Antimicrobial Stewardship Implications for Primary Health Care, and how it can

can work Petrozavodsk, Nov 2019
Lars Blad
MD, Infectious Disease Specialist
Dep. Regional Medical

virus, protozoan, fungus
The most widely used antimicrobials are commonly called

need to buy us time until new classes of antibiotics

What is ABS?

To give todays patients optimal therapy;
while causing as little ”antibiotic resistance pressure” as possible
AB:s only when indicated – quantity comes down
AB choice – consider spectrum, thus minimizing ”collateral damage”
We call this ”rational therapy”

Ways to get there

al, The Lancet Infectious Diseases, January 2019
Attributable deaths and

therapy using the Drug Resistance Index
BMJ Global Health 2019;4:e001315.
There is an

of Modern Medicine that would not be possible without Antibiotics

phylogenetics: Influence on unraveling a major hospital outbreak of carbapenem-resistant

classes of antibiotics become available

respiratory or urinary infection develop bacterial resistance to that antibiotic.

BMJ 2010;340:c2096
doi:10.1136/bmj.c2096

Antibiotic consumption drives antibiotic resistance, 2; at all levels: patient, community, country, regional and global

but small part of all antibiotic use
To achieve some impact

antibiotic use it causes, and thus ”resistance drive”
Upper Resp Tract
Infection

Seriousness of the infection for the patient

Antibiotics spent on the diagnosis in society as a whole

DIAGNOSIS:

his/her present illness – with no or minimized collateral harm

Spectrum – narrow but effective

Optimally: know the causing agent and resistance patterns for each patient – not possible, so:
Empiric treatment – treat according to clinical treatment guidelines, based on:
Knowledge of common infections; what are the important causing bacteria?
Knowledge of local resistance pattern among important pathogens
Knowledge on ”ABR drive” of the various choices

Reduced amount in total

No antibiotics where damage outweighs benefit
No antibiotics for viral infections
No antibiotics for many self-limited bacterial infections

all viral respiratory infections
From wide to narrow spectrum – much

SPECTRUM is at least equally important
Antimicrobial consumption/pressure drives antimicrobial resistance;

Swedish Public Health Agency

WHO EML AWaRe classification

Clin Microbiol Infect 2015; 21: 344.e1–344.e11 Clinical Microbiology and Infection © 2014 European Society of Clinical Microbiology and Infectious Diseases. Published by Elsevier Ltd. All rights reserved http://dx.doi.org/10.1016/j.cmi.2014.11.016

condition..)
At the right time (not too late – pneumonia..)
In the

Obviously, the decisions on what is rational treatment should be taken on purely medical grounds, independent from pharma industry or other economic interests.

countries. A practical toolkit. Geneva: World Health Organization; 2019.

use pc V. Amoxicillin works as well
AOM, sinusitis, pneumonia: Pneumococci,

Erysipelas: Strep A. See tonsillitis.

Other skin infections, wound infections: Staph aureus.
We use cloxacillin/flucloxacillin.

E. coli, Klebsiella pn:
For lower UTI/cystitis, we use mecillinam or nitrofurantoin
For acute pyelonephritis we use ciprofloxacin

Of all the first choices above, only ciprofloxacin/f-quinolones have a significant impact on the gut flora. Amoxicillin some, but limited.

to 90%
Patients with pneumonia and bacteria in blood

resistance surveillance in pneumococci c:a 1300 invasive isolates per year.

to society
Examples: shigella, typhoid, salmonella, meningococcal infection
Based on already proven

Generation II

Generation II/AMR

Focus on infections dangerous to patient
Syndrome based rather than microbiological
Evidence based
Considering the normal etiology for a given syndrome – e g purulent meningitis, or bacterial pneumonia
Covering more patients..

Focus on infections responsible for largest flows of antibiotics
Syndrome based (e g URTI, tonsillitis, sinusitis, otitis media, pneumonia, lower UTI)
Clarifying which antibiotic to use for which syndrome
Also clarifying when NOT to treat with antibiotics

useful in the clinical PHC setting; simplified example of Sweden
Challenge:
Finding

changes until antibiotic use is changed on the ground
Distribute to

Strama working lunch meeting:
Discuss PRESCRIPTION DATA; for PHC Centre, for County/Region, for nation
Distribute individual data; when possible diagnose related
Go through new guidelines
Discuss cases

Info in ”App” format

PHA
Expedited antibiotic prescriptions per 1000 inhab. and year for various

(among many febrile/viral/flu patients) in time takes training, skill, and

Patient comes in late – easy
Patient comes in early – impossible; must be reassured, and given chance to return – if to withhold treatment more than a parent would
The more skilled the doctor, the better the chance

Standard course for many viral RTI

Possible trajectory for a patient with pneumonia

Medical Officers for Communicable Diseases Control took a leading role

Sigvard Mölstad,
Professor and PHC clinician

”Champions”..

Gunnar Kahlmeter, Professor Clin. Microbiology

The local (regional) Strama groups (typically):
County medical officer
Pharmacist
Microbiologist
General practitioner
Infectious diseases specialist
Infection control
ENT, paediatrician, geriatrician, dentist…

Local Authorities and Regions
Medical
Products Agency
The Dental and Pharmaceutical Benefits Agency
European

Network of local Strama groups

Swedish Institute for Communicable Disease Control, now Public Health Agency

Political level

Professional organizations

Strama
coordination and feedback

Exchange ideas - What works locally?
- Web page
- Larger yearly meetings

National coordination has always been there but the forms have shifted

work of Strama

Local engagement
Network: bottoms-up, top-down, lateral sharing
Early and

Peace >200 years..