EAAD 2017 – Toolkit for professionals in hospitals and other healthcare settings

What is EAAD?

European Antibiotic Awareness Day (EAAD) is a European health initiative coordinated by ECDC, which aims to provide a platform and support for national campaigns on the prudent use of antibiotics. Each year across Europe, EAAD is marked by national campaigns on the prudent use of antibiotics on or around 18 November.

What are the key messages and how they will be used?

To support communication activities at national level, ECDC has produced several communication toolkits containing template materials and evidence-based key messages which may be adapted for use at national level.

Key messages are the cornerstone of any communication campaign. The key messages for the new toolkit:

-Aim at creating a sense of individual responsibility in tackling antibiotic resistance and at empowering professionals to take action.

-Provide a set of water-tight statements, each of which is accompanied by a reference, that should be used as a basis for the content of the template materials;

-Cover a number of professionals working at hospitals and other healthcare settings: managers/administrators, infectious disease specialists, infection prevention and control professionals, epidemiologists, prescribers, junior doctors and students, pharmacists, nurses, clinical microbiologists, and professionals in emergency departments, in intensive care units, and in long-term care facilities.

The issues surrounding antibiotic resistance may differ in each EU/EEA country. It is important to stress that the template materials developed by ECDC provide core information and common messages, but will be most effective if adapted to respond to the needs and situations in each country, and even each hospital or healthcare setting. Countries could consider leveraging the national antibioticresistance and antibiotic consumption data available from EARS-Net and ESAC-Net respectively, and consulting with national professional associations on the most appropriate tools to be used in their country.

What is “expert consensus”?

When, in this document,a reference to a message is indicated as“expert consensus”, ECDC is referring to the agreement reached in the outlined decision-making process, including ECDC experts’ internal agreement, EAAD TAC members’ opinion, and consultation with external experts and stakeholders.

1.General key messages for healthcare professionals in hospitals and other healthcare settings

What is the problem?

  1. Antibiotic[1] resistance threatens thehealth and safety of patients in all healthcare settings in Europe [1].
  1. The emergence of bacteria resistant to multiple classes of antibiotics is particularly concerning. Such multidrug-resistant bacteria are a real and constant threat to clinical practice in all healthcare settings in Europe [1].
  1. Infections with multidrug-resistant bacteria can be severe, fatal and costly and can directly lead to [2-11][expert consensus]:

a)Delayed access to effective antibiotic therapy for individual patients, causing treatment failures, longer illnesses, prolonged stays in hospital and increased morbidity and mortality;

b)More adverse events, because alternative antibiotic therapies, that are more toxic,must often be used;

c)Fewer effective antibiotic treatments for immunosuppressed patients and those undergoing surgical operations;

d)Reduced quality of patient stay due to anxiety because of the need for rigorous infection control measures;

e)Higher direct and indirect hospital costs.

Examples

- Patients with bloodstream infections have a threefold higher mortality rate, prolonged hospital stays, and higher costs if their infection is due to third-generation cephalosporin-resistant Escherichia coli, compared with third-generation cephalosporin-susceptible isolates[12].

- Patients have a 24% increased risk of mortality with any antibiotic-resistant Pseudomonas aeruginosa infection [13].

- Patients are up to three times more likely to die if their infections is caused by carbapenem-resistant Klebsiella pneumoniae, compared with carbapenem-susceptible isolates[14].

  1. Misusing antibiotics increases the risk of infections with multidrug-resistant bacteria [15].

Example

Gram-negative bacteria, such as Escherichia coli, Klebsiella spp., Pseudomonas aeruginosa, and Acinetobacter spp., are becoming resistant to most available antibiotics [16,17].

  1. Antibiotics are misused when they are prescribed unnecessarily (i.e. antibiotic treatment is not clinically needed) or when they are prescribed inappropriately, i.e. one of the following [18]:

a)Delayed administration of antibiotics in critically ill patients;

b)The spectrum of antibiotic therapy is either too narrow or too broad;

c)The dose of antibiotic is either too low or too high;

d)The duration of antibiotic therapy is either too short or too long;

e)Antibiotic therapy is not reviewed after 48-72 hours, or the choice of antibiotic is not streamlined when microbiological culture data become available.

  1. Misusing antibiotics increases the incidence of Clostridium difficile infections [19-22].

Example

In European hospitals, Clostridium difficile infections can lead to up to a 42% increase in mortality, 19 extradays of hospital stay, and more than EUR 14,000 of additional costs per patient [23,24].

  1. Many prescribers do not know antibiotic resistance prevalence rates in their local setting [25,26], and recognise lacks in their training regarding antibiotic use [27]. Availability of guidelines, consultation with infectious diseases specialist, and trainings represent the most helpful interventions to promote better use of antibiotics [25,27].
  1. Only a few antibiotics in the research and development pipeline maybe effective against existing multidrug-resistant bacteria[28-30].
  1. Losing effective options for the treatment and prevention of infections is a global health security threat[31].

How is our use of antibiotics contributing to the problem

  1. Misuse of antibiotics accelerates the emergence and dissemination of antibiotic resistance [8,31-34].
  1. Antibiotics are given to many hospital inpatients [35,36].
  1. Up to a half of all antibiotic use in European hospitals is unnecessary or inappropriate [6,37,38].
  1. Antibiotic resistance is more likely to develop and spread when[39] [expert consensus]:
  • Broad-spectrum antibiotics are used;
  • Long durations of antibiotics are used;
  • Too low doses of antibiotics are used.

Example

Cephalosporins, carbapenems, fluoroquinolones and anti-anaerobe antibiotics have a high risk of selecting for multidrug-resistant Gram-negative bacteria [40].

  1. Antibiotics have long-term effects on the development and persistence of antibiotic resistance in the microbiota. This resistance may be transferred to other bacteria[41].
  1. Antibiotics are often prescribed to patients in hospitals without explaining the importance of prudent antibiotic use [expert consensus].

Why hospitals should be promoting antibiotic stewardship?

  1. Promoting prudent antibiotic use is both a patient safety and a public health priority [31,42].

Example

Increasingly, many European countries have national guidance on antimicrobial stewardship programmes for hospital prescribers. The ECDC directory (link) contains online resources for developing guidelines.

  1. Antimicrobial management initiatives that promote prudent antibiotic use are called antibiotic stewardship programmes[19,42-45].
  1. Antibiotic stewardship programmes, can contribute to[42,45,46][expert consensus]:

a)Optimising how infections are treated;

b)Increasing infection cure rates and reduce treatment failures;

c)Reducing adverse events from antibiotic use; and

d)Preventing and reducing antibiotic resistance, together with infection prevention and control measures.

Examples[2]

In a recent survey of hospitals that had implemented anantibiotic stewardship programme [47]:

  • 96% hospitals reported reduced inappropriate prescribing;
  • 86% reported reduced use of broad-spectrum antibiotics;
  • 80% reported reduced expenditures;
  • 71% reported reduced healthcare-associated infections;
  • 65% reported reduced length of stay or mortality;
  • 58% reported reductions in antibioticresistance.
  1. Antibiotic stewardship programmes can successfully reduceClostridium difficile infection rates [19,22,43,44,48].

Example

The incidence of Clostridium difficileinfections decreased in the medical and surgical wards of an acute general hospital in the United Kingdom in response to revised empirical antibiotic treatment guidelines for common infections and restrictive measures for fluoroquinolone and cephalosporin usage [48].

  1. Antibiotic stewardship programmes can reduce patient care costs[42,45,46].

Example

In a pooled analysis of antibiotic stewardship programmes, total consumption fell (by 19% hospital-wide and by 40% in intensive care units), overall antibiotic costs were reduced (by about one third), and the hospital length of stay shortened (by 9%). These improvements did not cause any increase in adverse patient outcomes [46].

How do antibiotic stewardship programmes work?

  1. Antibiotic stewardship programmes consist of multifaceted actions, such as [19,42,43,44,48-57]:

a)Leadership commitment: ensuring the necessary resources in terms of staff, technology and budget are available.

b)Appointing leaders that are responsible for the overall programme and for antibiotic use.

c)Hospital-based teams, which include infectious disease specialists, clinical pharmacists and microbiologists, providing support to prescribers;

d)Proactive auditing of antibiotic prescriptions with feedback to team members;

e)Training and education for medical, pharmacy, laboratory, nursing, and non-clinical staff, as well as patients and their families;

f)Using evidence-based antibiotic guidelines and policies;

g)Using restrictive measures for antibiotic prescriptions (e.g., pre-approval and post-authorization requirements for specific antibiotics);

h)Monitoring antibiotic resistance and use, and making this information available to prescribers.

Examples of antibiotic stewardship strategies, actions and outcomes in European countries include:

  1. France - Restricting use of fluoroquinolones reduced consumption of this class of antibiotics and decreased the rate of meticillin-resistant Staphylococcus aureus in a teaching hospital [58].
  1. France – Using information technology support for antibiotic prescriptions decreased antibiotic consumption in many hospitals [59].
  1. Germany - Implementing a computerised decision support system led to higher adherence to locally adapted guidelines, increased antibiotic-free days and reduced mortality over a five-year period in five intensive care units [60].
  1. Hungary - Infectious disease specialist consultation in a surgical intensive care unit, together with a restricted prescribing policy, led to lower use of all antibiotics and a marked reduction in use of broad-spectrum antibiotics [61].
  1. Italy – A four-year infection control programme decreased the incidence of infections and colonisation caused by carbapenem-resistant bacteria in a teaching hospital. The programme included antibiotic stewardship measures targeting carbapenem use[62].
  1. Netherlands – Implementing rapid processing of microbiology tests increased the proportion of patients receiving appropriate treatment within the first 48 hours in a teaching hospital [63].
  1. Netherlands - Case audits for the reassessment of antibiotic use after 48 hours reduced antibiotic consumption and length of stay in a urology ward of an academic hospital, and also had a positive direct return on investment [64,65].
  1. Poland - Developing guidelines for antibiotic prescriptions and pre-authorisation approval for restricted antibiotics decreased total antibiotic consumption in a general paediatric ward [66].
  1. Spain – After only one year, education on guidelines combined with regular feedback led to a 26% improvement in the rate of appropriate treatments, and a 42% reduction of antibiotic consumption at a tertiary teaching hospital [67].
  1. Sweden – Twice weekly audit and feedback in an internal medicine department led to an absolute 27% reduction of antibiotic use , especially of broad-spectrum antibiotics (cephalosporins and fluoroquinolones), as well as shorter antibiotic treatment durations and earlier switching to oral therapy [68].

2.Key messages relevant for all prescribers

Things you can do

  1. Learn and apply all antibiotic use and infection prevention and control recommendations that are relevant to your area of specialisation [expert consensus].
  1. If you see staff members at the hospital or healthcare setting who breach guidelines or protocols, ask them why they are doing so and provide them with tools to understand what they are doing wrong [69] [expert consensus].
  1. Remain aware of local antibiotic resistance patterns in your department, your hospital and in the community[31] [expert consensus].
  1. If in doubt before you prescribe an antibiotic, you should[25,26,53,70][expert consensus]:
  • Check local, regional and national epidemiological data;
  • Seek guidance and advice from a senior colleague or a member of the antibiotic stewardship team.
  1. Ensure that cultures are appropriately taken and send to the microbiology laboratory, before starting antibiotics [31,42,70,71].
  1. Only start antibiotic treatment if there is evidence of a bacterial infection, and do not treat colonisation [31,72].
  1. Avoid unnecessary antibiotic prophylaxis [31,73].
  1. For patients with severe infections, initiate effective antibiotic treatment as soon as possible[31,74].
  1. Document the indication of antibiotic treatment, drug choice, dose, route of administration and duration of treatment in the patient chart[31,42,70,71].
  1. Regularly participate in training courses and in meetings that support the implementation in the hospital of: a) prudent antibiotic use, b) evidence-based, local antibiotic guidelines, and c) infection prevention and control measures [52,53].
  1. Answer the followingkey questions when reassessing antibiotic therapy after 48-72 hours (or as soon as microbiological results are available) [42,70]:

Does the patient have an infection that will respond to antibiotics?

If yes:

  1. Is the patient on the correctantibiotic(s), correct dose, and correct route of administration?
  2. Could an antibiotic with a narrower spectrum be used to treat the infection?
  3. For how long should the patient receive the antibiotic(s)?

3.Key messages for hospital managers / administrators

Tasks

  1. Your tasks related to improving antibiotic use include [31,42,56,71,75]:

a)Establishing a multidisciplinary team for your hospital antibiotic stewardship programme. This team should include infectious disease specialists, clinical microbiologists and pharmacists, and should receive dedicated funding and resources;

b)Supporting implementation of antibiotic guidelines and infection prevention and control measures;

c)Implementing targeted educational activities and training that:

  1. optimise the diagnostic and therapeutic management of patients;
  2. ensure that antibiotic stewardship recommendations are followed;
  3. address behavioural factors shaping misuse of antibiotics;
  4. enhance prevention and control of healthcare-associated infections and the spread of antibiotic-resistant bacteria.

d)Promoting prescribers and antibiotic stewardship team leaders to collaborate and conduct proactive audit and feedback.

e)Setting quality indicators and quantity metrics to measure the progress and outcomes of the antibiotic stewardship programme;

f) Ensuring that antibiotics listed in hospital formulary are always available; and

g) Ensuring that prudent antibiotic use and prevention of antibiotic resistance are “priority action areas” in your hospital’s annual plan.

Things you should know

  1. Antibiotic stewardship programmes, together with infection prevention and control practices,can increase patient safety and quality of care and reduce hospital costs across all services by improving how antibiotics are used, as well as by decreasing C. difficile infections and other adverse events[19,42].

Example

Implementing antibiotic stewardship programmes has resulted in[46]:

  • Reducing antibiotic consumption by 20%,
  • Reducing the incidence of hospital-acquired infections,
  • Shortening the length of hospital stays, and
  • Reducing antibiotic costs by 33%.
  1. Infectious disease specialists, clinical microbiologists, and clinical pharmacists are all key leaders in the antibiotic stewardship team [56,76].
  1. Many prescribers and other healthcare professionals believe their training in prudent antibiotic use is insufficient. They are asking for local antibiotic guidelines, specific education and antibiotic stewardship teams [25,27].
  1. Clinicians are responsible for prescribing and they must be fully engaged in shared decision-making with the antibiotic stewardship team [42].
  1. For antibiotic stewardship teams to be successful, they need the active support of other key professionals in hospitals, such as infection prevention and control professionals, emergency department practitioners, hospital epidemiologists, nurses and IT staff [42,77].
  1. Improving antibiotic use in the emergency department can lead to better antibiotic use across the entire organisation, because the emergency department is a common point of entry to the inpatient setting [77].
  1. Both restrictive measures and persuasive measures can decrease antibiotic use [19,43,54,56]:
  • Restrictive measures include pre-approval and post-authorization decisions for specific antibiotics;
  • Persuasive measures include proactive audit and feedback by infectious diseases physicians, microbiologists and pharmacists.
  1. Antibiotic guidelines and regular educational sessions and rounds improve how physicians manage infections [78].
  1. Certain structural strategies can improve antibiotic prescribing and patient outcomes. Theseinclude[54,79-81]:
  • computer-supported decisions, which link clinical indication, microbiological data and prescribing data together, and
  • use of rapid and point-of-care diagnostic tests.

Things you can do in your hospital or institution

  1. Support your multidisciplinary antibiotic stewardship team by designating the specific leaders for accountability and drug expertise, and by stating the supportive roles of other key groups[42,71].
  1. Prioritise antibiotic stewardship and infection prevention and control policies, as well as strategies and activitiesthat support prudent antibiotic use and prevent the spread of antibiotic-resistant bacteria[31,71].
  1. Provide funds and resources for an antibiotic stewardship programme (including e.g., salaries for dedicated staff, IT capabilities, rapid and point-of-care diagnostic tests)[31].
  1. Fund and promote educational activities, training, and meetings about antibiotic stewardship and antibiotic resistance for all healthcare professionals (physicians, infectious disease specialists, pharmacists, microbiologists and nursing staff)[19,53,56].
  1. Strengthen surveillance activities for antibiotic use and antibiotic resistance[56].
  1. Promote compliance with evidence-based guidelines for diagnosing and managing common infections, and for perioperative antibiotic prophylaxis. If these guidelines do not exist in your hospital, then support their development[31,54,56].
  1. Promote using local microbiology and antibiotic resistance patterns to inform guidelines and empirical antibiotic choices[31].
  1. Promote compliance with evidence-based guidelines for infection control measures, to reduce transmission of antibiotic-resistant bacteria[82].
  1. Promote proactive audits and ensure that individual prescribers receive feedback[54,56].
  1. Promote peer-review of antibiotic prescriptions and infection management, and encourage communication among healthcare professionals[71].

4.Key messages for hospital infectious disease specialists

Tasks

  1. Your tasks related to improving antibiotic use include[31,56,68,71,83]:

a)Participating in the antibiotic stewardship team, as a key member of the team;