Antibiotic policy to prevent resistance development Inga Odenholt Associate professor Department of Infectious Diseases, Malmö Lund University, Sweden

Antibiotic Resistance - THE RESULT OF A GLOBAL FAILURE FAILURE Antibiotic Resistance - THE RESULT OF A GLOBAL FAILURE FAILURE

Antibioticresistance New treatment options

Sulphonamides Tetracyclines Penicillins Aminoglycosides 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?

STRAMA Swedish Strategic programme for The Rational use of Antimicrobial Agents and Surveillance of Resistance

How 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 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

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

STRAMA Voluntary basis Supported by the Swedish Government with EUR yearly 2003 Funding increased to EUR

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

Antibiotic consumption on a national level Swedish Diagnosis- Antibiotic Prescribing study 2000 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

Tetracyclins Amoxicillin Penicillin V Cephalosporins Macrolids Antibiotic consumption on a regional level

Antibiotics age group 0-6 years, municipalities in Sweden with the highest and lowest consumption, 2002.

Resistance pattern

Consumption of fluoroquinolones in 4 districts Uppsala County The effect of prescriber feed-back and educational outreach (DDD/1000 inhabitants/day) 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)

Conclusions 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 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/ 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 study

Diagnoses Central nervous system Ophthalmic infections Mouth and throat Upper respiratory tract Bronchitis Pulmonary infections Cardiovascular 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

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 study

Percentage of antibiotic treated patients per speciality; PPS 2003 och : tot 4178 treated of patients 2004: tot 3622 treated, of ipatients 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% akutklinik allm internmed allm kirurgi barnhabilitering barnkirurgi barnmedicin BB/förlossning endokrinologi gastroenterologi geriatrik gynekologi handkirurgihematologi hudklinik infektionsklin kardiologikärlkirurgi lungmedicin med rehab neonatalavdneuro rehab neurokirurgi neurologi njurmedicin onkologi ortopedisk kirurgi plastikkirurgi reumatologi thoraxkirurgi transplantations kirurgi urologi ögon öron-näsa-hals Alla specialiteter Andel behandlade/inneliggande patienter PPS 2003 PPS 2004

What antibiotics were used?

Too much quinolones and cephalosporins!

CID, 2004;38 (suppl 4):

SANT-study Swedish Antibiotic Nursing home Trial

Aims of the study To describe and evaluate the treatment of infections in elderly patients in nursing homes

Results of the registration 58 nursing homes with 2752 patients 890 infection registrations Mean age of 86 years. Appr. 2/3 were women

Results 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 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

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?

Hospital-acquired infections

Asymptomatic patients with or without indwelling catheters should not be treated with antibiotics

Antibiotic 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?

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 prescribing Butler C et al. JAC 2001; 48:435–440