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TRANSCRIPT
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
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
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.
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
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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