1 Drug Resistant Streptococcus pneumoniae

2 “… the microbes are educated to resist penicillin and a host of penicillin-fast organisms is bred out which can be passed on to other individuals and perhaps from there to others until they reach someone who gets a septicemia or a pneumonia which penicillin cannot save. In such cases the thoughtless person playing with penicillin treatment is morally responsible for the death of the man who finally succumbs to infection with the penicillin-resistant organism. I hope this evil can be averted.” Sir Alexander Fleming, New York Times, June 26, 1945

3 Importance of Pneumococcal Infections in the U.S. 1st3,300Meningitis 2nd60,000Bloodstream infection 1st7 millionOtitis Media 1st135,000Pneumonia Rank Cases per Year Type of Infection 2000 CDC Active Bacterial Core Surveillance (ABCs)

4 Drug Resistant Streptococcus pneumoniae Emerged in Spain and South Africa Emerged in the U.S. in the last decade Use of antibiotics for viral infections Threatening use of antibiotics for common infections

5 Resistance and Antibiotic Prescribing Risk factors for resistant S. pneumoniae are: –young age (< 1 year) –higher socioeconomic status –day-care attendance –recent receipt of antibiotics (2-5 times greater risk) Pediatrics 1993;92:761-7.

6 Pneumococcal Carriage in Day Care Center Outbreak, East Tennessee, 1996 Craig, Clin Infect Dis 1999;29:

7 Penicillin Resistance in S. pneumoniae U.S : CDC Sentinel Surveillance Network : CDC Active Bacterial Core Surveillance (ABCs) /Emerging Infections Program vaccine 2003 data are preliminary

8 CDC Active Bacterial Core Surveillance (ABCs) Trends in Pneumococcal Susceptibility, U.S,

9 Invasive Pneumococcal Disease, Proportion of Non-susceptible Isolates, Tennessee,

10 Invasive Pneumococcal Disease, Tennessee,

11 NAMCS data (1992): –Antibiotics 2 nd leading class of Rx in the US most for RTI (JAMA 1995;273:214-19) Antibiotic use in children: –URI: 44% –Colds: 46% –Bronchitis: 75% (JAMA 1998;279:875-77) Evidence of Excessive Antibiotic Use in the US

12 NAMCS data (2000): Children < 15 – Population-based antibiotic prescriptions decreased 40% –Visit-based antibiotic prescriptions decreased 29% – Declines coincide with increased media attention – Antibiotic resistance has continued to increase through the 1990’s (JAMA 2002;287: ) UPDATE!

13 Antibiotic use in Tennessee In 2002, TN had the highest prescription rates in the country. Novartis Pharmacy Benefit Report: 2002 Facts and Figures. In 2001, Tennessee’s utilization rates for -Penicillins, -Cephalosporins -Trimethoprims were over 20% higher than the national average. Novartis Pharmacy Benefit Report: 2001 Facts and Figures.

14 Oral Antibiotic Prescriptions, Knox County, Perz, JAMA 2002;287:

15 Changes in Prescribing From Year 1 to Year 3, per Child-year

16 Ratio of Prescriptions : URI Visits, Knox County,

17 Patient Concerns want clear explanation green nasal discharge need to return to work/child care Physician Concerns patient expects antibiotic diagnostic uncertainty time pressure Barden, Clin Pediatric 1998;37: Antibiotic Prescription Reasons for Antibiotic Use: Conclusions from 8 Focus Groups

18 Hamm, J Fam Pract 1996;43:56 Mangione-Smith, Pediatrics 1999;103:711-8  Satisfaction predicted by: –time spent by MD explaining illness –patient understanding of treatment choice  Satisfaction not predicted by receipt of antibiotics Patient Satisfaction and Antibiotics

19 Public health campaign in Iceland following dramatic increase in the rates of penicillin-resistant pneumococci from 2.3% to 20% in 4 years Rates fell from peak of 20% in 1993 to 16.9% in 1994 Carriage rates of resistant strains among day care attendees dropped from 20% to 15% in same period JAMA 1996;275;175 Can Resistance Trends Be Reversed?

20 Episodes of otitis media should be classified as acute otitis media (AOM) or otitis media with effusion (OME) Antibiotics are not indicated for initial treatment of OME Principles of Judicious Antimicrobial Use: Otitis Media - Key Messages

21 Principles of Judicious Antimicrobial Use: Rhinitis and Sinusitis - Key Messages Rhinitis: –antibiotics should not be given for viral rhinosinusitis Sinusitis: –prolonged URI symptoms –more severe URI symptoms (i.e. facial swelling, high fever) –antibiotic treatment with the most narrow- spectrum agent

22 Principles of Judicious Antimicrobial Use: Pharyngitis- Key Messages Diagnose as group A strep Penicillin is the drug of choice in treating group A strep –use erthromycin if penicillin allergic

23 Principles of Judicious Antimicrobial Use: Cough and Bronchitis - Key Messages Cough/bronchitis rarely needs antibiotics Antibiotic treatment for prolonged cough (>10 days) may be needed –Mycoplasma pneumonia- use macrolide agent for children >5

24 23-valent polysaccharide vaccine (PPV) –~60% effective in preventing bacteremic pneumococcal infection in immunocompetent adults 7-valent conjugate vaccine (PCV-7) for children age months –>95% effective in preventing invasive disease in young children Bartlett, Clin Infect Dis 2000;31: CDC, MMWR 2000;49(RR-9):1-34 Prevention - Pneumococcal Vaccination

25 National Immunization Survey, Q3/2002-Q2/ Receipt of PCV7 Among Children Months, U.S,

26 Appropriate Antibiotic Use Intervention Sites, 2002 LA County Federally Funded programs (N=27)

27 Mission –To reduce inappropriate antibiotic use and the spread of antibiotic-resistant bacteria that cause many upper respiratory illnesses through state and local partnerships Tennessee’s Appropriate Antibiotic Use Campaign

28 TAAUC History Created in the Spring of 2002 in response to TN’s high levels of antibiotic resistance : Began developing partnerships and focused on educating health care providers and parents and relaying the program’s key messages : Continued Year 1 activities, developed a coalition and partnerships, developed and produced program materials, and began media campaign development : Continuing Year 1 and Year 2 activities, program expansion, development, etc.

29 Campaign Goals Reduce inappropriate antibiotic use and the prevalence of antibiotic resistance in Tennessee by: Increasing parental knowledge of appropriate antibiotic use Changing practitioner’s antibiotic prescribing behavior Increasing community awareness of appropriate antibiotic use and resistance

30 TAAUC Partners  Knox County Health Dept.  Metropolitan Health Dept. of Nashville and Davidson County  East TN Regional Office  St. Thomas Hospital  East Tennessee Children’s Hospital  Bristol-Myers Squibb  University of TN Medical Center  Vanderbilt University  Knox County Schools  Vanderbilt Health Plan Blue Cross Blue Shield of TN Nashville Academy of Medicine Shaller Anderson of TN John Deer Health TN Pharmacists Association UT Medical Center GlaxoSmithKline Abbott Laboratories TN Academy of Family Physicians Pfizer Xantus Daiichi Bayer Roche TennCare Head Start Lamar Outdoor Advertising American Academy of Pediatrics (TN Unit) TN Radio Network

31 Program Components Provider Education Parent/Childcare Center Education Public Education

32 TAAUC Billboard

33 Increasing antibiotic resistance threatens success of antibiotic treatment for common infections Many consumers use antibiotics inappropriately Decreased antibiotic use has been shown to reverse antibiotic resistant trends Physician and public education: principles of appropriate use, educational materials, presentations & mass media Conclusions

34

35 CDC Treatment Guidelines TAAUC Website