Plenary presentation of Prof. Michael.A Borg (Mater Dei Hospital, University fo Malta) at ESCAIDE 2018.

1. Prof. Michael A. Borg
Mater Dei Hospital & University of Malta
Malta
1
What have we overlooked in the
epidemiology of antimicrobial resistance
(AMR) in Europe?

2. What haven't we overlooked…
• >650,00 infections caused by antibiotic-
resistant bacteria resulting in:
– >30,000 attributable deaths
– >870,000 disability-adjusted life years (DALYs)
2

3. 3
3GCR MDR
E. coli K. pneumoniae
Carbapenem R Meticillin R
A. Baumanii S. aureus

4. Understanding the epidemiology
4

5. 5
-5
-4
-3
-2
-1
0
1
0 5 10 15 20 25
DDD beta-lactam antibiotics/1000 population/d
ln(R/(1-R))
GR
NL
DE
SE
FI
UK
IE LU
IT
PT
ES
BE
Figure 2: The logodds of resistance of invasive isolates of S. pneumoniae to penicillin (PNSP; ln(R/(1-R))) is regressed
against out-patient sales of beta-lactam antibiotics in 12 European countries;

6. Quinolone resistance & use
in Europe
6
R2 = 0.596 (p<0.001)

7. Use of antibiotics for cold, flu and
sore throat in EU countries
0
10
20
30
40
50
60
70
80
90
Cold Sore throat Flu >95% prescribed
%
7

8. 8
Spearman correlation with
EARS-Net MRSA proportions:
rho = 0.507 (p<0.001)
R2 = 0.348 (p=0.001)

9. High resistance countries
Evidence suggests that in
high resistance European
countries, antibiotics are
used:
• more commonly
• less appropriately
than in countries with lower
resistance prevalence
9

10. High resistance countries
Evidence suggests that in
high resistance European
countries, antibiotics are
used:
• more commonly
• less appropriately
than in countries with lower
resistance prevalence
10

11. • Consumption of:
• total antibacterials for systemic use (J01);
• penicillins (J01C);
• cephalosporins (J01D);
• macrolides, lincosamides, streptogramins (J01F);
• quinolones (J01M)
• No relationship with
– Gross National Income
– Mean years of schooling
– Number of physicians
11

12. µm
12
• Significant correlations: Bootstrap analysis
– Cultural values:
F(6,19) = 5.86, P < .001; R2= 0.65
– Socio-economic factors:
F(5,20) = 6.93, P < .001; R2= 0.63
– Personality characteristics*:
F(3,10) = 4.07, P = .04; R2= 0.55
*only 14 countries studied

13. µm
13
• Significant correlations: Bootstrap analysis
– Cultural values:
F(6,19) = 5.86, P < .001; R2= 0.65
– Socio-economic factors:
F(5,20) = 6.93, P < .001; R2= 0.63
– Personality characteristics*:
F(3,10) = 4.07, P = .04; R2= 0.55
*only 14 countries studied

14. What is “culture”
‘pattern of basic assumptions…
that a given group has invented, discovered or
developed in learning to cope with its problems
of external adaptation and internal integration…
which have worked well enough to be
considered valid…
and, therefore to be taught to new members as
the correct way to perceive, think, and feel in
relation to those problems’
14
Schein 1995

15. Culture…
• Deals with values
– commonly held standards of what is acceptable or
unacceptable, important or unimportant, right or
wrong, workable or unworkable, etc., in a community
or society
• Values which are deemed essential in one culture will be
unacceptable in another.
– Cannot be measured directly
• Cultural dimensions
– Constructs of identifiable behavioural manifestations
that can be measured
– provide a model to understand cultural differences
15

16. 16

17. 17

18. • Uncertainty avoidance and
masculinity country scores
significantly associated with
prescribing of antibiotics for
colds, flu and sore throat
(R-adjusted = 0.45; P<0.001)
18
0
10
20
30
40
50
60
70
80
90
Cold Sore throat Flu

19. 19

20. Countries with high power distance:
• Power holders:
– make all the decisions
– reluctant to share power / consult in decision making
• Less powerful stakeholders will defer responsibility.
• “I am not going to question the doctor why he prescribed an antibiotic for my
cold/flu…. he’s the expert and I do what he says”
20
Power distance
All societies incorporate
hierarchy but the way
power is exercised varies
substantially.
All animals are equal but
some animals are more
equal than others
(George Orwell: Animal Farm)

21. Uncertainty Avoidance
In high uncertainty avoidance countries, antibiotic prescribing
may be used to reduce ambiguity for clinician & patient:
• Given even in dubious clinical presentations
– “started antibiotics... just in case”
• Excessive use of wide spectrum formulations
– “need the widest possible cover…. to be safe”
• Unnecessarily long treatment duration
– “need to ensure treatment has been sufficient”
despite the increased and unnecessary risk of AMR 21
Societies differ in their ability
to handle daily uncertainties
of life and adapt to
ambiguous situations

22. 22
Power distance + + + ++ ++ ++ +++ +++ +++ No data
Uncertainty avoidance + ++ +++ + ++ +++ + ++ +++ No data
Cultural dimensions in Europe

23. Not stereotyping…
Cultural dimension score
Prevalenceinpopulation
23

24. Addressing the situation
• What can be done to implement
effective antibiotic stewardship
when cultural dimensions may be
a challenge?
24

25. To assess the impact of the 2015/16 NHS England
Quality Premium on antibiotic prescribing by
General Practitioners (GPs) for respiratory tract
infections (RTIs).
25

26. • Inclusion of antibiotic prescribing in national Quality
Premium (QP),
• Financial remuneration to Clinical Commissioning
Groups (CCGs)
– Responsible for the planning and commissioning of
healthcare services in their region.
• Required CCGs to achieve a reduction of 1% in total
antibiotic prescribing in primary care and a 10%
decrease in the proportion of broad-spectrum
antibiotics prescribed,
– Specifically co-amoxiclav, cephalosporins and quinolones
26

27. Interrupted time series analyses of the total antibiotic prescription rate for RTI consultations
• 3% drop in the rate of antibiotic prescribing (p<0.05),
coinciding with the introduction of the Quality Premium.
– Equated to 14.65 prescriptions per 1000 RTI consultations 27

28. Changes in ambulatory antibiotic prescriptions per 1000 inhabitants per year in France
between 1980 and 2009 according to the different IMS data sources.

29. • Largest decrease in prescriptions was observed for
nasopharyngitis and influenza.
• Antibiotic prescribing rates for bronchitis, sinusitis, otitis
media and tonsillitis remained persistently high.
– “Physicians might more easily abandon unnecessary prescribing
for infectious conditions …. with a low diagnostic uncertainty
compared with acute bronchitis, which continues to be a common
cause of antibiotic prescribing despite its frequent viral origin”
– “… while physicians only slightly improved their prescribing habit
for this indication … (the) campaign targeting the public may have
been effective in persuading patients with a sore throat not to
seek medical attention”
29

31. 31

32. µm
• Significant correlations: Bootstrap analysis
– Cultural values:
F(6,19) = 5.86, P < .001; R2= 0.65
– Socio-economic factors:
F(5,20) = 6.93, P < .001; R2= 0.63
– Personality characteristics*:
F(3,10) = 4.07, P = .04; R2= 0.55
*only 14 countries studied
32

33. Socio-economic factors
• Governance quality:
– “…badly managed countries also fail in their health policies
and, consequently, in regulation of antibiotic use.”
• E.g. non-prescribed use, influence of pharma, veterinary practices…
33

34. • …the tools to address antibiotic prescribing and consequently
AMR are to be found primarily in behavioural – rather than
biomedical – science.
• Cultural influences are strong and pervasive
– Major effort needed to change antibiotic practices in high
prescribing countries.
– “Copy and paste” approaches are doomed to fail
• Behaviour change can best be achieved
through a combination of:
• Education (incl. guideline development)
• Motivational interventions
• System change
• It is not easy but it can be done!
What have we overlooked?