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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
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““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”
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What causes antibiotic resistance / HAIs?What causes antibiotic resistance / HAIs?
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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
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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)
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VRE
Quinolone-RE. coli
ESBLK. pneumoniae
MRSA
C. difficileQuinolone-R
Aminoglycoside-R Pyo
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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
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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
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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
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ESGARSESGARS
H. GoossensH. Goossens
ESGARS Steering GroupESGARS Steering Group
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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)
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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
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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%)
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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
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ESGNIESGNI
M. StruelensM. Struelens
ESGNI Steering GroupESGNI Steering Group
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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
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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
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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
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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
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ESGEMESGEM
K. TownerK. Towner
ESGEM Steering GroupESGEM Steering Group
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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
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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
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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)
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ESGAPESGAP
I.M. GouldI.M. Gould
ESGAP Steering GroupESGAP Steering Group
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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
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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
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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?
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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
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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