Experience with Stramain Sweden
Lars Blad
MD, Inf Dis Specialist
Dep Regional Medical Officer Region Västmanland
Chairman Strama Network
Member Swedish ICG AMR
WHO EURO Consultant on containment of AMR
European Centre for Disease Prevention and Control. Surveillance of antimicrobial resistance in Europe – Annualreport of the European Antimicrobial Resistance Surveillance Network (EARS-Net) 2017. Stockholm: ECDC; 2018.
European Centre for Disease Prevention and Control. Surveillance of antimicrobial resistance in Europe – Annual report of the European Antimicrobial Resistance Surveillance Network (EARS-Net) 2017. Stockholm: ECDC; 2018.
Antibiotic use Sweden 1987-2017 per age group
0-4 year: 74 % reduction
Start of Strama
This report has been generated from ESAC-Net data submitted to TESSy, The European Surveillance System on 2018-11-20. The report reflects the state of submissions in TESSy as of 2018-11-20 at 20:00
Peace >200 years..
•
•
•
Sigvard Mölstad, Professor
and PHC clinician
”Champions”..
Remit and financing first from government, now
from regional health-care providers
National Strama
The local (regional) Strama groups (typically):
✓ County medical officer
✓ Pharmacist
✓ Microbiologist
✓ General practitioner
✓ Infectious diseases specialist
✓ Infection control
✓ ENT, paediatrician, geriatrician, dentist…
Strama´s organization
The overall aims of Strama
• Best available treatment to the patient
• To preserve the effectiveness of antibiotics and prevent the emergence and spread of resistant bacteria
Multifaceted approach
• Increase awareness about AMR among professionals,
politicians and the public
– Regular information to Swedish media - local data!
– Campaigns to improve prescribing and avoid unnecessary
prescribiing
• National and regional meetings to share experiences
and ideas and catalyze multisectoral collaboration
• Education and workshops - multiple target groups
• Scientific studies; optimize use of old antibiotics, PPS
• Monitoring the international scientific literature and
media
Strama AdvisoryCouncil -
experts
SwedishMedical
Association
National Board of Health and Welfare
SwedishVeterinaryInstitute
SwedishAssociation of
Local Authoritiesand Regions
MedicalProducts Agency
The Dental and PharmaceuticalBenefits Agency
European Centre for Disease
Prevention and Control
Network of local Strama groups
Swedish Institutefor CommunicableDisease Control
Political level
Professional organizations
Stramacoordination and feedback
Exchange ideas - What
works?
- Web page
- Larger yearly meetings
National coordination has has always been needed but the means have shifted…
Public Health Agency
Strama Programme
Council
21 local
Strama groups
-network
Specialist associations:-Infectious diseases-Microbiology-Infection Control-General Practitioners-Pediatrics-Surgery-ENT
Expert groups:
Veterinary-
Strama
Pharmacist-
Strama
Dental care-
Strama
Intersectoral Coordinating Mechanism
23 agencies and organisations within
different sectors led by the Public
Health Agency and the Swedish
Board of Agriculture
Ministry of Health and Social Affairs
Swedish Association of
Local Authorities and Regions
Current organization, 2 million SEK national level
The continuous work of the Strama group
Hospitals, Clinics,
PHC C:s
Pharmacy,Bact. lab,
Strama group
Prescription
of AB:s /changed/
Local data
on ABR, and
AB use
Feed back of data;
interventions
Resistance
is influenced
Cultures are
taken
Collecting best
available data
Analysis
Epid.Int.
Lars Blad, 2009
Fluoroquinolone-Resistant E.coli in Europe, 2001-2006
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
NO
(1
11
7)
EE
(1
16
)
SE
(2
90
4)
FI
(15
43
)
IS (
99
)
NL
(2
14
0)
FR
(4
61
0)
GR
(9
50
)
SI
(52
6)
HR
(5
27
)
BE
(1
11
8)
LU
(1
91
)
UK
(1
87
9)
PL
(1
53
)
IE (
11
84
)
AT
(1
33
6)
CZ
(1
80
9)
BG
(1
55
)
HU
(7
23
)
IT (
82
6)
IL (
86
2)
PT
(7
54
)
ES
(2
81
6)
DE
(1
04
0)
MT
(8
4)
CY
(5
7)
RO
(4
7)
TR
(7
82
)
Country code (average number of isolates reported per year)
% f
luo
ro
qu
ino
lon
e r
esi
sta
nce
2001
2002
2003
2004
2005
2006
Example: fluoroquinolone resistance in E. coli
ResNet 2007: E.coli
27
1,22,7
1,1
12
17,5
0
5
10
15
20
25
30
Ampicillin Mecillinam Cefadroxil Nitrofurantoin Quinolone * Trimethoprim
% R
1996
1997
1999
2001
2002
2003
2004
2005
2006
2007
Figure by Ulf Lindahl, Strama Västernorrland
Kirurgkliniken, Sundsvall, antibiotika på recept
0
500
1000
1500
2000
2500
3000
2006-
KV1
2006-
KV2
2006-
KV3
2006-
KV4
2007-
KV1
2007-
KV2
2007-
KV3
2007-
KV4
2008-
KV1
2008-
KV2
2008-
KV3
2008-
KV4
DDD (definierade dygnsdoser)
J01MA02 - ciprofloxacin
J01CF05 - flukloxacillin
J01FF01 - klindamycin
J01AA02 - doxycyklin
J01CE02 - fenoximetylpenicillin(pcV)
J01CA04 - amoxicillin
J01AA04 - lymecyklin
J01EE01 - sulfametoxazol +trimetoprim
J01MA06 - norfloxacin
J01CA08 - pivmecillinam
J01AA07 - tetracyklin
J01EA01 - trimetoprim
Surgical clinic, Sundsvall hospital, antibiotic prescriptions
2006 - 2008D
DD
, D
efined D
aily
Doses
Kinoloner (J01M), totalt (recept och rekvisitioner)
0,0
0,2
0,4
0,6
0,8
1,0
1,2
1,4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 (jan-
aug)
DDD / 1000 inv / dag
Riket
Västernorrland
Figure by Ulf Lindahl, Strama Västernorrland
Fluoroquinolone use (J01M), total (prescriptions and requisitions) D
DD
/1000 inhabitants
/day
Sweden
Västernorrland
Sales of antibiotics commonly used to treat lower urinary
tract infections in women (sales on prescriptions), age 18-79 years,
2000-2013, prescriptions/1000 women and year; Sweden
New recommendations from
MPA and Strama
• Written, evidence-based or consensus guidelines
are released by MPA, PHA and Strama, means
high credibility
• Distributed to all doctors
– Short pocket and full printed versions
National treatment guidelines form the basis
▪AOM, 2000, updated 2010
▪Tonsillitis 2001, updated 2012
▪Sinusitis, 2005 (update 2019-20)
▪Lower UTI, 2007, updated 2017
▪Lower RTI, 2008
▪Skin infections, 2009, updated
2018
▪Early warning signs of serious
infections in children, 2011
Face to face meetings by Stramagroups
Feed-back according to
prescription profile per
clinic
Info in ”App” format
0
50
100
150
200
250
300
350
400
Recipes/ 1000 inhabitants/
year per region
1 september 2015 - 31 augusti 2016 1 september 2016 - 31 augusti 2017 1 september 2017 - 31 augusti 2018
Open benchmarking at all levels(regions, municipalities, GP-station, hospital…)
Some LEAD WORDS – possible success factors
• Local engagement• Network: bottoms-up, top-down, lateral
sharing• Early and strong government support• Cooperation – multidisciplinary, multisectoral• Champions• Credibility• Adaptability• Long term perspective
Thank you for your attention!