UNDERSTANDING SOUTH AFRICA'S CONSUMPTION OF ANTIMICROBIALS Pharmacy Society of South Africa Conference 2018 Ruth Lancaster
Contents 1. Background AMR National Strategic Plan 2. Sources of antimicrobial use in South Africa 3. Analysis Defined Daily Doses 4. Results 5. Key learning points 6. Conclusion
WHA endorses Global Action Plan on AMR in May 2014 AMR Strategy Framework October 2015 AMR Implementation plan Approved in June 2015 AMS One Health Governance Guidelines
Strategic objective Enablers Pillars of the South African AMR Strategy Framework Impact: Rational Antimicrobial use and improved patient outcomes Antimicrobial resistance Governance Diagnostic stewardship Enhance Surveillance Antimicrobial Stewardship Prevention including IPC and vaccination Health systems strengthening, research, education and communication
Strategic Objective 2 & 3 Improve appropriate use of diagnostics and optimise surveillance Strengthen passive and active surveillance locally and nationally Antimicrobial resistance Antimicrobial use MAC-AMR: Surveillance Working Group co-ordinating the consolidation of data from private and public sectors on AMR resistance Goal: advise NDoH on EML and formularies; yearly report with resistance maps Escherichia coli (E coli) world benchmark 5 Figure 1-2: Percentage of extended-spectrum beta-lactamase producing Escherichia coli*, by country (most recent year, 2011-2014) 0-9 10-19 20-39 Source: CDDEP 2015, WHO 2014 and PAHO, forthcoming 40-59 60-79 80-100 No data 11
Sources of AMU in SA 4 Sources of AMU data in SA for human and animals: 1. South African Revenue Services Volume of antimicrobials in kg and rand value 2. South African Animal Health Association Volume per antibiotic class Represents + 80 pharmaceutical companies 3. Quintiles IMS Standard units per 1000 population antimicrobials supplied by pharmaceutica in the private sector 4. RSA Pharma Database Order and procurement data against contracts awarded by the NDoH Represents provincial ordering patterns 6
Sources of AMU in SA Combining the data from all data sources 7
Defined Daily Doses Assumed average maintenance dose per day for a medicine used for its main indication in Adults Sometimes a dose that is rarely prescribed, as it is an average of two or more commonly used dose sizes Uses: Technical measurement that allows measurement and comparison of volume of medicine use Rough estimate of consumption, not an exact picture of actual use https://www.whocc.no/ddd/definition_and_general_considera/ 8
Defined Daily Doses NATIONAL ORDER DATA Description ATC 5th level Dec 2015 Ampicillin 500mg/Vial 1 Vial J01CA01 528400 Ciprofloxacin 250mg 10 Tablet J01MA02 25690 Ciprofloxacin 250mg/5ml 100ml J01MA02 1430 9
Strength Strength Unit Pack Size Pack Size Unit DDD DDD unit DDD (mg) DDD unit mg Patient days DDD per pack Quantity Issued DDD Issued Defined Daily Doses Description ATC Ampicillin 500mg/Vial 1 Vial Ciprofloxacin 250mg 10 Tablet J01CA0 1 J01MA 02 500 mg 1 vial 2000 mg 2000 mg 365 0.25 528400 132100 250 mg 10 tablet 1 g 1000 mg 365 2.5 25690 64225 Ciprofloxacin 250mg/5ml 100ml J01MA 02 250 mg/5ml 100 ml 1 g 1000 mg 365 5 4783 23915 Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance; 2017 10
Strength Strength Unit Pack Size Pack Size Unit DDD DDD unit DDD (mg) DDD unit mg Patient days DDD per pack Quantity Issued DDD Issued Defined Daily Doses Description ATC Ampicillin 500mg/Vial 1 Vial Ciprofloxacin 250mg 10 Tablet J01CA0 1 J01MA 02 500 mg 1 vial 2000 mg 2000 mg 365 0.25 528400 132100 250 mg 10 tablet 1 g 1000 mg 365 2.5 25690 64225 Ciprofloxacin 250mg/5ml 100ml J01MA 02 250 mg/5ml 100 ml 1 g 1000 mg 365 5 4783 23915 Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance; 2017 11
Results Estimation of AMU internationally SA use per 1000/population 21 149 Higher than other countries but similar to other BRICS (increasing access to health services, strengthening PHC, NHI implementation) 12
Results Estimation of AMU nationally SA use per 1000/population 21 149 1/3 = cotrimoxazole PJP prophylaxis Increasing broad spectrum penicillin use 1.3 3.3 x other BRICS countries 0.8 x UK and USA 13
Antibacterials: J01 Pharmadatabase 2015-17 51% 49% Co-trimoxazole Antibacterials for systemic use excluding Co-trimoxazole Antibacterials: J01 excluding cotrimoxazole RSA Pharmadatabase 2015-2017 Broad spectrum Narrow spectrum Carbapenems Vancomycin 3rd generation cephalosporins Fluoroquinolones Macrolides 14
Results Estimation of AMU: human vs animal South Africa imported 4.35 tons of antimicrobials (2014) Animals = 23% USA reported 80% consumption by animal health 15
Results Estimated consumption: split between human and animals 16
Key learning points Limitations to the data Initial overview of the country AMU can be seen: Human use > animal use Broad spectrum penicillin most used antibiotic class Community or Hospital? Public or Private? Adherence to Standard Treatment Guidelines? 17
Conclusion Sustainable and consistent sources of data are critical Trend analysis to monitor interventions put into place http://www.bioethics.net/2018/04/the-end-is-nigh-bioethics-and-antibiotic-resistance/ 18
Thanks to Dr Kim Faure 19