Transcript Slide 1

The role of the English Surveillance
Programme on Antimicrobial Use &
Resistance in improving stewardship
Susan Hopkins
Consultant Infectious Diseases & Microbiology, Royal Free
Healthcare Epidemiologist, Public Health England
Hon Snr Lecturer, UCL
1
UK AMR Strategy:
Seven Key Areas for Action
1 Improving infection prevention and control practices
2 Optimising prescribing practice
3 Improving professional education, training and public
engagement
4 Developing new drugs, treatments and diagnostics
5 Better access to and use of surveillance data
6 Better identification and prioritisation of AMR research needs
7 Strengthened international collaboration
The
Antimicrobial stewardship
programmes
•
•
•
aim to improve quality of prescribing
usage data required to monitor impact
must be related to AMR epidemiology
BUGS
DRUGS
AMR
PHE ESPAUR:
English Surveillance Programme for AMU & AMR
• Support antimicrobial stewardship by
monitoring antimicrobial use
• Monitor key drug-bug combinations
• Enhance data analysis and advice
on use of carbapenemens & critically
important drugs
• Develop & measure quality
measures for optimal antimicrobial
prescribing
• Develop methods to monitor the
clinical outcomes/ unintended
consequences
• Develop initiatives to change public
and professional behaviour
• Input into national antimicrobial
guidance
Top 6 Blood stream infections, Voluntary
surveillance, 2002-11
30,000
Number of bacteraemia reports
25,000
20,000
Escherichia coli
Staphylococcus aureus
Streptococcus, non-pyogenic
15,000
Enterococcus
Klebsiella
10,000
Streptococcus, pyogenic
5,000
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
Staphylococcus aureus: MRSA &
MSSA
Number of Staphylococcus aureus bacteraemia per year, England,
Voluntary Surveillance, 1991-2012
MRSA
Number of SAB cases
MSSA
Year
Escherichia coli bacteraemia
No of E coli bacteraemia
Number of E coli Bacteraemia per year,
England, Voluntary Surveillance, 2000-1012
Year
25% were diagnosed ≥2 days after hospital admission
Increased AMR in hospital associated cases
Resistance in E coli, Blood,
2004-2013
N~30,000/year
Resistance in Klebsiella, Blood,
2004-2013
N~8,000/year
Declines in resistance to Ciprofloxacin & Ceftriaxone
Increases in resistance to Piperacillin-Tazobactam & Carbapenems
? Ecological Pressure
Rapid spread of resistance
Antimicrobial resistance
Image from slides produced by McKinsey & Company,
based on earlier image from Nature, 13th July 2013
PHE confirmed carbapenemase producers
1000
877
900
800
Others (n=64)
700
604
Enterobacter (n=119)
600
500
Escherichia (n=221)
407
400
Pseudomonas (n=355)
300
200
100
119
11
23
15
29
2003
2004
2005
2006
Klebsiella (n=1416)
54
36
Total (n=2175)
0
2007
2008
2009
2010
2011
2012
Klebsiella
Pseudomonas
Escherichia
Enterobacter
Other
0%
10%
20%
30%
40%
IMP
KPC
50%
NDM
OX48
60%
VIM
70%
80%
90%
100%
Changes 2007-2012
100
90
80
Tetracyclines
Macrolides
Cephalosporins
Sulphonamides & trimethoprim
Co-Amoxiclav
Quinolones
Metronidazole & tinidazole
All other antibacterial drugs
51% increase
22% increase
55% decrease
27% increase
21% increase
36% decrease
4.5% increase
183% increase
Items per 1000 Patients
70
60
50
40
30
20
10
0
Apr.98- Apr.99- Apr.00- Apr.01- Apr.02- Apr.03- Apr.04- Apr.05- Apr.06- Apr.07- Apr.08- Apr.09- Apr.10- Apr.11- Apr.12Mar.99 Mar.00 Mar.01 Mar.02 Mar.03 Mar.04 Mar.05 Mar.06 Mar07 Mar08 Mar09 Mar.10 Mar.11 Mar.12 Mar.13
Trends in Prescribing of Antibacterials , excluding
penicillins, in General Practice in England
AMP Key Trends
Diane Ashiru-Oredope
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AMP Key Trends
Diane Ashiru-Oredope
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AMP Key Trends
Diane Ashiru-Oredope
AMP Key
Trends
Diane Ashiru-Oredope
Antimicrobial Usage for English Hospitals
n=165
80000000
COMBINATIONS OF PENICILLINS, INCL. BETALACTAMASE INHIBITORS
BETA LACTAMASE RESISTANT PENICILLINS
70000000
MACROLIDES
60000000
PENICILLINS WITH EXTENDED SPECTRUM
TETRACYCLINES
50000000
FLUOROQUINOLONES
40000000
TRIMETHOPRIM AND DERIVATIVES
BETA LACTAMASE SENSITIVE PENICILLINS
30000000
OTHER AMINOGLYCOSIDES
20000000
CARBAPENEMS
COMBINATIONS OF SULFONAMIDES AND
TRIMETHOPRIM, INCL. DERIVATIVES
10000000
GLYCOPEPTIDE ANTIBACTERIALS
0
2007/8
2008/9
2009/10
2010/11
2011/12
Carbapenem usage for English
Hospitals, 2007-2012
1400000
1200000
CILASTATIN/IMIPENEM
DORIPENEM
800000
ERTAPENEM
MEROPENEM
600000
TOTAL
400000
200000
201112
201011
200910
20089
0
20078
Total DDD
1000000
Carbapenem usage as % of total use
in English hospitals in 2011-2012
12.0%
10.0%
8.0%
6.0%
4.0%
2.0%
1
5
9
13
17
21
25
29
33
37
41
45
49
53
57
61
65
69
73
77
81
85
89
93
97
101
105
109
113
117
121
125
129
133
137
141
145
149
153
157
161
0.0%
UCLp Hospitals & Point Prevalence
Survey
• First national prevalence antimicrobial use
survey 2011
• Many UCLp hospitals participated
• Overall England Prevalence 35%
• Variation across hospital type
• Variation with age, sex, comorbidity, specialty,
history of surgery
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Point prevalence Survey: Antimicrobial
use
AMP Key Trends
Diane Ashiru-Oredope
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Variation in AMU prevalence, SAUR
2
Crude AMU Prevalence
% (95% CI)
SAUR (O/E): 1.03 (95%CI 0.84-1.26; P 60)
2
1
32.3 (27.1-37.9)
.5
1
SAUR (O/E) - EU
1.5
Hospital
1.5
SAUR (O/E): 1.17 (95%CI 0.98-1.39; P 88)
39.9 (34.6-45.5)
1
0
2
.5
2
SAUR (O/E) - EU
0
Standardized AU ratio (SAUR), based on all patient risk factors (standard risk adjustment)
Standardized AU ratio (SAUR), based on all patient risk factors (standard risk adjustment)
1
43.8 (39.8-48.0)
0
2
.5
3
SAUR (O/E) - EU
1.5
SAUR (O/E): 1.11 (95%CI 0.97-1.25; P 77)
0
2
.5
31.5 (28.3-35.0)
1
SAUR (O/E) - EU
4
SAUR (O/E): 0.95 (95%CI 0.83-1.07; P 34)
1.5
Standardized AU ratio (SAUR), based on all patient risk factors (standard risk adjustment)
Standardized AU ratio (SAUR), based on all patient risk factors (standard risk adjustment)
1
.5
41.8 (36.8-47.1)
0
5
SAUR (O/E) - EU
1.5
SAUR (O/E): 1.21 (95%CI 1.03-1.42; P 92)
Standardized AU ratio (SAUR), based on all patient risk factors (standard risk adjustment)
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Proportion of AMU by drug
Drug
National
1
2
3
4
5
Co-amox
13.8
26.7
23.1
22.8
14.7
0
Pip-tazo
10.9
5.8
11.5
12.8
11.3
24.1
Gent
4.2
6.7
1.9
2.3
1.9
4.5
Mero
5.0 (8th) 0 (>20th) 2.6 (10th) 3.8 (7th)
6.8 (4th) 9.5 (3rd)
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Can use influence national AMR?
• Until 2007, major increases in cephalosporin and quinolone
resistance amongst Escherichia coli & Klebsiella spp
• Plateau/ fall in resistance was from 2007 (LabBase / BSAC)
• Fall in resistance coincides with the large reduction in
cephalosporin and quinolone use
– due to national antimicrobial stewardship guidance to reduce
Clostridium difficile infections nationally
• Replacement have been penicillin/b-lactamase inhibitors
which may have another impact
Livermore D M et al. J. Antimicrob. Chemother. 2013;jac.dkt212
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Conclusion
• AMR major threat to future
healthcare
• AMU recognised driver of
resistance
• ESPAUR a national surveillance
programme developed by PHE will
– focus on integrating data
– develop & measure quality measures
• UCLp key role
– working across hospitals to support
initiative
– validate data and
– be a national leader
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Acknowledgements:
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Diane Ashire-Oredope
Jonathan Cooke
Sue Faulding
Russell Hope
Alan Johnson
Cliodna McNulty
Pete Stephens
Neil Woodford
GPs, microbiology, pharmacy, infection
prevention & control teams