An  overview  of  the  South  African  An1bio1c  Stewardship  Programme  

Marc  Mendelson  Division  of  Infec1ous  Diseases  &  HIV  Medicine    

University  of  Cape  Town    

Quality  Improvement  Summit•  28th  October  2013•  CTICC  •  Overview  of  SAASP  

The  Whats  Whys  and  Wherefores  

•  Why  are  we  in  the  posi1on  we  are  in?  

•  What  is  the  global  situa1on?  

•  What  is  the  South  African  situa1on?  

•  What  is  the  response?  

•  What  needs  to  be  done?  

Enzyme  inhibi1on  

 (β-­‐lactamases    

Efflux  pumps  

Protec1on  or  altera1on  of  target  sites  

Overproduc1on  of  target  

Decreased  Permeability  

Bypass  the    inhibited  process  

Mechanisms  of    Resistance  

Selec1on  of  an1bio1c  resistant  bacteria  

An1bio1c    

Sensi1ve  bacterium  

Resistant  bacterium  

replica1on  

1  in  2  prescribed  an1bio1cs    are  unnecessary    

There  is  no  such  thing  as  a  ‘safe  an1bio1c’.    New  Delhi  Metallo-­‐β-­‐lactamase-­‐1  (NDM-­‐1)  Plasmid  

•  Resistance  to  –  β-­‐lactams  –  Aminoglycosides  –  Fluoroquinolones  

•  Mul1ple  efflux  pumps  •  Resistance  gene  to  uv  light  

•  Mobile  inser1on  sequence  i.e.  can  jump  between  plasmids  

Plos  ONE  March  2011;  6(3)  e17989  

Simultaneous  prescrip1on  of  an1bio1cs  in  the  PISA  study  

Paruk  et  al.  SAMJ  2012;  102(7):  613-­‐6  

Example:  1  pa1ent  simultaneously  received:  Cloxacillin  Teicoplanin  Metronidazole  Amikacin  Cecazadime  Meropenem  Levofloxacin  Erythromycin  Co-­‐trimoxazole  Fluconazole  

The  Cri1cal  Balance  

Early,  appropriate  therapy    is  the  key  to  survival  

82% 77%

70% 61%

57% 50%

43%

32% 26%

19%

9% 5%

Time to Appropriate Antimicrobial Rx following Onset of Hypotension (Hrs)

Survival – Patients with Septic Shock

Kumar  et  al.  Crit  Care  Med.  2006  Jun;34(6):1589-­‐96.  

Paruk  et  al.  SAMJ  2012;  102(7):  613-­‐6  

hjp://interna1onal.cgdev.org/page/looking-­‐drug-­‐resistance  

Global  spread  of  NDM-­‐1-­‐producing-­‐Klebsiella  pneumoniae,  as  of  June  2012  

hjp://dx.doi.org/10.3201/eid1710.110655  

Global  burden  of    Health  Care  Associated  Infec1ons  (HCAI)  

WHO  report  on  burden  of  endemic  HCAI  worldwide.  2011  

Europe   United  States  

Affected  Pa1ents   >  4  million   1.7  million  

Annual  ajributable  deaths  

37,000  Contributor  in  addi1onal    110,000  

99,000*  

Direct  Financial  loss   7  billion  Euros   6.5  billion  dollars**  

*2002  data,  **2004  data  

Prevalence  of  HCAI  in    high  income  countries  1995-­‐2010  

WHO  report  on  burden  of  endemic  HCAI  worldwide.  2011  

Prevalence  of  HCAI  in  low-­‐  &    middle-­‐income  countries  1995-­‐2010  

WHO  report  on  burden  of  endemic  HCAI  worldwide.  2011  

OXA-48-like GES NDM

Slide  courtesy  of  Adrian  Brink  

KPC VIM

NDM KPC OXA-48-like VIM

GES

OXA-48-like GES

GES NDM VIM

Witbank

NDM

NDM

Spread  of  Carbapenem  Resistant  Enterobacteriaceae  (CRE)  in  South  Africa  

SAMJ  2012;  102(7):  599-­‐601   J  Clin  Micro  2013;  51(1):  369-­‐72  

Outbreak  of  Oxa-­‐181  Klebsiella  pneumoniae    on  a  Heaematology  Transplant  Unit  

Slide  courtesy  of  Colleen  Bamford  

Outbreak  of  Fatal  MDR  Pseudomonas  aeruginosa    on  a  Heaematology  Transplant  Unit  

Slide  courtesy  of  Colleen  Bamford  

The  Gram  nega1ve  an1bio1c  pipeline  for  the  next  15-­‐20  years  

hjp://www.mistymountaingraphics.com/gallery6.html  

SAASP  Working  Group  Infec9ous  Diseases  

Microbiology   Pharmacy   Infec9on  Control   Dis9nguished  others  

Alan  Karstaedt   Adrian  Brink*   Andries  Gous   Angela  Dramowski    

Andre  Loubscher  (Surgery)  

Cloete  van  Vuuren   Andrew  Whitelaw   Andrieje  van  Jaarsveld  

Adriano  Duse   Andy  Parish  (Medicine,  EDL)  

Heather  Finlayson   Chetna  Govind   Debbie  Goff**   Gary  Kantor  (Best  Care  Always…)  

Dena  van  den  Bergh  (Quality  Leadership)  

James  Nujall   Colleen  Bamford   Sabiha  Essack   Lesley  Devenish   Ivan  Joubert  (ICU)  

Jantjie  Taljaard   Eugene  Elliot   Preshnie  Moodley   Kim  Faure  

Marc  Mendelson*   Mark  Nicol   Shaheen  Mehtar   Maia  Lesosky  (Hosp  Epidemiol)    

Tom  Boyles   Olga  Perovic  

Shameema  Kahn  *Co-­‐chair,  **Interna1onal  Advisor  

Components  of  an1bio1c  stewardship  

•  Knowledge  of  local  resistance  profiles  

•  Appropriate  an1bio1c  use  

•  Effec1ve  Infec1on  Preven1on  and  Control  

 An1bio1c  Stewardship  

 interven1ons    

Front  End   Back  End  

Specialist  interven1on   Stop  orders  

Formulary  restric1on   Therapeu1c  drug  monitoring  

Pre-­‐authoriza1on   Drug  de-­‐escala1on  

Guidelines   Intravenous  to  oral  switch  

The  Power  of  the  Team  

An1bio1c  Prescribing  at  Groote  Schuur  Hospital  

Boyles  et  al.  PLOS  ONE  (in  press)  

An1bio1c  Prescribing  at  Groote  Schuur  Hospital  

Boyles  et  al.  PLOS  ONE  (in  press)  

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hjp://www.fidssa.co.za/images/SAASP_An1bio1c_Prescrip1on_Chart_Feb_2013.pdf  

SAASP  Targets  (1)  •  Meaningful  engagement  with  the  Na1onal  Department  of  Health  

•  Make  An1bio1c  Stewardship  part  of  the  Na1onal  Core  Standards  – All  health  care  ins1tu1ons  to  have  an  AS  commijee  and  an  effector  arm  (the  AS  team)  

– AS  to  become  part  of  a  prac11oner’s  job  descrip1on  with  contractual  obliga1ons  

– Na1onal  An1bio1c  Stewardship  guidelines  and  formulary  restric1ons  

– Dovetail  in  with  na1onal  core  standards  for  IPC  

SAASP  Targets  (2)  

•  Human  resources  planning  

–  ID,  Microbiology,  Pharmacy  and  Infec1on  Control  

•  Iden1fy  AS  champions  within  hospitals  or  

employ  AS  specialists  to  oversee  ac1vi1es  

•  Provincial  AS  taskforces  to  visit  healthcare  ins1tu1ons,  audit  and  change  prac1ce  with  

ongoing  mentorship  

SAASP  Targets  (3)  •  Build  Surveillance  – Mandatory  repor1ng  of  all  drug-­‐resistant  infec1ons  

– Real-­‐1me  feedback    

•  Strengthening  of  related  IPC  ac1vi1es  – Hand  Hygiene  –  Iden1fica1on  and  isola1on  of  pa1ents  colonized/infected  with  resistant  bacteria  

•  Sustained  Public  Health  Campaign  – Pa1ent  &  public  empowerment  

 

hjp://www.fidssa.co.za/A_SAASP_Home.asp  

@southafricanasp