Num
ber o
f tre
atm
ents
Asymptomatic patients with or without indwelling catheters should not be treated with
antibiotics
Asymptomatic patients with or without indwelling catheters should not be treated with
antibiotics
Antibiotic prophylaxisAntibiotic prophylaxis
PPS 2003All peri-operative prophylaxis in surgical departments
0
20
40
60
80
100
120
Urology 40 Orthopaedics212
Ear surgery 15 General surgery202
Gynaecology 48 Other surgery 65
Nu
mb
er
of
the
rap
ies
Prophylaxis single dose Prophylaxis 24 hours Prophylaxis >24 hours
PPS 2003 Urology, length of peri-operative prophylaxis, 37 therapies
0
5
10
15
20
25
30
Prophylaxis one dose Prophylaxis one day Prophylaxis >1 day
Num
ber o
f the
rapi
es
PPS 2003 Urology, spectrum of substances in peri-operative prophylaxis in DDD
0
2
4
6
8
10
12
14
16
18
Penicillinbroadspectrum
Cephalosporins Trimetoprim Co-trimoxazole Aminoglycosides Fluoroquinolones Imidazoles
Num
ber
of D
DD
Prophylaxis one dose, 3,5
Prophylax one day, 7
Prophylaxis >1 day, 27,4
Too long prophylaxis!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
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
If we stop using one antibiotic, can the resistance trend be
reversed?
If we stop using one antibiotic, can the resistance trend be
reversed?
The resistance of E. coli in Sweden
0
5
10
15
20
25
1995 1996 1997 1998 1999 2000 2001 2002 2003 2004
År
% r
esis
ten
s
Ampicillin
Trimetoprim
Nalidixinsyra
Cefadroxil
Mecillinam
Nitrofurantoin
Consumption of Trimethoprim in Kronoberg 1998-Jan 2005
A difficult balance
The best interests
of the individual
The global need for
effective antibacterial
treatment
Appropriate antibacterial Appropriate antibacterial prescribingprescribing
Butler C et al. JAC 2001; 48:435–440