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How is Ireland performing on antibiotic prescribing?
Dr Rob Cunney National Clinical Lead HCAI AMR Clinical
Programme Ajay Oza
HSE-Health Protection Surveillance Centre
1
European Antibiotic Awareness Campaign 2016November Webinar Series on Antibiotic Prescribing
Why?
o Resistance to antibiotics in bacteria is increasing
o Multi-drug resistance is increasingo Novel drug discovery is slowing down
– Very few new antibiotics in the pipeline!
o Therefore, use what we have prudently
….but first measure what we use
Sourcing the Data
2
Manufacturer
Retail chemist
Wholesaler
Hospital
Primary care
Sourcing the Data
Hospital pharmacists from public acute hospitals provide dispensary data
IMS Health
3
Where?
Manufacturer
Retail chemist
Wholesaler
Extended care
Sales rep
Reimbursement
Regional Offices
?
Hospital
“Online pharmacy”
Dentist
GP
Sourcing the Data
4
What?“Antibiotics”
o Systemic Anti-bacterial Agents– Not anti‐fungal– Not anti‐viral– Not anti‐parasitic– Not anti‐TB
o Parenteral (IV), suppositories,inhalants and oral preparation
– Not lotions or creams
Sourcing the Data
5
How?
o WHO has a code Anatomic Therapeutic Chemical (ATC) and value Defined Daily Dose (DDD) for each drug
o We look at how many packs of which drug are used in a particular location over a specific time period
o Map this to ATC/DDD, sum and express as a rate per population
Germentin 500mg/125mg x 16 Fc Tabs J01CR02 8.0 DDD 6
7
Primary-care Antimicrobial Consumption
o EU Comparisonso Antibacterial class of drugo Seasonal fluctuation & recent
trendo Geographic distributiono Latest data
Retail chemistPrimary care
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
8
2014
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
9
2014
2015
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
Penicillins60.6%
Macrolides and related drugs
16.5%
Tetracylines10.1%
Cephalosporins and other beta‐lactam drugs
4.6%
Sulfonamides and Trimethoprim
4.1% Quinolones3.6%
Other antibiotics0.4%
Antibacterials 2015
Narrow spectrum penicillins
7%Beta‐
lactamase resistant penicillins
14%
Broad spectrum penicillins
35%
Penicillin with beta‐
lactamase inhibitor44%
Penicillins 2015
• Co‐amoxilcav use in Ireland is high; macrolide use is also high
10
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
10
15
20
25
30
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Defined
Daily Doses per 1000 Inha
bitants p
er Day
(DID)
Observed Use Underlying Trend
• Winter rises mean the usage in some months is very high and the overall rates appear to be increasing steadily
11
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
10
15
20
25
30
1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4 1 2 3 4
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015Defined
Daily Doses per 1000 Inha
bitants p
er Day
(DID)
Observed Use Underlying Trend
• Winter rises mean the usage in some months is very high and the overall rates appear to be increasing steadily
12
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013Defin
ed Daily Doses per 100
0 Inhabitants pe
r Day
(DID)
High Influenza Activity Observed Use
Modelled Use Influenza Like Illness Rate (not to scale)
0
5
10
15
20
25
30
35
2005 2006 2007 2008 2009 2010 2011 2012 2013Defin
ed Daily Doses per 100
0 Inhabitants pe
r Day
(DID)
High Influenza Activity Observed Use
Modelled Use Influenza Like Illness Rate (not to scale)
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data
European Union range on bar is 2014 dataIreland rate on triangle and map are 2015 data
• Some areas have very high use
13
Primarycare Antimicrobial Consumption
o EU Comparisons
o Antimicrobial class
o Seasonal fluctuation & recent trend
o Geographic distribution
o Latest data• So far the preliminary results show monthly rates for
2016 are lower than 2015 rates
14
15
Hospital Antimicrobial Use
o Routine quarterly datao Point prevalence survey
Hospital
16
Surveillance Expert User
Web-based Data System
17
Secure, detailed breakdown for professionals…
18
…open access outputs for the public
19
Overall use in hospitals
0
20
40
60
80
100
2007 2008 2009 2010 2011 2012 2013 2014 2015
Rate (D
DD per 100
BDU)
Tetracyclines Other Antimicrobials
Glycopeptides and related drugs
Quinolones
Aminoglycosides
Macrolides and related drugs
Sulfonamides and Trimethoprim
Cephalosporins and other beta‐lactam drugs
Penicillins
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD pe
r 100
BDU
Quinolones (J01M) use in Irish hospitals
0
0.5
1
1.5
2
2.5
3
3.5
4
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD per 100
BDU
Carbapenems (J01DH) use in Irish hospitals
20
Overall use in hospitals
0
20
40
60
80
100
2007 2008 2009 2010 2011 2012 2013 2014 2015
Rate (D
DD per 100
BDU)
Tetracyclines Other Antimicrobials
Glycopeptides and related drugs
Quinolones
Aminoglycosides
Macrolides and related drugs
Sulfonamides and Trimethoprim
Cephalosporins and other beta‐lactam drugs
Penicillins
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD pe
r 100
BDU
Quinolones (J01M) use in Irish hospitals
0
0.5
1
1.5
2
2.5
3
3.5
4
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD per 100
BDU
Carbapenems (J01DH) use in Irish hospitals
*2016 Provisional data to end of Q2
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
200
400
600
800
1000
1200
1400
1600
%MRS
A
Numbe
r of isolates
YearMRSA MSSA %MRSA
Fluoroquinolone Use & Resistance
o Was the focus of hospital stewardship groups since 2006; particularly switching IV use to oral
o Infection prevention/control team also focused on reduction of catheters
o Guidelines released in re-enforced this
o Perhaps impacted on %MRSA – why?
o What about resistance in E. coli?
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD pe
r 100
BDU
Quinolones (J01M) use in Irish hospitals
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
0
200
400
600
800
1000
1200
1400
1600
%MRS
A
Numbe
r of isolates
YearMRSA MSSA %MRSA
Fluoroquinolone Use & Resistance
o Was the focus of hospital stewardship groups since 2006; particularly switching IV use to oral
o Infection prevention/control team also focused on reduction of catheters
o Guidelines released in re-enforced this
o Perhaps impacted on %MRSA – why?
o What about resistance in E. coli?
0
1
2
3
4
5
6
7
8
9
10
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD pe
r 100
BDU
Quinolones (J01M) use in Irish hospitals
0%
5%
10%
15%
20%
25%
30%
0
500
1000
1500
2000
2500
3000
2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
%Re
sistance
Numbe
r of isolates
YearTotal E. coli %FQREC %GEN‐R %GEN/TOB/AMK‐R %3GC‐R
FQREC, fluoroquinolone (e.g. ciprofloxacin)‐resistant E. coli; GEN, gentamicin, TOB, tobramycin; AMK, amikacin (GEN, TOB and AMK are aminoglycosides); 3GC, 3rd‐generation cephalosporins (e.g. cefotaxime, ceftazidime)
Carbapenemase-producing Klebsiellapneumoniae
o Sharp increase carbapenem use
o Carbapenem Resistant Enterobacteriaceae(CRE) global problem
o Numbers of carbapenemase-producing K. pneumoniaeincreasing
o Outbreak control team put in place 0%
1%
2%
3%
4%
0
50
100
150
200
250
300
350
400
450
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
%CB
P‐R
Num
ber o
f isolates
YearTotal K. pneumoniae tested for CBP CBP‐R KPN %CBP‐R
0
0.5
1
1.5
2
2.5
3
3.5
4
2006 2007 2008 2009 2010 2011 2012 2013 2014 2015*
DDD per 100
BDU
Carbapenems (J01DH) use in Irish hospitals
AMC WHO, Copenhagen, August ‘16
European Antimicrobial Resistance Surveillance Network (EARS-Net)
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%Prop
ortio
n resistan
ce
Year
Quinolone‐ResistantE. coli
Cephalosporin‐Resistant E. coli
ESBL‐producing E. coli
Multiple‐ResistantE. coli
Vancomycin‐ResistantEnterococcus faecium
Meticillin‐ResistantStaph. aureus
Penicillin‐ResistantStrep. pneumoniae
Erythromycin‐ResistantS. pneumoniae
25
Point Prevalence Survey (PPS)o Number of patients on antimicrobial therapy on a
given day– Ireland median for 2015: 37.8% (n=39 hospitals)– EU‐Wide PPS (2011‐12): 32.7%– Global PPS (2015): 31.5% for Europe
0%
10%
20%
30%
40%
50%
60%
70%
80%
Medicine Surgery Intensivecare
Otherspeciality
OVERALL
% Prevalence of Antim
icrobial Prescrib
ing
2009
2010
2011
2013
2014
2015
Source: HSE-HPSC, Ireland
Source: Public Health Wales, by Health Board
26
PPS 2016, Ireland Findings
• Number of hospitals participating 41• Median prevalence: 37.8%• Median number of antimicrobial therapies per regimen: 1.39
• Median proportion of IV over all therapies: 64.3%
Provisional results for 2016
27
PPS 2016 - Drugs
28
PPS 2016 - Indications
0%
20%
40%
60%
80%
100%
2009 2010 2011 2013 2014 2015
Prevalen
ce
Ireland
Single Dose
One Day
>1 day
29
PPS 2016 - Compliance
30
EAAD
31
Acknowledgements
o Antimicrobial pharmacists in Ireland
o Infection control teams and microbiology laboratories in hospitals
o Clinical HCAI Programme in Ireland
o Colleagues at HPSCo ESAC-Net at ECDC
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