Global Point Prevalence Survey of Antimicrobial Consumption and Resistance Presenter date Supporting healthcare professionals in the fight against resistance

Expand the standardized antimicrobial web based PPS at a global scale to collect consistent, valid and comparable antimicrobial prescribing data. Monitor rates of antimicrobial prescribing in hospitalized adults, children and neonates. Determine the variation in drug, dose and indications of antimicrobial prescribing across continents. Identify targets to improve quality of antimicrobial prescribing. Help designing hospital interventions to promote prudent antimicrobial use. Assess effectiveness of interventions through repeated PPS. Increase public health capacity. AIMS Global-PPS 2

Importent research questions  What is the quantity and quality of antimicrobial prescribing?  Geographical distribution and ranges  Broad versus narrow spectrum antibiotic use  Adults – children - neonates  Dose  ……  What are determinants of inappropriate antimicrobial prescribing ?  Patient related : age, diagnosis, indication  Institutional : hospital type, ward type, national/local policy, existing guidelines, ….  Geographical factors: region, country, cultural, availability of drugs on market, prescriber related (training), custum, …. 3

METHODOLOGY Global Point Prevalence Survey 4

Organization at hospital level Creation of multidisciplinary team Allocation of local Global-PPS administrator Ethical approval Guarantee of data privacy – Hospital names will never be revealed in any report or publication – Complete anonymous patient data-entry Data are property of the respective hospital Publication policy available on request 5

Departments concerned All wards (units/departments) of the hospital will be included “once” during February-April Data collection is done on a working day and never during a day of the weekend or bank holiday. Surgical departments are not to be surveyed on a Monday (or after a not-working day or bank holiday) to allow retrospective data collection on surgical prophylaxis. 6

Wards pre-defined categorization 7 Adult departmentsPaediatric departments AMW (Adult Medical Ward)PMW (Paediatric Medical Ward) HO-AMW (Haematology-Oncology AMW)HO-PMW (Haematology-Oncology PMW) T-AMW (Transplant (BMT/solid) AMW)T-PMW (Transplant (BMT/Solid) PMW) P-AMW (Pneumology AMW) ASW (Adult Surgical Ward)PSW (Paediatric Surgical Ward) AICU ([Adult] Intensive Care Unit)PICU (Paediatric Intensive Care Unit) Neonatal departments NMW (Neonatal Medical Ward) NICU (Neonatal Intensive Care Unit)

Global-PPS data collection, entry and management 1.Data collection on paper forms :  Department (Ward) form (denominator data)  Patient form (numerator data) 2.Web-based data-entry, verification, validation and reporting with the help of the Global-PPS programme. URL: 8

Global-PPS data collection, entry and management 1.Data collection on paper forms :  Department (Ward) form (denominator data)  Patient form (numerator data) 2.Web-based data-entry, verification, validation and reporting with the help of the Global-PPS programme. URL: 9

10 Description of ward : * Total of patients presents on the ward before 8 am and * Total beds on the ward at 8 am on the day of the survey.

Patients Include all in-patients receiving an “active/ongoing” antimicrobial prescription at 8 am on the day of survey Numerator – Inclusion criteria 11

Antimicrobials under surveillance ( Antimicrobials under surveillance (according to WHO ATC classification) Antibacterials for systemic use: J01 Antimycotics and antifungals for systemic use: J02 and D01BA Antibiotics and other drugs used for treatment of tuberculosis: J04A Antibiotics used as intestinal anti-infectives: A07AA Antiprotozoals used as antibacterial agents, nitroimidazole derivatives: P01AB Antivirals used for influenza - Neuraminidase inhibitors: J05AH Antimalarials: P01B Antimicrobial for topical use are excluded ! 12 Definition of an antimicrobial agent – Which one and when to include ? Prescribed at 8 am the day of the survey Include active and ongoing antimicrobials : include an ongoing antimicrobial prescribed e.g. 3 times/week but not on the day of the survey Numerator – Inclusion criteria

Day hopsitalizations and amulatory care patients Patients admitted on the ward after 8 am on the day of the survey  Those patients are NOT counted in the numerator neither in the denominator! 13 Exclusion criteria : to be applied on the numerator and denominator

Essential data to collect: numerator At the level of the patient: age, gender and weight At the level of the antimicrobial prescription:  Antimicrobial agent/s (substance level - generic name)  Dose per administration - N doses/day - route of administration  Reasons for treatment (anatomical site of infection): what the clinician tends to treat  Indication for therapy (Community Acquired or Health care Associated Infection; Medical or Surgical Prophylaxis)  Reason of therapeutic or prophylactic prescription written in notes?  Stop of review date prescription written in notes?  Prescription compliant with local guidelines?  “Empiric” versus “Targeted” treatment 14

At the level of the antimicrobial prescription, next:  Treatment based on biomarker; and which one (CRP, PCT or other lab-based biomarker)  Microbiology data (if targeted treatment and one of the following): MRSA Methicillin-resistant coagulase-negative staphylococci VRE ESBL-producing Enterobacteriaceae 3 rd generation cephalosporin resistant Enterobacteriaceae non- ESBL producing or ESBL status unknown Carbapenem-resistant Enterobacteriaceae ESBL-producing nonfermenter Gram-negative bacilli Carbapenem-resistant non fermenter Gram-negative bacilli MDR organisms 15 Essential data to collect: numerator

16 Ward Name/codeActivity (M, S, IC) Patient IdentifierSurvey NumberPatient Age v Weight In kg, 2 decimals Gender M or F Years (if ≥ 2 years) Months (1-23 month) Days (if <1 month) Hemato-D4M456def 16 51,50M Antimicrobial Name V 1. Meropenem2.Co-trimoxazole3. Teicoplanin4. Amikacin 5. Single Unit Dose vi Unit (g, mg, or IU) vi 770mg480mg400mg500mg Doses/ day vii Route (P, O, R, I) ix 3P1O1P1P Diagnosis x (see appendix II) SEPSISMPSEPSIS Type of indication xi (see appendix III) HAI2MPHAI2 Reason in Notes (Yes or No) xii NO Guideline Compliance (Y, N, NA, NI) xiii NYNY Is a stop/review date documented?(Yes/No) NO YES Treatment (E: Empirical; T: Targeted) TETT Treatment based on biomarker data (Yes or No) xiv NO If yes, on which biomarker xv (fill in: CRP, PCT or other) //// The next section is to be filled in only if the treatment choice is based on microbiology data (targeted treatment) AND the organism is one of the following: MRSA (Yes or No) xvi YES MRCoNS (Yes or No) xvii VRE (Yes or No) xviii ESBL-producing Enterobacteriaceae (Yes or No) xix YES 3rd generation cephalosporin resistant Enterobacteriaceae non-ESBL producing or ESBL status unknown (Yes or No) Carbapenem-resistant Enterobacteriaceae (Yes or No) xx ESBL-producing non fermenter Gram-negative bacilli (Yes or No) xxi Carbapenem-resistant non fermenter Gram- negative bacilli (Yes or No) xxii Targeted treatment against other MDR organisms (Yes or No) xxiii GLOBAL-PPS PATIENT Form (Please fill in one form per patient on antimicrobial treatment/prophylaxis)

17 Following anatomical site of infection  Therapeutic  Prophylactic Surgical Medical  Neonates

18  Community acquired  Nosocomial  Prophylaxis Surgical Medical  Other CAI Community acquired infection Symptoms started <48 hours from admission to hospital (or present on admission). HAI Healthcare- Associated Infection  Symptoms start 48 hours after admission to hospital HAI1 Post-operative surgical site infection (within: 30 days of surgery OR; 1 year after implant surgery) HAI2 Intervention related infections including CR-BSI, VAP and C-UTI HAI3 C. difficile associated diarrhoea (CDAD) (>48 h post- admission or <30 days after discharge from previous admission episode. HAI4 Other hospital acquired (includes HAP, etc) HAI5 Infection present on admission from another hospital HAI6 Infection present on admission from long-term care facility (LTCF) or Nursing Home*. SP Surgical prophylaxis SP1 Single doseSP2 one daySP3 >1 day For surgical patients, administration of prophylactic antimicrobials should be checked in the previous 24 hours in order to encode the duration of prophylaxis as either one dose, one day (= multiple doses given within 24 hours) or >1 day. MP Medical prophylaxis For example long term use to prevent UTI’s or use of antifungals in patients undergoing chemotherapy or penicillin in asplenic patients etc. OTH OtherFor example erythromycin as a motility agent (motilin agonist). UNKCompletely unknown indication Select 1 possibility for each reported antimicrobial APPENDIX III - Type of Indication

Global-PPS data collection, entry and management 1.Data collection on paper forms :  Department (Ward) form (denominator data)  Patient form (numerator data) 2.Web-based data-entry, verification, validation and reporting with the help of the Global-PPS programme. URL: 19

20 Web-Based Data Entry (English)

21 Register each institution

22 Each department need to have a unique name !

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Feedback of results 1.Extraction of own data containing raw data allowing verification and analysis of own hospital results (excel). 2.Generation of simple, easy to use feedback on own hospital data ready to use for local presentations.  Descriptive statistics comparing your hospital with average national (if N≥3 institutions) and continental results. 28

Examples: Antimicrobial prevalence rates – Adult wards 29 Ward type All wardsAMWHO-AMWT-AMWP-AMWASWAICU Centre N patients N treated patients % treated patients Country N patients % treated patients Europe N patients % treated patients EU - type of centre N patients % treated patients Web-Based PPS Report

Antimicrobial prevalence rates by activity CentreCountryEuropeEU – type of centre Adults (>=18 year) Medical Surgical AICU Children (=<17 year) Medical Surgical AICU Neonates GNMW NICU 30

Overall proportional antibiotic use Hospital Country level Same graph for all hospitals together at country level European level Same graph for all European participating hospitals 31

DISCUSSION 32

Key message: obtain meaningful comparisons Uniformity of data collection - Use of similar study designs, standardized protocol and data collection templates  Implementation of common methodology to collect valid and comparable antimicrobial consumption data SIMPLE protocol and web-based tool for data entry and validation = feasible & achievable surveillance Quality assurance approach – implementation of data validation process Central support towards data collection or other (helpdesk, FAQ, IT-manual) Continuous work on data accuracy Opportunity to stimulate local networking Mutual cooperation/feedback is highly motivating 33

Instant web-report per hospital with quantifiable outcome measures and targets for quality improvement of antibiotic treatment and prophylaxis Enables in-depth interpretation of antimicrobial consumption data at different levels (geographical, institutional and patient characteristics) Creation of reference database for scientific research and hypothesis formulation at national and international level (data are safeguarded at the University of Antwerp, Belgium, Europe). Data-sharing upon agreement with all partners  publication policy is available at 34 Key message: towards data interpretation

Tool for assessing interventions to improve antibiotic prescribing in hospitals when PPS repeated Consistency and reproducibility Continually improve healthcare quality Combat antibiotic resistance Improve antibiotic use for better patient health “sustained awareness” Features of the Global-PPS 35

1-day PPS = cross-sectional snapshot of prescribing practice  Seasonal variation No risk factors in denominator data except for institutional factors (hospital and ward type, geographical localization) Lack of standardized clinical information  diagnosis refers to what the clinician tends to treat (for example pneumonia) Self-training on protocol and web-based data entry, however helpdesk ! No information on therapeutic antimicrobial course duration Pitfalls of the Global-PPS

Global-PPS Timing Pilot-PPS: October 2014 Global-PPS: February-April Discussion of first results and future plans at the 5th HAI Forum: June Global dissemination at the (European) Antibiotic Awareness Day/Week: 18 November

Sponsor bioMérieux is the sole sponsor of the GLOBAL Point Prevalence Survey. The funder has no role in study design, data collection, data analysis, data interpretation, or writing the report. Data are strictly confidential and stored anonymous at the coordinating centre of the University of Antwerp.” Lead Investigators Herman Goossens (University Hospital of Antwerp, Belgium) Dilip Nathwani (Ninewells Hospital and Medical School, Dundee, Scotland) Acknowledgements 38

Any hospital can participate Ready to join us ? Contact Ann Versporten at URL 39

If you want to go Fast, go alone. If you want to go Far, go together.