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
Competing interests Andalusian Health Service Ministry of Health (ISCIII), European Commission Novartis, Astellas, Pfizer, MSD, Janssen y Astra-Zeneca 2
Antimicrobial use Laxaminarayan R et al. Science 2016 4
SAMR P. aeruginosa CeftaR 2015 E. coli QR Acinetobacter sp CR https://ecdc.europa.eu/en/antimicrobial-resistance (access 2 July 2017) 5 5
Impacto clínico BMR DISEÑO - 82 hospitales (26% estancias España) - 12 al 18 de marzo - Seguimiento 30 días tras diagnóstico RESULTADOS - 903 pacientes con infección por BMR - 177 fallecidos (19,6%) ESTIMACIONES 2018 En los 82 hospitales: - 46.956 pacientes con infección por BMR - 9.204 fallecerán En España: - 180.600 pacientes con infección por BMR - 35.400 fallecerán Colegio de Médicos de Madrid, 17 de mayo de 2018
Las causas y los responsables? El 50% del uso de antimicrobianos es inapropiado Conocimiento insuficiente de las enfermedades infecciosas PRIOAM 7
Guidelines 9
Diploma de experto UNED
Global antibiotic consumption by country: 2000 2015 (https://www.iqvia.com/solutions/commercialization/geographies/midas
Spain: National plan to fight antimicrobial resistance 2014 13
The PIRASOA programme Institutional Programme for the Prevention and Control of Healthcare Associated Infections and Appropriate Use of Antimicrobials http://pirasoa.iavante.es/ https://www.protocols.io/view/the-pirasoa-programme-design-structure-organisatio-r3bd8in 14
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
The setting: Andalucía 8.4 M habitants 16
Andalusian Public Healthcare Service >90% population 34 Hospitals 8 University 27 primary care areas 17182 physicians 8683 million 17
Definition 1. Quality programme 2. Integral Healthcare Acquired Infections Antimicrobial Stewardship Programs 3. Professional lidership 4. Institutional support 18
The PIRASOA programme PIRASOA Hospitals Primary Care Nursing home Infection control ASP ASP ASP (2019) 19
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
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
Indicators n = 171 - Antimicrobials: use, quality use, cost - Resistance: density in clinical samples - Nosocomial infections: prevalence and incidence - Clínical: mortality of patients with bacteremia 22
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 = 15 5. Educational interviews n = 79841 23
Educational interviews: methodology Cisneros JM et al. Clin Microbiol Infect 2014;20:82-8 Molina J et al. Clin Infect Dis 2017;65:1992 9 24
Educational interview form
Nº de aislados Laboratorio de referencia 400 200 Nº de aislados 0 2013 2014 2015 2016 7 164 297 380 Nº episodios 2 57 118 152 años + 76%
Laboratorio de referencia
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
PIRASOA s RESULTS January 2014 to September/December 2017 29
DDD/1000 OBD Antibiotic use in hospitals 950 900 923 850 800 750 700 835 849 835 880 803 794 822 818 773 777 786 753 778 744-19,3% P<0.05 650 600 550 500 30
DDD/1000 OBD Carbapenem use 100 90 80 87 70 60 67 50 40 30 55 54 52 52 52 49 48 48 51 47 44 45 49-44% P <0,05 20 10 0 31
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
Clinical outcomes in hospitals Variation Q1- Q14 Trend QPC CI95% p value Overall inappropriate treatment rate (%) 50.6-29.4-4.1% (-4.7%,-3.5%) <0.001 Total DDDs/1000 OBD 923-780 -0.9% (-1.3%,-0.5%) <0.001 DDDs/1000 OBD carbapenems 64.9-55.3-1.2% (-1.8%,-0.5%) 0.002 DDDs/1000 OBD amoxycillin/clavulanic 183.1-153.9-1.5% (-1.8%,-1.3%) <0.001 DDDs/1000 OBD piperacillin/tazobactam 50.0-45.9 0.4% (0%,0.7%) 0.038 DDDs/1000 OBD quinolones 194.4-116.3-1.6% (-1.9%,-1.2%) <0.001 DDDs/1000 OBD antifungal agents 42.7-36.4-1.5% (-2.1%,-0.8%) <0.001 ID multidrug-resistant pathogens/1000 OBD (1) 1.30-0.98-2.3% (-3.3%,-1.3%) <0.001 Overall crude mortality rate associated with bacteraemias (%) (2) 16.4-15.3 0.1% (-0.8%,1.1%) 0.748 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
DDD/1000 hab. día Antibiotic use in primary care 30 25 25 27,3 20 15 19,8 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 <0,05 10 5 0 34
DDD/1000 hab. día Annual antibiotics consumption in Primary Care 21 20,5 20,6 20,3 20 19,5 4.8 millon DDD 19 18,7 18,5 18 17,5 17,5 2.8 millon DDD 17 16,5 16 15,5 2014 2015 2016 2017 35
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 10,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 PIRASOA 36
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 10,0 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 PIRASOA 37
DDD/1000 hab. día Amoxicillin/clavulanic use in primary care 12 10 11 10,5 8 6 4 8,7 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 <0,05 2 0 38
Ecological impact in primary care: E. coli BLEE +2,9% (p<0,01-10,5% p<0,05) Peñalva G et al. ECCMID 2017 39
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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
Conclusions (II) The PIRASOA program needs: Maintain professional motivation Add to current institutional support Technical resources Human Resources Nursing homes Spread the results 42
Clinical Infectious Diseases 2017;65(12):1992 9 43
Antimicrobial use - 217 DDD/1000 OBDs -19,9% Clin Infect Dis 2017;65(12):1992 9 44
Incidence of nosocomial bloodstream infections by MDR bacteria and candidemia Clinical Infectious Diseases 2017;65(12):1992 9 45
Mortality of nosocomial bloodstream infections by MDR bacteria and candidemia Clinical Infectious Diseases 2017;65(12):1992 9 46
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
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
Acknowledgments @guiaprioam http://guiaprioam.com/ http://pirasoa.iavante.es/ 49