Peter Zarb

European Surveillance of Antibiotic Consumption (ESAC) point prevalence survey 2008: paediatric antimicrobial prescribing in 32 hospitals of 21 European countries.

BACKGROUND Antimicrobials are the most common medicines prescribed to children, but very little is known about patterns of hospital paediatric antimicrobial prescribing. This study aimed at describing paediatric antimicrobial prescribing in European hospitals to identify targets for quality improvement. METHODS The European Surveillance of Antibiotic Consumption (ESAC) project (www.esac.ua.ac.be) collected data during 2 calendar weeks between May and June 2008 in 32 hospitals of 21 European countries with paediatric departments, using a standardized method. The ESAC point prevalence survey included all inpatient beds and identified all patients who were receiving systemic antimicrobials on the day of the survey or had received antimicrobial surgical prophylaxis on the previous day. RESULTS Of 1799 children, 583 (32%) received one or more antimicrobials (range 17%-100%). The indications were therapeutic in 71%, prophylactic in 26% and both indications in 3% of patients. The parenteral route was used in 82% of therapeutic indications and in 63% of prophylactic indications. Third-generation cephalosporins were the most prescribed antimicrobials for therapeutic indications (18%). A high proportion of treated children received antimicrobial combinations (37%). The most commonly treated diagnosis site was the respiratory tract for both therapeutic use (30%) and prophylaxis (25%). The duration of surgical prophylaxis was >1 day in 67%. CONCLUSIONS Targets identified for quality improvement of antimicrobial use in children included excessive use of antimicrobial combinations and a high proportion of parenteral antimicrobials, both of which require further investigation. Surgical prophylaxis for >1 day should also be curbed in order to achieve quality improvement.

European Surveillance of Antimicrobial Consumption (esac): Value of a Point-prevalence Survey of Antimicrobial Use Across Europe

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% in 2006 and 2008) since samples were either not taken or no information was available for the majority (>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.

Antibiotic consumption in southern and eastern Mediterranean hospitals: results from the ARMed project

OBJECTIVES The intensity of antibiotic use in hospital settings is recognized 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. METHODS As part of the ARMed project, antibiotic use in 25 hospitals from the southern and eastern Mediterranean countries of Cyprus, Egypt, Jordan, Lebanon, Malta, Tunisia and Turkey was assessed prospectively for 24 months during the years 2004-05. The surveillance focused primarily on systemic antibiotics used in hospital care, aggregated at the level of the active substance, in accordance with the Anatomic Therapeutic Chemical (ATC) classification. RESULTS The median total antibiotic use during the study period was 112 defined daily doses per 100 bed-days (DDD/100BD), with an inter-quartile range of 84-428 DDD/100BD. The most common antibiotic groups prescribed were the extended-spectrum and combination penicillins, first- and third-generation cephalosporins and quinolones. Overall, a predominant consumption of wide-spectrum agents was noted, with a significant correlation between the levels of use of third-generation cephalosporins and carbapenems. CONCLUSIONS Emphasis on wide-spectrum agents could explain one possible factor behind the documented high prevalence of resistance in important pathogens within these same hospitals and suggests the need for improved antibiotic stewardship and prescribing programmes, which may well be applicable to the whole region.

Antibiotic consumption as a driver for resistance in Staphylococcus aureus and Escherichia coli within a developing region.

BACKGROUND This study aimed to provide insight into possible antibiotic drivers of methicillin-resistant Staphylococcus aureus (MRSA) and Escherichia coli resistant to third-generation cephalosporins (3GCREC) in southern and eastern Mediterranean institutions. METHODS MRSA and 3GCREC susceptibility proportions from 19 regional hospitals, previously published by the ARMed project, were correlated with antibiotic use data from the same institutions. RESULTS Hospitals reporting below-median MRSA proportions had significantly lower total antibiotic use. MRSA proportions increased with greater use of carbapenems (P=.04). In multivariate analysis, a positive correlation was identified with the use of carbapenems (P=.002), combination penicillins (P=.018), and aminoglycosides (P=.014). No difference was ascertained between 3GCREC proportions and total antibiotic use. In multivariate linear regression, a correlation was identified only for 3GCREC (P=.005), but a negative association was evident for beta-lactamase-resistant penicillins (P=.010) and first-generation cephalosporins (P=.012). CONCLUSIONS The results suggest an association between resistance and antibiotic use, especially for carbapenems and third-generation cephalosporins. These data support the urgent implementation of antibiotic stewardship initiatives in hospitals in developing countries that focus on more judicious use of broad-spectrum formulations.

Drug utilization 75% (DU75%) in 17 European hospitals (2000-2005): results from the ESAC-2 Hospital Care Sub Project.

The study aimed to assess 75% of drug utilization (DU75%) in participating hospitals and identify quality indicators which should be used to monitor performance within the hospitals. In the European Surveillance of Antimicrobial Consumption (ESAC; http://www.esac.ua.ac.be) project anatomic therapeutic chemical (ATC), defined daily dose (DDD) and route of administration (RoA) were used for drug categorization. Data were collected for: antibacterials for systemic use; intestinal antibiotics; rifampicin; and nitroimidazole derivatives. Each hospitals annual data were analyzed separately (hospital-year) adding up to a total of 97 hospital-year data-sets. The drug most persistently present within DU75% was ciprofloxacin (84/97 hospital-years). Co-amoxiclav was the drug which most frequently ranked first (28 times). The number of drugs constituting the DU75% by substance ranged from 7-15 (median 12) and 8-19 (median 15) by RoA which identified oral amoxicillin most frequently ranking first (17 times). In many hospitals the oral route accounted for most of the DU75%. Therefore, the extent of oral use was identified as a quality indicator which could be monitored using DU75% methodology. Since substantial variation both in extent and distribution of antibiotic use was observed, DU75% methodology is best adapted for intra-hospital consumption trend analyses or for hospitals with comparable characteristics and formularies. The number of drugs within DU75% was identified as another quality indicator. Thus, aspiring to decrease the consumption of overused drug classes should be set by the hospitals as a quality indicator on prescribing patterns.

Antimicrobial prescribing in hospitalized adults stratified by age: data from the ESAC point-prevalence surveys.

Background: Geriatric infectious diseases are a major health care issue. Infections in the elderly occur more frequently than in younger adults, are often associated with higher morbidity and mortality, and may present atypically. Elderly patients are also often taking multiple medications, which increases the likelihood of drug-drug interactions. Dosing decisions should take into consideration the reduced lean body mass and declining renal function in this age group.Objective: Antimicrobial prescribing in three age groups (65–74, 75–84 and ≥85 years) was compared with a reference age group (18–64 years), with the aim of identifying quality of care indicators specific to the elderly.Methodology: The ESAC (European Surveillance of Antimicrobial Consumption) final phase performed two hospital point-prevalence surveys in 2008 and 2009, respectively, using the defined daily dose (DDD) and Anatomical Therapeutic Chemical (ATC) classification system. The prescribed daily dose (PDD) was compared with the DDD. Differences in prescribing were assessed using multivariate logistic regression analyses.Results: The majority of patients (19 549 [64% of 30 836]) were from Northern Europe and 13 830 (48%) belonged to the reference group. The largest proportion of patients was admitted through the hospital’s medical specialty (55% of patients) [range: 49% in the reference group to 72% in the ≥85 years age group]. Penicillins were the most frequently used antimicrobials in all age groups (range: 32% in the reference group to 41% in the ≥85 years age group). Multivariate analyses showed three significant variations between the 65–74 years age group and the reference group (quinolones: odds ratio [OR] 1.17 [95% CI 1.05, 1.29]; tetracyclines: OR 1.58 [95% CI 1.26, 1.98]; aminoglycosides: OR 0.81 [95% CI 0.70, 0.93]). The number of significant variations increased to seven and eight in the 75–84 and ≥85 years age groups, respectively. A lower likelihood for PDD > DDD was observed in the 65–74 years age group for three parenteral antimicrobials (amoxicillin/clavulanic acid, gentamicin and vancomycin). This was reiterated in the older age groups (75–84 and ≥85 years), where piperacillin/tazobactam, meropenem and oral ciprofloxacin also showed a lower likelihood for PDD > DDD was observed in the 65–74 years age group for three parenteral antimicrobials (amoxicillin/clavulanic acid, gentamicin and vancomycin). This was reiterated in the older age groups (75–84 and ≥85 years), where piperacillin/tazobactam, meropenem and oral ciprofloxacin also showed a lower likelihood for PDD > DDD.Conclusions: Despite the methodology not being dedicated to elderly patients, the study identified elevated use of antimicrobial agents that are associated with serious adverse effects or a narrow therapeutic index as a target for quality of care improvement in elderly patients.

Point prevalence survey on antibiotic use in a Croatian Infectious Disease Hospital

Abstract Antibiotic use is the driving force for increasing antibiotic resistance. A large proportion of antibiotics in hospitals are used inadequately. The objective of this study was to evaluate antibiotic use at the Hospital for Infectious Diseases through point-prevalence surveys conducted in 2006, 2008, and 2009. Point prevalence surveys were part of the European Surveillance on Antimicrobial Consumption (ESAC) Hospital Care Subproject and patients’ data were collected following ESAC protocol. Additionally, the adequacy of antimicrobial therapy and administration of the first line antibiotic according to the local guidelines were assessed by an infectious disease doctor and a clinical microbiologist. In the study period among the 599 patients admitted to hospital, 352 (58·8%) received antibiotics. Out of 448 antimicrobial treatments, 313 (69·9%) were administered parenterally and 135 (30·1%) orally. Altogether in years 2006, 2008, and 2009 the most commonly prescribed antibiotics were ceftriaxone (19·9%), co-amoxiclav (15·4%), ciprofloxacin (12·3%), narrow spectrum penicillins (6·5%), and penicillinase resistant penicillins (5·6%). Most (82·6%) of the treated infections were community acquired infections. The predominating diagnoses were urinary tract infections and infections with no primary site defined, followed by skin, soft tissue and bone and joint infections. The overall adequacy of antimicrobial therapy was 82% and the first line antibiotic according to the local guidelines was administered with high frequency for central nervous system and cardiovascular infections (100%), and low for ear, nose, and throat infections, urinary tract infections, lower respiratory tract and bone and joint infections (23·0%, 51·6%, 52·5%, 65·0%, respectively) which indicates a significant overuse of antibiotics for diagnoses listed. The results of an individual point prevalence survey provided reliable and representative data for the hospital. Point-prevalence surveys proved to be a valuable method for detecting targets for antibiotic prescribing improvement and they clearly showed that our local hospital guidelines offered too many choices of antibiotic treatment for each clinical indication and needed revision.

Do medical students feel prepared to prescribe antibiotics responsibly? Results from a cross-sectional survey in 29 European countries

Background In an era of antibiotic resistance, medical students must be prepared to prescribe antibiotics responsibly. Objectives To assess self-reported preparedness among final-year medical students at European universities, using a comprehensive set of topics related to prudent antibiotic use. Methods We conducted a cross-sectional, multicentre, web-based survey. All medical-degree students in their final year of studies at European universities were eligible to participate. A preparedness score was calculated for each student and mean scores were compared at medical school and country levels. Comparisons were made with national-level data on resistance among four common bacterial pathogens. Results In total, 7328 responses were included from 179/296 eligible medical schools in 29/29 countries. Students felt at least sufficiently prepared on a mean of 71.2% of topics assessed, ranging from 54.8% (Portugal) to 84.8% (Latvia). The proportion of students wanting more education on prudent antibiotic use or general antibiotic use ranged from 20.3% (Sweden) to 94.3% (Slovakia), with a mean of 66.1%, and was strongly inversely correlated with preparedness scores (Spearmans ρ = -0.72, n = 29, P < 0.001). Higher prevalence rates of antibiotic-non-susceptible bacteria were associated with lower preparedness scores and higher self-reported needs for further education (P < 0.01). Conclusions Most final-year European medical students feel they still need more education on antibiotic use for their future practice as junior doctors. Patterns of preparedness on specific topics were identified, were highly consistent across countries, and correlated with both perceived need for further education and levels of antibiotic resistance among common bacteria.

Legal framework of antimicrobial stewardship in hospitals (LEASH): a European Society of Clinical Microbiology and Infectious Diseases (ESCMID) cross-sectional international survey

Antimicrobial stewardship (AMS) is the cornerstone activity in the combat against antimicrobial resistance. In order to ensure sustainable deployment and development of AMS, a strategic and regulatory framework needs to be provided by national healthcare authorities. Experts from 32 European countries, Israel and Turkey were invited to participate in a cross-sectional internet-based survey from October 2016 to May 2017 on the legal framework and mandatory components (structures, activities) of AMS in hospitals, i.e. components required by legislation or regulations. We collected data from 25 countries and two regions (in countries with federal health administration). Laws regulating AMS existed in seven countries and one region. Other health ministry regulations were applicable in 13 countries and one region. National strategies and/or action plans approved by ministries of health were in place in 13 countries and one region. Conversely, five countries and one region had no regulation of AMS in hospitals. Funding for AMS in hospitals was provided in five countries and one region. Eight countries and one region reported mandatory AMS structures and activities complying with the Transatlantic Taskforce on Antimicrobial Resistance (TATFAR) structure, policy and practice indicators. In 10/27 cases, however, the mandatory AMS activities were not being fully carried out. The survey showed heterogeneous legal frameworks for AMS in hospitals, and in many countries it was even lacking. The situation may be critical in countries with poor control of antimicrobial use and resistance. Recent international initiatives calling on policy-makers to address the threat of antimicrobial resistance could yield improvement.

Erratum to ‘Forgotten antibiotics: a follow-up inventory study in Europe, the USA, Canada and Australia’

a Service des maladies infectieuses et tropicales, Université de Lorraine Faculté de médecine, Centre hospitalier régional universitaire (CHRU) de Nancy, Nancy, France b ReAct—Action on Antibiotic Resistance, Department of Medical Sciences, Uppsala University, Uppsala, Sweden c University Medical Centre Ljubljana, Ljubljana, Slovenia d Department of Medicine, Radboud University Nijmegen Medical Centre, and Department of Medical Microbiology and Infectious Diseases, Canisius-Wilhelmina Hospital, Nijmegen, The Netherlands e Hasselt University, Hasselt, Belgium f Centre for Anti-Infective Agents, Vienna, Austria