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Consumption of antibiotics at the national level – human medicineAnne IngenbleekMat GoossensNatacha ViseurSylvanus FonguhNaima HammamiMarie-Laurence LambertKarl MertensKatrien LatourBéatrice JansBoudewijn Catry*www.nsih.be
Anne IngenbleekMat GoossensNatacha ViseurSylvanus FonguhNaima HammamiMarie-Laurence LambertKarl MertensKatrien LatourBéatrice JansBoudewijn Catry*www.nsih.be
Rue Juliette Wytsmanstraat 14 | 1050 Brussels | BelgiumT +32 2 642 51 11 | F +32 2 642 54 10 | email: [email protected] | http://www.nsih.be
Causal relationship antibiotic consumption & resistance
Carb
apen
em-r
esis
tant
Pseu
dom
onas
aeru
gino
sa(%
)
Carb
apen
emus
e (D
DD
s)
Lepper PM et al., 2002 (Germany)
Intervention programmes (AST)
Causal relationship inadequatetherapy & mortality
The Influence of Inadequate AntimicrobialTreatment of Bloodstream Infections onPatient Outcomes in the ICU Setting*
Ibrahim et al., Chest 2000, 118 (1)
ObjectiveTo demonstrate at the individual patient level
associations between antibiotic (AB) consumption and antibacterial resistance
• Infections & colonisation (Pathogens & commensals)• Dosis/response effect (Defined Daily Dose, WHO)• Adjusting for covariates
Risk factors for antibacterial resistance at the individual level: a multicentric study (IARG)
Evidence: aggregated population level
Risk factors MRSA infection/colonisationmultivariate analysis (n= 6844)Variable Adjusted OR (95%CI) p-value
MRSA positive related to type of health care setting
No admission 1527 1 -
Acute hospital 4647 0,86 0,74 1,01 0,069
Nursing home (LTCF) 560 3,53 2,79 4,46 <0,001
Other setting 110 1,43 0,93 2,19 0,102
AB consumption prior to sampling (prescription prior or on the day of sampling)
Absent 1519 1 -
Ambulant (FARM) 3706 0,91 0,73-1,14 0,425
In hospital (HOSP) 1619 1,62 1,30 2,01 <0,001
Amount of AB use prior to sampling
per DDD 1,32 1,25 1,40 <0,001
Age category
0-14 757 1 -
15-54 1837 1,63 1,23 2,16 0,001
55-104 4250 4,32 3,32 5,63 <0,001
Monthly FQ consumption, expressed as DDD/1000 PD. Filled circles, pre-intervention period values; open circles, intervention period values; diamonds, post-intervention period values.
Lafaurie M et al. J. Antimicrob. Chemother. 2012;67:1010-1015
© The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
Monthly consumption of ABHR solution.
Lafaurie M et al. J. Antimicrob. Chemother. 2012;67:1010-1015
© The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
Change in monthly FQ-resistant P. aeruginosa rates, from 2002 to 2010.
Lafaurie M et al. J. Antimicrob. Chemother. 2012;67:1010-1015
© The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
Change in monthly MRSA rates, from 2002 to 2010.
Lafaurie M et al. J. Antimicrob. Chemother. 2012;67:1010-1015
© The Author 2012. Published by Oxford University Press on behalf of the British Society for Antimicrobial Chemotherapy. All rights reserved. For Permissions, please e-mail: [email protected]
Mission
To provide standardized definitions and tools for the containment of health care associated infections in hospitals and nursing
homes, and to establish national reference data on incidence of nosocomial infections and antimicrobial resistance.
SURVEILLANCE (1/2)SURVEILLANCE (1/2)
Four Mandatory Surveillances in Acute Care Hospitals
1. Methicillin resistant Staphylococcus aureus2. Clostridium difficile (optional: ribotyping)3. Antimicrobial use in hospitals4. One out of 4 optional surveillances:
• Septicaemias hospital wide• Surgical site infections • Intensive care units • Extended spectrum beta-lactamases
In progress: quality indicators
SURVEILLANCE (2/2)SURVEILLANCE (2/2)Volontary projects in Hospitals & Nursing homes
Hand hygiene campaigns (fifth in preparation, launch 2012)Point Prevalence survey on HCAI & AMMRSA, ESBL & VRE in Nursing homes (BAPCOC)
Other projects - Expertise
EARSS, ESAC, BelVet-SAC, ESVAC, PILGRIM…TATFAR, CODEX alimentarius (WHO/FAO/OIE)promotor Master Thesis, reviewing articles, parlementary questions
Point prevalence survey: PPS (photo)
Surveillance contineously (film)
&
Surveillances
&
FEEDBACKMRSA
Campagnes
IndicateursUSI & ISOSepticémies
C. difficile
Gram -
ABU
Rectangle = mandatory
Jaarlijks aantal doden
2000 in 2008(www.wiv-isp.be)
MRSA in ziekenhuizen: 6121 MRSA infecties in 2010 (www.nsih.be)Ongeveer 525 doden door nosocomiale MRSA infectie in 2007
944 in 2009 (bivv.be)
Courtesy: S. Vandendriessche
MRSA evolution
Portage connu 43,6%
Transfert d'un hôpital 14,1%
Transfert d'une MR/MRS 12,6%
Transfert d'un Hôpital et MR/MRS
6%
Communautaire 14,4%
Contacts inconnus9,3%
Jans & Denis, 2011Individual hospital/NH is client!
Carbapenemase producing enterobacteriaceae
SHC, 2012
Global evolution of hand hygiene compliance
4th campaignpreliminary results!
Point prevalence survey: PPS (photo)
Surveillance contineously (film)
&
Materials & methodsSpecialities to be reported (WHO, ESAC,
pubMED) ATC classification:
A07A Antibiotics for gastro-intestinal useJ01, P01AB AntibioticsJ02, D01BA Antimycotics for systemic use J04A Tuberculostatics
AmphenicolsJ01B0Antifungals for systemic use D01BTetracyclinesJ01A3Agents against amoebiasis/protozoal diseasesP01AIntestinal anti-infectivesA07ASulfonamides and trimethoprimJ01EDrugs for treatment of tuberculosisJ04AAminoglycoside antibacterialsJ01GMacrolides, lincosamides and streptograminsJ01FAntimycotics for systemic use J02AOther antibacterialsJ01XQuinolone antibacterialsJ01MOther beta-lactam antibacterialsJ01D Beta-lactam antibacterials, penicillinsJ01C
Class ATC
Outils informatiques
SEP, SI (ICU), ISO (SSI), HH: NSIHwin (Application MS Access)
CDIF, MRSA … ABU (déc 07)…: NSIHweb• => comparaison immédiate avec les données nationales• => mise à jour « automatique »• => input & upload des données ( charge de travail)• Données communes (dénominateurs/mois,
charactéristiques des hôpitaux, services & unités)• Autres fonctions d’analyse etc (ex. détection des
épidémies) à définir avec groupe de travail
DATA MANAGEMENT
Upload Feedback
• ‘Tarification Units’• ljst TUC codes
• ‘molecules’• expressed as DDD
(Defined Daily Dose)
use (TUC) / Factor = use (DDD)
Example
Example : amoxicillin
J01CA04
J01CA04ATC code
20 units
40 unitsUse (TUC)
1000
1000
DDD202AMOXICILLINE TEVA
CAPS 1 X 500 MG744185
54AMOXICILLINE TEVA SIR 1 X 250MG/5ML
744433
Use (DDD)FactorLabelTUC
use (TUC) / Factor = use (DDD)
REALTIME FEEDBACK
FEEDBACKCompare own use with national mean
AUTOMATIC FEEDBACK Local follow up
FEEDBACK
OBJECTIVES MODULE
Hospitals• realtime feedback
• Automatic recalculation (TUC DDD)
• Local monitoring information for ABMT
Authorities• trend monitoring
DDD/1000 patient days
DDD/1000 admissions
J01: ANTIBACTERIALS FOR SYSTEMIC USE
Antibacterials for Systemic Use (JO1)
0
100
200
300
400
500
600
700
2006 2007 2008 2009 2010
DD
D/1
000
hosp
italis
atio
n da
ysNational meanmedian (p50)
Antibacterials for Systemic Use (J01)
0
1000
2000
3000
4000
5000
6000
2006 2007 2008 2009 2010
DD
D/1
000
adm
issi
ons
National meanmedian (p50)
Graph 1 ‐ Total AMD use ALL antimicrobials (DDD/1000 beddays), 2006‐2010J01 + J02 + J04A + A07A + P01AB + D01B
573570558565479p50
20102009200820072006
Graph 1 – use ANTIBACTERIALs (DDD/1000 beddays), 2006‐2010
ANTIBACTERIALS FOR SYSTEMIC USE J01
537545530527467p50
20102009200820072006
J01
Non Pediatric Wards
Stratified by ward: antibacterials
Stratified by ward: antimycotics
ESACNational level, all antimicrobials included
Year Participants Total DDD for the year DDD/1000 Nights
2008 121 7315319.20 579.734
2009 124 7273099.57 583.651
2010 120 6940067.65 585.087
2011* 106 6561559.15 581.215
2011*: The data collection for the year 2011* is on‐going.
HOSPITALS
Community
Hospitals
Evolution - long term
Point prevalence survey: PPS (photo)
Surveillance contineously (film)
&
Point Prevalence Survey: Hai - ABU
Why? - A need to standardize protocols in EU- Measuring prevalence, not incidence short measuring period
less labor intensive
What is measured? AB use – Hai
Result:• estimate the total burden• describe patients
• invasive procedures• infections • antimicrobials prescribed
Point Prevalence Survey: Hai - ABU
Percentage patients with HAI: 7.0%
0%
5%
10%
15%
20%
25%
11 13 15 20 38 59 58 34 27 63 49 30 50 2 62 14 51 61 40 37 7 48 55 41 16 18 17 46 33 24 57 21 12 36 56 19 39 43 60 5 53 22 42 4 29 45 23 28 32 44 52 35 6 54 8 47 3 1 26 31 9 25 10
Hospital number
% p
atie
nts
with
HA
I
Mean prevalence: 7% [0%-23%]
Courtesy UA
Prevalence of AM use by Hospital
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
% on AM
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
10 17 44 7 19 20 8 13 6 60 28 4 23 18 9 5 12 3 22 21 11 59 25 45 26 43 47 16 34 36av
erag
e 61 52 54 39 32 40 46 49 35 42 41 24 33 58 1 37 27 56 62 2 63 29 50 51 48 53 57 31 55 14 38 30 15
Mean: 38% [2% – 100%] Net: 35%
Courtesy UA
Point Prevalence Survey: Hai - ABUOn antimicrobials: 36.6%
Mean antimicrobials for those on antimicrobials: 1.5
:acute hospital-acquire:community-acquired :acquired in NH:medical prophylaxis :unknown reason:single dose:one day:> 1 day
Surg
Les infections liées aux soins et la consommationd’antimicrobiens dans les institutions de soins chroniquesbelges (projet HALT, 2010)
Rue Juliette Wytsmanstraat 14 | 1050 Brussels | BelgiumT +32 2 642 51 11 | F +32 2 642 50 01 | email: [email protected] | www.wiv-isp.be
Résultats: Nursing homes
• 722 LTCF de 25 pays européens
• 111 établissements belges• 107 MRS
• 3 institutions Sp
• 1 institution de psychiatrie
chronique
• 12 727 résidents éligibles
Eligible residents:< 250250 ‐ 499500 ‐ 9991000 ‐ 4999> 5000
Courtesy: K. Latour
Résultats: caractéristiques des résidents
50% 85+ ans 25.7% masculin
8.1%3.4%0.2%2.6%
41.1%48.3%59.0%
020406080
100
Incontinence
Désorientation
Chaise roulanté ou alitée
Cathéter urinaire
Cathéter vasculaire
Plaie d'escarre
Autre plaie
Résultats: la consommation d’antimicrobiens
• 554 résidents, 578 molécules
• Prévalence: 4.7% (0‐15.7%)
• 96% antibactériens à usage systémique (classe ATC J01)
Aminoglycosides (J01G) 0,4%
Tétracyclines (J01A) 2,3%
Sulfamides (J01E) 3,2%
Autres beta‐lactams
(J01D) 4,1%Macrolides (J01F) 4,7%
Quinolones(J01M) 20,4%Beta‐lactam
pen. (J01C) 27,9%
Autres antibactériens(J01X) 36,9%
1
3
2
Résultats: la consommation d’antimicrobiens
• 68.5% prescriptions thérapeutiques• 31.5% prescriptions prophylactiques
48.7% 31.8% 10.8%
Résultats: les infections liées aux soins
•390 infections confirmées, 361 résidents
•Prévalence: 3.1% (0‐11.9%)
Infection GI; 21; 5%Fièvre; 3; 1%
BSI; 2; 1% Autre infection; 21; 5%
Nez/gorge/oreilles/yeux; 39;
10%
Infection respiratoire; 187; 48%
Infection cutanée; 81;
21%
Infection urinaire; 36; 9%1
3
2
4
Courtesy: Jans B. & Latour K.
Concluding remarksWithin hospital evolution >> bench marking
stratification: service (ICU), type, size, regionHospital evolution
MRSA, MRE, Cdiff, HH compliance… can be combined- Monthly introductin required
- Many have done this retrospectively!!!
Future: evolution i.f.v. DRG (project AMTABU)- hip/knee replacement & CAP
Nursing homes: less AB use profylaxis UTI can be improved
Links
• NSIH web• https://nsihweb.wiv-isp.be .
• Manual NSIHweb - AB• www.nsih.be > geneesmiddelen > download > handleiding
voor de webapplicatie• List TUC codes
• www.nsih.be > geneesmiddelen > download > geneesmiddelenregister
• Protocol• www.nsih.be > geneesmiddelen > download >
surveillanceprotocol
Acknowledgements
Slides available on: www.nsih.be
[email protected] (ABU, ESAC)
Dr. Stien Vandendriessche (LA-MRSA)
Drs. Katrien Latour (HALT)
Mevr. Beatrice Jans (MRSA, ESBL, CPE, HALT)
Participating hospitals
Consumption of antibiotics in veterinary medicine
Boudewijn Catry*Anne Ingenbleek Bart PardonStien VandendriesscheBea Janswww.nsih.be
Boudewijn Catry*Anne Ingenbleek Bart PardonStien VandendriesscheBea Janswww.nsih.be
Rue Juliette Wytsmanstraat 14 | 1050 Brussels | BelgiumT +32 2 642 51 11 | F +32 2 642 54 10 | email: [email protected] | http://www.iph.fgov.be
MRSA evolution
n. hôpitaux 29 34 44 48 41 43
Evolution of MRSA‐incidence upon admission
Vandendriessche et al, 2012
QUIZ: Prevalence Livestock associated MRSA
Veal calves farmer a 72% LA-MRSASwine farmer 38% LA-MRSAInpatient hospital 1.6-25% MRSANursing home resident 13% MRSAVeterinarians 7.5% LA-MRSA Poultry farmers a 3% LA-MRSAUpon hospital admission 1.6% MRSA General population 0.5% MRSA
a Samples from non-mixed farms
Livestock-associated MRSA
Gordts, 2007Denis, JAC 2010Denis, EID 2009
Vandendriessche, JAC 2012Garcia‐Graells, E&I 2011
Goossens et al., 2012
18 13
4
103
1
1
4
MRSA ST398 (infection + screening)
ReferentieLaboratoriumvoor Stafylokokken ‐MRSA
Courtesy: Vandendriessche S
Swine farms density
Ribbens, Prev Vet Med 2009
Veal calves density
E. Ducheyne and B. Pardon, 2012
Courtesy: Vandendriessche S
Consumption patterns across animal species
75
Persoons et al., 2012 Callens et al., 2012 Catry et al., under revision Pardon et al., 2012
Courtesy: B. Pardon
Indications and timing
BRD (53%)Arrival prophylaxis (13%), diarrhea (12%), dysbacteriosis (12%)
Pardon ea, JAC 2012
Which compounds are used?
Oxytetracycline (23,7%), amoxicillin (18,5%), tylosin (17,2%) and colistin (15,2%) were most frequently used
Pardon ea, JAC 2012
Resistentieprofiel LA-MRSA
Aminosides Macrolides, lincosamides
Co‐selectie van resistentie
MRSA huidinfecties bij de mens worden vaak behandeld met doxycyclineof clindamycine Niet aangewezen voor LA-MRSA infecties
Vandendriessche, JAC 2012
Possible outcomes of exposureto resistant bacteria
P.L. Geenen, M.G.J. Koene, H. Blaak, A.H. Havelaar, A.W. van de Giessen
Bacteria & Co-selection of Resistance
Evolution E. coli multiresistance
P.L. Geenen, M.G.J. Koene, H. Blaak, A.H. Havelaar, A.W. van de Giessen
Evolution E. coli multiresistance
P.L. Geenen, M.G.J. Koene, H. Blaak, A.H. Havelaar, A.W. van de Giessen
Vaporization: ceftiofur
Evolution E. coli multiresistance
P.L. Geenen, M.G.J. Koene, H. Blaak, A.H. Havelaar, A.W. van de Giessen
www.BelVet-SAC.ugent.be
Among European countries 2010: Belgium is the 3rd highestconsumer of antimicrobials in veterinary medicine.
www.BelVet-SAC.ugent.be
Comparison Oral (Feed) vs Injection
Checkley e.a., CVJ / VOL 51 / AUGUST 2010
Resistance E. coli
Type period (N
herds)
N ARIa AMPb
AMC CEF TET TMP NEO GEN SPT STR NAL FLU ENR
Dairy I (10) 447 0.04 2.91 0.45 0.45 8.28 4.25 0.67 1.12 0.22 24.83 1.34 0.22 0 II (10) 396 0.01 2.02 0.25 0 3.79 0.25 1.52 0 0.25 4.55 0.76 0.25 0.25 III (10) 419 0.02 4.3 0.24 0 4.3 3.58 2.15 0.48 0 7.88 1.19 0.72 0.24
Beef I (10) 436 0.03 9.17 1.15 0 6.88 4.13 2.52 0.92 0.69 13.3 2.52 0.46 0.46
II (9) 346 0.06 12.14 1.45 0.58 17.05 5.49 4.91 2.31 0.87 18.21 8.67 4.33 2.89
Veal T1 (5) 276 0.62 93.12 4.71 0.36 94.93 92.75 83.33 45.29 22.46 89.49 79.00 73.13 64.23 T2 (5)
230 0.32 79.57 2.61 1.74 95.22 65.22 27.83 5.22 5.65 78.26 14.01 6.22 4.12
> 25%
Catry et al., 2008 National Report
Dense communities= hotspots for AB & ABR
Vulnerable populations
Co-selection = accumulation – persistence…
Acknowledgements: S Vandendriessche, C Garcia, O Denis,
B Jans, M Goossens, N Viseur, A IngenbleekB. Pardon, B Callens, J Dewulf, F Haesebrouck
the labs & hospitals & nursing homes & veterinarians
[email protected]@@wivwiv--isp.beisp.be