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Monitoring antibiotic consumption in hospitals: results from the French

nationwide network “ATB-RAISIN” in 2012

April 2014

• B. SCHLEMMER, AC. CREMIEUX, French Committee for prudent use of antibiotics

• S. ALFANDARI , French infectious disease society (SPILF)

• X. BERTRAND, Microbiology, Besançon• S. TOURATIER, Pharmacy, GH St Louis, Paris• E. REMY, Regional observatory for medicines,

Rouen

ATB-RAISIN Network: Surveillance of antibiotic consumption in hospitals

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• A. INGELS, P. JARNO CCLIN West • S. BOUSSAT, L. MOUCHOT, CCLIN East• L. LACAVÉ, F. L’HÉRITEAU, CCLIN Paris

& North • M. GIARD, A. MACHUT, CCLIN S-East• C. DUMARTIN, M. PÉFAU, AM. ROGUES,

CCLIN S-West • S. VAUX, InVS

ATB-RAISIN steering committee

5 CCLIN* and InVS** Other experts

* Coordinating centres for prevention and control of healthcare associated infections** French Institute for Public Health Surveillance

* Coordinating centres for prevention and control of healthcare associated infections** French Institute for Public Health Surveillance

Background

Monitoring antibiotic consumption in Healthcare facilities (HCF)

Guidelines : 1996, 2008 (National Authority for Health) Ministerial circular : 2006

HAI national programmes

since 1994

« ATB-RAISIN » set up in 2009

Standardised methodology

Antibiotic use national plan

since 2001

Objectives of ATB-RAISIN

• To describe antibiotic consumption in French healthcare facilities (HCF) at hospital and at ward level To provide a tool for benchmarking To promote analysis of consumption data against antimicrobial resistance rates To identify areas for improvement at the hospital level and at the national level

• To describe antimycotic consumption at hospital level, in intensive care units (ICU) and hematology

• To monitor trends

Methods

• Retrospective survey

• Voluntarily participating HCF

• Self-completion questionnaire Antibiotics and antimycotics for systemic use

• Antibiotics: J01 AND Rifampicin + oral imidazole derivatives

• Antimycotics: J02

• Dispensed by the pharmacy for inpatients wards only

• Number of defined daily doses (DDD) [WHO, ATC/DDD system] Administrative data

• HCF type, ward clinical activity, no. patient-days Antimicrobial resistance

• Selected antibiotic/bacteria combinations

Results• Participation

1411 HCF in 2012 Coverage: 66% PD at national level

861997

1 115

1 2621 411

0

200

400

600

800

1 000

1 200

1 400

1 600

2008 2009 2010 2011 2012

Results: ATB RAISIN, 2012

• Total antibiotic use in 1 411 HCF: 374 DDD/1000 PD Variations in total antibiotic use according to HCF type

02

00

40

06

00

80

01

00

01

20

0

Teachinghospital

N=37

Nonteaching

publichospital<=33

N=73

Nonteaching

publichospital>33

N=299

NonteachingprivatehospitalN=418

Cancerhospital

N=12

Militaryhospital

N=7

Rehabcentre

N=318

Localhospital

N=111

Longtermcare

N=18

Psychiatrichospital

N=118

Nu

mb

er

of

DD

D /

10

00

PD

Outlier

Highest value still within P75+1,5(P75-P25)

P75

Pooled mean

Median

P25

Lowest value still within P25-1,5(P75-P25)

01

00

02

00

03

00

0

Medicine

N=527

Hematology

N=25

Infectiousdiseases

N=12

Surgery

N=426

Intensivecare

N=179

Gynae-cologyN=279

Paediatrics

N=190

Rehabi-litationN=701

Longterm care

N=282

Psychiatry

N=204

Nu

mb

er

of

DD

D / 1

00

0 P

D

Results: ATB RAISIN, 2012

Variations in total antibiotic use according to ward/clinical activity

17%

32%

3%4%

8%

1%

2%

2%

5%

3%

12%

2%4%

5%Penicillins with extended spectrum (J01CA)

Amoxicillin+ clavulanic acid (J01CR02)

Beta lactamase resistant penicillins (J01CF)

1GC+2GC (J01 DB,DC)

3GC (J01DD, J01DE,J01DC07)

Carbapenems (J01DH)

Other beta-lactam antibacterials

Sulfamides (J01E)

MLS (J01F)

Aminoglycosides (J01G)

Fluoroquinolones (J01MA)

Glycopeptides (J01XA)

Imidazole derivatives (J01XD+P01AB)

Miscellaneous

Results: ATB-RAISIN, 2012

• Most used antibiotics in 1 411 HCF, 2012

AntibioticDDD /1 000 PD

Amoxiclav 118

Amoxicillin 65

Ceftriaxone 20

Ofloxacin 18

Ciprofloxacin 13

Top 567%

Results: ATB-RAISIN, 2012

Consumption of antibiotics (J01+P01AB+J04) in number of DDD/1 000 PD (regional pooled mean), and surveillance coverage (% beds) (N= 1 409 HCF)

Warning: data from voluntarily participating hospitals. Coverage is not homogenous among regions and the number of HCF may be small in some regions. Differences in patients case-mix may partially explain some of the variations in this map.

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67%

100% 68%

88%

58%

75%

72%

79%

85%

23%

84%

31%

28%

57%

60%

58%

84%

58%

81%

80%

94%

64%

62%

50%

100%

44%

401.9 (P75) ≤ consumption < 515.0 (max)

356.5 (P50) ≤ consumption < 401.9 (P75)

331.8 (P25) ≤ consumption < 356.5 (P50)

165.2 (min) ≤ consumption < 331.8 (P25)

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100%

34%

81%

2%

80%

48% 34% 30%

25%58%70%58%

93%

20%

75%73%

58%

34%

31%

39% 74%

31%

44%

56%63%

Results: ATB-RAISIN, 2012

Carbapenems consumption in number of DDD/1 000 PD (regional pooled mean), in acute care wards and surveillance coverage (% beds) (N= 630 HCF)

Warning: data from voluntarily participating hospitals. Coverage is not homogenous among regions and the number of HCF may be small in some regions. Differences in patients case-mix may partially explain some of the variations in this map.

Insufficient data

9.6 (P75) ≤ consumption < 16.5 (max)

7.1 (P50) ≤ consumption < 9.6 (P75)

3.3 (P25) ≤ consumption < 7.1 (P50)

0.4 (min) ≤ consumption < 3.3 (P25)

Results: ATB-RAISIN, 2012

Proportion of antibiotics according to clinical wards

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Med

icin

e

Hemat

ology

Infe

ctio

us d

isea

ses

Surge

ry ICU

Gynae

colo

gy

Paedia

trics

Rehab

ilita

tion

LTC

Miscellaneous

Glycopeptides

Fluoroquinolones

Aminoglycosides

Carbapenems

3GC

1GC+2GC

Beta lactamase resistant penicillins

Amoxicillin + clavulanic acid

Amoxicillin

363

376

386 388 389

300

320

340

360

380

400

2008 2009 2010 2011 2012

No

. DD

D /

1 0

00

PD

Results: ATB-RAISIN, 2008-2012

• Trends in total antibiotic use, 2008 – 2012 (number of DDD/1000 PD), cohort of 565 hospitals

+ 7.2% over the period… but trend toward stabilisation

+3.7%+3.7% +2.5%+2.5% +0.3%+0.3%+0.6%+0.6%

Results: ATB-RAISIN, 2008-2012

Trends in antibiotic use in no. DDD/1 000 PD (pooled mean) in 565 HCF that participated each year from 2008 to 2012

Antibiotics 2008 2009 2010 2011 2012

Amoxicillin-clavulanic acid 121 124 125 124 127

Oral 97 100 100 100 102

Parenteral 24 24 24 24 24

1GC+2GC 12 13 14 14 14

3GC (J01DD+J01DE+J01DC07) 26 28 31 33 34

Ceftriaxone 14 17 18 20 21

Carbapenems 4 4 5 5 5

Fluoroquinolones 52 52 52 50 48

Ciprofloxacin 14 14 15 14 14

Levofloxacin 9 10 11 11 11

Ofloxacin 20 20 20 19 18

Vancomycin 5 5 5 5 5

Teicoplanin 1 1 1 1 1

Total 363 376 386 388 389

Results: ATB-RAISIN, 2008-2012

Antibiotic use in number of DDD/1000 PD (pooled mean) in 565 hospitals, 2008-2012 (% change between 2008 and 2012)

0,0

2,0

4,0

6,0

8,0

10,0

12,0

14,0

16,0

18,0

20,0

22,0

PiperacillintazobactamJ01CR05

CeftriaxoneJ01DD04

CeftazidimeJ01DD02

CefotaximeJ01DD01

CarbapenemsJ01DH

Nu

mb

er

of

DD

D /

1000 P

D

2008 2009 2010 2011 2012

+72.7%

+48.2%

+2.0%+3.4% +37.4%

0,00

0,10

0,20

0,30

0,40

0,50

0,60

0,70

0,80

0,90

2008 2009 2010 2011 2012

Res

ista

nt

stra

ins

/ 100

0 P

D

E. coli / Ciprofloxacin

Staphylococcus aureus /Oxacillin

E. coli / Cefotaxime orceftriaxone

Pseudomonas aeruginosa /Ciprofloxacin

Enterobacter cloacae /Cefotaxime

Pseudomonas aeruginosa /Ceftazidime-28%

+13%

-22%

+75%

-17%

+33%

Results: ATB-RAISIN, 2008-2012

Incidence of antimicrobial resistance in selected bacteria, in number of strains/1000 PD, in hospitals providing data each year from 2008 to 2012Incidence of antimicrobial resistance in selected bacteria, in number of

strains/1000 PD, in hospitals providing data each year from 2008 to 2012

• Contrasted changes in AMR • Contrasted changes in AMR

0 20 40 60 80 100 120 140

Nb DDJ / 1000 JH

0.0

0.2

0.4

0.6

0.8

1.0

1.2

Sou

ches

R /

1000

JH

Results: ATB-RAISIN, 2012

Third generation cephalosporins (3GC) consumption and incidence of cefotaxime-resistant Enterobacter cloacae (N=334)

Median = 0.18 / 1000 PD

Median = 36.8 DDD/ 1000 PD

3GC use in DDD/1000 PD

Analysis: High AMR and AB UseActions: Infection control to prevent spread

Prudent use of AB

Analysis: High AMRActions: • Infection control, admission screening• Prudent use of AB other than 3CG

Results: ATB-RAISIN, 2012

Antimycotics consumption

Antimycotics consumption (J02) according to clinical activity and for the whole HCF, in no. DDD/1000 PD

Clinical ward

Number of participants

Pooled mean Median

Hematology 26 340 201

Intensive care units 97 163 139

Whole HCF 239 18 7

Results: ATB-RAISIN, 2012

Antimycotics consumption

Hematology (n=26) ICU (n=97)

Pattern of antimycotic consumption (J02) in hematology and ICUs

Posaconazole0%

Itraconazole0%

Micafungin1%

Amphotericin B 1%

Liposomal Amphotericin B

7%Flucytosine

0%

Caspofungin13%

Voriconazole5%

Fluconazole73%

Itraconazole 2%

Flucytosine 0%

Caspofungin 11%

Micafungin 0% Amphotericin B 5%

Voriconazole 13%

Posaconazole 12%

Fluconazole 32%

Liposomal Amphotericin B

25%

Discussion

• Participation in ATB-RAISIN increased

• Antibiotic consumption did not decrease in HCF• Stabilisation of total use: good news in a context of

decreasing length of stay• Decrease in FQ use

• Actions needed to reduce the use of ceftriaxone

Perspectives

Mobilisation still needed!

•Data used for action At the local level

• Analysis of consumption to foster implementation of actions such as practice audits, restricted dispensation

At regional and national levels• Awareness raised on antibiotic exposure: FQ, carbapenems, 3GC…

Tools for audits, educational material

• Best use of data: quality indicator?

Thanks to all healthcare professionals

in participating hospitals

More information on antibiotic use in French hospitals

http://www.cclin-arlin.fr/

http://www.invs.sante.fr/raisin