Recommendation on prudent use of antimicrobial agents in human medicine – Slovenian experiences Intersectoral Coordination Mechanism Prof. Milan Čižman, MD, Head

Implementation of the Council recommendation 2002/77/EC on the prudent use of antimicrobial agents in human medicine in Slovenia Intersectoral coordination mechanism established in 2005 National strategy prepared in 2006 National action plan formulated in 2006

Agenda MRSA prevalence in Slovenia –21.4% to 7.1% - reduction of 67% Outpatient antibiotic use in Slovenia 2000 – 2007 –20.1 to 16.0 DDD/1000 inhab./day – reduction 20.3% Increase of VRE prevalence  –<1 to 6% Recommendations –MRSA –antibiotic consumption in outpatients

Resistance levels (%) for invasive strains of S. aureus to methicillin (MRSA) in Slovenia and at University Medical centre (UMC), Ljubljana, Slovenia

MRSA in Slovenia /1 PPS of hospital acquired infections (HAI) in Slovenian adult ICU, April 1997 – 6/8 (75% of adult ICUs) PPS of HAI in Slovenian adults ICU, October 2001 – 5/8 (60 % of adult ICUs) National PPS of HAI in acute care hospitals, October /34 (62% of acute care hospitals) Muzlovic I, et al. IDSA Klaus I, et al. J Hosp Infect 2003, 54: 149.

MRSA in Slovenia /2 Comprehensive infection control program: MRSA cases acquired in hospitals decreased from 50% to 6.1% ( ) Infection control measures: incidence of ICU – acquired MRSA decreased from 7.8 to 1.9 %. Legislation and regulation of infection control program in health care institutions (1999)* Audit of infection control implementations in health cares institutions (2006)** Tomič V, et al. Arch Intern Med 2004, 164:2038 Trampuž A. ICAAC 2001 K-1219 *Official Journal of the R Slovenia. Uradni list RS. št /1999 **Official Journal of the R Slovenia. Uradni list RS. št. 92/2006

Strategy for MRSA in Slovenia /1 Active Surveillance Culture –Selective screening for MRSA in all patients at risk for carriage on admission. Barrier precautions for patients –Contact isolation for patient with MRSA Promotion of hand hygiene –Use of alcohol–based hand rub Selective decolonization – eradication of MRSA carriage

Strategy for MRSA in Slovenia /2 Improved communication (reporting) about patients with MRSA (MDROs) within and between health care facilities. Continuous education of HCW on appropriate hygiene procedures (hospitals, nursing homes). Use of hospital computer system to record MRSA carriers.

Strategy for MRSA in Slovenia /3 Education Professionals –Postgraduate educational courses are organized by Medical Faculty Ljubljana since 1984 (162 physicians and 290 nurses). –National scientific meetings Patients –Newspapers, magazines, TV, leaflets Spread of informations to media and politicians.

Outpatient antibiotic use in Slovenia

Analysis of decreased outpatient antibiotic consumption in Slovenia The consumption decreased more for restricted than for non-restricted antibiotics: 27.7% vs 16.1% decrease ( ) Positive correlation between antibiotic consumption and repeated media reports Negative correlation between antibiotic consumption and the number of rapid diagnostic tests (CRP, Streptococcal antigen tests)

Antibiotic prescriptions (J01) in children (0-14 years) and adults (  15 years) and %penicillin-non- susceptible (I+R) S. pneumoniae,

CONCLUSION Compliance to infection control guidelines for MRSA control Nation-wide awareness: HCW, lay public, politicians Enough single rooms, and staff To control antibiotic consumption in outpatients the combinations of restrictive and education measures are recommended Prudent use of rapid diagnostic tests may decrease the antimicrobial consumption in outpatients Higher antibiotic consumption and resistance rates in certain bacteria are observed in children