translating challenges into opportunities: preventing ......stop overuse of antibiotics in humans...

Stop overuse of antibiotics in humans – rational use Dominique L. Monnet, Senior Expert and Head of Disease Programme Antimicrobial resistance and Healthcare-associated infections (ARHAI) European Centre for Disease Prevention and Control

Copenhagen, 15 March 2012

Scenario planning: key certainties

• Antibiotic resistance will exist as long as antibiotics are used

• New resistance mechanisms will necessarily emerge

• Antibiotics will always be misused to a certain extent

• Compliance with hand hygiene and other infection control measures will never be 100%

Photo: FreeFoto.cm

Disclaimer: The expert opinion expressed on this slide is personal and may not be understood or quoted as being made on behalf of or reflecting the position of ECDC.

Antibiotic resistance: a battle that we can can win?

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1000 1200 1400 1600 1800 2000 Car

bo

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ioxi

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PM

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Carbon dioxide mixing ratio in ice cores, Antarctica (PPM)

Antibiotics discovered

Source: Etheridge et al. (CSIRO), Carbon Dioxide Information Analysis Center, http://cdiac.ornl.gov; Danish Staphylococcus Reference Laboratory, Statens Serum Institut, Denmark; and EARSS/EARS-Net.

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MR

SA (

%)

MRSA, Denmark (blood, %, Y-2 axis)

MRSA, EU (blood and CSF, population-weighted %, Y-2 axis)

Prevention and control of AMR

Activities in only a few countries

Activities in many countries

No

Yes

Scenario planning: uncertainties and implications

Ne

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• Must rely on rational use of existing antibiotics and on infection control

• Mitigation an achievable goal?

• Must rely on rational use of existing antibiotics and infection control

• Increase awareness among new generations

• New antibiotics always essential

• Focus on rational use of new and other antibiotics

• Re-emphasise infection control

• Market for new antibiotics mostly empiric treatment of severe inf.

• Focus on detection and control of emerging AMR

• Re-emphasise rational use of antibiotics


What is rational use of antibiotics in human medicine?

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• No self-medication

• Only when prescribed by a medical doctor (or a nurse)

• Only when indicated

• Correct dose

• Correct dose intervals

• Correct duration

Antibiotics obtained without a prescription EU Member States, 2002 & 2009

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Aust

ria

Belg

ium

Bulg

aria

Cypru

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ece

Hungary

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Italy

Latv

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Lithuania

Luxem

bourg

Malta

Neth

erlands

Pola

nd

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ugal

Rom

ania

Slo

vakia

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venia

Spain

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eden

UK

Resp

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who o

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without

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resc

ription

at

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harm

acy

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(%

)

Eurobarometer (2002)

Eurobarometer (2009)

Source: European Commission, Eurobarometer. In: Lancet Infect Dis 2012 Mar;12(3):182-3.

Sales of antibiotics without prescription: SWOT analysis

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Strengths Weaknesses

• EU Directive transposed in the national law of each individual Member State

• Some Member States are taking action

• Varying levels of law enforcement

• National habits and cultural differences (can law be enforced when the public and professionals are not aware of the need for change?)

• Potential savings for national insurance systems (prescription-only medicines obtained OTC often are reimbursed)

• Pressure for change of some antibiotics from prescription- only medicine to pharmacy (POM-to-P) status (already in UK for azithromycin for proven Chlamydia infection)

Opportunities Threats

A.C.T.I.O.N.

A.C.T.I.O.N.


Impact of regulation on ”prescription only” sales of antibiotics, Chile

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• Sep. 1999: regulatory measures introduced as part of ”Action plan to assure rational Antibiotic Use”, incl.: • Restriction of antibiotic sales to prescription-only

• Enforced supervision by regulatory authorities

• Public campaign, leaflets and posters in pharmacies

• 1998 to 2002: sales of oral antibiotics decreased by 43%

• Since 2002: increase to a level close to the 1997 baseline

• Need for other concomitant interventions, e.g. improving the knowledge and attitudes of consumers and prescribers

Source: The evolving threat of antimicrobial resistance. WHO, 2012.

Total outpatient antibiotic use (ATC J01) in 29 European countries, 1998-2005

9 Source: ESAC, 2007. Adapted from: Muller A, et al. Eurosurveillance (11 October 2007)

*Total use for Bulgaria and Iceland, and for Greece (2004 & 2005 only). **Reimbursement data, which do not include over-the-counter sales without a prescription.

National media campaign

National media campaign

Media coverage

Media coverage

Education prog. for paediatricians

Education prog. for paediatricians

Decreases in antimicrobial resistance following national media campaigns

10 Source: French Nat. Ref. Ctr. for S. pneumoniae (Courtesy: E. Varon, L. Gutmann & B. Schlemmer) & Belgian Nat. Ref. Ctrs. for S. pneumoniae and for S. pyogenes (Courtesy: BAPCOC, H. Goossens)

Awareness campaigns on the prudent use of antibiotics / AMR: SWOT analysis

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• Several examples of best practice in Member States

• European Antibiotic Awareness Day (antibiotic.ecdc.europa.eu)

• Cultural differences between Member States

• Must be repeated every year

• Potential large savings for national insurance systems (8€ saved for 1€ invested)

• Use national culture characteristics as levers for change

• ”Campaign fatigue” (need to regularly vary and update key messages)

• Communicating on AMR (rather than prudent use) may lead to more prescriptions


A.C.T.I.O.N.

A.C.T.I.O.N.


Educational programmes for the public and for professionals: SWOT analysis

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• Several examples of best practice in Member States

• e-Bug programme for junior/senior school children (www.e-bug.eu)

• Eurobarometer (as a measure of knowledge of general public)

• Limited space in various curricula (schools, universities)

• Limited public funds available for continuous education of professionals (in many Member States)

• Increasing interest (general public, media, parents, school teachers, professional societies, media)

• New technical possibilities (phone apps, social networks)

• Limited sustainability of e-Bug (after end of EU project)

• Pressure for direct-to- consumer advertising for prescription-only medicines


A.C.T.I.O.N. A.C.T. I.O.N.


Financial incentives/disincentives: SWOT analysis

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• Several examples from Member States: - BE: perioperative prophylaxis - DK: delisting of antibiotics - FR: free Strep test for GP - DK: extra income for rapid diagnostic tests

• Most antibiotics are available as (cheap) generics

• In hospitals, the costs of antibiotics do not necessarily impact the hospital budget (depending on the country)

• Potential savings for national insurance systems (if incentives/disincentives are properly placed)

• Professionals and the public may resist change if perceived as done only for saving costs


A.C.T.I.O.N.


Effects of delisting of fluoroquinolones (mainly ciprofloxacin), Denmark

Source: Danish Medicines Agency, 2006 & Jensen US, et al. JAC 2010;65:1286-91.

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EL CY* FR IT LU BE SK PL PT MT° IE LT* ES** IS BG CZ FI UK HU DK AT NO DE SI SE NL EE LV

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Penicillins (J01C) Cephalosporins and other beta-lactams (J01D)

Tetracyclines (J01A) Macrolides, lincosamides and streptogramins (J01F)

Quinolones (J01M) Sulfonamides and trimethoprim (J01E)

Other J01 classes

Source: European Surveillance of Antimicrobial Consumption (ESAC), 2011.

Outpatient antibiotic (J01) use, by antibiotic class according to ATC classification, 2009

* Total use, i.e. including inpatients, for Cyprus and Lithuania.

** Reimbursement data, i.e. not including over-the-counter sales without a prescription, for Spain

Malta: 2008 data

Targets / benchmarking of antibiotic consumption: SWOT analysis

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• Clear message about the objective (size of decrease, by a certain date)

• A few Member States are taking the lead

• Choice of target may be difficult (e.g., size of achievable decrease? measurement unit?)

• Potential large savings for national insurance systems

• Uncertainty about antibiotic consumption threshold below which the number of adverse effects due to non prescription of antibiotics (to patients who really need them) would increase


A.C.T.I.O.N.


Rapid diagnostic tests: SWOT analysis

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• Several positive experiences from Member States

• Contributes to a more rational use of antibiotics

• Implementation may vary depending on country (who performs the test? who pays for the test?)

• Potential savings for national insurance system

• Business opportunity

• Misuse of test may result in increasing expenses for national insurance system (potential threat)


A.C.T.I.O.N.


Vaccines: SWOT analysis

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• Several examples from Member States and other countries (pneumococcal conjugate vaccine)

• Reduces burden of the disease covered by vaccine

• Serotype replacement means need for new vaccines

• Cost of vaccination (for national insurance system or for the patient if not reimbursed)

• Not for healthcare-associated infections (so far)

• Business opportunity

• Difficult-to-reach populations in most countries

• Should not distract us from working at improving use of antibiotics


A.C.T.I.O.N.


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Time for ACTION Reducing overuse

Awareness and education: prudent use (primary care, healthcare settings)

Commitment: professional, individual, political

Targets / benchmarking: primary care, hospitals

Incentives: rapid diagnostic tests, absence from work for sick child, vaccination

One-to-one relationship: patient/doctor

No self-medication

translating challenges into opportunities: preventing ......stop overuse of antibiotics in humans...

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