Antimicrobial stewardship as a tool to fight resistance
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1 Havana, septiembre 2018 Antimicrobial stewardship as a tool to fight resistance José Miguel Cisneros Herreros Infectious Diseases Department University Hospital Virgen del Rocío, Sevilla, SPAIN
2 Competing interests Andalusian Health Service Ministry of Health (ISCIII), European Commission Novartis, Astellas, Pfizer, MSD, Janssen y Astra-Zeneca 2
3
4 Antimicrobial use Laxaminarayan R et al. Science
5 SAMR P. aeruginosa CeftaR 2015 E. coli QR Acinetobacter sp CR (access 2 July 2017) 5 5
6 Impacto clínico BMR DISEÑO - 82 hospitales (26% estancias España) - 12 al 18 de marzo - Seguimiento 30 días tras diagnóstico RESULTADOS pacientes con infección por BMR fallecidos (19,6%) ESTIMACIONES 2018 En los 82 hospitales: pacientes con infección por BMR fallecerán En España: pacientes con infección por BMR fallecerán Colegio de Médicos de Madrid, 17 de mayo de 2018
7 Las causas y los responsables? El 50% del uso de antimicrobianos es inapropiado Conocimiento insuficiente de las enfermedades infecciosas PRIOAM 7
8
9 Guidelines 9
10 Diploma de experto UNED
11
12 Global antibiotic consumption by country: (
13 Spain: National plan to fight antimicrobial resistance
14 The PIRASOA programme Institutional Programme for the Prevention and Control of Healthcare Associated Infections and Appropriate Use of Antimicrobials
15 General objectives 1. To reduce the incidence of HAIs until reaching the level of the European countries with the best outcomes. 2. To optimize the use of antibiotics until reaching the level of the European countries with the best outcomes. 15
16 The setting: Andalucía 8.4 M habitants 16
17 Andalusian Public Healthcare Service >90% population 34 Hospitals 8 University 27 primary care areas physicians 8683 million 17
18 Definition 1. Quality programme 2. Integral Healthcare Acquired Infections Antimicrobial Stewardship Programs 3. Professional lidership 4. Institutional support 18
19 The PIRASOA programme PIRASOA Hospitals Primary Care Nursing home Infection control ASP ASP ASP (2019) 19
20 Structure and organization Scientific committee Hospitals - Local team Primary Care Area - Local team Clinical Management Units (UGCs) - Counselors Clinical Management Units (UGCs) - Counselors Digital platform Reference laboratory 20
21 PIRASOA teams Profesionals n = 638 Local teams in hospitals (HAIs and ASP) n = 34 - Infectious diseases - Pharmaceuticals - Microbiologists - Preventivits - Nurses Local teams in primary care areas (ASP) n = 27 - Primary care doctor - Pediatrician - Pharmaceuticals 21
22 Indicators n = Antimicrobials: use, quality use, cost - Resistance: density in clinical samples - Nosocomial infections: prevalence and incidence - Clínical: mortality of patients with bacteremia 22
23 Interventions: training 1. Symposium (18th november) n = 4 2. Massive Online Open Course (MOOC) n = 6979 participants Basic ASP ASP for severe infections Infection Control Infection Control and ASP (forthcoming) 3. Local guides for antimicrobial therapy 4. Quarterly reports n = Educational interviews n =
24 Educational interviews: methodology Cisneros JM et al. Clin Microbiol Infect 2014;20:82-8 Molina J et al. Clin Infect Dis 2017;65:
25 Educational interview form
26 Nº de aislados Laboratorio de referencia Nº de aislados Nº episodios años + 76%
27 Laboratorio de referencia
28 Institucional support Official program Andalusian Health Service Presentation in the Andalusian Parliament Official councils of Medicine, Pharmacists and Dentists The management agreements Specific budget for reference Laboratory 28
29 PIRASOA s RESULTS January 2014 to September/December
30 DDD/1000 OBD Antibiotic use in hospitals ,3% P<
31 DDD/1000 OBD Carbapenem use % P <0,
32 Nº isolates / 1000 BOD Evolution of enterobacterial CR infections/colonizations 0,14 0,12 0,12 0,12 0,1 0,1 0,08 0,09 0,08 0,09 0,08 0,08 0,09 0,08 0,08 0,08 0,09 0,08 0,06 0,07 0,04 0,02 0 1T2014 2T 3T 4T 1T2015 2T 3T 4T 1T2016 2T 3T 4T 1T2017 2T 3T 32
33 Clinical outcomes in hospitals Variation Q1- Q14 Trend QPC CI95% p value Overall inappropriate treatment rate (%) % (-4.7%,-3.5%) <0.001 Total DDDs/1000 OBD % (-1.3%,-0.5%) <0.001 DDDs/1000 OBD carbapenems % (-1.8%,-0.5%) DDDs/1000 OBD amoxycillin/clavulanic % (-1.8%,-1.3%) <0.001 DDDs/1000 OBD piperacillin/tazobactam % (0%,0.7%) DDDs/1000 OBD quinolones % (-1.9%,-1.2%) <0.001 DDDs/1000 OBD antifungal agents % (-2.1%,-0.8%) <0.001 ID multidrug-resistant pathogens/1000 OBD (1) % (-3.3%,-1.3%) <0.001 Overall crude mortality rate associated with bacteraemias (%) (2) % (-0.8%,1.1%) : Multiresistant both Pseudomonas aeruginosa and Acinetobacter baumanii, methicillin-resistant Staphylococcus aureus, vancomicin-resistant Enterococcus sp, Extended-Spectrum β-lactamase-producing both Escherichia coli and Klebsiella Pneumoniae and carbapenemase-producing Enterobacteriaceae. 2: Bacteraemias caused by Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumoniae, Acinetobacter baumanii, Staphylococcus aureus and Candida sp. 33
34 DDD/1000 hab. día Antibiotic use in primary care , ,8 16,6 21,1 18,7 15,6 19,5 22,6 18,4 14,4 18,5 21,6 16,5 13,9 18,3-26,8% P <0,
35 DDD/1000 hab. día Annual antibiotics consumption in Primary Care 21 20,5 20,6 20, ,5 4.8 millon DDD 19 18,7 18, ,5 17,5 2.8 millon DDD 17 16, ,
36 DDD/1000 hab. día Antibiotic use in primary care: Andalucia, Spain and Germany 26,0 Andalucía España (excl. AND) Alemania 24,0 24,0 + 23% +2,6 p<0,01 22,0 20,0 21,5 18,0 16,0 19,4 18,5 17,5-19% - 1,7 p<0,01 14,0 14,6 14,1 P =0,7 12,0 10, PIRASOA 36
37 DDD J01 por 1000 people Antibiotic use in primare care, Andalucia: Estimated prediction 23,5 22,0 20,5 19,0 17,5 16,0 14,5 13,0 11,5 10, PIRASOA 37
38 DDD/1000 hab. día Amoxicillin/clavulanic use in primary care , ,7 7,9 9,1 7,4 6,7 7,5 8,2 6,4 5,6 6,3 7 5,5 5 5,6-49% P <0,
39 Ecological impact in primary care: E. coli BLEE +2,9% (p<0,01-10,5% p<0,05) Peñalva G et al. ECCMID
40 40
41 Conclusions (I) 1. The PIRASOA program has been successfully implemented and developed in Andalucia. 2. The preliminary outcomes show: Reduction of antimicrobial consumption Improvement of antimicrobial prescription profile Reduction of microbial resistance 41
42 Conclusions (II) The PIRASOA program needs: Maintain professional motivation Add to current institutional support Technical resources Human Resources Nursing homes Spread the results 42
43 Clinical Infectious Diseases 2017;65(12):
44 Antimicrobial use DDD/1000 OBDs -19,9% Clin Infect Dis 2017;65(12):
45 Incidence of nosocomial bloodstream infections by MDR bacteria and candidemia Clinical Infectious Diseases 2017;65(12):
46 Mortality of nosocomial bloodstream infections by MDR bacteria and candidemia Clinical Infectious Diseases 2017;65(12):
47 Antimicrobial stewardship as a tool to fight resistance The results of these studies suggest that the decrease and better use of antibiotics achieved by ASP had a sustained ecological and clinical impact. 47
48 Acknowledgments Local teams: 638 professionals Thousands of professionals of the Andalusian Public Healthcare System who have participated Reference Laboratory Scientific Committee (18) Scientific societies (10) Andalusian Government Health Counselor Secretary of Public Health Managing Director of the Andalusian Health Service General Director of Health Care Support Services of the Andalusian Health Service Strategic Direction of IT IAVANTE Canal SUR television 48
49
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