Title: Antibiotic policy to prevent resistance development
1Antibiotic policy to prevent resistance
development
- Inga Odenholt
- Associate professor
- Department of Infectious Diseases, Malmö
- Lund University, Sweden
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3Antibiotic Resistance -THE RESULT OF A GLOBAL
FAILURE
4Antibiotic resistance
New treatment options
5Introduction 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
6How to combat the increasing resistance?
7STRAMA
Swedish Strategic programme for The Rational use
of Antimicrobial Agents and Surveillance of
Resistance
www.strama.org
8How 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)
9STRAMA 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
11STRAMA 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
13Antibiotic 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
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16Antibiotics for urinary tract infections in the
2000 and 2002 STRAMA Diagnosis-antibiotic
prescribing study
17Antibiotic consumption on a regional level
Tetracyclins
Amoxicillin
Penicillin V
Cephalosporins
Macrolids
18Antibiotics age group 0-6 years, municipalities
in Sweden with the highest and lowest
consumption, 2002.
19Resistance pattern
20Feed-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)
21Consumption of fluoroquinolones in 4 districts
Uppsala County The effect of prescriber
feed-back and educational outreach
(DDD/1000 inhabitants/day)
22Conclusions
- 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)
23Treatment guidelines
24STRAMA 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
25The 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
26Diagnoses 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
27The 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
28Percentage 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
29What antibiotics were used?
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33Too much quinolones and cephalosporins!
34CID, 200438 (suppl 4) 341-345
35SANT-study
Swedish Antibiotic Nursing home Trial
36Aims of the study
- To describe and evaluate the treatment of
infections in elderly patients in nursing homes
37Results of the registration
- 58 nursing homes with 2752 patients
- 890 infection registrations
- Mean age of 86 years.
- Appr. 2/3 were women
38Results
- 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
39Treatment 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
40What 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
41Hospital-acquired infections
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44Asymptomatic patients with or without indwelling
catheters should not be treated with antibiotics
45Antibiotic prophylaxis
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49Too 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
50Conclusions
- 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
51If we stop using one antibiotic, can the
resistance trend be reversed?
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53Consumption of Trimethoprim in Kronoberg 1998-Jan
2005
54A 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
55Thank you for your attention