Antibiotic Awareness Week 2018

Insert your organisation’s name here

#AAW2018
Insert presenter’s name here
Overview
•Antibiotics are vital life-saving medicines
•Antimicrobial resistance is both a global and local problem
•The link between antibiotic use and resistance
•Addressing antimicrobial resistance in Australia
•Antimicrobial stewardship (AMS)
•Antibiotic Awareness Week
Antibiotic Awareness Week in Australia

12 – 18 November 2018

Aims to encourage best practice in relation to antibiotic

use, among the general public, health workers and policy
makers to prevent and contain the spread of antimicrobial
resistance.
 Antimicrobials

• Antibiotics are a type of antimicrobial

Ref:1
Broad vs Narrow Spectrum

• Narrow spectrum antibiotics work against a limited group

of bacteria
• Broad spectrum antibiotics work against a larger group of
bacteria
• Overuse of unnecessarily broad spectrum antibiotics can
drive antimicrobial resistance
What is antimicrobial resistance
(AMR)?
• Antimicrobial resistance (AMR) occurs when bacteria,
parasites, viruses or fungi change to protect themselves from
the effects of antimicrobial drugs designed to destroy them.

• This means previously effective antimicrobial drugs (e.g.

antibiotics) used to treat or prevent infections may no longer
work.

• The World Health Organization (WHO) has identified AMR as

‘one of the biggest threats to global health’.

• Australia has in place a national AMR strategy.

Why are antibiotics and
antimicrobial resistance important?
• Antibiotics treat infections caused by bacteria

• Modern medicine, especially surgery and cancer treatments, depends

on effective antibiotics to minimise the risk of infection
− Currently, antibiotics reduce post-operative infection rates to below 2.0%
− Without effective antibiotics, this could increase to around 40% to 50%.
Up to 30% of these patients could die from resistant bacterial infections
− The risk of mortality without access to effective antibiotics may make
some treatments and surgical procedures too risky to continue

• Antimicrobial resistance results in substantial financial cost for

patients and healthcare systems.
 Antibiotics are unique

• In general, the impact of medications are limited to the

patient taking them
• Use of antibiotics has an impact not just for the patient
using them but the global community as well

Ref:2
How has antimicrobial resistance
developed?
• Antimicrobial resistance is a natural phenomenon
• Overuse, misuse and inappropriate use of antibiotics may
accelerate this
• The delivery of more complex health care which may
require longer use of antibiotics
• Prolonged hospitalisation
• The potential impact of surgical procedures undertaken
overseas
• Resistant pathogens can now spread easily
− during hospitalisation if infection prevention is poor
− potential for cross-border transmission through increased travel.
Ref:3
 Resistance is not new

Ref:4
Resistance is getting worse
Carbapenem-resistant Enterobacteriaceae

2013 2015

Ref:5
 Antibiotic use is related to
antimicrobial resistance
Relationship between total
antibiotic consumption and
Streptococcus pneumoniae
resistance to penicillin in
20 industrialised countries.

Ref:6
 Antibiotic use in Australia

Ref:7
 Antibiotic use in Australia

Ref:8
 Decline in antibiotic production
• Very few
antibiotics have
been developed
in the last 20
years
• Most ‘new’
antibiotics are
variations of
existing
antibiotics
• Only 5 novel
classes have been
developed in the
last 20 years.

Ref:9
 Decline in antibiotic production
• Trends in sales of recently launched antibiotics
discourage pharmaceutical companies to invest in their
research and development

Ref:10 Ref:11
 Antimicrobial Resistance – Global
Response
In May 2015, the World Health Assembly adopted a Global
Action Plan on Antimicrobial Resistance, which outlines five
key objectives to:

1. Improve awareness and understanding of antimicrobial

resistance

2. Strengthen the knowledge and evidence base

3. Reduce the incidence of infection

4. Optimise the use of antimicrobial medicines

5. Develop the economic case for sustainable investment.

Ref:12
 Australia’s response to antimicrobial
resistance
In June 2015, the Australian Government released its first National
Antimicrobial Resistance Strategy 2015–2019 to guide the response to
the threat of antimicrobial misuse and resistance.

Objectives:
1. Communication, education and training
2. Antimicrobial stewardship
3. Surveillance
4. Infection prevention and control
5. National research agenda
6. Strengthen international partnerships
7. Clear governance arrangements.

Ref:13
 Surveillance of Antimicrobial Use
and Resistance in Australia (AURA)
The AURA Surveillance System:
⎻Coordinates the integration of data
from a range of sources on
antimicrobial use and
antimicrobial resistance
⎻Contributes significantly to the
development and implementation
of health strategies to respond to,
monitor and prevent antimicrobial
resistance in Australia
⎻AURA 2019 due in March 2019

Ref:14
Australia’s response to antimicrobial
resistance
• In Australia, antimicrobial resistance also affects aged care homes
and the community. High levels of antibiotic use in the community
(which includes primary and aged care) is a growing concern
• Australia is better placed than many countries to respond to
antimicrobial resistance through having:
- The Antimicrobial Use and Resistance in Australia (AURA) Surveillance
System
- The National Alert System for Critical Antimicrobial Resistances – CARAlert
(as part of AURA)
- The Australian Government’s National Antimicrobial Resistance Strategy
2015-2019
- Initiatives developed and implemented by states and territories, and the
private sector
Surveillance of Antimicrobial Use and
Resistance in Australia (AURA)
The AURA National Coordination Unit is responsible for the AURA
Surveillance System. Funding for AURA is provided by the Australian
Government, and state and territory health departments. Multiple partners
contribute data.

National
Neisseria National
Network Notifiable
Diseases
Surveillance
System

OrgTRx
AURA 2017 Key Findings –
Antibiotic use in the Community
• Australia has very high usage of antibiotics in the community - 46%
of individual Australians received an antibiotic in 2015
• Antibiotics were most commonly dispensed for very young people
and older people, with:
− 51% of those aged 0–4 years
− 60% of those aged 65 years or over, and
− 76% of those aged 85 years or over
being supplied at least one antibiotic in 2015
• 30% of MedicineInsight patients (just under 1 million people) were
prescribed systemic antibiotics between 1 January and 31 December
2015
Prescribing for Upper Respiratory
Tract Infection (URTI)
• Significant amount of
Marked seasonal variation in agents used for RTI
antibiotics prescribed
for respiratory tract
infections (RTI)

• Seasonal variation is
driven by viruses –
which do not respond
to antibiotics

• Data shows that 60%

of patients who
present with RTI will
be prescribed
antibiotics.
 Patient impact of antimicrobial
resistant infections
• Treatment failures
• Recurring infections
• Longer hospital stays
• Longer recovery
times
• A higher risk of
mortality or long
term implications
• Significant financial
Watch Glen’s Story here
cost of treatment

Preventing infections is everybody's business Ref:15

Antimicrobial resistance locally –
What is happening in our health
service?
• Which infections are we seeing? [Insert surveillance data,
i.e. what is the most common cause of bacteraemia in your
facility]
• What are our susceptibility and resistance patterns?
⎻[Insert hospital data]
⎻[Numbers of cases]
⎻[Examples of cases]
• Are there local antimicrobial resistance issues?
• What are local rates of MRSA, C diff?
• Do you have access to a local antibiogram?
Patient story

• This is a placeholder for a local example of a patient who

experienced a resistant bacterial infection at your
healthcare facility

• Insert a case study (optional)

• You may want to detail the:

− diagnosis and the method of diagnosis
− bacterium that was resistant to the preferred antibiotic
− medications used to treat the bacterial infection
− time, resources and people involved to treat the infection
− impact on the patient, the patient’s life and patient’s family
− immediate, medium or long-term health implications (if any).
Monitoring of Critical Antimicrobial
Resistance (CARAlert)

Link to latest CARAlert Report

Critical Antimicrobial Resistances
(CAR)
• Organisms which are resistant to ‘last-line’ antibiotics
• 653 results - October 2017 – March 2018
• 87% of all CARs were from the 3 most populous states:
− New South Wales (32%)
− Victoria (34%)
− Queensland (21%)
• Only 4 reports received from the Northern Territory and 5 from
Tasmania
• Most common CAR - Azithromycin non-susceptible Neisseria
gonorrhoeae
• Followed by Carbapenemase-producing Enterobacterales (CPE)
 Aggregate Hospital Antibiotic Use
2016 (NAUSP)
The National Antimicrobial Utilisation Surveillance Program (NAUSP) is a partner in
AURA and collects data on antimicrobial use.
Factors that are likely to have contributed to reduced use include:
• Increased capacity of local, state and territory, and national AMS programs
• Changes in clinical practice
• More effective adoption of recommendations in Therapeutic Guidelines: Antibiotic.

Ref:16
Local Antibiotic Use

• Insert local antibiotic use data (if available)

• Include information about your contributions to National

Antimicrobial Usage Surveillance Program (NAUSP)

• Insert NAUSP data.

Utilisation vs Appropriateness
Whilst antimicrobial utilisation is a good measure for the success of
antimicrobial prescribing interventions it does not assess why the
antimicrobial was used.

Utilisation: how much we use?

Appropriateness: was it a good choice?

 Appropriateness of prescribing in
Australia

• National Antimicrobial Prescribing Survey (NAPS) - In 2017, 22.4%

of all prescriptions from all participants were deemed
“inappropriate” (n= 24 987 prescriptions)
Ref:17
Appropriateness of prescribing at
our hospital
• Does your healthcare facility audit appropriateness of prescribing?
• What tools are used (e.g.. National Antimicrobial Prescribing Survey
[NAPS], jurisdictional audit tools)

• If participating in NAPS, insert your healthcare facilities results here:

• Consider
− results compared to national results
− Time series data
− how the your facility’s NAPS results have contributed to your AMS
program.
 Why is inappropriate use important?
Reasons for a reported prescription being
assessed as inappropriate, Hospital NAPS
May increase risk of contributors, 2017
adverse effects, including:
Not
⎻AMR (current and Reason Yes (%) No (%) specified
(%)
future patients) Spectrum too
⎻Antimicrobial allergy broad 21.9% 46.3% 31.8%

⎻Treatment failure
Incorrect dose or
20.1% 50.9% 29.0%
frequency

⎻Toxicity (e.g. Antimicrobial not

required
17.5% 49.8% 32.7%

ototoxicity) Incorrect duration 16.5% 51.0% 32.5%

⎻Clostridium difficile Spectrum too
6.6% 58.8% 34.6%
⎻Increased health care narrow

costs (i.e. length of Incorrect route 5.2% 60.6% 34.3%

stay)
n = 5,864

Ref:17
 Antibiotics in primary care –
Pharmaceutical Benefit Scheme
(PBS)
• In 2015, around half of the Australian population had at
least one antimicrobial dispensed under the PBS (44.7% n
= 10,701,804)

Ref:18
Antibiotics in primary care –
NPS MedicineWise Medicine Insight
• In 2015, only 23.5% of patients prescribed antimicrobials
had an indication recorded
• Of these people, 60% who were reported to have
colds/upper respiratory tract infections were prescribed
an antimicrobial
⎻But antimicrobials are not generally recommended for these
conditions
Understanding Variation
• Variation raises concerns about equity and safety and
appropriateness of care
• There is marked variation in use of antibiotics
− between states
− between hospitals
 different sizes
 within the same size
• The reasons for this are not well understood
• Also marked variation in community dispensing of antibiotics
− The first Australian Atlas of Healthcare Variation (2015) included
information on community antibiotic use
− The third Atlas will be released later this year containing antibiotic data
at a national level
− Further data will be available at state and territory level in 2019
Number of PBS prescriptions
dispensed for amoxicillin-
clavulanate per 100,000
people, age
standardised, by local area,
2013–14

Ref:19
 Antimicrobial Stewardship (AMS)
Antimicrobial Stewardship isn’t about “not using antimicrobials”
but rather “identify that small group of patients who really need
antibiotic treatment and then explain, reassure and educate the
large group of patients who don’t”

• Stewardship means to protect something

• AMS is a systematic approach to optimising the use of antimicrobials
• Goals of AMS are to:
‒ improve patient outcomes / patient safety
‒ reduce antimicrobial resistance
‒ reduce costs.

• AMS works hand-in-hand with infection prevention and control strategies

Ref:20
Antimicrobial Stewardship (AMS) –
Safety, Quality and Equity dimensions

Does your organisation keep up to

Quality – aspiring to the best
date with the latest evidence and
possible quality and effectiveness
strive to innovate and implement
of care
that standard of care?

Equity – ensuring every patient Is there a systematic approach to

regardless of their cultural or ensure each patient using
linguistic background has the same antimicrobials is managed with the
experience of care principles of AMS?

Has the right patient received the

Safety – bring up to the minimum right antibiotic, at the right time, at
acceptable and sustainable the right dose, via the right route
standard for the right duration?
 A Critical Balance

Risk of toxicity and adverse drug

reactions

Ref:21
Antimicrobial Stewardship

Right
antibiotic
Right
Right
Right
Right
duration
patient
Antimicrobi route
dose
time
al
Stewardship
= least harm to current/future patients
Enablers for effective for AMS
Programs
• Clear organisational structure and governance
• Executive and clinical leadership
• AMS advisory committee
• Multidisciplinary clinical AMS team
• Expert advice from
− infectious diseases experts
− microbiologists
− pharmacists
• Education and training
− prescribers, pharmacists, nurses
− consumers
• Information technology resources.
Essential strategies for AMS
Programs
Pre-prescription Post-prescription
Formulary management Direct patient input eg AMS Round
Restriction System Audit and Feedback
Guidelines Monitor appropriateness – National
Antimicrobial Prescribing Survey (NAPS)
Education Monitor utilisation – National Antimicrobial
Utilisation Surveillance Program (NAUSP)
Antibiograms (susceptibility of Education
microogranisms to antimicrobials)
Selective reporting of susceptibility Electronic solutions - eMeds – automatic stops
testing
Confirming patient’s allergy status IV to Oral switch
 Antimicrobial Stewardship in our
healthcare facility
Insert information on Infection
Control
Nurses AMS
your AMS service: Pharmacy
Technicia

⎻Structure, governance
n

Antimicrobi

– who is responsible? al
Stewardship
Pharmacist

⎻Who leads AMS

activities? AMS
Team
⎻Who is on your local
AMS team? Infectiou
s
Diseases
⎻What AMS activities Specialist

are undertaken?
Micro
⎻What AMS activities biologi
st
are you / your
department involved
Antimicrobial Stewardship – not just
for hospitals
• In the community
⎻General Practice
 Not prescribing antibiotics for colds and flu
 Delayed prescribing
 Shared decision making
 Public declarations in the practice about conserving antibiotics

⎻Pharmacies
 Offering symptomatic support for cold and flu
• In the home
⎻Not taking antibiotics that haven’t been prescribed for you
• In industry
⎻Investing in research and development for antimicrobials
Commission Resources for AMS
Partnering with
consumers

Link
National Safety and Quality Health
Service Standards
AMS Clinical Care Standard
Describes best-practice in antibiotic prescribing:
1. Urgent treatment of severe infection
2. Appropriate investigations collected
(preferably before antibiotics)
3. Information given to patient about diagnosis
4. Prescribing as per Therapeutic Guidelines:
Antibiotic (or other local guidelines)
5. Information given to patient about treatment
6. Documentation of treatment plan in the record
7. Narrowing of broad-spectrum empiric
treatment when appropriate
8. Investigations reviewed in a timely way
9. Surgical prophylaxis in accordance with
guidelines
Therapeutic Guidelines: Antibiotic

• Always use the most current

version
⎻Currently version 15, 2014)
⎻New version due March 2019
• Check hospital intranet
• A ‘go to’ reference, especially
where there are limited local
guidelines
• Learn more
⎻www.tg.org.au
⎻click ‘Products’, then ‘Antibiotic’
• Use this slide to highlight any AMS initiatives your
organisation has completed recently
• This may be
⎻A new guideline
⎻A new audit
Local Antibiotic Awareness Week
Activities
Insert information on AAW in your health service:

• Join the conversation on social media:

⎻Hashtags
 #AAW2018
 #WAAW
 #AntibioticResistance
 #AMR
⎻@ACSQHC and @NPSMedicineWise

• Local activities and contact people

• Include information about local activities

Key messages
Antimicrobial resistance:
⎻ occurs when an organism evolves and develops resistance to an antimicrobial that
should inhibit or destroy it
⎻ is reducing the effectiveness of antimicrobials to treat infections

⎻ is happening now

• Few new antimicrobials are being developed

• The misuse, overuse, and inappropriate use of antimicrobials
contributes to antimicrobial resistance
• Antimicrobial stewardship works hand in hand with prevention and
control strategies to help address antimicrobial resistance.
Online Resources for AMS
• NPS MedicineWise/ACSQHC Antimicrobial Prescribing Modules -
https://learn.nps.org.au/mod/page/view.php?id=4282
• Future Learn -
https://www.futurelearn.com/courses/antimicrobial-stewardship
• Stanford AMS Course -
http://errolozdalga.com/medicine/pages/OtherPages/AntibioticRevi
ew.ChanuRhee.html

• MAD-ID Course - http://mad-idtraining.org/certification/ 

• Infections in Surgery Course -
https://infectionsinsurgery.org/management-of-intra-abdomianl-inf
ections-free-online-course/

• WHO Course - https://openwho.org/courses/AMR-competency

References
1. https://www.reactgroup.org/toolbox/understand/antibiotics/

2. http://blog.nus.edu.sg/singaporesling/2016/11/16/the-resistible-rise-of-antibiotic-resistance/

3. Image courtesy of CDC / Melissa Brower Centers for Disease Control and Prevention Public Health Image Library http://phil.cdc.gov/phil/home.asp

4. https://www.businessinsider.com.au/alexander-fleming-predicted-post-antibiotic-era-70-years-ago-2015-7

5. https://ecdc.europa.eu/sites/portal/files/media/en/publications/Publications/carbapenem-resistant-enterobacteriaceae-risk-assessment-april-2016.pdf

6. Source: The Antimicrobial Resistance Standing Committee (2013)

National Surveillance and Reporting of Antimicrobial Resistance and Antibiotic Usage for Human Health in Australia.

7. AURA 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/

8. AURA 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/

9. Butler M, Blaskovich M, Cooper M. Antibiotics in the clinical pipeline in 2013. J. Antibiot 2013;66: 571-591

10. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4378521/

11. https://www.sciencedirect.com/science/article/pii/S0006295216303082

12. http://www.who.int/drugresistance/documents/surveillancereport/en/

13. https://www.amr.gov.au/resources/national-amr-strategy

14. AURA 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/

15. Youtube - Glen’s Story - https://www.youtube.com/watch?v=RIsBB6TmZvA

16. NAUSP 2016 Report -

https://www.safetyandquality.gov.au/publications/antimicrobial-use-in-australian-hospitals-results-of-the-2016-national-antimicrobial-utilisation-surveillance-progra
m/

17. NAPS 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/naps-2/?section=4

18. AURA 2017 Report - https://www.safetyandquality.gov.au/antimicrobial-use-and-resistance-in-australia/2017-report/

19. Australian Atlas of Healthcare Variation - https://www.safetyandquality.gov.au/atlas/atlas-2015/

20. British Journal of General Practice 2009, 59: 567

21. https://c.ymcdn.com/sites/www.ohioshp.org/resource/resmgr/AM_2016_Slides/4BoyleCraftetal-MeettheAntim.pdf
Safetyandquality.gov.au

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