Consumption of antibiotics at St Luke’s Hospital : a critical factor behind the local prevalence of antimicrobial resistance?

The intensity of antibiotic use in hospital settings is recognised as possibly the most important factor for the selection of antimicrobial resistance. Hospitals are therefore being encouraged to undertake surveillance and benchmarking of antimicrobial consumption patterns with a view to identify and rectify possible evidence of overuse or misuse. Use of antibiotics at St. Luke's Hospital, Malta (SLH) was assessed retrospectively for the year 2001 as part of participation in two pan-European antibiotic surveillance networks. Total antibiotic use during the study period averaged 147 Defined Daily Doses (DDD) /100 bed days with the three most common antibiotic groups prescribed being the penicillins, cephalosporins and macrolides. Combinations of penicillin with beta-lactamase inhibitor were the predominant antimicrobials in use and their consumption was twice the median for other participating hospitals in the European ARPAC network. Differences were additionally seen for second generation cephalosporins and macrolides, where consumption was also significantly higher at SLH. These findings would explain one possible factor behind the high prevalence of resistance, particularly in Staphylococcus aureus, at SLH and suggest the need to intensify efforts for improved antibiotic stewardship programmes in hospital prescribing.peer-reviewedpeer-reviewe

Consumption of antibiotics within ambulatory care in Malta

Background: Antibiotic use is recognised as the most important driver for the development of antimicrobial resistance in community pathogens. Surveillance is therefore critical for improvement programmes. Methods: Antimicrobial distribution data for the years 2007 to 2009 were collected retrospectively by the National Antibiotic Committee from all licensed wholesale distributors (WSL) in Malta and analysed according the World Health Organization Anatomical Therapeutic Chemical classification (ATC) level 4 criteria. Results: Overall consumption increased from 18.6 defined-daily-doses/1000-inhabitant-days (DID) in 2007 to 22.7 DID in 2008 and reached 24.4 DID in 2009 - an increase of more than 30% over the three years, Penicillins with beta-lactamase inhibitor increased in volume (7.1 to 8.8 DID) but decreased in proportion (38.4% to 36.0%) between 2007 and 2009. On the other hand, second generation cephalosporins increased in both volume and proportion (2.8 to 5.4 DID; 15.0% to 22.0%). The proportion for macrolides remained stable at approximately 16% but the volume of use again increased (2.9 DID to 3.9 DID). Fluoroquinolone proportion decreased from 9.1% to 6.8%, maintaining a stable volume of use in the region of 1.7 DID. Conclusions: Antibiotic consumption in Malta has shown a consistent increasing trend over the past three years, despite a reduction in over-the-counter acquisition. Furthermore, there is evidence of a strong, and possibly unjustified, prescription of wide spectrum antibacterials. This is potentially an important driver for documented resistance in Streptococcus pneumoniae and Escherichia coli and needs to be addressed at a national level.peer-reviewe

Antibiotic susceptibility patterns of local strains of Pseudomonas aeruginos

The resistance patterns of 100 local strains of Ps. aeruginosa were investigated using two different methods: (1) Broth Dilution and (2) ε-test. From the seven antibiotics tested, Ps. aeruginosa showed a 100% sensitivity to imipenem (n=30). Among the first-line agents, azlocillin, ceftazidime, and gentamicin showed the highest sensitivity rates, 87%, 93% and 92% respectively. Aztreonam and ciprofloxacin showed the presence of intermediately sensitive strains, with 61% of the isolates tested being fully sensitive to each antibiotic. Only 47% of the strains were found to be sensitive to ceftriaxone. The results obtained were similar to studies carried out abroad.peer-reviewe

Antimicrobial consumption in Albanian reference teaching hospital (2012-2015)

Human antibiotic consumption has been increasing globally with the greatest increase being observed in low and middle income countries (LMICs). Despite an estimated 80% of use being attributed to the community, where both prescribed and over the counter (OTC) use are common, especially in LMICs, the volume of patients with serious medical conditions in hospitals and the resultant high density of antibiotic use in such institutions, makes hospital antibiotic use disproportionately important. A recent publication from Albania showed the combined community and hospital consumption in Albania for 2011-2012. However, in a recent World Health Organization (WHO) European Region (WHO/Euro) press release no data from Albania was reported. LMICs generally lack resources for surveillance of antimicrobial consumption rendering any antimicrobial stewardship initiatives more difficult.peer-reviewe

European surveillance of antimicrobial consumption (ESAC)

All 27 EU member states and another seven countries participate in the European Surveillance of Antimicrobial Consumption (ESAC) project. ESAC carried out three hospital point-prevalence surveys on antimicrobial use. Point-prevalence surveys linked antimicrobial use to indication and also assessed dosing using a standardized methodology for data collection and online data submission with feedback capability using a dedicated web-based tool. The objectives of the ESAC hospital point-prevalence surveys were to first determine the feasibility of a pan-European survey and identify targets for quality improvement. Hospitals were voluntarily selected by the lead national or hospital representatives for each country. The WHO Anatomical Therapeutic Chemical Classification of drugs was used for classification of antimicrobials. The three surveys were carried out during a maximum of 2 weeks in the second quarter of 2006, 2008 and 2009. Each department had to be surveyed in 1 day. All systemic antibacterials (J01), rifampicin (J04AB), oral vancomycin (A07AA) and oral/rectal metronidazole (P01AB) were the antimicrobials surveyed, including the prescribed regimen. The number of participating hospitals increased from 20 to 172 from 2006 to 2009. The patient demographics and indications for treatment were similar throughout the three point-prevalence surveys. 'Reason in notes' and 'surgical prophylaxis >24 hours' were also similar. Guideline compliance (51%) was only introduced in the 2009 point-prevalence survey, replacing 'sample for culture and sensitivity' (50%) of patients. The use of combination therapy, although exhibiting a wide range within each category, was related to hospital type, with teaching and tertiary hospitals having a significantly higher use of combination therapy (teaching : non-teaching hospitals [p < 0.0001]; and primary : tertiary hospitals [p < 0.0001]). Point-prevalence surveys are useful when time and resources do not allow for continuous surveillance. Repeated point-prevalence surveys within the same institution(s) can be used to monitor trends and effectiveness of antimicrobial-stewardship initiatives. Targets should be set as quality indicators for the individual hospital(s) and effectiveness of any intervention monitored through repeated point-prevalence surveys. Spin-off initiatives, such as the Antibiotic Resistance and Prescribing in European Children, and the European Centre for Disease Prevention and Control point-prevalence survey on healthcare-associated infections and antimicrobial use, will utilize adapted versions of WebPPS, the point-prevalence survey software developed by ESAC. WebPPS will also be made available for non-commercial use to third parties. Interest has been shown from three continents outside Europe, namely North America, Australia and Africa.peer-reviewe

Control strategies for late blight in organic potato production

This report was presented at the UK Organic Research 2002 Conference. Protective copper fungicides are currently used to control late blight in most organic production systems, but approval for their use in organic farming will be revoked in 2002. Evidence suggests that organic potato production will not be reliably economic in the absence of Cu. Current controls for late blight are reviewed including: variety selection/breeding for blight resistance, diversification strategies, agronomic strategies for the management of late blight, and alternative treatments to Cu-fungicides

Antifungal therapy in European hospitals : data from the ESAC point-prevalence surveys 2008 and 2009

The study aimed to identify targets for quality improvement in antifungal use in European hospitals and determine the variability of such prescribing. Hospitals that participated in the European Surveillance of Antimicrobial Consumption Point Prevalence Surveys (ESACPPS) were included. The WHO Anatomical Therapeutic Chemical (ATC) classification for ‘antimycotics for systemic use’ (J02) 2009 version was used. Demographic data and information about indications and diagnoses were collected in 2008 and 2009. From 99 053 patients, 29 324 (29.6%) received antimicrobials. Antifungals represented 1529 of 40 878 (3.7%) antimicrobials. Antifungals were mainly (54.2%) administered orally. Hospital-acquired infections represented 44.5% of indications for antifungals followed by medical prophylaxis at 31.2%. The site of infection was not defined in 36.0% of cases but the most commonly targeted sites were respiratory (19.2%) and gastrointestinal (18.8%). The most used antifungal was fluconazole (60.5%) followed by caspofungin (10.5%). Antifungal–antibacterial combinations were frequently used (77.5%). The predominance of fluconazole use in participating hospitals could result in an increase in prevalence of inherently resistant fungi, increasing the need for newer antifungals. Although acknowledging that antifungal prophylaxis in the immunocompromised host needs further exploration, repetitive surveys using ESAC-PPS methodology may help to monitor the effects of interventions set to regulate antifungal use.The ESAC project was supported by a grant from the European Centre for Disease Prevention and Control (ECDC; Grant Agreement 2007/001).peer-reviewe

Comparison of outpatient systemic antibacterial use in 2004 in the United States and 27 European countries

The European Surveillance of Antimicrobial Consumption (ESAC) project collects data on antibacterial use in Europe, applying the Anatomic Therapeutic Chemical classification system and defined daily dose methodology, as recommended by the World Health Organization. Comparable data for the United States have been collected from IMS Health. The IMS Health sales data, processed according to ESAC methodology, suggest that outpatient antibacterial use in the United States is high (only 3 of 27 European countries used more) and is mainly characterized by a shift towards newer antibiotics.peer-reviewe

Antibiotic prescribing for respiratory tract complaints in Malta : a 1 year repeated cross-sectional surveillance study

Objectives: To determine the 1 year antibiotic prescribing patterns by GPs for acute respiratory tract complaints (aRTCs) in Malta. Methods: In this repeated cross-sectional surveillance study, GPs collected data for patients seen for aRTCs during a designated 1 week period each month, between May 2015 and April 2016. GPs received three text reminders during surveillance weeks and were contacted by phone at most four times during the year. GPs also received 3 monthly individual- and aggregate-level feedback reports on their antibiotic prescribing patterns. Descriptive statistics were used to examine patient, consultation and clinical characteristics, and to describe GPs’ prescribing patterns. Results: Participating GPs (n = 33) registered 4641 patients with an aRTC, of whom 2122 (45.7%) received an antibiotic prescription. The majority (99.6%) of antibiotics prescribed were broad-spectrum and the most commonly prescribed antibiotics were macrolides (35.5%), followed by penicillins with a β-lactamase inhibitor (33.2%) and second-generation cephalosporins (14.2%). Specifically, co-amoxiclav (33.2%), clarithromycin (19.6%), azithromycin (15.1%) and cefuroxime axetil (10.9%) represented 78.8% of all antibiotics prescribed. Patients with tonsillar exudate (99.1%), purulent sputum (84%), otorrhoea (78%), tender cervical nodes (74.4%) and fever (73.1%) received most antibiotics. The diagnoses that received the highest proportion of antibiotic treatment were tonsillitis (96.3%), otitis media (92.5%) and bronchitis (87.5%). Wide variation in the choice of antibiotic class by diagnosis was observed. Conclusions: GP antibiotic prescribing in Malta is high. The abundant use of broad-spectrum antibiotics, particularly macrolides, is of particular concern and indicates that antibiotics are being used inappropriately. Efforts must be made to improve GP awareness of appropriate antibiotic prescribing.peer-reviewe

Antibiotic use in ambulatory care in Europe (ESAC data 1997-2002) : trends, regional differences and seasonal fluctuations

Purpose: The ESAC project (European Study on Antibiotic Consumption) aims to collect antibiotic-use data through a European network of national surveillance systems. This paper reports on the retrospective data collection in ambulatory care for the period 1997–2002. Methods: Valid data of antibiotic consumption of 24 European countries for 2002 and of 18 countries for the entire 6-year period was classified according to the Anatomical Therapeutic Chemical Classification (ATC) and expressed in defined daily dose (DDD) per 1000 inhabitants per day (DID). Overall and subgroup comparison of antibiotic consumption over time as well as between geographical clusters was performed. Results: Total use of antibiotics in Europe remained at a median level of 20 DID in the period 1997–2002 with a wide variation between countries ranging from 9.8 DID in The Netherlands to 32.2 DID in France. A substantial increase in subclass consumption of co-amoxiclav and fluoroquinolones was noted while the use of narrow-spectrum penicillins, erythromycin, quinolones and sulfonamides decreased. Total consumption as well as seasonal fluctuations showed remarkable geographical clustering with low consumption and low variation between summer and winter in the North, high consumption patterns in the South and a mixed model in the East. Conclusions: Within the ESAC project, valid time series of antibiotic-use data are publicly available now, enabling to improve the study of determinants of use, the evaluation of governmental antibiotic consumption policies and the investigation of the associated emergence of antibiotic resistance.peer-reviewe