Antibiotic Resistance Prevention And Control (ARPAC) in European hospitals Fiona M. MacKenzie (Aberdeen, Scotland) ARPAC Steering Group

Development of Strategies for Control and Prevention of Antibiotic Resistance in European Hospitals

What causes antibiotic resistance / HAIs?

Policies associated with low antibiotic resistance rates & low rates of transmissible pathogens I.M.G

European Study Group on Antibiotic Policies (ESGAP) European Study Group on Epidemiological Markers (ESGEM) European Study Group on Antimicrobial Resistance Surveillance (ESGARS) European Study Group on Nosocomial Infections (ESGNI)

VRE Quinolone-R E. coli ESBL K. pneumoniae MRSA C. difficile Quinolone-R Aminoglycoside-R Pyo

ARPAC Geographical Regions Northern Europe Southern Europe (+ Israel, Turkey) Western Europe Central /Eastern Europe + Baltic States South-East Europe

ESGAP ESGARS ESGNI ESGEM Questionnaires (2001 data) 1.Demographic data & ability to provide data 2.Antimicrobial susceptibility Antibiotic consumption 3.Antibiotic prescribing Infection control policies typing

Participation levels Demographics n = 263 (100%) Antibiotic susceptibility n = 192 (73%) Antibiotic use (WH) n = 146 (55%) Antibiotic use (ICU) n = 110 (42%) Antibiotic prescribing policies n = 169 (64%) Infection control policies n = 168 (64%) All data n = 99

ESGARS H. Goossens ESGARS Steering Group

Antimicrobial Susceptibility 1.Antimicrobial susceptibility testing 2.Breakpoints 3.Quality assurance 4.Detection of specific resistance phenotypes (Alert organisms) 5.Alert organism prevalence data (All patient, ICU patient, blood cultures)

Yes (%)No (%)Missing (%) 167 (88)20 (11) 2 In 2001, did your laboratory routinely use a disc diffusion AST method? 50% used Oxoid discs Yes (%)No (%)Missing (%) 132 (70)56 (30) 1 (1) In 2001, did your laboratory routinely determine MICs? 82% used E-test Yes (%)No (%)Missing (%) 165 (87)21 (11) 2 (1) Did your laboratory routinely use breakpoints to interpret AST resuts? 84% used NCCLS

MRSA Screening Disc diffusion Screening plates Used by how many hospitals?65%49% Oxacillin concentration1 g (89%)5 g/ml (70%) NaCl concentration4% (38%) 2% (35%) 4% (60%) 2% (18%) Incubation temperature Incubation time 35 o C (48%) 30 o C(23%) 35 o C (55%) 37 o C(22%) 24h (53%) 48h(16%) 24h (45%) 48h(30%)

No data <3% 3 - <10% 10 – 30% >30% ARPAC % MRSA in all samples 2001 No data <3% 3 - <10% 10 – 30% >30% EARSS % MRSA in Blood Cultures 99-01

ESGNI M. Struelens ESGNI Steering Group

Infection Control Policies 1.Infection control management 2.Screening for patients with Alert organisms 3.Incidence of Alert organisms 4.Isolation & standard infection control precautions 5.Decolonisation / decontamination 6.Audit & feedback 7.Education n=168

n = 169 Presence of written infection control policy NorthWestSouth (IL, TK) South -East Central/ East Hand hygiene Standard precautions

p<0.01 Products used for hand hygiene by region NorthWest South (IL, TK) South- East Central/ East Medicated / antiseptic soap Alcohol based solutions All

Decolonisation procedure for patients / HCWsPatients HCWs NorthWest South (IL, TK) South- East Central/ East All

ESGEM K. Towner ESGEM Steering Group

1.Alert organism typing data The following also comprised a major portion of ESGEMs work on ARPAC 1.Development of a DNA typing database and data exchange format for tracking antibiotic-resistant micro-organisms 2.Development of standard operating procedures for molecular typing of ARPAC Alert organisms Alert Organism Typing

MRSA typing carried out in hospital MRSA typed by reference laboratory N. Europe W. Europe Central / E. Europe + Baltic States S.E. Europe S. Europe + Israel, Turkey % Hospitals which carried MRSA typing Preliminary Typing Data Analysis n=168

MRSA prevalence (n = 167 hospitals) Any typing (either local or ref. lab)18.0 No typing29.5 Typing done in-house 13.7 No typing done in house 27.7 Sent to reference lab 25.1 Not sent to ref. lab 20.2 Median MRSA prevalence (p=0.223) (p=0.061) (p=0.051)

ESGAP I.M. Gould ESGAP Steering Group

Antimicrobial Prescribing 1.Committees 2.Antibiotic availability 3.Antibiotic policies 4.Education / implementation 5.Audit of antibiotic use 6.Role of the laboratory 7.Role of the pharmacy n=169

Antibiotic Policies Do you have a national Antibiotic Policy / Guideline? Do you have a local Antibiotic Policy / Guideline? No 54% No 32% Yes 33% Yes 63% Dont know 13% Dont know 3% n = 263

Did you have a drugs & therapeutics committee in 2001? Missing No Yes n=144 n=23 n=2 Committees Who sat on the DTC? Micro / ID specialist, n=116 IC personnel, n=72 ICU physician, n=108 Pharmacist, n=136 Who sat on the antibiotic committee? Micro / ID specialist, n=88 IC personnel, n=58 ICU physician, n=65 Pharmacist, n=132 n=88 n=76n=5 Did you have an antibiotic committee in 2001?

Non ICUICU Did you have a written antibiotic formulary in 2001? n = 130 n = 86 n = 35 n = 57 n = 4 n = 26 Did your formulary contain a list of antibiotics for which use is restricted? n = 70 n = 46 n = 53 n = 101 n = 41 n = 27 Non ICUICU Antibiotic Formularies

Antibiotic Policies In 2001, did your hospital have a written antibiotic policy? Non ICU ICU n = 72 n = 69 n = 28 n = 96 n = 67 n = 6 Yes No Missing

Did hospitals assess the above? Prescriber knowledge of antibiotics Effectiveness of education campaigns n = 11 n = 32 n = 126 n = 12 n = 29 n = 128 Did hospitals audit adherence to the above? n = 14 n = 32 n = 123 General antibiotic policy n = 18 n = 54 n = 97 Restricted antibiotic list n = 15 n = 50 n = 104 Policy on surgical prophylaxis n = 17 n = 27 n = 125 Policy on empiric therapy Audit

ABC Calc Antibiotic Consumption Calculator Version 1.9 Monnet DL. ABC Calc - Antibiotic consumption calculator [Microsoft® Excel application]. Version 1.9 Copenhagen (Denmark): Statens Serum Institut 2003

Antibiotic use data: Distribution (n = 103) Frequency Antibiotic use (DDDs / 100 bed-days) Median = 57 Minimum = 5 Maximum = 111

Antibiotic use data: Geographical area distribution Western EuropeNorthern Europe Central / Eastern Europe Southern Europe South / East Europe

J01A Tetracyclines J01B Amphenicols J01C -lactams, Penicillins J01D Other -lactams J01E Sulfonamides & Trimethoprim J01F Macrolides, Lincosamides, Streptogramins J01G Aminoglycosides J01M Quinolones J01X Other antibacterials DDDs /100 bed-days n = 103

EAEAEAEAEA North West South (IL, TK) South-EastCentral/ East ESAC versus ARPAC Antibiotic Used Data

Relative use of Class J01D (Other -lactams) NorthWest South (IL, TK) South- East Central/ East All

Relative use of Class J01C (Penicillins) NorthWest South (IL, TK) South- East Central/ East All

ECCMID Monday, May 03, : :30 h Small Hall Official symposium Antibiotic resistance, prevention and control in Europe Invitation

ARPAC Consensus Conference Control of resistance in European Hospitals………… ………informing future evidence based practice ………informing future evidence based practice Amsterdam, The Netherlands 22 nd – 24 th November

Acknowledgements ARPAC Steering Group ARPAC participating hospitals Julie Bruce (Aberdeen)