Stop overuse of antibiotics in humans rational use

Transcription

1 Stop overuse of antibiotics in humans rational use Dominique L. Monnet, Senior Expert and Head of Disease Programme Antimicrobial resistance and Healthcare-associated infections (ARHAI) European Centre for Disease Prevention and Control Copenhagen, 15 March 2012

2 Scenario planning: key certainties Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. Antibiotic resistance will exist as long as antibiotics are used New resistance mechanisms will necessarily emerge Antibiotics will always be misused to a certain extent Compliance with hand hygiene and other infection control measures will never be 100% Photo: FreeFoto.c m

3 Carbon dioxide mixing ratio in ice cores (PPM) Antibiotic resistance: a battle that we can can win? 330 Carbon dioxide mixing ratio in ice cores, Antarctica (PPM) MRSA, Denmark (blood, %, Y-2 axis) MRSA, EU (blood and CSF, population-weighted %, Y-2 axis) MRSA (%) 280 Antibiotics discovered Year 0 Source: Etheridge et al. (CSIRO), Carbon Dioxide Information Analysis Center, Danish Staphylococcus Reference Laboratory, Statens Serum Institut, Denmark; and EARSS/EARS-Net. 3

4 New antibiotics with a novel mechanism of action Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. Scenario planning: uncertainties and implications Activities in only a few countries Prevention and control of AMR Activities in many countries No Must rely on rational use of existing antibiotics and on infection control Mitigation an achievable goal? Must rely on rational use of existing antibiotics and infection control Increase awareness among new generations Yes New antibiotics always essential Focus on rational use of new and other antibiotics Re-emphasise infection control Market for new antibiotics mostly empiric treatment of severe inf. Focus on detection and control of emerging AMR Re-emphasise rational use of antibiotics

5 What is rational use of antibiotics in human medicine? No self-medication Only when prescribed by a medical doctor (or a nurse) Only when indicated Correct dose Correct dose intervals Correct duration 5

6 Respondents who obtained antibiotics without a prescription at a pharmacy or elsewhere (%) Antibiotics obtained without a prescription EU Member States, 2002 & 2009 Austria Belgium Bulgaria Cyprus Czech Rep. Denmark Estonia Finland France Germany Greece Hungary Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Poland Portugal Romania Slovakia Slovenia Spain Sweden UK 20 Eurobarometer (2002) Eurobarometer (2009) Source: European Commission, Eurobarometer. In: Lancet Infect Dis 2012 Mar;12(3):182-3.

7 Sales of antibiotics without prescription: SWOT analysis Strengths EU Directive transposed in the national law of each individual Member State Some Member States are taking action Weaknesses Varying levels of law enforcement National habits and cultural differences (can law be enforced when the public and professionals are not aware of the need for change?) A.C.T.I.O.N. Potential savings for national insurance systems (prescription-only medicines obtained OTC often are reimbursed) Opportunities Pressure for change of some antibiotics from prescriptiononly medicine to pharmacy (POM-to-P) status (already in UK for azithromycin for proven Chlamydia infection) Threats A.C.T.I.O.N. Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 7

8 Impact of regulation on prescription only sales of antibiotics, Chile Sep. 1999: regulatory measures introduced as part of Action plan to assure rational Antibiotic Use, incl.: Restriction of antibiotic sales to prescription-only Enforced supervision by regulatory authorities Public campaign, leaflets and posters in pharmacies 1998 to 2002: sales of oral antibiotics decreased by 43% Since 2002: increase to a level close to the 1997 baseline Need for other concomitant interventions, e.g. improving the knowledge and attitudes of consumers and prescribers Source: The evolving threat of antimicrobial resistance. WHO,

9 Total outpatient antibiotic use (ATC J01) in 29 European countries, National media campaign Education prog. for paediatricians National media campaign Education prog. for paediatricians Media coverage Media coverage *Total use for Bulgaria and Iceland, and for Greece (2004 & 2005 only). **Reimbursement data, which do not include overthe-counter sales without a prescription. Source: ESAC, Adapted from: Muller A, et al. Eurosurveillance (11 October 2007) 9

10 Decreases in antimicrobial resistance following national media campaigns Source: French Nat. Ref. Ctr. for S. pneumoniae (Courtesy: E. Varon, L. Gutmann & B. Schlemmer) & Belgian Nat. Ref. Ctrs. for S. pneumoniae and for S. pyogenes (Courtesy: BAPCOC, H. Goossens) 10

11 Awareness campaigns on the prudent use of antibiotics / AMR: SWOT analysis A.C.T.I.O.N. Strengths Several examples of best practice in Member States European Antibiotic Awareness Day (antibiotic.ecdc.europa.eu) Weaknesses Cultural differences between Member States Must be repeated every year A.C.T.I.O.N. Potential large savings for national insurance systems (8 saved for 1 invested) Use national culture characteristics as levers for change Opportunities Campaign fatigue (need to regularly vary and update key messages) Communicating on AMR (rather than prudent use) may lead to more prescriptions Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 11

12 Educational programmes for the public and for professionals: SWOT analysis Strengths Several examples of best practice in Member States e-bug programme for junior/senior school children ( Eurobarometer (as a measure of knowledge of general public) Increasing interest (general public, media, parents, school teachers, professional societies, media) New technical possibilities (phone apps, social networks) Weaknesses Limited space in various curricula (schools, universities) Limited public funds available for continuous education of professionals (in many Member States) A.C.T.I.O.N. A. C. T. I. O. N. Limited sustainability of e-bug (after end of EU project) Pressure for direct-toconsumer advertising for prescription-only medicines Opportunities Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 12

13 Financial incentives/disincentives: SWOT analysis A.C.T.I.O.N. Strengths Several examples from Member States: - BE: perioperative prophylaxis - DK: delisting of antibiotics - FR: free Strep test for GP - DK: extra income for rapid diagnostic tests Weaknesses Most antibiotics are available as (cheap) generics In hospitals, the costs of antibiotics do not necessarily impact the hospital budget (depending on the country) Potential savings for national insurance systems (if incentives/disincentives are properly placed) Professionals and the public may resist change if perceived as done only for saving costs Opportunities Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 13

14 Effects of delisting of fluoroquinolones (mainly ciprofloxacin), Denmark Source: Danish Medicines Agency, 2006 & Jensen US, et al. JAC 2010;65:

15 Outpatient antibiotic (J01) use, by antibiotic class according to ATC classification, 2009 DDD per 1000 inhabitants and per day Penicillins (J01C) Tetracyclines (J01A) Quinolones (J01M) Other J01 classes Cephalosporins and other beta-lactams (J01D) Macrolides, lincosamides and streptogramins (J01F) Sulfonamides and trimethoprim (J01E) EL CY* FR IT LU BE SK PL PT MT IE LT* ES** IS BG CZ FI UK HU DK AT NO DE SI SE NL EE LV * Total use, i.e. including inpatients, for Cyprus and Lithuania. ** Reimbursement data, i.e. not including over-the-counter sales without a prescription, for Spain Malta: 2008 data Source: European Surveillance of Antimicrobial Consumption (ESAC), 2011.

16 Targets / benchmarking of antibiotic consumption: SWOT analysis A.C.T.I.O.N. Strengths Clear message about the objective (size of decrease, by a certain date) A few Member States are taking the lead Weaknesses Choice of target may be difficult (e.g., size of achievable decrease? measurement unit?) Potential large savings for national insurance systems Uncertainty about antibiotic consumption threshold below which the number of adverse effects due to non prescription of antibiotics (to patients who really need them) would increase Opportunities Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 16

17 Rapid diagnostic tests: SWOT analysis Strengths Several positive experiences from Member States Contributes to a more rational use of antibiotics Weaknesses Implementation may vary depending on country (who performs the test? who pays for the test?) A.C.T.I.O.N. Potential savings for national insurance system Business opportunity Misuse of test may result in increasing expenses for national insurance system (potential threat) Opportunities Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 17

18 Vaccines: SWOT analysis A.C.T.I.O.N. Strengths Several examples from Member States and other countries (pneumococcal conjugate vaccine) Reduces burden of the disease covered by vaccine Business opportunity Weaknesses Serotype replacement means need for new vaccines Cost of vaccination (for national insurance system or for the patient if not reimbursed) Not for healthcare-associated infections (so far) Difficult-to-reach populations in most countries Should not distract us from working at improving use of antibiotics Opportunities Threats Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC. 18

19 Time for ACTION Reducing overuse Awareness and education: prudent use (primary care, healthcare settings) Commitment: professional, individual, political Targets / benchmarking: primary care, hospitals Incentives: rapid diagnostic tests, absence from work for sick child, vaccination One-to-one relationship: patient/doctor No self-medication