Antibiotic Review Kit - Hospital (ARK-hospital) Mar$n Llewelyn Brighton and Sussex Medical School The challenge of 45 antibiotic resistant 40 GNRs in the UK 2010 2011 35 Rates of resistance to key agents… 2012 2013 Gentamicin 30 2014 Ciprofloxacin t n a t Co-amoxiclav s i25 s e r Piperacillin – tazobactam s e t a l20 ….now compromise reliability as o s I % empiric treatment choices 15 46% of E. coli bacteraemia isolates 10 now reported as co-amoxiclav resistant 5 0 E. coli - Co-amox K. pneumoniae - Pip-tazo English surveillance programme for anPmicrobial uPlisaPon and resistance (ESPAUR) report 2015 Antibiotic consumption correlates with antibiotic resistance Log odds of penicillin resistance in Strep. pneumoniae Defined Daily Doses of beta-lactam anPbioPcs / 1000 populaPon Bronzwae S et al 2002 Emerg Infect Dis Antibiotics also place individual patients at risk of resistant infection •  Explored relaPonship between prior anPbioPc use and anPbioPc resistance •  Reviewed 24 studies –  19 ObservaPonal •  Urinary InfecPons –  5 RCTs •  Respiratory Tract infecPons –  >27,000 parPcipants Forest plots of included studies SubstanPal LasPng Impact on risk of resistant infecPon Urinary InfecPon Respiratory Tract InfecPon 5 Giving less antibiotics reduces this risk 1. Chastre J et al JAMA 2003 •  401 paPents with VAP on 51 French ICUs •  Randomized to 8 vs 15 days anPbioPc treatment •  Short course paPents had •  equivalent outcomes on every safety measure •  half as much anPbioPc exposure •  Lower risk of resistant re-infecPon 2. Singh N et al Am J Respir Crit Care Med 2000 1. 81 paPents treated for suspected VAP randomised to review and revise at 3 days or standard course 2. Lower risk of resistance / super-infecPon in the review and revise group (15 vs 35% p = 0.017). Giving less antibiotic probably improves clinical outcome Effect on mortality of anPbioPc de-escalaPon Concluded: Lower use of antibiotics probably does not increase mortality and likely reduces length of stay. Interventions were successful in safely reducing unnecessary antibiotic use in hospitals, despite the fact that the majority did not use the most effective behaviour change techniques. Overall 56% (95% CI 34-70%) REDUCED risk of mortality with AnPbioPc de-escalaPon strategies For common indications minimum durations of treatment have not been established Recommended course dura$ons have fallen There is a lack of evidence that recommended duraPons are superior to anPbioPc-sparing approaches* *w/excepPon of oPPs media, Hoberman A et al New Eng J Med. 2016;375:2446-2456 And yet it appears to be very hard to reduce antibiotic use in hospitals Hospital antibiotic use in England Total and broad-spectrum an$bio$c prescribing NHS England 2010 - 2014 Consump$on of systemic an$bacterials in the hospital sector in Europe 2014 180.0% UK 160.0% 140.0% 120.0% % CHANGE IN DDDS PER 1000 100.0% INHABITANTS PER DAY 80.0% RELATIVE TO YEAR 2010 60.0% 40.0% 20.0% 0.0% 2010 2011 2012 2013 2014 Piperacillin-tazobactam 100.0% 112.8% 130.4% 145.9% 161.7% Carbapenem (inpatients) 100.0% 113.6% 120.4% 130.6% 141.3% Total antibiotics (inpatients) 100.0% 103.2% 107.8% 111.9% 115.3% hlps://www.gov.uk/government/uploads/system/uploads/alachment_data/file/477962/ hlp://ecdc.europa.eu/en/healthtopics/anPmicrobial_resistance/esac- ESPAUR_Report_2015.pdf (accessed August 2016) net-database/Pages/AnPmicrobial-consumpPon-rates-by-country.aspx (accessed August 2016) Courtesy of Dr Kieran Hand