The role of the English Surveillance Programme on Antimicrobial Use & Resistance in improving

stewardship

Susan HopkinsConsultant Infectious Diseases & Microbiology, Royal Free

Healthcare Epidemiologist, Public Health EnglandHon Snr Lecturer, UCL

1

UK AMR Strategy:Seven Key Areas for Action

1 Improving infection prevention and control practices2 Optimising prescribing practice3 Improving professional education, training and public

engagement4 Developing new drugs, treatments and diagnostics5 Better access to and use of surveillance data 6 Better identification and prioritisation of AMR research needs7 Strengthened international collaboration

The

Antimicrobial stewardship programmes

BUGS DRUGS AMR

• aim to improve quality of prescribing • usage data required to monitor impact• must be related to AMR epidemiology

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

-

5,000

10,000

15,000

20,000

25,000

30,000

2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Nu

mb

er

of

ba

cte

rae

mia

re

po

rts

Escherichia coli

Staphylococcus aureus

Streptococcus, non-pyogenic

Enterococcus

Klebsiella

Streptococcus, pyogenic

Staphylococcus aureus: MRSA & MSSA

19911992

19931994

19951996

19971998

19992000

20012002

20032004

20052006

20072008

20092010

20112012

0

2000

4000

6000

800010000120001400016000

Number of Staphylococcus aureus bacteraemia per year, England, Voluntary Surveillance, 1991-2012

MRSA

MSSA

Year

Num

ber o

f SAB

case

s

Escherichia coli bacteraemia

20002001

20022003

20042005

20062007

20082009

20102011

20120

5,00010,00015,00020,00025,00030,000

Number of E coli Bacteraemia per year, England, Voluntary Surveillance, 2000-1012

Year

No

of E

coli

bact

erae

mia

25% were diagnosed ≥2 days after hospital admissionIncreased 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 & CeftriaxoneIncreases 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

2003 2004 2005 2006 2007 2008 2009 2010 2011 20120

100

200

300

400

500

600

700

800

900

1000

11 23 15 29 36 54119

407

604

877

Others (n=64)

Enterobacter (n=119)

Escherichia (n=221)

Pseudomonas (n=355)

Klebsiella (n=1416)

Total (n=2175)

Other

Enterobacter

Escherichia

Pseudomonas

Klebsiella

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

IMP KPC NDM OX48 VIM

11AMP Key Trends Diane Ashiru-Oredope

Trends in Prescribing of Antibacterials , excluding penicillins, in General Practice in England

Apr.98-Mar.99

Apr.99-Mar.00

Apr.00-Mar.01

Apr.01-Mar.02

Apr.02-Mar.03

Apr.03-Mar.04

Apr.04-Mar.05

Apr.05-Mar.06

Apr.06-Mar07

Apr.07-Mar08

Apr.08-Mar09

Apr.09-Mar.10

Apr.10-Mar.11

Apr.11-Mar.12

Apr.12-Mar.13

0

10

20

30

40

50

60

70

80

90

100

TetracyclinesMacrolidesCephalosporinsSulphonamides & trimethoprimCo-AmoxiclavQuinolonesMetronidazole & tinidazoleAll other antibacterial drugs

Item

s p

er

10

00

Pa

tien

ts51% increase22% increase55% decrease27% increase21% increase36% decrease4.5% increase183% increase

Changes 2007-2012

AMP Key Trends

Diane Ashiru-Oredope 12

AMP Key Trends

Diane Ashiru-Oredope

AMP Key Trends

Diane Ashiru-Oredope

2007/8 2008/9 2009/10 2010/11 2011/120

10000000

20000000

30000000

40000000

50000000

60000000

70000000

80000000

Antimicrobial Usage for English Hospitals n=165

COMBINATIONS OF PENICILLINS, INCL. BETA-LACTAMASE INHIBITORS

BETA LACTAMASE RESISTANT PENICILLINS

MACROLIDES PENICILLINS WITH EXTENDED SPECTRUM TETRACYCLINES FLUOROQUINOLONES TRIMETHOPRIM AND DERIVATIVES BETA LACTAMASE SENSITIVE PENICILLINS OTHER AMINOGLYCOSIDES CARBAPENEMS COMBINATIONS OF SULFONAMIDES AND TRIMETHOPRIM, INCL. DERIVATIVES

GLYCOPEPTIDE ANTIBACTERIALS

IMIDAZOLE DERIVATIVES FIRST GENERATION CEPHALOSPORINS THIRD GENERATION CEPHALOSPORINS LINCOSAMIDES SECOND GENERATION CEPHALOSPORINS POLYMYXINS OTHER ANTIBACTERIALS STEROID ANTIBACTERIALS MONOBACTAMS AMPHENICOLSSTREPTOGRAMINS

2007

-8

2008

-9

200

201

201

0

200000

400000

600000

800000

1000000

1200000

1400000

CILASTATIN/IMIPENEMDORIPENEMERTAPENEMMEROPENEMTOTAL

Tot

al D

DD

Carbapenem usage for English Hospitals, 2007-2012

1 6 11 16 21 26 31 36 41 46 51 56 61 66 71 76 81 86 91 96 101 106 111 116 121 126 131 136 141 146 151 156 1610.0%

2.0%

4.0%

6.0%

8.0%

10.0%

12.0%

Carbapenem usage as % of total use in English hospitals in 2011-2012

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

17

Point prevalence Survey: Antimicrobial use

AMP Key Trends

Diane Ashiru-Oredope 18

Variation in AMU prevalence, SAUR

19

Hospital Crude AMU Prevalence % (95% CI)

1 32.3 (27.1-37.9)

2 39.9 (34.6-45.5)

3 43.8 (39.8-48.0)

4 31.5 (28.3-35.0)

5 41.8 (36.8-47.1)

SAUR (O/E): 1.03 (95%CI 0.84-1.26; P 60)

0.5

11.

52

SA

UR

(O/E

) - E

U

Standardized AU ratio (SAUR), based on al l patient ris k fac tors (s tandard ris k adjus tment)

SAUR (O/E): 1.17 (95%CI 0.98-1.39; P 88)

0.5

11.

52

SA

UR

(O/E

) - E

U

Standardized AU ratio (SAUR), based on al l patient risk fac tors (s tandard risk adjus tment)

SAUR (O/E): 1.11 (95%CI 0.97-1.25; P 77)

0.5

11.

52

SA

UR

(O/E

) - E

U

Standardized AU ratio (SAUR), based on al l patient risk fac tors (s tandard risk adjus tment)SAUR (O/E): 0.95 (95%CI 0.83-1.07; P 34)

0.5

11.

52

SA

UR

(O/E

) - E

U

Standardized AU ratio (SAUR), based on all patient risk fac tors (s tandard risk adjus tment)

SAUR (O/E): 1.21 (95%CI 1.03-1.42; P 92)

0.5

11.

52

SA

UR

(O/E

) - E

U

Standardized AU ratio (SAUR), based on all patient risk fac tors (s tandard risk adjus tment)

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)

20

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

21

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

22

Acknowledgements:• Diane Ashire-Oredope• Jonathan Cooke• Sue Faulding • Russell Hope• Alan Johnson• Cliodna McNulty• Pete Stephens • Neil Woodford• GPs, microbiology, pharmacy, infection prevention

& control teams