IMPACTO DE INTERVENCIONES EDUCACIONALES

EN USO DE ANTIBIOTICOS

Dr. Luis Bavestrello ExCoordinador Comité Antimicrobianos Sochinf

Presidente Asociacion Panamericana de Infectologia

Viña del Mar-Chile

DISCLOSURES

Respaldo para concurrir a conferencias: Bayer, GlaxoSmithKline, Merck Sharp&Dohme y Pfizer.

Advisory Boards: Bayer, Pfizer y Sanofi-Aventis.

Honorarios como expositor:

Merck Sharp&Dohme y Pfizer.

Agradecimientos

Se agradece por su inestimable aporte de material

Dr Ian Gould

Dr Stephan Harbarth

QF Angela Cabello

Alexander Fleming warned that its benefit might

not last. Accepting the 1945 Nobel Prize in

Medicine, he said:

“It is not difficult to make microbes resistant to penicillin in the laboratory by exposing them to concentrations not sufficient to kill them… There is the danger that the ignorant man may easily underdose himself and by exposing his microbes to non-lethal quantities of the drug make them resistant.”

Resistencia Eritromicina en Streptococo del grupo A, Finlandia

0

0,5

1

1,5

2

2,5

3

3,5

87 88 89 90 91 92 93 94 95 96

Co

nsu

mo

Eri

tro

mic

ina

(DD

D/1

00

0)

Consumo Eritromicina Eritromicina resistente

Fuente: Seppala, NEJM 1997; 337-441

Resisten

cia E

ritrom

icina

(%)

30

25

20

15

10

5

Uso Antibióticos Recientemente

EstudioResistente

(%)

Sensible

(%)

Odds

RatioValor p

Jackson 56% 14% 9.3 0.009

Pallares 65% 17% 9.3 <0.001

Tan 70% 39% 3.7 0.02

Nava 30% 11% 3.5 <0.001

Moreno 57% 4% 3.6 <0.001

Block 69% 25% 6.7 <0.001

Fuente: Dowell. Am Fam Phys 1997;55:1647

Correlación entre Uso reciente de

Antimicrobianos e Infección por el

Pneumococo Resistente

Utilización de Antibióticos, Externo,

EEUU, 1992

Otitis

Media

22%

IRA

16%

Faringitis

12%

Sinusitis

12%

Otros

25%

Bronquitis

13%

(> 120.000.000 Tratamientos)

McCaig, JAMA 1995; 273:214

Reducción Potencial

en uso de Antibióticos

Diagnóstico MensajeReducción

Potencial (%)

Reducción

Potencial (#)

Resfriado

ComúnNo abx 100% 17.922.000

Bronquitis

No infección

específica o

enfermedad de base

80% 13.059.200

Otitis Media No abx para OME 30% 7.094.400

FaringitisNo abx menos que

Strep+50% 6.555.000

Sinusitis No abx <10-14d 50% 6.480.500

TOTAL 46% 51.115.600

Total antibiotic use in ambulatory care (32 countries, 2009 ESAC)

Wirtz V, Dreser A, Gonzales R. Trends in antibiotic utilization in eight Latin American countries, 1997-2007. Rev Panam Salud Publica 27(3),2010.

PLAN DE ACCION

Cumplimiento de la condición de venta de los antimicrobianos.

Información a la población: dípticos y afiche en

Farmacias privadas.

Campaña educativa.

Verificación del cumplimiento de la condición de venta.

Limitaciones

Datos rara vez se publican

Poca información publicada en revistas científicas

Pocas campañas evaluadas formalmente

Verificación de outcomes es difícil

Información rescatada generalmente de

contactos personales

Muchas veces difíciles de establecer

El caso de México: Reacciones Anuncio de cambio regulatorio genera dudas, oposición,

“descuentos” en Ab y apertura de consultorios en farmacias!

“Los antibióticos se venderán con

receta médica ¿Por qué? ¿Con

quién se quieren congraciar? Si

mucha gente no va al médico es

porque no tiene dinero .Y no va al

IMSS porque ahí no tienen

medicinas.”

La razón, 05/2010 Gentileza Anahi Dreser.

January 2010

Sixth Framework

Programme

Asia ?

Geographic overview

22 campaigns 2 Oceania

3 North America

1 Israel

16 Europe

2000 –

1996-2006

1999 –

1995 – 2001, 2003, 2006

1998 –

past

Public campaigns with the aim to

improve antibiotic use in Europe

ongoing

Since 2008

Malta

Israel

2008 • Materials for general public

• 32 countries participated

2009

• Article in Eurosurveillance

• Materials for primary care prescribers

• Website translated in all EU languages, TV spots developed

• 34 countries participated

• 36 countries participated

• Matched Get Smart week in the United States and Canada

http://antibiotic.ecdc.europa.eu

2010: Focus on hospital prescribers

Communication, 2008-2011

Total outpatient antibacterial use in the United States and 27 European countries in 2004

Goossens et al. (2007). Clin Infect Dis 44:1091-5.

21 DID

Campaigns

Mostly in countries with “high“ antibiotic use

17 DID

Overview over national

campaigns

England Andybiotic

Yearly campaign since 1999

Antimicrobial Resistance Strategy and Action Plan (NHS)

about 800’000 €/year

Target

Mothers of children <12 years

Lower socioeconomic class

GPs, pharmacists

Interventions

Posters, pamphlets

Advertisements in national newspapers and magazines

Population

50.5 million

New 2007-2008 campaign: Antibiotics! Do you need them?

http://www.dh.gov.uk/en/Publichealth/Patientsafety/Antibioticresistance/DH_082512

England - Results

Evaluation mainly via telephone surveys

(1999 and 2003)

Survey 2003: 7120 respondents (65%

response rate)

McNulty et al. (2007). J Antimicrob Chemother 59:727-738

Woodhead and Finch (2007). J Antimicrob Chemother 60, Suppl. 1, i53–i55.

McNulty et al. (2007). J Antimicrob Chemother 60, Suppl. 1, i53–i55.

campaign awareness

2000-2002

5.8 reduction in prescribing

(november-march)

Lambert et al. (2007). Can mass media campaigns change antimicrobial prescribing? A

regional evaluation study. J Antimicrob Chemother 59:537-543

Specific Therapeutic group Age-sex Related prescribing unit

5.8% reduction in antibiotic prescriptions

over winter months compared to control

Belgium www.antibiotics-info.be

Population

10.5 million

• Yearly campaign since 2000

– about 385’000 €/year

• Interventions

– Information material

– Treatment guidelines

– TV and radio spots

Courtesy: H. Goossens

Belgium Evolution of bacterial resistance of S. pneumoniae

0

5

10

15

20

25

30

35

40

1991

1993

1995

1997

1999

2001

2003

2005

2007

Year

% o

f is

ola

tes

PNSP

R Ery

Goosens et al. (2008). Euro Surveill 13 pii: 19036.

PCV-7 1st campaign

Antibiotic Resistance of Throat Isolates of

S. pyogenes in Belgium (2002 – 2007)

0

2

4

6

8

10

12

14

16

18

2002 2003 2004 2005 2006 2007

year

per

centa

ge

erythromycin

National Reference Centre S. pyogenes (University of Antwerp) Courtesy: H. Goossens

“Antibiotics Are Not Automatic”

Yearly campaign since 2002

About 4 million €/year

Interventions

Ads on TV, radio, newspaper

Information leaflets, internet campaign, exhibitions

Academic detailing, promotion of streptococcal rapid

antigen test, treatment guidelines

France www.antibiotiquespasautomatiques.com

IMS Health, France

Antibiotic prescriptions in France,

stratified by age groups

0

10

20

30

40

50

60

70

80

90

100

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

% o

f co

nsu

ltati

on

s fo

r a s

pecif

ic d

iag

no

sis

resu

ltin

g i

n a

n a

nti

bio

tic

pre

scri

pti

on

Calendar years

tonsillitis

sinusitis (ICD-9)

sinusitis (ICD-10)

otitis media

bronchitis

nasopharyngitis

influenza

pharyngitis

Proportion of consultations for a specific diagnosis resulting in

antibiotic prescriptions in France, 1995-2009

IMS Health, France

http://www.sante-jeunesse-sports.gouv.fr/dossiers/antibiotiques/Pres_Varon.pdf

Germany I Informationskampagne Antibiotika-Resistenz

www.viamedica-stiftung.de

Campaign since 2007

Private Foundation to

promote: “Equilibrium

between medicine,

man and nature"

Few interventions, no

evaluation

• "Use herbal remedies first "

• "Patients should always ask their

doctor if a herbal remedy can be

prescribed instead of antibiotics"

Germany II www.zuendstoff-antibiotika-resistenz.de

“If you have fever, symptoms

are long-lasting and your nasal

secretions or expectorations are

yellow-greenish, then antibiotics

might be necessary”

Spain www.antibioticos.msc.es

“Campaign for the responsible use

of antibiotics”

Yearly campaign since 2006

6.5 million € (2006)

Target population

General population, parents

GPs, paediatricians,

pharmacists

Interventions

Mass mailing to physicians

Ads on TV, radio, print-media

Population

43 million

“Preliminary analysis suggests that the impact of antibiotic campaigns

may have been of very limited effect in Spain.”

http://www.sante-jeunesse-sports.gouv.fr/dossiers/antibiotiques/Pres_Campos.pdf

Antibiotic campaign

Main slogan “Antibiotics are not a cure for flu“

January 2001, 2003 and 2006

Organized by Maccabi Health Services

Israel‘s 2nd largest Health Maintenance

Organization

Israel www.maccabi4u.co.il/antibiotic Population

7.2 million

USA

Population

300.9 million

Different focus for Spanish speaking population

(focus on self-medication)

Get Smart

National media campaign

TV spots, radio spots,

advertisements produced by

the CDC

Provided free to the states

Problem

Produced as public service

anouncements

Shown in the middle of the

night

Funding

Unites States, 1998

Amount spent by pharmaceutical

companies to promote antibiotics:

1’600’000’000 USD Ma et al. (2005). Clin Ther 25:1503-17

Amount spent by the CDC in the same

year on its “Campaign for Appropriate

Antibiotic Use in the Community”:

155’000 USD

Data from the National Ambulatory Medical

Care Survey prescribing data in the ambulatory care setting (including emergency

rooms) for 21000-37000 visits/year

decrease in the percentage of patients with a diagnosis

of URTI in emergency departments receiving an

antibiotic (from 55% in 1993 to 35% in 2004)

decrease in the percentage of prescriptions for

ambulatory care visits (from 17.9% in 1995-1996 to

15.3% in 2001-2002)

increase in broad-spectrum antibiotic prescriptions (from

41.0% in 1995-1996 to 76.8% in 2001-2002)

increase in the percentage of children with otitis media

who were prescribed antibiotics (79.2% in 1996 and

91.3% in 2005). Vanderweil et al. (2007). Acad Emerg Med 14:366-9.

Roumie et al. (2005). J Gen Intern Med 20:697-702.

Fischer et al. (2007). Acad Emerg Med 14:1172-5.

Get Smart (USA) Conclusions

Quality of the state campaigns variable

No synergy between states

Rare use of mass media (lack of funding)

Campaign impact not evaluated

Funding & future uncertain….

Australia www.nps.org.au

Yearly campaign since 2000

National Prescribing Service

55’000 -450’000 €/campaign

Targets

General public, parents

GPs, pharmacists

Population

19.9 million

Harvey the wombat

Australia www.nps.org.au

Interventions

Patient information material

TV and radio spots, billboard and magazine

advertising

Guidelines, seminars and some academic

detailing

Modest but consistent positive changes in:

• consumer awareness

• beliefs & attitudes

• behaviour to appropriate AB use for RTIs

Wutzke et al. (2007). Health Promot Int 22:53-64.

Outcome regarding antibiotic use

Malta

1999-2006: 32% reduction

1992 -1997: 35% reduction (children)

2002-2007: 23.4% reduction

1999-2002: 15 % reduction

2003-2005: 10% reduction

2004-2005: 5.8% reduction over

winter months compared to control

Self reported use

Prescription data

1997- 2005: 9% reduction

1997- 2007: about 35% reduction

(children 0-5 years)

1999- 2003: decrease by 0.18

prescriptions/1000 consultations/

GP/ month.

Outcome regarding antibiotic use

Malta

No significant impact

or

probably no impact

Data not (yet)

available

Israel

???

Italy

France

Trends in antibiotic consumption

France and Italy (1999-2006)

DDD/1000 inhabitants/day

England

1992-2002: admissions for peritonsillar

abscesses, mastoiditis and rheumatic fever in

children stable Sharland et al. (2005). BMJ 331:328-9

• Sweden

– 1987-2003: no increase in admissions for acute sinusitis,

peritonsillar abscess and acute mastoiditis

– 1995-2004: outpatient antibiotic use ↓20%

Potential adverse effects of reduced prescribing?

Mölstad et al. (2008). Lancet Infect Dis 8:125-32.

• Alpes-Maritimes

– 1998-2003: stables rates of invasive infections:

S. pneumoniae, S. pyogenes, N. meningitidis

– 1999-2002: AB use in children (self reported) 15% ↓ Blanc et al. (2008). Presse Med 37:1739-45.

Impact of campaigns on antibiotic resistance

Antibiotic campaign

Reduced antibiotic use

Reduced antibiotic resistance

Antibiotic use not

always evaluated

Antibiotic resistance

not always evaluated

PCV7

Secular trends Seasonal variation in RTI

Clonal spread

?

?

?

?

• Alianza: Kaiser, Denver

• Estudio controlado: • Intervención múltiple

• Educación de médicos

• Educación en la consulta

• Educación en la comunidad

• Intervención parcial • Solamente en la consulta

• No Intervención (Control)

Intervención: Reducir el uso de

Antibióticos para el tratamiento de

la Bronquitis

Intervención para Reducir el uso de

Antibióticos, Denver, 1997-1998

0

10

20

30

40

50

60

70

80

90

Fuente: Gonzalez et al. JAMA 1999; 281: 1512-9

0

10

20

30

40

50

60

70

80

90

Control Intervención Parcial Intervención completa

Basal Intervención 11/96 02/97 11/97 02/98

Children as Health Information

Advocates: An “Edutainment”

Intervention Concerning Rational

Use of Antibiotics

Charlotte Kristiansson, PhD student Div. of International Health (IHCAR), Karolinska Institute, Sweden

STRAMA-project

What do you mean? Bacteria that helps protecting me??

Yes, all humans have bacteria in their bodies even when they are not sick. These bacteris usually doesn’t harm you, they help you.

Penicillin and other types of antibiotics kill the bacteria that helps protecting you.

Esquema de la intervención realizada y su evaluación.

Octubre de 2009: Test diagnóstico.

Noviembre de 2009: Taller 1. Marzo de 2010:

Taller 2. Julio de 2010: último test.

Porcentaje de aprobación del cuestionario basal,

con posterioridad a primer y segundo taller

educativo.

Las campañas de Antibioticos, pueden generar

efectos beneficiosos sobre la prescripción.

Al menos en países de alto consumo,

asociadas a campañas masivas.

Mejor evidencia:

Datos discrepantes en otros paises

Efecto real es difícil de demostrar

Conclusiones I

Conclusiones II

Impacto en Resistencia ?

Muchas variables confundentes (e.g. vaccine)

Bias ecológico

Efectos adversos o reducción en prescripción ?

No hay monitoreo rutinario.

Intervenciones más eficaces ?

Focalizadas en público general y en Medicos

Puede variar según los países

Se requieren mayores evidencias...

0

10

20

30

40

50

60

70

80

White African-

American

Asian Latino

Expectativas de padres sobre la prescripción de AB. Niveles de ansiedad

según variación étnica.

Mangione-Smith et al; Pediatrics 2004; 113: e385-e394

%

EDUCACION

•Un programa educativo en conjunto con el Ministerio de Educación local, que introduzca los conceptos de resistencia y uso de antimicrobianos desde la educación primaria, para asegurar un cambio de conducta a largo plazo.

Que podemos hacer?