How is Ireland performing on antibiotic prescribing?

European Antibiotic Awareness Campaign 2016 November Webinar Series on Antibiotic Prescribing 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

Sourcing the Data Why? o Resistance to antibiotics in bacteria is increasing o Multi-drug resistance is increasing o 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 2

Sourcing the Data Where? Manufacturer Wholesaler IMS Health Hospital pharmacists from public acute hospitals provide dispensary data Retail chemist Primary care Hospital 3

Sourcing the Data? Online pharmacy Manufacturer Wholesaler Extended care Sales rep Retail chemist Dentist GP Regional Offices Reimbursement Hospital 4

Sourcing the Data 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 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

Primary-care Antimicrobial Consumption o EU Comparisons o Antibacterial class of drug o Seasonal fluctuation & recent trend o Geographic distribution o Latest data Retail chemist Primary care 7

Primarycare Antimicrobial Consumption o EU Comparisons o Antimicrobial class o Seasonal fluctuation & recent trend o Geographic distribution o Latest data 2014 8

Primarycare Antimicrobial Consumption o EU Comparisons o Antimicrobial class o Seasonal 2015 fluctuation & recent trend o Geographic distribution o Latest data 2014 9

Primarycare Antimicrobial Consumption o EU Comparisons o Antimicrobial class o Seasonal fluctuation & recent trend o Geographic distribution o Latest data Sulfonamides and Trimethoprim 4.1% Quinolones Cephalosporins 3.6% and other betalactam drugs 4.6% Tetracylines 10.1% Macrolides and related drugs 16.5% Antibacterials 2015 Penicillins 2015 Penicillin with betalactamase inhibitor 44% Other antibiotics 0.4% Penicillins 60.6% Narrow spectrum penicillins 7% Broad spectrum penicillins 35% Betalactamase resistant penicillins 14% 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 Defined Daily Doses per 1000 Inhabitants per Day (DID) 30 25 20 15 10 1234123412341234123412341234123412341234123412341234123412341234 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 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 35 o Antimicrobial 30 25 class 20 o Seasonal 15 10 fluctuation & 5 recent trend 0 o Geographic distribution Modelled Use o Latest data Defined Daily Doses per 1000 Inhabitants per Day (DID) Defined Daily Doses per 1000 Inhabitants per Day (DID) 30 25 20 15 10 1234123412341234123412341234123412341234123412341234123412341234 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 Observed Use Underlying Trend 2005 2006 2007 2008 2009 2010 2011 2012 2013 High Influenza Activity Observed Use Winter rises mean Influenza the Like usage Illness in Rate some (not to scale) months is very high and the overall rates appear to be increasing steadily 12

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 data Ireland 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

Hospital Antimicrobial Use o Routine quarterly data o Point prevalence survey Hospital 15

Web-based Data System Surveillance Expert User 16

Secure, detailed breakdown for professionals 17

open access outputs for the public 18

Overall use in hospitals 100 Rate (DDD per 100 BDU) 80 60 40 20 Tetracyclines Other Antimicrobials Glycopeptides and related drugs Quinolones Aminoglycosides Macrolides and related drugs Sulfonamides and Trimethoprim Cephalosporins and other beta lactam drugs 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 Penicillins DDD per 100 BDU 10 9 8 7 6 5 4 3 2 1 0 Quinolones (J01M) use in Irish hospitals 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* DDD per 100 BDU Carbapenems (J01DH) use in Irish hospitals 4 3.5 3 2.5 2 1.5 1 0.5 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 19

Overall use in hospitals 100 Rate (DDD per 100 BDU) 80 60 40 20 Tetracyclines Other Antimicrobials Glycopeptides and related drugs Quinolones Aminoglycosides Macrolides and related drugs Sulfonamides and Trimethoprim Cephalosporins and other beta lactam drugs 0 2007 2008 2009 2010 2011 2012 2013 2014 2015 Penicillins DDD per 100 BDU 10 9 8 7 6 5 4 3 2 1 0 Quinolones (J01M) use in Irish hospitals 0 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* DDD per 100 BDU *2016 Provisional data to end of Q2 4 3.5 3 2.5 2 1.5 1 0.5 Carbapenems (J01DH) use in Irish hospitals 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 20

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? Number of isolates DDD per 100 BDU 10 9 8 7 6 5 4 3 2 1 0 1600 1400 1200 1000 800 600 400 200 0 Quinolones (J01M) use in Irish hospitals 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Year MRSA MSSA %MRSA %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? Number of of isolates DDD per 100 BDU 10 9 8 7 6 5 4 3 2 1 0 3000 1600 1400 2500 1200 2000 1000 1500 800 600 1000 400 500 200 Quinolones (J01M) use in Irish hospitals 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 30% 50% 45% 25% 40% 35% 20% 30% 15% 25% 10% 15% 10% 5% 5% 0 0% 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* Year Year Total E. coli MRSA %FQREC %GEN R MSSA %GEN/TOB/AMK R %MRSA %3GC R 20% %MRSA %Resistance FQREC, fluoroquinolone (e.g. ciprofloxacin) resistant E. coli; GEN, gentamicin, TOB, tobramycin; AMK, amikacin (GEN, TOB and AMK are aminoglycosides); 3GC, 3 rd generation cephalosporins (e.g. cefotaxime, ceftazidime)

Carbapenemase-producing Klebsiella pneumoniae o Sharp increase Carbapenems (J01DH) use in Irish hospitals 4 carbapenem use 3.5 3 o Carbapenem 2.5 Resistant 2 1.5 Enterobacteriaceae 1 (CRE) global 0.5 0 problem o Numbers of 450 4% 400 carbapenemaseproducing K. 300 350 3% 250 pneumoniae 2% 200 increasing 150 1% 100 o Outbreak control 50 team put in place 0 0% DDD per 100 BDU Number of isolates 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015* Year Total K. pneumoniae tested for CBP CBP R KPN %CBP R %CBP R

European Antimicrobial Resistance Surveillance Network (EARS-Net) Proportion resistance 50% 45% 40% 35% 30% 25% 20% 15% 10% 5% 0% Quinolone Resistant E. coli Cephalosporin Resistant E. coli ESBL producing E. coli Multiple Resistant E. coli Vancomycin Resistant Enterococcus faecium Meticillin Resistant Staph. aureus Penicillin Resistant Strep. pneumoniae Year Erythromycin Resistant S. pneumoniae AMC WHO, Copenhagen, August 16

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 80% % Prevalence of Antimicrobial Prescribing 70% 60% 50% 40% 30% 20% 10% 2009 2010 2011 2013 2014 2015 0% Medicine Surgery Intensive care Other speciality OVERALL Source: Public Health Wales, by Health Board Source: HSE-HPSC, Ireland 25

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 26

PPS 2016 - Drugs 27

PPS 2016 - Indications 100% Ireland 80% Prevalence 60% 40% Single Dose One Day >1 day 20% 0% 2009 2010 2011 2013 2014 2015 28

PPS 2016 - Compliance 29

EAAD 30

Acknowledgements o Antimicrobial pharmacists in Ireland o Infection control teams and microbiology laboratories in hospitals o Clinical HCAI Programme in Ireland o Colleagues at HPSC o ESAC-Net at ECDC 31