The Global Challenge of Antibiotic Resistance: Urgent Call to Action

2. Overview • Antibiotics – miracle medicines • Antibiotic resistance – a critical global problem • The link between antibiotic use and resistance • Addressing antibiotic resistance • The role of antimicrobial stewardship • Prescribing and using antibiotics with care Whenever they are used, antibiotics must be used with care.

3. The “miracle” of antibiotics • Discovery of penicillin revolutionised treatment of infectious disease • Increased life expectancy due to ability to prevent and treat infection Crude mortality rates for all causes, non infectious causes and infectious diseases over the period 1900-1996. 1. Armstrong GL et al, JAMA 1999;281(1):61-66

4. Antibiotics continue to save lives,every day… • Ability to control infection is critical to other advances in medicine • Neonatal care • Transplantation • Chemotherapy • Immunosuppression • Complex and routine surgery • Obstetric care • Intensive care interventions

5. But…antibiotics are a limited resource 2. Spellberg, B. et al. Clinical Infectious Diseases 2008; 46 (2):155-64 3. Gottlieb, T and Nimmo, G. Medical Journal of Australia 2011; 194 (6): 281-3 • Increasing antibiotic resistance • Increased use of antibiotics • Decreasing pipeline of new antibiotics Urgent call to action

6. Emergence of antibiotic resistance “It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them, and the same thing has occasionally happened in the body.” Sir Alexander Fleming, 1945 The issue of antibiotic resistance was recognised early in the ‘antibiotic era’. It threatens our ability to control infection. 4. Sir Alexander Fleming, Nobel Lecture, December 1945

7. Emergence of antibiotic resistance Antibiotic resistance threatens ability to control infection 5. Pray LA Insight Pharma Reports 2008, in Looke D ‘The Real Threat of Antibiotic Resistance’ 2012

8. Resistance spreads rapidly 6. Centers for Disease Control and Prevention http://www.cdc.gov/hai/

9. Impact of resistance: real people are affected • Increased morbidity/mortality • Evidence across many pathogens • Pan drug resistant infections • Now being encountered • Increased costs • $18-29,000 US/patient • Excess length of stay 6.4 – 12.7 days/patient Glen’s story 7. Glen’s story access at http://www.hha.org.au/ForHealthcareWorkers/education.aspx 8. Magiorakos, A. P., Srinivasan, A et al Clinical Infectious Diseases 2012; 18 (3); 268-81. 9. Roberts RR et al. Clinical Infectious Diseases 2009; 49:1175-84

10. Antibiotic resistance: a global problem… Key findings: • Very high rates of resistance observed for common bacteria that cause health care associated and community acquired infections (for example urinary tract, pneumonia) in all WHO regions. • Significant gaps in surveillance. • Urgent need to strengthen collaboration on global surveillance as the foundation of global strategies to address antimicrobial resistance (AMR). 10. World Health Organization 2014 Antimicrobial Resistance: Global Report on surveillance. http://www.who.int/drugresistance/documents/surveillancereport/en/ Last accessed 21/9/14

11. ...a problem in our region High prevalence of drug resistance reported in clinically important pathogens including serious hospital acquired skin infections. For example • prevalence rates of 77.6% and 74.1% of methicillin-resistant S. aureus reported in Republic of Korea and Vietnam respectively. • prevalence rates of 68–90% of gonorrhoea infections with reduced susceptibility and resistance to quinolones reported in Japan, Malaysia and Singapore. 11. WHO 2015. Action agenda for antimicrobial resistance in the Western Pacific Region. Access at: http://www.wpro.who.int/entity/drug_resistance/policy/en/last accessed 8 September 2015

12. Antibiotic resistance in our region Korea ECOL: 37% KPNE: 40% China* ECOL: 54% KPNE: 41% Japan† ECOL: 17% KPNE: 11% HongKong ECOL: 46% KPNE: 23% Taiwan ECOL: 91% KPNE: 75% India ECOL: 78% KPNE: 64% Thailand* ECOL: 55% KPNE: 50% Philippines ECOL: 47% KPNE: 23% Singapore ECOL: 21% KPNE: 32% Malaysia ECOL: 36% KPNE: 45% Indonesia ECOL: 71% KPNE: 64% Australia ECOL: 12% KPNE: 15% Resistance (%ESBL) in the Asia Pacific region NewZealand ECOL: 11% KPNE: 10% 12. Mendes et al., Antimicrob. Agents Chemother. 2013 13. Xiao et al, Drug Resist Updat, 2011 (2009 data) 14. Chong et al., EJCMID, 2011 (2009 data)

13. …and a problem here in Australia 15 Looke DF, Gottlieb T, Jones CA, Paterson DL Med J Aust. 2013 Mar 18;198(5):243-. 16. Harris P, Paterson D, Rogers B Med J Aust. 2015 Facing the challenge of multidrug-resistant gram-negative bacilli in Australia. Mar 16;202(5):243-7.

14. Antibiotic resistance locallyWhat is happening in our health service • Which infections are we seeing? • What are our susceptibility and resistance patterns ? • [Insert hospital data] • [Numbers of cases] • [Examples of cases]

15. The link between use and resistance Countries with high penicillin consumption also have high rates of penicillin resistance in pneumococci Occurrence of penicillin-nonsusceptible Streptococcus pneumoniae (PNSP) versus outpatient use of penicillins in 17 European countries. 17. van de Sande-Bruinsma N et al. Emerging Infectious Diseases 2008; 14(11):1722-1730

16. Antibiotic usage varies Overall antimicrobial usage rates (N=129) NAUSP 2014 * Antimicrobial use in Australian hospitals: 2014 annual report of the National Antimicrobial Utilisation Surveillance Program http://www.safetyandquality.gov.au/publications/antimicrobial-use-in-australian-hospitals-2014-report-of-the-national-antimicrobial-utilisation-surveillance-program/ Within the country there is variation in consumption of antibiotics, not easily accounted for by case-mix. .

17. Antibiotic usage varies Between hospitals consumption also varies. Annual carbapenem usage by AIHW* peer group (FY2014-15) *Australian Institute of Health and Welfare 19. Data source: National Antimicrobial Utilisation Surveillance Program (NAUSP) – unpublished data

18. Antibiotic use in Australian Hospitals 30-40% of hospitalised patients are prescribed antibiotics20,21 The 2014 NAPS* Report indicates that around one quarter of antibiotics prescribed in Australian hospitals are prescribed inappropriately21 Australian hospitals dispense higher volumes of antibiotics than some other countries22 *Hospitals that participate in NAPS are provided with data on the appropriateness of their own prescribing patterns for local quality improvement. 20. Duguid M, Cruickshank M (eds). Antimicrobial Stewardship in Australian Hospitals.Sydney: ACSQHC, 2011 21. Australian Commission on Safety and Quality in Health Care (2015). Antimicrobial prescribing practice in Australian hospitals: results of the 2014 National Antimicrobial Prescribing Survey, ACSQHC, Sydney. 22. Antimicrobial use in Australian hospitals: 2014 report of the National Antimicrobial Utilisation Surveillance Program

19. What is inappropriate use ? Inappropriate use includes: • Using broad-spectrum antibiotics (such as third generation cephalosporins, carbapenems) when narrow-spectrum antibiotics are effective • Prescribing too low or too high a dose of antibiotic • Not prescribing according to microbiology results • Continuing treatment for longer than necessary • Omitting doses or delayed administration. Top reasons for inappropriate use – NAPS 2014

20. Adding to the problem …Antibiotics are a limited resource The dwindling development of antibiotics… number of US FDA Antibiotic approvals23 Few new antibiotics • majority developed pre 1970 • 3 new classes in 20 years Global recognition that: • new antibiotics are urgently required • need to conserve what we have now 24 23: Adapted from Spellberg B et al. The epidemic of antibiotic resistant infections: A call to action for the medical community from the Infectious Diseases Society of America. Clin Inf Dis 2008;48:155-64 24. SpellbergB New antibiotic development: barriers and opportunities in 2012. APUA Clinical Newsletter 2012; 30(1):8-10

21. Antibiotic usage in our health service • Insert local usage data if available • Include information about • Contributions to National Antimicrobial Usage Surveillance Program (NAUSP)

22. What about antibiotic appropriateness in ourhealth service? • Insert local prescribing data including • Participation in the National Antimicrobial Prescribing Survey, results and trends over time if relevant.

23. The National Antimicrobial Resistance (AMR) Strategy25Responding to the threat of AMR Seven objectives focused on • Awareness, education • Antimicrobial stewardship • Surveillance • Infection prevention and control • International management • Research and development • Governance 25. Commonwealth of Australia. National Antimicrobial Resistance Strategy. 2015. Access at: www.health.gov.au/amr

24. Addressing antibiotic resistance: a multidisciplinary, comprehensive approach Prevent and manage infections Infection prevention and control Includes hand hygiene, standard and transmission-based precautions, environmental cleaning. Prolong effectiveness of existing antibiotics Antimicrobial stewardship Addressing antibiotic resistance is everybody’s business.

25. Antimicrobial stewardship (AMS) Principles: promote best clinical outcome for the treatment or prevention of infection minimal toxicity to the patient minimal impact on resistance and other adverse events timely and optimal selection, dose and duration of an antimicrobial. Requires team work at all levels: “everybody's business" executive and clinical leadership clinical team (doctors, nurses, pharmacists, allied health) consumers.

26. Essential strategies for effectiveAMS

27. NSQHS Standards, Standard 3: Antimicrobial Stewardship Criterion 27. National Safety & Quality Health Service Standards .Access at www.safetyandquality.gov.au/our-work/accreditation/nsqhss/

28. Clinical Care Standard for AMSWhat role do you play? Nine statements describing best practice for managing a patient who has, or is suspected of having a bacterial infection, regardless of setting. • For consumers: describes the care they can expect to receive • For clinicians: provides support in the delivery of care the patient is expecting • For health services: systems are in place to support clinicians in providing the care that is expected by the patient 28. Australian Commission on Safety and Quality in Health Care. Antimicrobial Stewardship Clinical Care Standard. Access at www.safetyandquality.gov.au/ccs

29. Antimicrobial Use and Resistance in Australia • The AURA Project will establish a national antimicrobial usage and resistance surveillance system by June 2016. • Working with existing programs, such as NAPS and NAUSP, will enhance capacity for surveillance and build new systems such as the National Alert System for Critical Antimicrobial Resistances (NASCAR). • The key objective is to increase access to data for action against AMR. • Funded by the Australian Government Department of Health. • http://www.safetyandquality.gov.au/national-priorities/amr-and-au-surveillance-project/

30. Antimicrobial stewardship in our hospital • Multidisciplinary, team approach • Local roles and responsibilities • Medicine, nursing, pharmacy • Consumer participation • Executive and clinical leaders • Local processes for stewardship • Include local processes for • seeking ID/micro consults • guideline and formulary information • pharmacy advice • contacts • other relevant information.

31. Our Health service tools and activities to promote appropriate use of antibiotics Responsible committees e.g. infection control, drug and therapeutics committees AMS team to coordinate activity Education Local prescribing guidelines Therapeutic Guidelines: Antibiotic AMS Clinical Care Standard Policy Formulary with restrictions and approval Access to expert prescribing advice ID, micro, pharmacy Monitoring, audit and feedback appropriateness, usage, indicators Who to contact? 29. Antibiotic Expert Groups. Therapeutic guidelines: antibiotic. Version 15. Melbourne: Therapeutic Guidelines Limited; 2014.

32. Therapeutic Guidelines: AntibioticA quick note… • Check hospital intranet • Current Version 15 • released November 2014 • Learn more • www.tg.org.au • click ‘Products’, then ‘Antibiotic’ • summary of new information and major changes for version 15: www.tg.org.au/uploads/PDFs/Whats_New_in_Antibiotic15.pdf

33. Antibiotic Awareness Week 2015 • Coordinated by The Australian Commission on Safety and Quality in Health Care • National working group, “One Health” focus: • Australian Government Department of Agriculture and Water Resources • Australian Government Department of Health • State and Territory Health representatives • NPS MedicineWise • Australian Veterinary Association. • Supported by: • Australasian College for Infection Prevention and Control • Australasian Society for Infectious Diseases • Australian Society for Antimicrobials • Society of Hospital Pharmacists of Australia.

34. Australian Commission on Safety and Quality in Health CareAntibiotics. Handle with Care. The AMS Clinical Care Standard outlines evidenced-based approaches for using antibiotics with care. Access at www.safetyandquality.gov.au/ccs

35. Antibiotic Awareness Week What is happening in our health service ? Local activities, contacts Include information about local activities.

36. Fight antibiotic resistance: take the pledge • NPS MedicineWise is asking consumers and health professionals to take the pledge to fight antibiotic resistance • Health professionals are encouraged to have the sometimes difficult conversations with patients when antibiotics are not appropriate • Visit nps.org.au/aaw to download resources to use throughout AAW • Join the conversation - tag @NPSMedicineWise or hashtag #AntibioticResistance on social media

37. World Health Organization (WHO) First World Antibiotic Awareness Week Antibiotics: Handle with Care Antibiotics are a precious resource and should be preserved. Aim of World Antibiotic Awareness Week: • increase awareness of global antibiotic resistance • encourage best practices among general public, health workers and policy makers to avoid further emergence and spread of antibiotic resistance. • resources and more information available: • WHO international http://www.who.int/drugresistance/en/ • Who Western Pacific Regional Office http://www.wpro.who.int/topics/drug_resistance/en/

38. A global effort Canada: Healthy Canadians Antibiotic http://www.canada.ca/antibiotics United States: Get Smart About Antibiotics http://www.cdc.gov/GetSmart/ Europe: Antibiotic Awareness Day http://ecdc.europa.eu/en/eaad/Pages/Home.aspx

39. Join the conversation Monday 16 November • Australian Antibiotic Awareness Week • #ABxAus Wednesday 18 November • A global Twitter chat involving partner countries • Organisations and experts participating • #AntibioticResistance “Never underestimate the importance of consumer groups and civil society in combating antimicrobial resistance. They are important movers, shakers, and front-line players, especially in this age of social media.” Dr Margaret Chan30 30. Dr Margaret Chan, Keynote address at the conference on Combating antimicrobial resistance: time for action Copenhagen, Denmark 14 March 2012 . http://www.who.int/dg/speeches/2012/amr_20120314/en/ last accessed 22/9/14

40. Remember… Antibiotics are a limited, precious resource Antibiotics are a precious resource that could be lost. Antibiotic resistance is happening now – it is a worldwide problem that affects human and animal health. Antibiotic resistance happens when bacteria stops an antibiotic from working effectively – meaning some infections may be impossible to treat. Misuse of antibiotics contributes to antibiotic resistance. Few new antibiotics are being developed to help solve this problem. To preserve the miracle of antibiotics, whenever they are used, antibiotics must be used with care.

41. Acknowledgements This presentation is intended to be used by health professionals, and reasonable care has been taken to ensure that the information is correct at the date of creation. It is intended to be used in its original version. The original version along with a complete list of references can be downloaded from the Commission web page: www.safetyandquality.gov.au/aaw • Australian Commission on Safety and Quality in Health Care • Antibiotic Awareness Week working group members • AMS Jurisdictional Network • AMS Advisory Committee • Australian Group on Antimicrobial Resistance • National Antimicrobial Utilisation Surveillance Program • National Centre for Antimicrobial Stewardship • European Centre for Disease Prevention and Control • World Health Organization (WHO) • References available at www.safetyandquality.gov.au/aaw