How is Ireland performing on antibiotic prescribing? - … · How is Ireland performing on antibiotic prescribing? ... Comparisons o Antimicrobial class ... Carbapenems (J01DH) use

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


o EU Comparisons




o Latest data

9

2014

2015


o EU Comparisons




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


o EU Comparisons




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


o EU Comparisons




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)


o EU Comparisons




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


o EU Comparisons




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




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




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


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


*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


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


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


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

Documents

How is Ireland performing on antibiotic prescribing? - … · How is Ireland performing on antibiotic prescribing? ... Comparisons o Antimicrobial class ... Carbapenems (J01DH) use