Antimicrobial Resistance and Dentistry. LDC Officials Day 4 December 2015 Susie Sanderson

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1 Antimicrobial Resistance and Dentistry LDC Officials Day 4 December 2015 Susie Sanderson

2 Who am I? Why are we interested in AMR? Where is the leadership? Who is taking action? What is the BDA doing? Is dentistry the same as medicine? What about animal medicine? What does it mean for the day job?

3 What s the problem? On average, antibiotics add 20 years to each person s life Many existing antibiotics and other antimicrobials are becoming ineffective 25,000 unnecessary human deaths in the EU annually Costs Euro1.5 billion annually in extra healthcare and productivity losses Serious situation of running out of ability to treat Development pipeline at all-time low

4 In 2014, dental prescribing in England cost 26m 66.4% of dental prescription items in 2014 were for antibacterial drugs Clindamycin is considered to be a specific risk Dental prescribing in 2014 accounted for more than 20% of all the prescription items of Clindamycin This means dental prescribing is identified as causal factor in Healthcare Acquired Infections (HAI), particularly (Cdif) and Cdif-associated disease

5 The big numbers $100,000,000,000,000 Cumulative additional costs by ,000,000 Additional deaths per annum by Source: Antimicrobial Resistance: Tackling a Crisis for the Future Health and Wealth of Nations, December 11, 2014.

6 6 Our reliance on antibiotics

7 Resistance is a deadly reality 25,000 people per year in Europe die of sepsis caused by resistant bacteria 23,000 deaths per year from sepsis caused by resistant bacteria in United States (conservative estimate) 1 child every 5 minutes dies of infection caused by resistant bacteria in South East Asia 7

8 Antibiotic consumption in England AB consumption % General practice 4% Hospital inpatients 12% Other community 32% Total consumption 2013 = 27.4 DDD per 1000 inhabitants per day General practice 79% Hospital inpatients 15% Other community 6% 8

9 Rapid diagnostics Rapid diagnostics offer a major and rapidly evolving opportunity to slow the growth and impact of AMR across the world. 9

10 10 Key reports in 2013

11 UK action 5 year strategy improving infection prevention and control practices in human and animal health optimising prescribing practice through implementation of antimicrobial stewardship programmes improving professional education, training and public engagement developing new drugs, treatments and diagnostics better access to and use of surveillance data better identification and prioritisation of AMR research strengthened international collaboration

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20 WHO at World Health Assembly May 2015 Improve awareness and understanding of antimicrobial resistance Strengthen surveillance and research Reduce incidence of infection Optimise the use of antimicrobial medicines Ensure sustainable investment in countering AMR

21 EU Action Plan against AMR: 12 actions Human Both Veterinary 1. Promote appropriate use 4. Prevention of infections 6. New antibiotics 9. Surveillance 2&3. Appropriate use 5. Prevention of infections 7. Need for new antibiotics 10. Surveillance 8. International cooperation 11. Research & Innovation 12. Communication, education & training: survey & comparative effectiveness research

22 EU action plan Whole of society engagement Actions based on best available knowledge and evidence Prevention first Access not excess Sustainability Incremental targets for implementation

23 EU POLICY DEVELOPMENTS European Antibiotic Awareness Day marked annually on 18 November

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27 Closer to home

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31 Dental Practice From 2011 to 2014, there was a 6% decrease (231,038 less prescriptions) in the total number of prescription items prescribed by NHS dental practices (Figure 3.26). The predominant antibiotic prescriptions were for penicillins and metronidazoles, as shown in Figure Almost 99% of prescriptions were narrowspectrum penicillins, metronidazole or macrolides.

32 Key points in dentistry 9-10% of all antibiotics prescribed in UK 3 authoritative sets of guidance A view from some researchers that only 19% of prescriptions comply with guidance Increasing attention on audit and compliance Education and audit reduces inappropriate prescribing Regulators critical of inappropriate prescribing practices Challenges of contractual and time tensions Unscheduled emergency appointments are the most difficult to plan for

33 What to do? Most of attention currently on general practice medicine Veterinary profession now well engaged Dentistry to some degree until recently below the radar but for how long? Lead or react?

34 BDA summit on AMR and dentistry 10 November 2014 Hosted by BDA Multidisciplinary and panprofessional Invited participants from expert groups and relevant stakeholders Was followed by open session at BDA Conference 2015

35 Executive summary

36 Some research findings University of Cardiff GDPs in Wales 71-81% of antibiotic prescribing not conforming to recommendations Qualitative interviews aware of guidelines but varying familiarity of detail Intrinsic (knowledge and attitude) Extrinsic (patient factors, healthcare system) Perception of low level of responsibility Fear of complications if no prescribing

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42 Trials in General Medical Practice To change prescribing behaviours we are experimenting with new ways of feeding back information about when GPs are prescribing more than their peers. The CMO wrote to randomly selected high prescribing GPs in September Stemming the Tide of Antibiotic Resistance (STAR) Social learning theory based blended learning programme in primary care medical practice - 4% reduction in prescribing with no apparent harmful patient outcome

43 and in General Dental Practice Reducing Antibiotic Prescribing in Dentistry (RAPiD) Audit and feedback scheme 2500 GDPs in Scotland 6% reduction in prescribing rates 12% reduction in highest prescribing group 4% reduction using Health Board comparators 6% with text message awareness raising

44 and in General Dental Practice in England In England, currently no practice or clinician level prescribing data is collected at national level But NHS prescriptions could easily be identified Harder but not impossible in the private sector Local prescribing governance already embedded in Health and Social Care Act ESPAUR Dental subgroup currently considering levels of granularity needed NICE Quality Standards consultation covers this and other suggested measures

45 and finally Hot global crisis that affects everyone UK giving attention to addressing AMR Dentistry now being included in stewardship agenda Audit and feedback produces results Consideration of time taken to deal with unscheduled urgent care in dentistry needs sympathetic approach from commissioners The public must receive consistent messages from all healthcare providers

46 Your thoughts?