English Surveillance Programme for Antimicrobial Utilisation and Resistance

(ESPAUR)

Berit Muller-Pebody HCAI & AMR Department, Centre for Infectious Disease Surveillance and Control

Chief Medical Officer - Annual Report 2013

Antimicrobial resistance poses ‘catastrophic threat’

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The 5-year UK AMR strategy •  improving infection prevention and control practices

•  optimising prescribing practices

•  improving professional education, training and public engagement

•  developing new drugs, treatments and diagnostics

•  better access to and use of surveillance data •  better identification of antimicrobial resistance research needs

•  strengthened international collaboration

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English Surveillance Programme for Antibiotic Use and Resistance (ESPAUR)

Established by PHE in 2013 in response to the strategy •  To develop surveillance systems to measure both

antimicrobial utilisation and resistance •  To measure the impact of antimicrobial utilisation on

resistance •  To develop quality measures for optimal prescribing •  To develop initiatives with key partners for both public and

professional behaviour change

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ESPAUR Report 2014 Main findings •  The number of patients with bloodstream infections has

increased each year

•  Increased numbers of these bloodstream infections are caused by resistant bacteria

•  Antibiotic prescribing to patients has increased form 2010 to 2013

•  Almost 80% of antibiotics are prescribed by General Practices (GPs)

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Antimicrobial resistance

Pathogen Antibiotic or antibiotic class % non-susceptible Escherichia coli Ciprofloxacin 18.2

Third-generation cephalosporins 10.9 Gentamicin 9.7 Imipenem/meropenem 0.1

Klebsiella pneumoniae Ciprofloxacin 11.1 Third-generation cephalosporins 11.4 Gentamicin 8.5 Imipenem/meropenem 1.0

Pseudomonas spp. Ciprofloxacin 10.4 Ceftazidime 6.7 Gentamicin 3.6 Imipenem/meropenem 9.5

Streptococcus pneumoniae Penicillin 3.1 Macrolides 8.1 Tetracycline 6.1

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Summary of key bacterial drug resistance in England, 2013

Resistance in Escherichia coli •  Proportion resistance stable •  Increased rate of bacteraemias & antibiotic resistant bacteraemias •  Regional variation across the country

E. coli isolates non-susceptible to ciprofloxacin, 3rd gen cephalosporins and gentamicin, England 2010-2013

% E. coli bloodstream infection isolates non-susceptible to indicated antibiotics, NHS Area Team, 2013

Grey areas represent ATs where <70% of isolates had susceptibility data available ESPAUR - BSAC Roundtable Series

Antibiotic consumption, England 2010-2013

Total prescriptions 6% GP 4.1% Hospital inpatients 11.9% Hospital outpatients stable other community (e.g. dentists) 32%

Total antibiotic consumption by prescriber, England, 2010-2013

Total antibiotic consumption by AB group, England, 2010-2013

GP consumption by ATs, England, 2013

Hospital consumption, by ATs, England, 2013

Total consumption, by ATs, England, 2013

Significant regional variation General Practice

Durham, Darlington and Tees over 40% higher than London 26.5 compared to 18.9 DID

Hospital London twice Leicestershire and Lincolnshire 6.0 DID compared to 2.9 DID

Total Merseyside, highest (similar to Southern Europe) over 30% higher Thames Valley 30.4 DID compared to 22.8 DID

Penicillins ~50% of total use 3.2% increase from 2010 to 2013 Co-amoxiclav 13% increase Piperacillin-tazobactam 46% increase

Consumption of penicillins by General Practice and Hospitals, DID, 2010-13

Consumption of most commonly utilised penicillins, DID, 2010-2013

Cephalosporins ~0.2% total use 48% decrease from 2010 to 2013 Hospital inpatients unchanged Lowest in Europe

Consumption of most commonly cephalosporins, DID, 2010-2013

Consumption of cephalosporins by General Practice and Hospitals, DID, 2010-13

Map of cephalosporin consumption by ATs, DID, 2013

Carbapenems ~0.3% of total use 31% increase from 2010 to 2013 99% hospital use Majority of regions increased Huge variability across AT

Consumption of most commonly used carbapenems, DID, 2010-2013

Consumption of carbapenems by General Practice and Hospitals, DID, 2010-13

Map of carbapenem consumption by ATs, DID, 2013

Comparisons with Europe (ESAC-Net)

General Practice

Very low quinolone/ cephalosporins use

Hospital

Much higher except for cephalosporins

Key issues

•  Prescribing continues to increase •  Too much regional variability •  Hospital use very high compared to Europe

•  Data not comparable?

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Next steps - improve quality of prescribing

•  Antimicrobial prescribing quality measures (APQM)

•  Active monitoring of national prescribing •  Open benchmarking

•  compare with peer and historic data

•  Education/teaching

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•  ESPAUR report data •  National General Practice Profiles •  ESAC-Net/EARS-Net •  UK One Health Report

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Next steps – data transparency

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•  Validate hospital data •  Develop methodology for paediatric data

• Prescribed Daily Dose (PDD)?

•  Develop case mix methodology

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Next steps – data quality improvements

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Health Protection Research Unit (HPRU) •  Imperial College/University of Oxford/PHE

•  E. coli bacteraemia study

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Next steps - research

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Susan Hopkins

Alan Johnson

Rebecca Guy

Diane Ashiru-Oredope

Alex Bhattacharya

Emma Budd,

Simon Thelwall

Mehdi Minaji

Katherine Henderson

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Acknowledgements

ESPAUR - BSAC Roundtable Series

ARHAI Antimicrobial Stewardship subgroup NHS Business Services Authority Health and Social Care Information Centre IMS Health NHS microbiology laboratories PHE regional information managers PHE field epidemiology services Antimicrobial pharmacists across English NHS Trusts East of England pharmacy network All members of ESPAUR oversight group