[PDF] Antibiotic Stewardship in Hospitals - SPILF - Infectiologie

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Nationales d'Infectiologie (French Infectious Diseases Society meeting) and Interscience Conference on Antimicrobial Agents and Chemotherapy in 2011 Correspondence: Ce´line Pulcini, MD, PhD, Centre Hospitalier Universitaire de Nice, Service d'Infectiologie, Hoˆpital l'Archet 1, 151 Route Saint Antoine de

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16es Journées Nationales d’Infectiologie, Nancy du 10 au 12 juin 2015 16es JNI, Nancy, du 10 au 12 juin 2015 3 A Little Bit of Geography France: 63 5 Mio

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Antibioclic : prise en charge des patients Covid+ en ville2 CMG : infographies de prise en charge (09/11/2020)3 Publication ministérielle : Organisation des centres dédiés Covid-19 en ville (10/11/2020)4 HAS : recommandations sur la prise en charge en médecine de ville (09/11/2020)5

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Française), membre de la Fédération Française d’Infectiologie Rédigé par le Dr S Alfandari Sources d’information nationales sur l’utilisation des antibiotiques Recommandations sur les ATB: infectiologie com ATB rationnelle en soins primaires: antibioclic com ANSM : AMM des ATB, surveillance des effets indésirables

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International de Recherche en Infectiologie, University of Lyon, France To help hospitals assess the best strategies for preventing the emergence of resistance, Shapiro

Penicillins’ defined daily doses must be changed

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16 es

JNI, Nancy, du 10 au 12 juin 2015 1

Antibiotic Stewardship in

H ospitals and Primary Care: the Slovenian Experience

Prof Bojana Beovic, MD, PhD

University Medical Centre Ljubljana

Slovenia

16 es

JNI, Nancy, du 10 au 12 juin 2015

Déclaration

de liens d'intérêt avec les industries de santé en rapport avec le thème de la présentation (loi

du

04/03/2002) :

Consultant ou membre d'un conseil scientifique

Conférencier ou auteur/rédacteur rémunéré d'articles ou documents: Pfizer, MSD, Alkaloid,

Astellas,

AstraZeneca, Sandoz

Prise en charge de frais de voyage, d'hébergement ou d'inscription à des congrès ou autres manifestations Investigateur principal d'une recherche ou d'une étude clinique

OUI NON

OUI NON

OUI NON

OUI NON

L'orateur ne

souhaite pas répondre

Intervenant :

Titre :

Prof

16es Journées Nationales d'Infectiologie, Nancy

du 10 au 12 juin 2015 16 es

JNI, Nancy, du 10 au 12 juin 2015 3

A Little Bit of Geography...

France:

63.5 Mio

Inhabitants

Slovenia:

2.1 Mio

Inhabitants

16 es

JNI, Nancy, du 10 au 12 juin 2015

Antibiotic Stewardship is...

•To choose the most effective antibiotic therapy •To minimize adverse events •To minimize the development of antibiotic resistance •At minimal cost

McGowan&Gerding, New

Horiz 1996; 4: 370

-6.

ANTIBIOTIC STEWARDSHIP

16 es

JNI, Nancy, du 10 au 12 juin 2015

Aspects

of Antibiotic Stewardship •Non-governemental initiatives: national, international •EU state-driven projects/programs •National activities •University-based initiatives •Regional activities •Hospital-based activities •Industry... projects programs recommendations legislation structures campaigns research... restriction education structural changes...

Public

Patients

Physician

Pharmacists

Nurses

IT... (management)...

OWNERSHIP

TYPE OF ACTIVITY

ACTIVITY

THE TARGET GROUP

16 es

JNI, Nancy, du 10 au 12 juin 2015

"(antimicrobial) AND stewardship" in PubMed

02004006008001000

N of publications

> 10 years

5 to 10 years

last 5 years 16 es

JNI, Nancy, du 10 au 12 juin 2015

Do the Interventions Work?

7 16 es

JNI, Nancy, du 10 au 12 juin 2015

Do the Interventions Work?

8

Interventions are effective in reducing

antimicrobial consumption and / or reducing antimicrobial resistance. 16 es

JNI, Nancy, du 10 au 12 juin 2015

Translational Medicine...

is a discipline that aims to improve the health of individuals and the community by "translating" findings into diagnostic tools, medicines, procedures, policies and education http://en.wikipedia.or 16 es

JNI, Nancy, du 10 au 12 juin 2015

Determinants of Hospital (Outpatient?) Antibiotic use •Sociocultural aspects •Socioeconomic aspects •Organisational policies •Knowledge •Attitudes 10 Huscher MEJL, Grol RPTM, van der Meer JW. Lancet ID, 2010; 10: 167 -75. 16 es

JNI, Nancy, du 10 au 12 juin 2015 11

Some Facts on Health-care System in France and in Slovenia 3,3 2,5 01234

FranceSlovenia

N of licensed medical doctors per 1000 Inh

6,3 4,5 02468

FranceSlovenia

N of hospital beds per 1000 Inh

16,8 17,1

05101520

FranceSlovenia

Hospital discharge rate per 1000 Inh

11,6 9,4

051015

FranceSlovenia

Health-care expenditure in % GDP

https://data.oecd.org/health.htm 16 es

JNI, Nancy, du 10 au 12 juin 2015

•Legislation •Infrastructure •Local strategy •Monitoring of outcomes 16 es

JNI, Nancy, du 10 au 12 juin 2015

Did the Recommendations Have Any Impact?

Report on the implementation 2003 (REPORT FROM THE COMMISSION TO THE COUNCIL, 22.12.2005)

•Almost all countries have national systems for surveillance of antimicrobial use and antibiotic consumption

•The majority of Member States co-ordinate actions to improve prescribing practices.

•Sixteen countries have measures in place to enforce regulations for prescription-only use of systemic antimicrobial agents.

•Most countries have nationally accepted guidelines on appropriate use of antimicrobials for at least some conditions/syndromes

•Twenty-two countries have a national programme for hospital hygiene and infection control in place, only about half of the countries have legal requirements or recommendations about the number of infection control nurses per hospital bed

•In all countries education is provided by non-sponsored continuing education, and in almost all of them also through sponsoring by the pharmaceutical industry

•All but six countries have performed a lay public campaign in some format in the past five years

•Twenty Member States, two EEA countries, and Bulgaria reported to have an intersectoral mechanism in place and five countries

are about to create it. One Member State did not report to create such a mechanism. 16 es

JNI, Nancy, du 10 au 12 juin 2015

Legislation on Antibiotic Stewardship in Slovenia

•Establishment of the intersectorial mechanisms (National antibiotic committee) 2005: ID physicians, clinical microbiologists, pharmacists, veterinarians , IT, a MoH representative •By-laws on antimicrobial consumption surveillance and responsible use of antibiotics 2011: antimicrobial consumption surveillance is mandatory antimicrobial stewardship programmes are mandatory in each hospital audits of antimicrobial stewardship programmes by ICM (since 2013) 14

Official Journal of Slovenia 2011; 21: 1022

-5. 16 es

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Infrastructure in Slovenian Hospitals

•Mandatory AS programme •Antimicrobial committee / drug committe or at least one dedicated person with additional training in AS (in small hospitals) 15 16 es

JNI, Nancy, du 10 au 12 juin 2015

Local

Strategies in Slovenian Hospitals: Audits in 10

Hospitals, Major Findings

(2013 2015)

•The physicians do not receive information on antimicrobial resistance and consumption in the hospital: 4/10

•Poor adherence to guidelines: 7/10 •Indication for antibiotics not in the records: 6/10 •Poor adherence to antibiotic surgical prophylaxis guidelines: 7/8 •No de-escalation: 4/10 •Combination of antibiotics in-appropriate: 5/10 •Missing antibiotic prescribing improvement plan: 4/10 •No guidelines for prescribing "CIA" antibiotics: 6/10 •In-appropriate duration of therapy: 7/10 16 es

JNI, Nancy, du 10 au 12 juin 2015

Recommendations for Antimicrobial Use in Outpatients and Inpatients in Slovenia (1998 - 2013) 16 es

JNI, Nancy, du 10 au 12 juin 2015 18

16 es

JNI, Nancy, du 10 au 12 juin 2015 19

1.55 2.17

16 es

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In hospital Antibiotic Consumption: F vs SI •The French hospitals (2007): 41.1 DDD/100 patient- days •Slovenian hospitals (2007): 50 DDD/100 patient-days Why : Less hospital beds in Slovenia? 20 Amadeo B, et al. J Antimicrob Chemother 2011; 66: 434 -42. www.anbico.si 16 es

JNI, Nancy, du 10 au 12 juin 2015

Antibiotic Consumption in General and University Hospitals in Slovenia in DDD/100 patient-days 21

0102030405060

Tetraciklini (J01A)

Sulfonamidi in trimetoprim (J01E)

Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F)

Drugi beta-laktamski antibiotiki (J01D)

Betalaktamski antibiotiki, penicilini (J01C)

All hospitals included from 2003 onwards

www.anbico.com 16 es

JNI, Nancy, du 10 au 12 juin 2015

Antibiotic Consumption in General and University Hospitals in Slovenia in DDD/1000 admissions 22

050100150200250300350400

Tetraciklini (J01A)

Sulfonamidi in trimetoprim (J01E)

Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F)

Drugi beta-laktamski antibiotiki (J01D)

Betalaktamski antibiotiki, penicilini (J01C)

Aminoglikozidni antibiotiki (J01G)

Amfenikoli (J01B)

All hospitals included from 2003 onwards

www.anbico.si 16 es

JNI, Nancy, du 10 au 12 juin 2015

Antibiotic Consumption in General and University Hospitals in

Slovenia in DDD/1000 admissions

23

050100150200250300350400

Tetraciklini (J01A)

Sulfonamidi in trimetoprim (J01E)

Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F)

Drugi beta-laktamski antibiotiki (J01D)

Betalaktamski antibiotiki, penicilini (J01C)

Aminoglikozidni antibiotiki (J01G)

Amfenikoli (J01B)

All hospitals included from 2003 on

www.anbico.si

INTENSIFICATION OF TREATMENT

16 es

JNI, Nancy, du 10 au 12 juin 2015

Strategies in Ambulatory Antibiotic Use in Slovenia •Education of family physicians during the specialisation curriculum •Education of family physicians provided by Slovenian Medical Association, ICM at the MoH, Health Insurance Institute)

•Restricted prescribing of some antibiotics by the Health Insurance Institute (proposed by professionals)

•Antibiotic pocket-books 24
16 es

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16 es

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31.1
14.5 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Antibiotic Consumption in Slovenia in DDD/1000 Inh/day (DID) 27

0510152025

Tetraciklini (J01A)Sulfonamidi in trimetoprim (J01E)Makrolidni in piranozidni antibiotiki (linkozamidi) (J01F)

Drugi beta-laktamski antibiotiki (J01D)

Betalaktamski antibiotiki, penicilini (J01C)Aminoglikozidni antibiotiki (J01G) 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Consumption of Co

-amoxiclav in Slovenia in DID 28

01234567

www.anbico.si 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Consumption of Co

-amoxiclav in Slovenia in DID 29

01234567

www.anbico.si

Restriction of co-amoxiclav prescribing, if

the indication was not recognized as appropriate, the physician is fined.* *Level and trend change p< 0.001 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Consumption of Macrolides in Slovenia in DID 30

0,000,501,001,502,002,503,003,504,004,50

Telithromicin (J01FA15)

Roksitromicin (J01FA06)

Miokamicin (J01FA11)

Midekamicin (J01FA03)

Klindamicin (J01FF01)

Klaritromicin (J01FA09)

Eritromicin (J01FA01)

Diritromicin (J01FA13)

Azitromicin (J01FA10)

www.anbico.si 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Consumption of Macrolides in Slovenia in DID 31

0,000,501,001,502,002,503,003,504,004,50

Telithromicin (J01FA15)

Roksitromicin (J01FA06)

Miokamicin (J01FA11)

Midekamicin (J01FA03)

Klindamicin (J01FF01)

Klaritromicin (J01FA09)

Eritromicin (J01FA01)

Diritromicin (J01FA13)

Azitromicin (J01FA10)

www.anbico.si

Restriction of macrolides

introduced because of high resistance of pneumococci* *decrease after intervention was not significant 16 es

JNI, Nancy, du 10 au 12 juin 2015

Ambulatory Consumption of Fluoroquinolones in Slovenia in DID 32

0,000,200,400,600,801,001,201,401,601,80

Pefloksacin (J01MA03)

Ofloksacin (J01MA01)

Norfloksacin (J01MA06)

Moksifloksacin (J01MA14)

levofloksacin (J01MA12)

Ciprofloksacin (J01MA02)

Restriction of fluoroquinolones*

*level and trend change <0.001 www.anbico.si 16 es

JNI, Nancy, du 10 au 12 juin 2015

Antibiotic Resistance: France vs Slovenia (2013)

051015202530

E. coli resistant

to 3rd gen cephalosporinsE. coli resistant to fluoroquinolonesK. pneumoniae resistant to 3rd gen cephalosporinsK. pneumoniae non-susceptible to carbapenemsP. aeruginosa resistant to ceftazidimeP. aeruginosa resistant to carbapenemsMRSAS. pneumoniae non-susceptible to penicillinS. pneumoniae resistant to macrolidesE. faecium resistant to vancomycin resistance , sterile samples

France

Slovenia

33
EARS

-net. http://ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/table_reports.aspx

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JNI, Nancy, du 10 au 12 juin 2015

Conclusions: Can Slovenia Serve as an Example

•Good control of antibiotic prescribing in the community, less success in the hospital sector •Relatively high resistance rates (poor health-care resources, fewer hospital beds, less effective infection control?) •Country-wide antibiotic stewardship activities easier to perform in small countries 34
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