Antibiotic Awareness Week 2018

1. Antibiotic Awareness Week 2018 Insert your organisation’s name here Insert presenter’s name here #AAW2018

2. Overview Antibiotics are vital life-saving medicines Antimicrobial resistance is both a global and local problem The link between antibiotic use and resistance Addressing antimicrobial resistance in Australia Antimicrobial stewardship (AMS) Antibiotic Awareness Week

3. Antibiotic Awareness Week in Australia 12 – 18 November 2018 Aims to encourage best practice in relation to antibiotic use,among the general public, health workers and policy makers to prevent and contain the spread of antimicrobial resistance.

4. Antimicrobials • Antibiotics are a type of antimicrobial Ref:1

5. Broad vs Narrow Spectrum • Narrow spectrum antibiotics work against a limited group of bacteria • Broad spectrum antibiotics work against a larger group of bacteria • Overuse of unnecessarily broad spectrum antibiotics can drive antimicrobial resistance

6. What is antimicrobial resistance (AMR)? • Antimicrobial resistance (AMR) occurs when bacteria, parasites, viruses or fungi change to protect themselves from the effects of antimicrobial drugs designed to destroy them. • This means previously effective antimicrobial drugs (e.g. antibiotics) used to treat or prevent infections may no longer work. • The World Health Organization (WHO) has identified AMR as ‘one of the biggest threats to global health’. • Australia has in place a national AMR strategy.

7. Why are antibiotics and antimicrobial resistance important? • Antibiotics treat infections caused by bacteria • Modern medicine, especially surgery and cancer treatments, depends on effective antibiotics to minimise the risk of infection • Currently, antibiotics reduce post-operative infection rates to below 2.0% • Without effective antibiotics, this could increase to around 40% to 50%. Up to 30% of these patients could die from resistant bacterial infections • The risk of mortality without access to effective antibiotics may make some treatments and surgical procedures too risky to continue • Antimicrobial resistance results in substantial financial cost for patients and healthcare systems.

8. Antibiotics are unique • In general, the impact of medications are limited to the patient taking them • Use of antibiotics has an impact not just for the patient using them but the global community as well Ref:2

9. How has antimicrobial resistance developed? • Antimicrobial resistance is a natural phenomenon • Overuse, misuse and inappropriate use of antibiotics may accelerate this • The delivery of more complex health care which may require longer use of antibiotics • Prolonged hospitalisation • The potential impact of surgical procedures undertaken overseas • Resistant pathogens can now spread easily • during hospitalisation if infection prevention is poor • potential for cross-border transmission through increased travel.

10. Ref:3

11. Resistance is not new Ref:4

12. Resistance is getting worse Carbapenem-resistant Enterobacteriaceae 2013 2015 Ref:5

13. Antibiotic use is related to antimicrobial resistance Relationship between total antibiotic consumption and Streptococcus pneumoniae resistance to penicillin in 20 industrialised countries. Ref:6

14. Antibiotic use in Australia Ref:7

15. Antibiotic use in Australia Ref:8

16. Decline in antibiotic production • Very few antibiotics have been developed in the last 20 years • Most ‘new’ antibiotics are variations of existing antibiotics • Only 5 novel classes have been developed in the last 20 years. Ref:9

17. Decline in antibiotic production • Trends in sales of recently launched antibiotics discourage pharmaceutical companies to invest in their research and development Ref:11 Ref:10

18. Antimicrobial Resistance – Global Response In May 2015, the World Health Assembly adopted a Global Action Plan on Antimicrobial Resistance, which outlines five key objectives to: • Improve awareness and understanding of antimicrobial resistance • Strengthen the knowledge and evidence base • Reduce the incidence of infection • Optimise the use of antimicrobial medicines • Develop the economic case for sustainable investment. Ref:12

19. Australia’s response to antimicrobial resistance In June 2015, the Australian Government released its first National Antimicrobial Resistance Strategy 2015–2019 to guide the response to the threat of antimicrobial misuse and resistance. Objectives: • Communication, education and training • Antimicrobial stewardship • Surveillance • Infection prevention and control • National research agenda • Strengthen international partnerships • Clear governance arrangements. Ref:13

20. Surveillance of Antimicrobial Use and Resistance in Australia (AURA) The AURA Surveillance System: • Coordinates the integration of data from a range of sources on antimicrobial use and antimicrobial resistance • Contributes significantly to the development and implementation of health strategies to respond to, monitor and prevent antimicrobial resistance in Australia • AURA 2019 due in March 2019 Ref:14

21. Australia’s response to antimicrobial resistance • In Australia, antimicrobial resistance also affects aged care homes and the community. High levels of antibiotic use in the community (which includes primary and aged care) is a growing concern • Australia is better placed than many countries to respond to antimicrobial resistance through having: • The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System • The National Alert System for Critical Antimicrobial Resistances – CARAlert (as part of AURA) • The Australian Government’s National Antimicrobial Resistance Strategy 2015-2019 • Initiatives developed and implemented by states and territories, and the private sector

22. Surveillance of Antimicrobial Use and Resistance in Australia (AURA) The AURA National Coordination Unit is responsible for the AURA Surveillance System. Funding for AURA is provided by the Australian Government, and state and territory health departments. Multiple partners contribute data. National Neisseria Network National Notifiable Diseases Surveillance System OrgTRx

23. AURA 2017 Key Findings – Antibiotic use in the Community • Australia has very high usage of antibiotics in the community - 46% of individual Australians received an antibiotic in 2015 • Antibiotics were most commonly dispensed for very young people and older people, with: • 51% of those aged 0–4 years • 60% of those aged 65 years or over, and • 76% of those aged 85 years or over being supplied at least one antibiotic in 2015 • 30% of MedicineInsight patients (just under 1 million people) were prescribed systemic antibiotics between 1 January and 31 December 2015

25. Prescribing for Upper Respiratory Tract Infection (URTI) Marked seasonal variation in agents used for RTI • Significant amount of antibiotics prescribed for respiratory tract infections (RTI) • Seasonal variation is driven by viruses – which do not respond to antibiotics • Data shows that 60% of patients who present with RTI will be prescribed antibiotics.

27. Patient impact of antimicrobial resistant infections • Treatment failures • Recurring infections • Longer hospital stays • Longer recovery times • A higher risk of mortality or long term implications • Significant financial cost of treatment Watch Glen’s Story here Preventing infections is everybody's business Ref:15

28. Antimicrobial resistance locally – What is happening in our health service? • Which infections are we seeing? [Insert surveillance data, i.e. what is the most common cause of bacteraemia in your facility] • What are our susceptibility and resistance patterns? • [Insert hospital data] • [Numbers of cases] • [Examples of cases] • Are there local antimicrobial resistance issues? • What are local rates of MRSA, C diff? • Do you have access to a local antibiogram?

29. Patient story • This is a placeholder for a local example of a patient who experienced a resistant bacterial infection at your healthcare facility • Insert a case study (optional) • You may want to detail the: • diagnosis and the method of diagnosis • bacterium that was resistant to the preferred antibiotic • medications used to treat the bacterial infection • time, resources and people involved to treat the infection • impact on the patient, the patient’s life and patient’s family • immediate, medium or long-term health implications (if any).

30. Monitoring of Critical Antimicrobial Resistance (CARAlert) Link to latest CARAlert Report

31. Critical Antimicrobial Resistances (CAR) • Organisms which are resistant to ‘last-line’ antibiotics • 653 results - October 2017 – March 2018 • 87% of all CARs were from the 3 most populous states: • New South Wales (32%) • Victoria (34%) • Queensland (21%) • Only 4 reports received from the Northern Territory and 5 from Tasmania • Most common CAR - Azithromycin non-susceptible Neisseria gonorrhoeae • Followed by Carbapenemase-producing Enterobacterales (CPE)

32. Aggregate Hospital Antibiotic Use 2016 (NAUSP) The National Antimicrobial Utilisation Surveillance Program (NAUSP) is a partner in AURA and collects data on antimicrobial use. Factors that are likely to have contributed to reduced use include: • Increased capacity of local, state and territory, and national AMS programs • Changes in clinical practice • More effective adoption of recommendations in Therapeutic Guidelines: Antibiotic. Ref:16

33. Local Antibiotic Use • Insert local antibiotic use data (if available) • Include information about your contributions to National Antimicrobial Usage Surveillance Program (NAUSP) • Insert NAUSP data.

34. Utilisation vs Appropriateness Whilst antimicrobial utilisation is a good measure for the success of antimicrobial prescribing interventions it does not assess why the antimicrobial was used. Utilisation: how much we use? Appropriateness: was it a good choice?

35. Appropriateness of prescribing in Australia • National Antimicrobial Prescribing Survey (NAPS) - In 2017, 22.4% of all prescriptions from all participants were deemed “inappropriate” (n= 24 987 prescriptions) Ref:17

36. Appropriateness of prescribing at our hospital • Does your healthcare facility audit appropriateness of prescribing? • What tools are used (e.g.. National Antimicrobial Prescribing Survey [NAPS], jurisdictional audit tools) • If participating in NAPS, insert your healthcare facilities results here: • Consider • results compared to national results • Time series data • how the your facility’s NAPS results have contributed to your AMS program.

37. Why is inappropriate use important? Reasons for a reported prescription being assessed as inappropriate, Hospital NAPS contributors, 2017 May increase risk of adverse effects, including: • AMR (current and future patients) • Antimicrobial allergy • Treatment failure • Toxicity (e.g. ototoxicity) • Clostridium difficile • Increased health care costs (i.e. length of stay) Ref:17

38. Antibiotics in primary care – Pharmaceutical Benefit Scheme (PBS) • In 2015, around half of the Australian population had at least one antimicrobial dispensed under the PBS (44.7% n = 10,701,804) Ref:18

39. Antibiotics in primary care –NPS MedicineWise Medicine Insight • In 2015, only 23.5% of patients prescribed antimicrobials had an indication recorded • Of these people, 60% who were reported to have colds/upper respiratory tract infections were prescribed an antimicrobial • But antimicrobials are not generally recommended for these conditions

40. Understanding Variation • Variation raises concerns about equity and safety and appropriateness of care • There is marked variation in use of antibiotics • between states • between hospitals • different sizes • within the same size • The reasons for this are not well understood • Also marked variation in community dispensing of antibiotics • The first Australian Atlas of Healthcare Variation (2015) included information on community antibiotic use • The third Atlas will be released later this year containing antibiotic data at a national level • Further data will be available at state and territory level in 2019

41. Number of PBS prescriptions dispensed for amoxicillin-clavulanate per 100,000 people, agestandardised, by local area, 2013–14 Ref:19

42. Antimicrobial Stewardship (AMS) Antimicrobial Stewardship isn’t about “not using antimicrobials” but rather “identify that small group of patients who really need antibiotic treatment and then explain, reassure and educate the large group of patients who don’t” • Stewardship means to protect something • AMS is a systematic approach to optimising the use of antimicrobials • Goals of AMS are to: • improve patient outcomes / patient safety • reduce antimicrobial resistance • reduce costs. • AMS works hand-in-hand with infection prevention and control strategies Ref:20

43. Antimicrobial Stewardship (AMS) – Safety, Quality and Equity dimensions Does your organisation keep up to date with the latest evidence and strive to innovate and implement that standard of care? Quality – aspiring to the best possible quality and effectiveness of care Equity – ensuring every patient regardless of their cultural or linguistic background has the same experience of care Is there a systematic approach to ensure each patient using antimicrobials is managed with the principles of AMS? Has the right patient received the right antibiotic, at the right time, at the right dose, via the right route for the right duration? Safety – bring up to the minimum acceptable and sustainable standard

44. A Critical Balance Risk of toxicity and adverse drug reactions Ref:21

45. Antimicrobial Stewardship = least harm to current/future patients

46. Enablers for effective for AMS Programs • Clear organisational structure and governance • Executive and clinical leadership • AMS advisory committee • Multidisciplinary clinical AMS team • Expert advice from • infectious diseases experts • microbiologists • pharmacists • Education and training • prescribers, pharmacists, nurses • consumers • Information technology resources.

47. Essential strategies for AMS Programs

48. Antimicrobial Stewardship in our healthcare facility Insert information on your AMS service: • Structure, governance – who is responsible? • Who leads AMS activities? • Who is on your local AMS team? • What AMS activities are undertaken? • What AMS activities are you / your department involved in?

49. Antimicrobial Stewardship – not just for hospitals • In the community • General Practice • Not prescribing antibiotics for colds and flu • Delayed prescribing • Shared decision making • Public declarations in the practice about conserving antibiotics • Pharmacies • Offering symptomatic support for cold and flu • In the home • Not taking antibiotics that haven’t been prescribed for you • In industry • Investing in research and development for antimicrobials

50. Commission Resources for AMS