Antibiotic Resistance Antibiotic Resistance Prevention And Control Prevention And Control (ARPAC) in (ARPAC) in

European hospitalsEuropean hospitals

Fiona M. MacKenzie (Aberdeen, Fiona M. MacKenzie (Aberdeen, Scotland)Scotland)

ARPAC Steering GroupARPAC Steering Group

““Development of Development of Strategies for Control Strategies for Control

and Prevention of and Prevention of Antibiotic Resistance in Antibiotic Resistance in

European Hospitals”European Hospitals”

What causes antibiotic resistance / HAIs?What causes antibiotic resistance / HAIs?

Policies associated with low antibiotic Policies associated with low antibiotic resistance rates & low rates of resistance rates & low rates of

transmissible pathogenstransmissible pathogens

I.M.G

European Study European Study Group on Group on Antibiotic Antibiotic PoliciesPolicies (ESGAP)(ESGAP)

European Study European Study Group on Group on Epidemiological Epidemiological MarkersMarkers (ESGEM) (ESGEM)

European Study European Study Group on Group on Antimicrobial Antimicrobial Resistance Resistance SurveillanceSurveillance (ESGARS)(ESGARS)

European Study European Study Group on Group on Nosocomial Nosocomial InfectionsInfections (ESGNI)(ESGNI)

VRE

Quinolone-RE. coli

ESBLK. pneumoniae

MRSA

C. difficileQuinolone-R

Aminoglycoside-R Pyo

ARPAC Geographical RegionsARPAC Geographical Regions

Northern Northern EuropeEurope

Southern Southern Europe (+ Europe (+

Israel, Turkey)Israel, Turkey)

Western Western EuropeEurope

Central Central /Eastern /Eastern

Europe Europe + Baltic States+ Baltic States

South-East South-East EuropeEurope

ESGAP

ESGARS

ESGNI

ESGEM

Questionnaires (2001 Questionnaires (2001 data)data)

1. Demographic data & ability to provide data

2. Antimicrobial susceptibility

Antibiotic consumption

3. Antibiotic prescribing

Infection control policies typing

Participation levelsParticipation levels

Demographics Demographics

n = 263 (100%)n = 263 (100%)

Antibiotic Antibiotic susceptibility susceptibility n = 192 (73%)n = 192 (73%)

Antibiotic use Antibiotic use (WH) (WH) n n

= 146 (55%)= 146 (55%)

Antibiotic use Antibiotic use (ICU) (ICU) n n

= 110 (42%)= 110 (42%)

Antibiotic Antibiotic prescribing policiesprescribing policies

n = 169 n = 169 (64%)(64%)

Infection control Infection control policies policies n = 168 (64%)n = 168 (64%)

All data All data

n = 99n = 99

ESGARSESGARS

H. GoossensH. Goossens

ESGARS Steering GroupESGARS Steering Group

Antimicrobial Antimicrobial SusceptibilitySusceptibility

1. Antimicrobial susceptibility testing

2. Breakpoints

3. Quality assurance

4. Detection of specific resistance phenotypes (Alert organisms)

5. Alert organism prevalence data (All patient, ICU patient, blood cultures)

Yes (%) No (%) Missing (%)

167 (88) 20 (11) 2

In 2001, did your laboratory routinely use a disc diffusion AST method?

50% used Oxoid discs

Yes (%) No (%) Missing (%)

132 (70) 56 (30) 1 (1)

In 2001, did your laboratory routinely determine MICs?

82% used E-test

Yes (%) No (%) Missing (%)

165 (87) 21 (11) 2 (1)

Did your laboratory routinely use breakpoints to interpret AST resuts?

84% used NCCLS

MRSA ScreeningMRSA Screening

Disc Disc diffusiondiffusion

Screening Screening platesplates

Used by how many hospitals? 65% 49%

Oxacillin concentration 1 g (89%)

5 g/ml (70%)

NaCl concentration 4% (38%)2% (35%)

4% (60%)2% (18%)

Incubation temperature

Incubation time

35oC (48%)30oC(23%)

35oC (55%)37oC(22%)

24h (53%)48h(16%)

24h (45%)48h(30%)

No data<3%

3 - <10%

10 – 30%

>30%

ARPACARPAC % MRSA in all samples 2001% MRSA in all samples 2001

No data<3%

3 - <10%

10 – 30%

>30%

EARSS EARSS % MRSA in Blood Cultures 99-01% MRSA in Blood Cultures 99-01

ESGNIESGNI

M. StruelensM. Struelens

ESGNI Steering GroupESGNI Steering Group

Infection Control PoliciesInfection Control Policies1. Infection control management

2. Screening for patients with Alert organisms

3. Incidence of Alert organisms

4. Isolation & standard infection control precautions

5. Decolonisation / decontamination

6. Audit & feedback

7. Education

n=168

0

1020

30

4050

60

7080

90

100

% h

ospi

tals

n = 169

Presence of written infection control policy

North West South (IL, TK)

South-East

Central/ East

Hand hygieneHand hygiene Standard precautionsStandard precautions

0102030405060708090

100

% h

ospi

tals

A ll No rth e rn We ste rn S o u th +Isr.+T K S o u th e a st C .+E .+B a lt.S t.

p<0.01

Products used for hand hygiene by region

North West South (IL, TK)

South-East

Central/ East

Medicated / antiseptic Medicated / antiseptic soapsoapAlcohol based solutionsAlcohol based solutions

All

0102030405060708090

100

% h

ospi

tals

A ll No rth e rn We ste rn S o u th +Isr.+T K S o u th e a st C .+E .+B a lt.S t.

Decolonisation procedure for patients / HCWs

PatientsPatients

HCWsHCWs

North West South (IL, TK)

South-East

Central/ East

All

ESGEMESGEM

K. TownerK. Towner

ESGEM Steering GroupESGEM Steering Group

1. Alert organism typing data

The following also comprised a major portion of ESGEM’s work on ARPAC

1. Development of a DNA typing database and data exchange format for tracking antibiotic-resistant micro-organisms

2. Development of standard operating procedures for molecular typing of ARPAC Alert organisms

Alert Organism TypingAlert Organism Typing

0

10

20

30

40

50

60

N o rth w e st c e n tra l/E S E S

MRSA typing carried out in hospital

MRSA typed by reference laboratory

N. Europe W. EuropeCentral / E. Europe + Baltic States

S.E. Europe S. Europe + Israel, Turkey

% Hospitals which carried MRSA typing

Preliminary Typing Data AnalysisPreliminary Typing Data Analysisn=168

MRSA prevalence (n = 167 hospitals)

Any typing (either local or ref. lab) 18.0

No typing 29.5

Typing done in-house 13.7

No typing done in house 27.7

Sent to reference lab 25.1

Not sent to ref. lab 20.2

Median MRSA Median MRSA prevalenceprevalence

(p=0.223)

(p=0.061)

(p=0.051)

ESGAPESGAP

I.M. GouldI.M. Gould

ESGAP Steering GroupESGAP Steering Group

Antimicrobial PrescribingAntimicrobial Prescribing

1. Committees

2. Antibiotic availability

3. Antibiotic policies

4. Education / implementation

5. Audit of antibiotic use

6. Role of the laboratory

7. Role of the pharmacy

n=169

Antibiotic Policies

Do you have a national Antibiotic Policy / Guideline?

Do you have a local Antibiotic Policy / Guideline?

No 54%

No 32%

Yes 33%Yes 63%

Don’t know 13% Don’t know 3%

n = 263n = 263

0%

20%

40%

60%

80%

100%

1

Did you have a drugs & therapeutics committee in 2001?

Missing

No

Yes

n=144

n=23

n=2 Committees

0% 20% 40% 60% 80% 100%

Who sat on the DTC?

Micro / ID specialist, n=116

IC personnel, n=72

ICU physician, n=108

Pharmacist, n=136

0% 20% 40% 60% 80% 100%

Who sat on the antibiotic committee?

Micro / ID specialist, n=88

IC personnel, n=58

ICU physician, n=65

Pharmacist, n=132

0%

20%

40%

60%

80%

100%

n=88

n=76

n=5n=5

Did you have an antibiotic committee in 2001?

0%

20%

40%

60%

80%

100%

Non ICU ICU

Did you have a written antibiotic formulary in 2001?

n = 130 n = 86

n = 35

n = 57

n = 4

n = 26

0%

20%

40%

60%

80%

100%

Did your formulary contain a list of antibiotics for which use is restricted?

n = 70

n = 46

n = 53

n = 101

n = 41

n = 27

Non ICU ICU

Antibiotic Formularies

0%

20%

40%

60%

80%

100%

Antibiotic Policies

In 2001, did your hospital have a written antibiotic policy?

Non ICU ICU

n = 72

n = 69

n = 28

n = 96

n = 67

n = 6

Yes

No

Missing

0%

20%

40%

60%

80%

100%

Did hospitals assess the above?

Prescriber knowledge of antibiotics

Effectiveness of education campaigns

n = 11

n = 32

n = 126

n = 12

n = 29

n = 128

0 %

2 0 %

4 0 %

6 0 %

8 0 %

1 0 0 %

Did hospitals audit adherence to the above?

n = 14

n = 32

n = 123

General antibiotic policy

n = 18

n = 54

n = 97

Restricted antibiotic list

n = 15

n = 50

n = 104

Policy on surgical prophylaxis

n = 17

n = 27

n = 125

Policy on empiric therapy

Audit

ABC CalcAntibiotic Consumption Calculator Version 1.9

Monnet DL. ABC Calc - Antibiotic consumption calculator [Microsoft® Excel application]. Version 1.9 Copenhagen (Denmark): Statens Serum Institut 2003

0

5

10

15

20

10 20 30 40 50 60 70 80 90 100 110 120 More

Antibiotic use data: Distribution (n = 103)Antibiotic use data: Distribution (n = 103)F

requ

ency

Antibiotic use (DDDs / 100 bed-days)

Median = 57

Minimum = 5

Maximum = 111

0

0.5

1

1.5

2

2.5

3

3.5

Fre

qu

en

cy

Antibiotic use data: Geographical area distributionAntibiotic use data: Geographical area distribution

0

2

4

6

8

10

12

14

Fre

qu

en

cy

01

23

45

67

89

10 30 50 70 90 110

More

Fre

qu

en

cy

0

0.5

1

1.5

2

2.5

3

3.5

10 30 50 70 90 110

More

Fre

qu

en

cy

0

1

2

3

4

5

6

Fre

qu

en

cy

Western Europe Northern Europe

Central / Eastern Europe

Southern EuropeSouth / East Europe

0 5 10 15 20 25

1

J01A Tetracyclines

J01B Amphenicols

J01C -lactams, Penicillins

J01D Other -lactams

J01E Sulfonamides & TrimethoprimJ01F Macrolides, Lincosamides, StreptograminsJ01G Aminoglycosides

J01M Quinolones

J01X Other antibacterials

DDDs /100 bed-days

n = 103

0%

20%

40%

60%

80%

100%

E S A C -3 A R P A C -3 E S A C -1 A R P A C -1 E S A C -2 A R P A C -2 E S A C -4 A R P A C -4 E S A C -5 A R P A C -5

J01X

J01M

J01G

J01F

J01E

J01D

J01C

J01B

J01A

E A E A E A E A E ANorth West South (IL, TK) South-East Central/ East

ESAC versus ARPAC Antibiotic Used Data - 2001ESAC versus ARPAC Antibiotic Used Data - 2001

0%

20%

40%

60%

80%

100%

All 3 1 2 4 5

J01DH

J01DF

J01DA-4GC

J01DA-3GC

J01DA-2GC

J01DA-1GC

Relative use of Class J01D (Other Relative use of Class J01D (Other -lactams)-lactams)

North West South (IL, TK)

South-East

Central/ East

All

0%

20%

40%

60%

80%

100%

All 3 1 2 4 5

J01CR

J01CG

J01CF

J01CE

J01CA

Relative use of Class J01C (Penicillins)Relative use of Class J01C (Penicillins)

North West South (IL, TK)

South-East

Central/ East

All

ARPAC @ ECCMIDARPAC @ ECCMID

Monday, May 03, 2004 Monday, May 03, 2004 15:30 - 17:30 h 15:30 - 17:30 h

Small Hall Small Hall

Official symposiumOfficial symposium

Antibiotic resistance, prevention and control Antibiotic resistance, prevention and control in Europein Europe

Invitation

ARPAC Consensus ARPAC Consensus ConferenceConference

““Control of resistance in European Control of resistance in European Hospitals…………Hospitals…………

………………informing future evidence based informing future evidence based practicepractice” ” 

Amsterdam, The Netherlands

22nd – 24th November 2004

www.abdn.ac.uk/arpac

AcknowledgementsAcknowledgements

ARPAC Steering GroupARPAC Steering Group

ARPAC participating hospitalsARPAC participating hospitals

Julie Bruce (Aberdeen)Julie Bruce (Aberdeen)

www.abdn.ac.uk/www.abdn.ac.uk/arpacarpac