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!