AURA 2016: first Australian report on antimicrobial use and resistance in human health

196 Pages·2016·2.27 MB·English

AURA 2016

First Australian report
on antimicrobial use
and resistance in
human health

AURA 2016
First Australian report on
antimicrobial use and resistance
in human health
© Commonwealth of Australia 2016
This work is copyright. It may be reproduced in whole or in part for study or training purposes, subject to the
inclusion of an acknowledgement of the source.
Address requests and inquiries concerning reproduction and rights for purposes other than those indicated
above in writing to:
AURA – Commonwealth Programs, Australian Commission on Safety and Quality in Health Care, GPO Box 5480,
Sydney NSW 2001
or email [email protected]
Suggested citation: Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: first
Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC, 2016.
An online version of this report can be accessed at www.safetyandquality.gov.au.
ISBN: 978-1-925224-41-2 (print) 978-1-925224-42-9 (online)
Acknowledgements
Many individuals and organisations gave their time and expertise over an extended period to this report, and
the Antimicrobial Use and Resistance in Australia (AURA) project, which were undertaken by the Commission.
In particular, the Commission wishes to thank the Australian Government Department of Health, the Australian
Group on Antimicrobial Resistance, the National Centre for Antimicrobial Stewardship, SA Health, Queensland
Health, Pathology Queensland, Sullivan Nicolaides Pathology, NPS MedicineWise, the National Neisseria Network,
the Australian Mycobacterium Reference Laboratory Network, and other key experts who have provided their
time and considered advice. The involvement and willingness of all concerned to share their experience and
expertise are greatly appreciated.
Members of the AURA Project Reference Group are Professor John Turnidge, Dr Phillipa Binns,
Professor Marilyn Cruickshank, Dr Jenny Firman, Ms Aine Heaney, Mr Duncan McKenzie,
Adjunct Professor Kathy Meleady, Dr Brett Mitchell, Professor Graeme Nimmo, Dr Alicia Segrave,
Professor Karin Thursky, Dr Morgyn Warner, Professor Roger Wilson and Associate Professor Leon Worth.
The members of the Commission’s AURA team are also acknowledged for their significant contribution to the
development of the AURA Surveillance System and this report.
Disclaimer
This report is based on the best data and evidence available at the time of development.
Edited and designed by Biotext Pty Ltd
Contents
Executive summary .......................................................................v
Chapter 1  Introduction ...............................................................1
Key messages ............................................................................................................1
1.1 Background ...................................................................................................2
1.2 Importance of antimicrobial resistance ..............................................2
1.3 Cost and impact of antimicrobial resistance to individuals
and the community ....................................................................................3
1.4 Australian healthcare system context .................................................4
1.5 Importance of surveillance ......................................................................5
1.6 Developing the Antimicrobial Use and Resistance in
Australia Surveillance System ................................................................6
1.7 AURA 2016 report ......................................................................................9
Chapter 2  Data sources and methods ..................................11
Key messages ...........................................................................................................11
2.1 Types of data and information collected under the
Antimicrobial Use and Resistance in Australia Surveillance
System............................................................................................................12
2.2 Sources of data for antimicrobial use and appropriateness .....12
2.3 Sources of data for antimicrobial resistance ...................................13
2.4 Considerations for interpreting the data ..........................................13
Chapter 3  Antimicrobial use and appropriateness ..........17
Key messages ..........................................................................................................17
3.1 Antimicrobial use in hospitals ...............................................................18
3.2 Antimicrobial use in the community – primary care ...................41
3.3 Antimicrobial use in the community – residential aged
care facilities ..............................................................................................60
Chapter 4  Antimicrobial resistance ....................................67
Key messages .........................................................................................................67
4.1 Introduction ................................................................................................68
4.2 Acinetobacter baumannii .......................................................................73
4.3 Enterobacteriaceae .................................................................................75
4.4 Enterococcus species ..............................................................................86
4.5 Mycobacterium tuberculosis ................................................................93
FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016 iii
CONTENTS
4.6 Neisseria gonorrhoeae ...........................................................................96
4.7 Neisseria meningitidis .............................................................................98
4.8 Pseudomonas aeruginosa ...................................................................100
4.9 Salmonella species ..................................................................................101
4.10 Shigella species .......................................................................................104
4.11 Staphylococcus aureus .........................................................................105
4.12 Streptococcus agalactiae .....................................................................113
4.13 Streptococcus pneumoniae .................................................................114
4.14 Streptococcus pyogenes.......................................................................116
Chapter 5  International comparisons .................................119
Key messages ........................................................................................................119
5.1 Antimicrobial use ....................................................................................120
5.2 Antimicrobial resistance .......................................................................124
5.3 Commentary ..............................................................................................131
Chapter 6  Emerging issues ..................................................135
Key messages .......................................................................................................135
6.1 Carbapenem use in Australian hospitals .......................................136
6.2 Carbapenemase-producing Enterobacteriaceae and
carbapenem resistance ........................................................................140
6.3 Antimicrobial use and appropriateness in surgical
prophylaxis ................................................................................................142
Chapter 7  Conclusions and future developments ..........145
Key messages .......................................................................................................145
7.1 Lessons from AURA 2016 ....................................................................146
7.2 Next steps for the AURA Surveillance System ............................147
7.3 Future AURA reports .............................................................................151
Appendix 1  Data source description .................................153
Appendix 2 Priority organisms ...........................................163
Appendix 3 Resources ...........................................................164
Appendix 4 Terminology .......................................................165
References ...................................................................................168
iv FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016
Executive summary
AURA 2016: first Australian report on The AURA Surveillance System will provide
antimicrobial use and resistance in human health critical information needed by clinicians, policy
provides the most comprehensive picture of makers, researchers and health system managers
antimicrobial resistance (AMR), antimicrobial to target efforts to inform antimicrobial
use (AU) and appropriateness of prescribing stewardship and AMR policy and program
in Australia to date. It sets a baseline that will development.
allow trends to be monitored over time. AURA
2016 also highlights areas where future work will
What is antimicrobial
inform action to prevent the spread of AMR.
resistance?
Comprehensive, coordinated and effective
surveillance of AMR and AU is a national priority. AMR is an issue of great importance for health
Surveillance is essential to understand the care in Australia. AMR occurs when bacteria
magnitude, distribution and impact of AMR and change to protect themselves from the effects of
AU, as well as to identify emerging issues and antimicrobials. This means that the antimicrobial
trends. It allows the early detection of critical can no longer eradicate or stop the growth of
antimicrobial resistances to ensure effective the bacteria. Antimicrobials can be life-saving
action can be taken, and provides information agents in the fight against infection, but their
on the effectiveness of measures designed to effectiveness is diminished by AMR.
promote appropriate AU and contain AMR.
AMR has a direct impact on patient care
Surveillance is a critical component of Australia’s
and patient outcomes, and it is a critical
National Antimicrobial Resistance Strategy.
and immediate challenge to health systems
The Antimicrobial Use and Resistance in Australia around the world. It increases the complexity
(AURA) Surveillance System is the new system of treatment and the duration of hospital stay,
to coordinate data from a range of sources and and places an additional burden on patients,
allow integrated analysis and reporting at a healthcare providers and the healthcare system.
national level. The AURA Surveillance System
AMR is an international challenge. Professor
brings together partner programs such as the
Dame Sally Davies, the Chief Medical Officer for
Australian Group on Antimicrobial Resistance,
England, has highlighted that the overuse and
the National Antimicrobial Prescribing Survey
inappropriate use of antimicrobials has resulted
(NAPS), the National Antimicrobial Utilisation
in increasing levels of resistance, stating that
Surveillance Program (NAUSP) and Queensland
‘resistant bugs are killing 25 000 people a year
Health’s OrgTRx system. Data is also sourced
across Europe … almost the same number as die
from the Pharmaceutical Benefits Scheme
on the road in traffic accidents’.a
and the Repatriation Pharmaceutical Benefits
Scheme (PBS/RPBS), NPS MedicineWise, Chapter 1 of AURA 2016 has more information
the National Neisseria Network, the National about the impacts and costs of AMR.
Notifiable Diseases Surveillance System, the
Report on government services 2015 and Sullivan
a Davies SC. The drugs don’t work: a global threat. London:
Nicolaides Pathology.
Penguin, 2013, p. xii.
FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016 v
ExECUTIvE SUMMARy
Key findings: antimicrobial In 2014, 20 agents accounted for 92%
of all antibacterials used in the hospitals
use and appropriateness of
participating in NAUSP. The agents most
prescribing
commonly prescribed in hospitals were
amoxicillin–clavulanate, flucloxacillin, cefazolin
AU is a key driver of AMR – the more we use
and amoxicillin.
antimicrobials, the more likely it is that resistance
will develop. Appropriate use of antimicrobials Differences in prescribing rates
can be life-saving, but inappropriate use needs AU rates, calculated from the hospitals
to be monitored and minimised to prevent participating in NAUSP, are measured as defined
and contain AMR. Examples of inappropriate daily doses (DDDs) per 1000 occupied-bed
use include prescribing antimicrobials when days (OBDs). This measure allows data to be
they are not necessary, prescribing the wrong compared across hospitals, jurisdictions or
type of antimicrobial and prescribing for the countries. According to the 2014 NAUSP data,
incorrect duration. there is large variation in AU across states and
territories. Tasmania has the highest rate of AU,
Antimicrobial use in hospitals
and Queensland has the lowest (Figure A).
NAUSP data indicates that the overall use of
Based on published experience in other
antimicrobials in Australian hospitals peaked in
countries, the four classes of antimicrobials
2010, and that there has been a steady decline
most likely to drive AMR in the hospitalised
since then. The rates of use have decreased
population are aminoglycosides, cephalosporins,
for some classes of antimicrobials, but have
fluoroquinolones and macrolides. Over the past
increased for other classes.
five years, rates of gentamicin use (the most
commonly used aminoglycoside) have decreased
steadily in all states and territories. Ceftriaxone
Figure A Overall antimicrobial usage rates in hospitals participating in NAUSP, by
jurisdiction, 2014
Australia
NSW and ACT
Qld
SA
Tas
Vic
WA
0 200 400 600 800 1000 1200 1400
DDD/1000 OBD
ACT = Australian Capital Territory; DDD/1000 OBD = defined daily doses per 1000 occupied-bed days; NSW = New South Wales;
Qld = Queensland; SA = South Australia; Tas = Tasmania; vic = victoria; WA = Western Australia
Source: National Antimicrobial Utilisation Surveillance Program, 2014 (129 participating hospitals)
vi FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016
ExECUTIvE SUMMARy
(the most commonly prescribed third-generation deemed to be inappropriate. Reasons for
cephalosporin) and some macrolides show inappropriateness included incorrect duration,
a pattern of seasonal use over the past five dose or frequency, and situations where an
years, reflecting their role in the treatment antimicrobial was not required.
of lower respiratory tract infections. Rates of
More information about AU in hospitals is
fluoroquinolone use over the past five years have
provided in Section 3.1.
remained relatively constant. Overall, usage rates
for these four antimicrobial classes have declined
Antimicrobial use in the community –
in the large and medium public hospitals, and
primary care
principal referral hospitals, that participate
in NAUSP. AU in the community setting in Australia is high.
In 2014, almost half (46%) of Australians had at
Understanding variation in prescribing
least one antimicrobial dispensed to them under
rates is critical to improving the quality and
the PBS/RPBS, with an overall rate of 23.8 DDDs
appropriateness of AU. However, there is
per 1000 inhabitants per day. This was an
currently insufficient evidence to identify which
increase compared with 2013, but still lower than
factors are driving variation in volumes and
the peak seen in 2008 (Figure B).
patterns of AU in Australian hospitals.
Appropriateness of prescribing
In 2014, more than 30 million
Data from the 2014 NAPS shows that 38.4%
prescriptions for antibacterials
of patients were being administered an
antimicrobial on the day of the survey. Of were prescribed to Australians
these prescriptions, 24.3% were noncompliant through the PBS/RPBS. Almost
with guidelines and 23% were considered half of the Australian population
to be inappropriate prescriptions. The main
took at least one course of
reasons why prescriptions were deemed to be
antibacterials in that year.
inappropriate were that an antimicrobial was not
needed, the antimicrobial chosen was incorrect
The 11 most commonly dispensed antimicrobials
(spectrum too broad), or the duration, dose or
accounted for 84% of all antimicrobials
frequency of treatment was incorrect.
dispensed in the community. Amoxicillin,
cephalexin and amoxicillin–clavulanate are the
In 2014, the most common indications (reasons)
most commonly prescribed antimicrobials.
for antimicrobial prescriptions in hospitals were:
• surgical prophylaxis (13.1%) Patterns of use
• community-acquired pneumonia (11.3%) Antimicrobials were most often dispensed for
very young people and older people. In 2014,
• medical prophylaxis (8.3%)
57% of those aged 0–4 years, 60% of those
• urinary tract infections (6.7%)
aged 65 years or over, and 74% of people
• cellulitis or erysipelas (skin infections) (4.4%).
aged 85 years or over were supplied at least
Inappropriate surgical prophylaxis one antimicrobial. These proportions have
(antimicrobials that are routinely prescribed been consistent over several years, and AU
to patients undergoing surgery to prevent in all age groups is higher during the winter
infection during and after the procedure) is a months. Children are prescribed more extended-
major concern. Surgical prophylaxis is the most spectrum penicillins, and older people are
common reason for antimicrobial prescriptions prescribed more cephalosporins, macrolides and
in hospitals, and has the highest level of penicillin – ß-lactamase inhibitor combinations
inappropriate use, with 40.2% of prescriptions than other age groups.
FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016 vii
ExECUTIvE SUMMARy
Figure B Volume of antimicrobials dispensed under the PBS/RPBS per year, 1994–2014
35 35
30 30
y
s) 25 25 da
ns (million 20 20 habitants/
o n
pti 15 15 0 i
cri 00
s 1
Pre 10 10 DD/
D
5 5
0 0
1994 1996 1998 2000 2002 2004 2006 2008 2010 2012 2014
Total antibacterial prescriptions J01 DDD/1000 population/day
J01 prescriptions
DDD = defined daily dose; PBS = Pharmaceutical Benefits Scheme; RPBS = Repatriation Pharmaceutical Benefits Scheme
Notes:
1. J01 is the ATC code for antibacterials for systemic use.
2. Before April 2012, includes estimates of under co-payment and private dispensing; after April 2012, includes actual under co-payment
data, but no estimate from private dispensing. The DDD/1000 inhabitants/day excludes some items for which there is no DDD.
Source: Drug Utilisation Sub Committee database, October 2015
General practitioners generate Appropriateness of prescribing
the majority of prescriptions Of the patients participating in the NPS
(88%); other prescribers MedicineWise MedicineInsight program,
include medical specialists, 30% (352 318 patients) were prescribed
systemic antimicrobials between 1 January
dentists, optometrists, midwives
and 31 December 2014. The overall rate of
and nurse practitioners.
antimicrobial prescriptions (originals) per
100 general practitioner consultations has
Different dispensing rates were seen across
remained constant between 2009 and 2014. This
the states and territories, between major
data also shows a pattern of seasonal variation,
cities and other regions, between different
with peaks in winter.
local areas, and across socioeconomic status.
Generally, rates were highest in areas of
High volumes of antimicrobials continue to be
lowest socioeconomic status, and decreased
prescribed unnecessarily for upper respiratory
with increasing socioeconomic status. This
tract infections. More than 50% of patients who
is consistent with decreasing socioeconomic
were identified as having a cold or other upper
status being associated with poorer health and
respiratory tract infection had an antimicrobial
higher infection rates. However, there is currently
prescribed when it was not indicated. A large
insufficient evidence to confirm the factors that
proportion of patients with acute tonsillitis,
are driving geographic patterns of antimicrobial
acute or chronic sinusitis (sinus inflammation),
prescribing in Australia.
viii FIRST AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE IN HUMAN HEALTH | 2016