Transcript Presentation - National Resource for Infection Control
Antimicrobial Stewardship Reflections on International Efforts
Professor Barry Cookson
Division of Infection and Immunity, Univ. College London
ECDC AMR Strategy Antimicrobial Stewardship Infection Prevention & Control
New Diagnostics, Antibiotics and Treatments AMR & AB Usage Surveillance Training/ Prioritisation Education: of R&D & Professio Interventions: nals & International Public Collaboration Organisational & Behavioural
Seven Key Areas
7 ) strengthened international collaboration
with a wide range of governmental and non-governmental organisations, international regulatory bodies and others to influence opinion, galvanise support, and mobilise action to deliver the scale of change needed globally.
8 components of WHO Regional Strategy
• Combined strategy on HAI and AMR and link to patient safety • Strengthen surveillance of HAI and combine AMR • Improve use of standardized surveillance methods and indicators, and process & progress indicators • Standardize guidelines and tools for infection control and prevention in health care settings, including AM drug use.
• Move from individual projects to national programmes • • Foster partnership with professional groups • Review research agenda, training needs and gaps
Political commitment
, advocacy, resources Pittet et al, Considerations for a WHO European strategy….
The Lancet Infectious Diseases
2005;
5:
242-250.
Sally Davies UK Representative WHO Executive 2014 AMR Strategy Champion?
Liam Donaldson WHO Patient Safety Kenneth Calman Clinical Governance & Total Quality Management
The Healthcare Associated Infection and related AMR paradox: high burden but little action
• Complex issue: with no immediate, easy solution • Requires multi disciplinary approaches: never easy • Control and Prevention seen as costly • Diffuse issue: Individual or Institutional or “Public Health” problem?
Why the increased profile in the “00”s?
• A Patient Safety Issue at last – WHO Global Patient Safety Alliance • Hand Hygiene • Surgical Site Infection • Antimicrobial Resistance (never progressed!) – DG SANCO funded European project
Improving Patient Safety in Europe
(IPSE) • International community & media views changed as a result of SARS & the Pandemic Flu threat • Crying wolf no longer: Armageddon organisms are evident globally
“EUROPE”
• • • •
17 Old Member States (MS) 10 New MS
•
EEA: European Economic Area adds Iceland, Liechtenstein
and Norway
EFTA: European Free Trade Association Switzerland , Iceland, Liechtenstein
and Norway
EU acceding countries: Croatia April 2013
See European Economic Area http://en.wikipedia.org/wiki/European_Free_Trade_Associa tion#Current_members
“In England (~2005) we make hospital acquired infection (HAI) rates publically available by named hospital” After the initial shock around Europe: in 2012 6/28 European countries are doing this!
Publication of hospital specific HAI infection rates
Cookson et al,
J Hosp Infect
2011: 79; 260-264
Vive la Différence
EU Directorate (SANCO) group suggested possibility of different systems: • Confidential within the health care institution, not public health authorities e.g. individual surgical team infection rates.
• Confidential benchmarking within surveillance networks with publication of anonymised or aggregated results e.g. surveillance of surgical site infections.
• Disclosure to public health authorities notifiable nosocomial events.
e.g. early warning of • Public reporting of agreed indicators e.g. composite structure and process indicators or HAI rates e.g. France, England
Consensus standards and performance indicators for healthcare associated infection in Europe Cookson et al,
J Hosp Infect
2011: 79; 260-264 Topic Agree Modify Neutral Disagree Organisation 85% 9% 4% 1% Control Surveillance Education 79% 79% 79% 7% 11% 14% 2% 1% 1% 2% 2% 3% Resources Overall Averages 79% 15% 2% 80% 11% 2% 5% 3%
Seven Key Areas
2) optimising prescribing practice
through implementation of antimicrobial stewardship programmes that promote rational prescribing and better use of existing and new rapid diagnostics
Behaviours of patients and doctors (Agricultural, Aquaculture, Vets use: science, politics and economic hurdles: overwhelmingly important!)
ECDC Activities (Council Recommendation 2002/77/EC)
• 2013 !!! Exploring misuse of antimicrobial agents in human medicine across whole chain of stakeholders : prescribers, pharmacists and patients. Sales of antimicrobial agents without a prescription (SCORE 2002-03) • 2014: Antibiotic Prescribing & Resistance in European Children (ARPEC) • 2014-15: Follow up review of EC Recommendations
Seven Key Areas
1) improving infection prevention and control practices
in human (and animal health), both through enhanced dissemination & implementation of best practice & better use of data and diagnostics
5) better access to and use of surveillance data ..
facilitate greater data consistency & standardisation across the system & encourage improved data linkage
Relevant DG SANCO EU Networks
HELICS Hospitals in Europe Link for Infection Control through Surveillance unofficial 1993 Embedded in Improving Patient Safety in Europe (IPSE) 2005 EARSS: European Antimicrobial Resistance Surveillance Scheme 2000
ESAC: European ECDC Surveillance of Antimicrobial Consumption
2002 HELICS 2008
SSI rate per 100 op.
10 9 8 7 6 5 4 3 2 1 0 A
C section
(n= 12 124)
HELICS-associated national networks (2000-2003)
B C D Anonymised Countries E F
Large differences are found between countries
• in rates of HAIs, • in distribution of rates • in the characteristics of the infections This is attributable to: Differences in definition interpretation/data collection? Differences in recruitment?
Difference in Antibiotic Rx & other medical policies?
Difference in the quality of care?
Healthcare-Associated Infections surveillance Network (HAI-Net)
• Coordination Groups (European experts) and contact points in participating countries • Modules: Surgical site infections: 16 countries HAI in intensive care units: 14 countries Point prevalence survey: 30 countries HAI in long-term care (HALT-2, outsourced): 24 countries Surveillance of
C. difficile
infections, pilot: 14 countries Concordance of definitions, Validation studies Need post discharge
Five Countries Reporting Hip Prosthesis Infections to ECDC have shown reduced infection rate trends between 2004-06 Source: HELICS-SSI, ECDC Annual Epidemiological Report 2008
Methicillin-resistant
Staphylococcus aureus
EU 2005- 2007
EARSS-ECDC 0 10 20 30 40 50 MRSA (%) 2 Countries with a significant increase (2005–2007) 8 Countries with a significant decrease (2005 – 2007)
Alcohol hand rub consumption in acute care hospitals, ECDC PPS 2011-2012
Structure and process indicators: percentage of single room beds
Austria Belgium Bulgaria Croatia Cyprus Czech Republic Denmark Estonia Finland France Germany Greece Hungary Iceland Ireland Italy Latvia Lithuania Luxembourg Malta Netherlands Norway Poland Portugal Romania Slovakia Slovenia Spain Sweden UK-England UK-Northern Ireland UK-Scotland UK-Wales *Poor data representativeness 0 20 40 60 80 100 N of single room beds*100 /Total beds Single room beds in participating hospitals (%): median = 11.1% Source: ECDC, 2012 (ECDC PPS data as of 23/11/2012)
Prevalence of antimicrobial use in acute care hospitals, ECDC PPS 2011-2012 *Poor PPS data representativeness
Seven Key Areas
3) improving professional education, training and public engagement
2013 COMPETENCY 1: Infection Prevention &Control COMPETENCY 2: Antimicrobial resistance & antimicrobials COMPETENCY 3: Prescribing antimicrobials COMPETENCY 4: Antimicrobial Stewardship COMPETENCY 5: Monitoring and learning
https://www.gov.uk/government/publications/antimicrobial-prescribing-and stewardship-competencies
Training HALT eBug
Seven Key Areas
4) developing new drugs, treatments and diagnostics (and infection prevention and control interventions) 6) better identification and prioritisation of AMR research needs e.g.
new drugs, improved rapid or point-of care diagnostic tests for humans (& animals).
Relevant DG R&D Projects
HARMONY (1999-2001) incl MRSA typing network Harmonisation of Antibiotic Resistance measurement, Methods of typing Organisms and ways of using these and other tools to increase the effectiveness of Nosocomial infection control ARPAC (2002-2005) Very useful papers Antibiotic Resistance Prevention and Control ARMed (2002-2006) Antibiotic Resistance in Mediterranean Countries MOSAR (2007-2012 ) Mastering hOSpital Antimicrobial Resistance in Europe
• BURDEN 2008-2013 Very useful data Burden of Resistance and Disease in Europe • IMPLEMENT 2008-2013 (www site?) Implementing Strategic Bundles for Infection Prevention & Management.
• PROHIBIT 2008-2013 Analyses existing guidelines and IPC practices • SATURN 2010-2015
Impact of Specific Antibiotic Therapies on the prevalence of hUman host ResistaNt bacteria
• R-GNOSIS 2011-2016 Studies in Multidrug-resistant GNRs
Other Ongoing Projects
• " Routine diagnostic tool for urinary tract infections caused by extended spectrum beta lactamase and carbapenamase producing bacteria" (ROUTINE) • "Rapid identification of respiratory tract infections (RID-RTI) • "Development of a handheld antibacterial drug resistance diagnostic device using nanowire technology" (NANOMAL) • "Automated next generation sequencing for diagnostic microbiology“ (PATHSEEK),
HORIZON 2020
• HEALTH.2013.2.3.1-1: Drugs and vaccines for infections that have developed or are at the risk of developing significant anti-microbial resistance. • HEALTH.2013.2.3.1-2: Stratified approaches to antibacterial and/or antifungal treatment
A “Perfect Storm” Companies withdrawing from antimicrobial market as: • New drug development expensive • Resistance, not just side effects, a huge challenge • Patient numbers often relatively small & regimens short • Patents short-lived
Founded in 2007 Spreading the costs of R&D
IMI New Drugs for Bad Bugs (ND4BB) initiative
COMbatting BACterial resistance in Europe (COMBACTE) €194.6m
“CLIN-Net”: large clinical trials “LAB-Net”: microbial surveillance for trial site selection – Studies : Novel antibiotic vs skin and respiratory infections New human immunoglobulin monoclonal antibody against S. aureus alpha toxin Molecular basis of the bacterial cell wall permeability (TRANSLOCATION) €29.3m
– Explore how to stop the Gram negative bacteria ejecting antimicrobials
Trans Atlantic Task Force Recommendations
Future Collaborations (1)