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
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
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
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
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
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
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
???
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?
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