Antibiotic Awareness 2019 #AAW2019 Ananda Aged Care Michael Page This presentation has been prepared by the Australian Commission on Safety and Quality in Health Care for use during Antibiotic Awareness Week 2018. The content within this presentation can be modified, expanded upon, or points/slides deleted to tailor it to clinical audiences within local hospitals and healthcare facilities where antibiotics are prescribed and used. This presentation can also be modified for use in aged care, primary care or any other healthcare setting where antibiotics are also prescribed and used. Disclaimer The content of this PowerPoint presentation is published in good faith by Australian Commission on Safety and Quality in Health Care (the Commission) for information purposes. This PowerPoint presentation is not intended to provide guidance on particular healthcare choices. You should contact your healthcare provider on particular healthcare choices. This PowerPoint presentation includes the views or recommendations of its authors and third parties. Publication of this PowerPoint presentation by the Commission does not necessarily reflect the views of the Commission, or indicate a commitment to a particular course of action. The Commission does not accept any legal liability for any injury, loss or damage incurred by the use of, or reliance on, this PowerPoint presentation. Michael Page

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 This presentation has been designed to be a resource used to explain antimicrobial resistance and the relationship to antibiotic use. It is designed for organisations to customise as they like. It will highlight the increased chance of resistant bacteria spreading readily between people in the community, as well as in primary care services, hospitals and aged care homes. This presentation will also outline the significant effect that antimicrobial resistance has on the community; individual patients; health services; and, the health system more broadly. Content covered in this presentation includes: The link between antibiotic use and the development of antimicrobial resistance The importance of appropriate antibiotic use as one strategy to contain and control antimicrobial resistance The action being undertaken globally and in Australia to prevent, monitor and reduce antimicrobial resistance The role antimicrobial stewardship (AMS) programs play in supporting the appropriate use of antibiotics.

Antimicrobials Antibiotics are a type of antimicrobial Ref:1 Antibiotics are one type of antimicrobial, referring to medicines used to treat infections caused by bacteria. Mostly importantly, antibiotics will have no impact on treating infections caused by viruses. The term ‘antimicrobial’ refers to a substance that inhibits or destroys bacteria, parasites, viruses or fungi. The term antimicrobial also refers to medicines used to treat or prevent infections caused by bacteria, parasites, viruses or fungi. Antimicrobials fall into four categories: Antibacterials (antibiotics) Antifungals Antivirals Antiparasitics. Ref:1

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

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. Antimicrobial resistance is one of the most significant challenges for the provision of safe, high-quality health services across the world. The term ‘antimicrobial resistance’ refers to the failure of an antimicrobial (which includes antibiotics) to inhibit or destroy bacteria, parasites, viruses or fungi for which it has been designed using standard dosing regimens Antimicrobial resistance has a direct effect on patient care and creates a set of critical ongoing challenges to health service delivery. It can increase a patient’s length of hospital stay and severity of patient illness. Severe infections caused by bacteria that do not respond to available ‘last-line’ antimicrobials (including antibiotics) can result in septicaemia and death. Antimicrobial resistance also increases the complexity of treatment, and places a significant burden on patients, health service organisations and the health system. Amina J. Mohammed (Deputy Secretary-General of the UN) was quoted as saying that “Antimicrobial resistance is one of the most pressing issues globally, not only for human health but it is a multi-sectoral problem involving animal health, agriculture, the environment, trade and many other sectors”. Dr Tedros Adhanom Ghebreyesus, Director-General of WHO was quoted as saying “A lack of effective antibiotics is as serious a security threat as a sudden and deadly disease outbreak. Strong, sustained action across all sectors is vital if we are to turn back the tide of antimicrobial resistance and keep the world safe." Prof Dame Sally Davies, England’s chief medical officer was quoted as saying “We will be given the choice of, well you can have an expensive treatment that’s likely to cure you, but you’ll get an infection that is likely to be resistant and you’ll probably die of it,” she told MPs. “Meanwhile all transplants will be out of the window because they are all prone to infections. There will be a lot of suffering and modern medicine will be lost.” In 2015 the Australian Government released a National Antimicrobial Resistance strategy with the aim to minimise the development and spread of AMR and ensure the continued availability of effective antimicrobials. NPS MedicineWise maintains a list of important antibiotic resistance myths: https://www.nps.org.au/medical-info/consumer-info/antibiotic-resistance-the-facts

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. Antimicrobial resistance occurs when bacteria develop resistance to an antimicrobial that was previously an effective treatment. Bacteria develop natural defences against antibiotics. When this occurs, potentially due to prolonged exposure to or overuse of a particular antibiotic, the antibiotic’s effectiveness to treat the infection decreases, and may reach a point where the antibiotic has no benefit. The overuse of antibiotics in health (human and animal) and agriculture has increased the amount of exposure bacteria have to them, giving bacteria more opportunity to develop resistance. The process of natural selection (‘survival of the fittest’ – favouring bacteria that develop the strongest natural defences) fuels the increasing prevalence of antimicrobial resistance. New challenges in infection control resulting from more complex health care (for example, outpatient chemotherapy) and increasing domestic and international travel have increased the spread of resistant bacteria both between individuals and between countries. When patients have longer hospital stays, this may increase the chance of patients acquiring resistant organisms from other patients.

Antibiotics resistance can spread by many vectors. Ref:3

In 2015, around half of the Australian population (44. 7%, about 10 In 2015, around half of the Australian population (44.7%, about 10.7 million people) had at least one antimicrobial dispensed under the PBS or the RPBS. Of these: 18.5% had one antimicrobial dispensed 3.2% had more than six antimicrobial prescriptions dispensed, including repeats. (These figures are very similar to the 2014 data.) Around 30.5 million prescriptions for antimicrobials were dispensed under the PBS/RPBS in 2015 (around 27.7 million prescriptions for systemic antimicrobials and 2.8 million for topical antimicrobials). This represents a small increase compared with 2014. The supply of PBS/RPBS systemic antimicrobials in 2015 totalled 27,667,198 prescriptions – a 6.7% increase in ‘defined daily doses’ (DDDs) per 1,000 inhabitants per day compared with 2014. A further 2,785,173 prescriptions were supplied for non-systemic (topical) preparations, making a total of 30,452,371 prescriptions (1,280 prescriptions per 1,000 inhabitants) for antimicrobials.

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 Infections caused by resistant bacteria may need to be treated with stronger antibiotics which can have severe side effects, be more expensive, and take longer to work. In the most severe cases of antimicrobial resistance, resistant bacteria may not be able to be treated by any currently available antibiotic. Antimicrobial resistance can also result in significant costs to society with the lost of productivity and reduced workforce capacity. Hint for presenters: If the video doesn’t work on your system, you can delete it and replace it with the link below (this will open YouTube in your Web browser) You can embed the video link into the presentation, so viewers can watch this 5 minute video. https://www.youtube.com/watch?v=RIsBB6TmZvA The website of the Infectious Diseases Society of America has a “patient stories” page. http://www.idsociety.org/Patient_Stories/ Ask the audience to think about patients they have cared for that have had a resistant infection. What was it like for the patient? The family? The team? Preventing infections is everybody's business Ref:15

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 Antimicrobial management or stewardship programs have been developed in response to the need to reduce unnecessary and inappropriate antimicrobial use. They are part of a broader system for infection prevention and control to minimise resistance. An AMS program alone is not sufficient to control resistance. To be effective a program needs to be established in conjunction with a comprehensive infection prevention and control program that includes hand hygiene, standard and transmission based precautions and cleaning and disinfection. Antimicrobial stewardship is taking into account: Evidence of efficacy Toxicity of the drug Ecological harm – the effect on resistance or development of Clostridium difficile infection. Successful antimicrobial stewardship requires executive support and clinical leadership as well as team work between prescribers, pharmacists and nurses. Essential elements of an antimicrobial stewardship program include: Use of treatment guidelines that take into account local microbiological susceptibility patterns An antibiotic formulary that includes restricting board spectrum and later generation antimicrobials to patients in whom use is clinically justified Selective reporting of susceptibility testing consistent with hospital treatment guidelines Monitoring and auditing antibiotic usage Reviewing antibiotic prescribing with intervention and feedback to prescribers. You may wish to play this clip providing an overview of Antimicrobial Stewardship https://www.youtube.com/watch?v=-G4cEYQBVu4&app=desktop Ref:20

Key messages Antimicrobial resistance: occurs when an organism evolves and develops resistance to an antimicrobial that should inhibit or destroy it is reducing the effectiveness of antimicrobials to treat infections is happening now Few new antimicrobials are being developed The misuse, overuse, and inappropriate use of antimicrobials contributes to antimicrobial resistance Antimicrobial stewardship works hand in hand with prevention and control strategies to help address antimicrobial resistance. Key messages of this presentation: Antimicrobial resistance is a worldwide problem that affects human and animal health The misuse, overuse, and inappropriate use of antimicrobials has contributed, and continues to contribute, to antimicrobial resistance.