hong kong training portal on infection control and infectious disease - sharing of amr ... sharing...
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Sharing of AMR control in local public hospital - hurdles and ways to overcome
Vincent CC Cheng MBBS (HK), MD (HK), MRCP (UK), PDipID (HK), FRCPath,
FHKCPath, FHKAM (Pathology)
Consultant & Infection Control Officer, Queen Mary Hospital Hon Associate Professor, Department of Microbiology,
The University of Hong Kong
Worldwide Concern on Improving the containment of Antibiotic Resistance
(2001)
http://www.cdc.gov/
http://www.who.int/en/
http://www.idsociety.org/
“Antibiotics” - “Societal drugs”
MRSA (1980s)
Evolution of antimicrobial resistance
(抗菌素耐藥性的演變)
VRE (1990s)
ESBL
(1990s)
Carbapenemase:
Class A: KPC
Class D: Oxa
Class B (metallo-b-lactamase): IMP, VIM, NDM
(2000s) 耐甲氧西林 金黃色葡萄球菌
耐萬古黴素腸球菌
廣譜β內酰胺酶腸桿菌科細菌
碳青黴烯酶
Inverse trajectory of declining antibiotic development
Selective pressure for
more MDROs
Use of broad
spectrum antibiotics
Emergence of MDROs
Antimicrobial stewardship & optimization program: patient safety vs public health concern
S. aureus
Penicillin
[1950s] Penicillin-resistant
S. aureus
Evolution of Drug Resistance in S. aureus Methicillin
[1970s] Methicillin-resistant S. aureus (MRSA)
Vancomycin-resistant enterococci (VRE)
Vancomycin
[1990s]
[1997]
Vancomycin intermediate-
resistant S. aureus (VISA)
2002 Vancomycin
resistant S. aureus
Know when to say “no” to vanco
Glycopeptide (vancomycin, teicoplanin) usage in Queen Mary Hospital before and after antibiotic auditing
Department of Medicine except BMT/ICU
Other departments
Immediate concurrent Feedback (ICF)
Br J Clin Pharmacol. 2001 Oct;52(4):427-32.
Overall prevalence of ESBL for K.pneumoniae and E. coli among all isolates in Queen Mary Hospital
Data from Dept of Microbiology, QMH
Big-Gun antibiotic audit (2002)
‘Big Gun’ Antibiotics in General Wards
‘Big Gun’ Antibiotic
Appropriate Reason for Preference
Invasive Infection Rx (Known /Suspected
Pathogen) Empirical Rx
Imipenem Atypical Mycobacteria* e.g. M. chelonae
1. Neutropenic fever (Quant’ & Qual’)
2. Fever in Transplant recipient on immuno-supression + +
3. Severe sepsis 4. Deteriorating or fever
persisting ≥72h
ESBL (or AmpC β-lactamase) producing organisms
Meropenem Cefepime
Ceftazidime 1. P.aeruginosa†
2. Melioidosis
Tazocin P.aeruginosa†
Preferably with:- other drugs* ; an aminoglycoside†; a macrolide or doxycyline ‡
0
20
40
60
80
100
120
140
160
CeftazidimeCefepimeTienamMeropenemTazocinSulperazon
Ceftazidime 8.7 7.6
Cefepime 22 51
Tienam 5.9 6.5
Meropenem 4.1 8
Tazocin 17.9 56.1
Sulperazon 7.1 6.2
2002 2003
Use of broad-spectrum antibiotics in ALL Specialties (exclude BMT) in QMH
DD
D p
er 1
000
patie
nt b
ed d
ays
Data from Clinical Pharmacy, QMH
Tazocin
F / 67 AML (diagnosed 4/08)
Chemo (4/08) Fever
Admit: 4 Jul 08
WBC
HGB
PLT
Neu
Lym
Mon
Eso
Baso
4 Jul 08
9.80
10.9
44
6.80
1.30
4.60
0.10
0
Range
4.4 – 10.10
11.7 – 14.8
170 - 380
2.2 – 6.7
1.2 – 3.4
0.2 – 0.7
0.0 – 0.5
0.0 – 0.1
Units
10^9/L
10^12/L
10^9/L
10^9/L
10^9/L
10^9/L
10^9/L
10^9/L
M/77 Past health :
IHD PTB Bronchiectasis BPH
fever for 2 days chills and rigor dysuria, hematuria nausea and vomiting
T 38 C, BP 130/80, P 79/min Chest clear Abd mild loin tenderness on
L side WCC 15.4 Cr 123 Septic workup done
Augmentin Tazocin
Antibiotic stewardship program
Augmentin Tazocin
Physician Immediate Concurrent Feedback
Baseline period
Percentage of conformance &
compliance
Usa
ge d
ensi
ty o
f ant
ibio
tics
(per
1,0
00 b
ed-d
ay-
occu
panc
y) &
cru
de m
orta
lity
(per
100
adm
issi
on)
0
10
20
30
40
50
60
70
80
1Q2004
2Q2004
3Q2004
4Q2004
1Q2005
2Q2005
3Q 2005
4Q 2005
1Q2006
2Q2006
3Q2006
4Q2006
1Q2007
2Q2007
3Q2007
4Q2007
0
10
20
30
40
50
60
70
80
90
100
Piperacillin-tazobactam Cefoperazone-sulbactam CeftazidimeCefepime Imipenem-cilastatin MeropenemConformace to guideline Compliance to memo ICF Compliance to phyisician ICFCrude mortality rate (per 100 admission)
Overview of the ASP in a 3-year study period (2005 – 2007)
Eur J Clin Microbiol Infect Dis. 2009 Dec;28(12):1447-56.
Ming Pao 18 Feb 2006
The Antibiotic Stewardship Program Hospital Authority
The Implementation Committee on Antibiotic Stewardship Program
HAHO
Crud
e ep
isode
of E
. col
i bac
tere
mia
(ESB
L +
/ -)
Annual rate / incidence per 10,000 hospital admission
J Antimicrob Chemother. 2012 Mar;67(3):778-80.
ESBL-positive E. coli bacteraemia in Hong Kong, 2000-2010
0
2
4
6
8
10
12
14
16
1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 20080
5
10
15
20
25
30
35
MDR rate Cumulative incidence Incidence density
Int J Antimicrob Agents. 2010 Nov;36(5):469-71.
Changes in the rate, cumulative incidence and incidence density of MDR-AB according to definition: resistance to carbapenems class (imipenem, meropenem)
MDR rate as defined by the annual MDR-AB rate among all A. baumannii isolates
Cumulative incidence as defined by the annual number of MDR-AB isolates per 10,000 hospital admissions
Incidence density as defined by the annual number of MDR-AB isolates per 100,000 patient-days
MD
R rate
Cum
ulat
ive
inci
denc
e &
inci
denc
e de
nsity
Antibiotic stewardship program in Queen Mary Hospital
Recommendation:
Empirical regimen of “A T & I” or “A T & T”
Stable patients: Amoxicillin / clavulanate (Augmentin®) as first line therapy
Not responding to first line therapy: Ticarcillin / clavulanate (Timentin®)
Critically ill patients: Imipenem / cilastatin (Tienam®)
Observation:
↑ consumption of meropenem & piperacillin / tazobactam in QMH > HA hospitals
Data from CDARS, HAHO
65.52 (in 2010) ↓ 18% 67.99 (2011)
Big Gun antibiotics consumption (6 Big Gun & Van / Lin) in QMH (MED / SUR / ORT / ONC / ICU & HDU) (DDD per acute 1000 BDO)
80.32 (in 2009)
Data from CDARS, HAHO
59.73 (in 2010) ↓ 18%
60.9 (2011)
Big Gun antibiotics consumption (6 Big Gun & Van / Lin) in HKWC (MED / SUR / ORT / ONC / ICU & HDU) (DDD per 1000 BDO)
73.09 (in 2009)
Antibiotic Stewardship Program (AT&T in 2010-2011)
Drugs with similar pharmacodynamic / kinetic profile / susceptibility profile
Daily cost: $ 222.6
Daily cost: $ 163.5
Daily cost: $ 318
Daily cost: $ 222
Antibiotic Stewardship Program vs Cost-Effective Usage
Drugs with similar pharmacodynamic / kinetic profile / susceptibility profile
Daily cost: $ 66.6
Daily cost: $ 163.5
Daily cost: $ 90
Daily cost: $ 189
???????
???????
Consumption of Big Gun Antibiotics in All Specialties at 7 Hospitals of HA (2012) U
sage
den
sity
(div
ided
dai
ly d
ose
per 1
000
bed-
day-
occu
panc
y)
[Cefepime, Ceftazidime, Linezolid (oral & intravenous), Meropenem, Piperacillin/tazobactam, Cefoperazone/sulbactam, Impenem/cilastatin, Vancomycin]
A B C D E F QMH HA overall Data from CDARS
Consumption of ALL Broad Spectrum Antibiotics with potential for selecting MDROs in All Key Specialties (ICU & HDU / MED / ONC / ORT / SUR) at 7 Hospitals of HA (2008 - 2013)
Usa
ge d
ensit
y (d
ivid
ed d
aily
dos
e pe
r 100
0 be
d-da
y-oc
cupa
ncy)
[Cefepime, Ceftazidime, Cefoperazone/sulbactam, Piperacillin/tazobactam, Meropenem, Impenem/cilastatin, Vancomycin, Linezolid (iv/po), Cefotaxime, Ceftriaxone, Ciprofloxacin (iv/po), Levofloxacin (iv/po), Moxifloxacin (iv/po), Ofloxacin (iv/po), Piperacillin, Ticarcillin/clavulanate]
Data from CDARS
A B C D E F HA consumption QMH
Inappropriate Appropriate use of “Big Gun” antibiotics
87% (1208/1383) 46%
(1383/3001)
On “Big Gun” antibiotics N=3001
Microbiology & Infectious Disease Consultation between 1 Jan and 31 Jul 2014 (Queen Mary Hospital)
Integration of ASP into daily clinical consultation
IMPACT Guidelines (Third Edition)
Local Key References for • Antibiotic resistance • Antibiotic stewardship program • Selected antimicrobial use • Empirical Rx of common infections • Known-pathogen therapy • Surgical prophylaxis • Cost & dosage of antimicrobials
Click here to view full guidelines
http://ha.home/ho/ps/impact.pdf
IV to oral switch Fluoroquinolones
Ciprofloxacin
Levofloxacin
Moxifloxacin
Bioavailability ~99% Bioavailability ~90% Bioavailability ~70-80%
IV to PO regimen 200mg IV q12h 250mg PO q12h 400mg IV q12h 500mg PO q12h 400mg IV q8h 750mg PO q12h
IV to PO regimen The Oral and IV route
of administration is interchangeable
IV to PO regimen 400mg IV q24h 400mg PO q24h
After IV to oral switch…
Ongoing ICF Unjustified Antibiotic
Combination
Rectified ?
Not Rectified ?
Trust and collaboration