Professor Barry Cookson

Division of Infection and Immunity, Division of Infection and Immunity, Univ. College LondonUniv. College London

Antimicrobial StewardshipReflections on International Efforts

Antimicrobial Stewardship

Infection Prevention &

Control

ECDC AMR Strategy

New Diagnostics, Antibiotics and

Treatments

Prioritisation of R&D &

Interventions:Organisational& Behavioural

Training/Education:Professio-

nals & Public

AMR & AB Usage

Surveillance

International Collaboration

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, resourcesPittet et al, Considerations for a WHO European strategy…. The Lancet Infectious Diseases 2005; 5: 242-250.

Kenneth CalmanClinical Governance & Total Quality Management

Liam DonaldsonWHO Patient SafetySally Davies

UK Representative WHO Executive 2014

AMR Strategy Champion?

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 Areahttp://en.wikipedia.org/wiki/European_Free_Trade_Association#Current_members

““In England (~2005) we make hospital acquired infection In England (~2005) we make hospital acquired infection (HAI) rates publically available by named hospital”(HAI) rates publically available by named hospital”

After the initial shock around Europe: After the initial shock around Europe: in 2012 6/28 European countries are doing this!in 2012 6/28 European countries are doing this!

Publication of hospital specific HAI infection ratesCookson et al, J Hosp Infect 2011: 79; 260-264

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 e.g. early warning of notifiable nosocomial events.

• Public reporting of agreed indicators e.g. composite structure and process indicators or HAI rates e.g. France, England

Vive la DiffVive la Difféérencerence

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 79% 7% 2% 2%

Surveillance 79% 11% 1% 2%

Education 79% 14% 1% 3%

Resources 79% 15% 2% 5%

Overall AveragesOverall Averages 80% 11% 2%80% 11% 2% 3% 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 SANCOEU Networks

EARSSEARSS:: European Antimicrobial European Antimicrobial

Resistance Surveillance Resistance Surveillance Scheme Scheme

ESACESAC:: European European Surveillance of Surveillance of AntimicrobialAntimicrobial ConsumptionConsumption

HELICSHELICSHospitals in Europe Link Hospitals in Europe Link

for Infection Control for Infection Control through Surveillancethrough Surveillance

ECDCECDC

unofficialunofficial19931993

20002000

HELICSHELICS20082008

Embedded in Improving Embedded in Improving Patient Safety in EuropePatient Safety in Europe

(IPSE) 2005(IPSE) 2005

20022002

C section (n= 12 124) HELICS-associated national networks (2000-2003)

0

1

2

3

4

5

6

7

8

9

10

A B C D E F

SSISSIraterateperper100100op.op.

Anonymised Anonymised CountriesCountries

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 studiesNeed 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

2 Countries with a significant increase (2005–2007)

8 Countries with a significant decrease (2005–2007)

MRSA (%)

No

. of c

ou

ntri

es

0 10 20 30 40 500 10 20 30 40 50

EARSS-ECDCEARSS-ECDC

Alcohol hand rub consumption in acute care hospitals, ECDC PPS 2011-2012

Structure and process indicators: Structure and process indicators: percentage of single room bedspercentage of single room beds

Single room beds in participating hospitals (%): median = 11.1%Single room beds in participating hospitals (%): median = 11.1%

Source: Source: ECDC, 2012 (ECDC PPS data as of 23/11/2012)ECDC, 2012 (ECDC PPS data as of 23/11/2012)

0 20 40 60 80 100N of single room beds*100 /Total beds

UK-WalesUK-Scotland

UK-Northern IrelandUK-England

SwedenSpain

SloveniaSlovakiaRomaniaPortugal

PolandNorway

NetherlandsMalta

LuxembourgLithuania

LatviaItaly

IrelandIceland

HungaryGreece

GermanyFranceFinlandEstonia

DenmarkCzech Republic

CyprusCroatia

BulgariaBelgiumAustria

*Poor data representativeness*Poor data representativeness

Prevalence of antimicrobial use in acute care hospitals, ECDC PPS 2011-2012

*Poor PPS data representativeness*Poor PPS data representativeness

Seven Key Areas

3) improving professional education, training and public engagement

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

2013

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 AMRresearch 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 networkHarmonisation 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 2011-2016Studies 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”A “Perfect Storm”Companies withdrawing from antimicrobial market as:Companies withdrawing from antimicrobial market as:

•New drug development expensiveNew drug development expensive•Resistance, not just side effects, a huge challengeResistance, not just side effects, a huge challenge

•Patient numbers often relatively small & regimens shortPatient numbers often relatively small & regimens short•Patents short-livedPatents short-lived

Founded Founded in 2007in 2007

Spreading the Spreading the costs of R&D 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)

Trans Atlantic Task Force Recommendations Future Collaborations (2)