THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE

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1 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE José Artur Paiva Director of Emergency and Intensive Care Department Hospital São João Porto Associate Professor of Medicine University of Porto Infection and Sepsis I&D Group Coordinator for the National Program on Prevention of Antimicrobial Resistance Directorate National of Health- DGS Portugal

2 THE PORTUGUESE PROGRAM RESISTANT FOR THE MICRORGANISMS PREVENTION OF ANTIMICROBIAL HOW BIG IS THE RESISTANCE PROBLEM? Penicillin Man: Alexander Fleming and the Antibiotic Revolution by Kevin Brown Sir Alexander Fleming Born: 6 August 1881 Deceased: 11 March 1955 Discovery of penicillin from Penicillium notatum: 1928 Nobel Prize: 1945

3 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Idade Mean life expectancy in Portugal Mulher Homem

4 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE The XXth century: The century of the antibiotic 1947: first report of penicillin resistant strains increasing resistance of bacteria > 70% of bacteria causing HAI are resistant 1 antibiotic usually used to treat them

5 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Antimicrobial drug resistance in Europe Europe, %, 2005 Trends, Maximum Minimum Increase Decrease (country) (country) fd (p<0.05) (p<0.05) PNSP 36 (FR) 1.3 (NL) 27.7 BG ES, UK FQRE 29 (PT) 3 (IS) 9.7 AT, BE, BG, CZ, DE, ES, FI, HR, HU, LU, NL, PT, SE

6 RESISTANT MICRORGANISMS HOW BIG IS THE PROBLEM? ESKAPE pathogens: Enterococcus vancomycin resistant Staph. aureus meticillin resistant Klebsiella ESBL+ Acinetobacter IMIP-R Pseudomonas aeruginosa IMIP-R Enterobacter CEF-R Rice J. Infection 2008; 197:

7 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE EARS-Net 2010 Methicillin R Staphylococcus aureus

8 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE EARS-Net 2010 Vancomycin R Enterococcus faecium

9 EARS-Net 2010 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Klebsiella pneumoniae 3rd gen. cephalosporin EARSS 2008

10 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE EARS-Net 2010 Quinolone resistant Escherichia coli Portugal Ano Resistência % %

11 EARS-Net 2010 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Carbapenem R Klebsiella pneumoniae

12 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE EARS-Net 2010 Pseudomonas aeruginosa R to carbapenems

13 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Occurrence of fluoroquinolone-resistant Escherichia coli (FQRE) plotted against outpatient use of fluoroquinolone antimicrobial agents in 17 European countries

14 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Outpatient Antibiotic Consumption Trend in Europe

15 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE ESAC 2008 Outpatient antibiotic use DDD / 1000 habitants / day

16 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Outpatient antibiotic consumption in Portugal DDD DDD ESAC

17 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE We have a problem! A worldwide one But at a high grade No sustained improvement

18 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Process indicator: to decrease antibiotic consumption - quinolones by 10% - 3rd gen cephalosporins by 5% - carbapenems by 5% until 2015 Outcome indicator to decrease antimicrobial resistance

19 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Surveillance systems Outpatient antimicrobial consumption surveillance system Hospital antimicrobial consumption surveillance system Veterinary medicine antimicrobial consumption surveillance system Antimicrobial resistance surveillance system Antimicrobial resistance surveillance system for alert microrganisms (quick response)

20 Alert microrganisms Unfrequent pattern of resistance and that need immediate infection control measures, namely: VISA and VRSA Staphylococcus aureus resistente to linezolide; Staphylococcus. aureus and Enterococcus spp. resistent to daptomicine; Enterococcus faecium and Enterococcus faecalis resistent to vancomycin, in health units with prevalence below 5%; Enterobacteriaceae resistent to carbapenems or presumably carbapenemase producers; Pseudomonas aeruginosa pan-resistent (PDR) Pseudomonas aeruginosa extensive resistant(xdr), in health units with prevalence below 5%; Acinetobacter baumannii resistent to carbapenems, in health units with prevalence below 5%; ; Acinetobacter baumannii PDR

21 Antibiotic Use and Infection Control DeLisle S. et al. Chest 2003;123:504S-518S

22 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Reduce antibiotic consumption Education Guidelines Regulation and Stewardship Antimicrobial Committees and Stewards Education / Campaign Role perception Risk perception Clinician Citizen

23 THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Guidelines a. General principles of antibiotic therapy b. Treatment of urinary tract infections c. Ampicillin e amoxicillin versus amoxicillin/clavulanate d. Surgical site infections prophylaxis e. Carbapenems use f. Quinolones use g. Carbapenem resistant Enterobacteriaceae: prevention and assessment h. Treatment of comunity acquired pneumonia PNPRA

24 Antibiotic Committees and Stwardship Role and goals standardization Empowerment THE PORTUGUESE NATIONAL PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Extension to Primary Care and Continued Care Easy access to and use of surveillance data Education and Stewardship Synergism between Antibiotic and Infection Control Committees Close relationship with the DNH and the program head

25 Campaign for the Citizen Preserve the Antibiotics GRUPO DE INFECÇÃO E SÉPSIS From the 28th September 2011 to the 29th February 2012

26 Increase society s awareness on the serious consequences of the inadequate use of antibiotics Increase knowlwdge on microrganisms and antibiotics Change attitudes and behavior Campaign for the Citizen Goals Avoid self-medication of antibiotics Promote compliance to prescription Promote rules on how to deal with spare pills Involve doctors, nurses, phaarmaceuticals and citizens in the same goal and purpose

27 Campaign: Supporting Partners

28 Campaign: MUPIs 200 MUPIs placarded in the main cities

29 Campaign: Flyers and Posters flyers and posters

30 Campanha: Spots

31 Campaign: Results 226 insertions / news 41 press 24 TV 20 radio 141 internet

32 Meeting people actions

33 THE PORTUGUESE PROGRAM FOR THE PREVENTION OF ANTIMICROBIAL RESISTANCE Antimicrobial use: a broader problem! Humans: 50% - Hospital: 20% - Community: 80% Agriculture: 50% - Therapy; 20% - Prophylaxis: 80% - Highly questionable: 20-50% - Innapropriate use: up to 50% - Highly questionable: 40-80%

34 Portuguese Intersectorial Alliance for the Preservation of the Antibiotic Instituto Nacional de Saúde Dr. Ricardo Jorge Direcção Geral de Veterinária Direcção Geral de Inovação e Desenvolvimento Curricular DECO Associação Nacional de Farmácias Associação Portuguesa de Indústria Farmacêutica Ordem dos Médicos Ordem dos Enfermeiros Ordem dos Farmacêuticos Ordem dos Médicos Veterinários Associação Portuguesa de Médicos de Clínica Geral Administrações Regionais de Saúde Secretarias Regionais de Saúde GRUPO DE INFECÇÃO ESEPSIS

35 Portuguese Intersectorial Alliance for the Preservation of the Antibiotic

36 Alliance Memorandum 1. Recognition that the antibiotic is endangered and needs to be protected, as it is an unique medication producing potential individual benefit but individual and colective risk; 2. Eviction of self-medication, promotion of compliance to medical prescription and of the pharmacist role as a pedagogue in antibiotic use;

37 Alliance Memorandum 3. Consolidation of the infection control activity and MDRMo cross transmission prevention, both in the community and in the hospital, namely promoting biosafety and vaccination in human and veterinary medicine; 4. Promotion of investigation on epidemiology and antimicrobial resistance, in human and veterinary sectors and of an easy access of clinicians to data on antibiotic consumption and prevalence and susceptibility of microrganisms;

38 Alliance Memorandum 5. Emanation and implementation of guidelines on the use of antibiotics in human and veterinary medicine; 6. Implementation of stuctures and processes of antibiotic stewardship in all health units, including primary and continued care, as stated in DGS 028/2011 of 15/07/2011; 7. Development of the use of rapid microbiological tests, that will permit decrease the avoidable use of antibiotics;

39 Alliance Memorandum 8. Implementation of rewardin policy for health units that attain good results, decreasing antibiotic consumption and antimicrobial resistance; 9. Promotion of a swift investigation, development and marketing of new, innovative and useful antibiotics 10. Promotion of the practices put forward by the European Platform for the Respondsible Use of Medication in Animals (EPRUMA).

40 World Alliance Against Multiresistant Organisms 3-4 Feb 2012

41 Contest for the 2nd and 3rd cycle Direcção Geral de Inovação e Desenvolvimento Curricular Direcção Geral da Saúde Grupo de Infecção e Sepsis Children and adollescents as vector of a chain of andragogy Enhance e-bug

42 Conclusions High incidence of MR microrganisms High level of antibiotic consumption Vicious circle Recognize the problem and commit ourselves to solve it! Antimicrobial Resistance Prevention and Infection Control: two faces of the same coin

43 To Do List in the near future Join efforts of different institutions Join data to get a better picture Don t just take pictures Create an effective chain of reaction Led by a structure DNH-based That leads, helps, facilitates and educates, in close relation to local stewardship structures Commit Regional Health Authorities Create a system able to finantially reward the merit of improving results and attaining goals Think broad. Put the Alliance to work

44 Armando Brito Sá Filipe Froes Luís Caldeira Luís Marques Lito Luísa Peixe Mafalda Ribeirinho José Artur Paiva PNPRA Steering Group