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

Key findings: international comparisons

Many countries, particularly in Europe, have established systems for reporting country-wide data on AU and AMR. Comparing Australia’s national data with that from other countries provides a benchmark that can help to inform practices in Australia.

Antimicrobial use in hospitals

AU in Australian hospitals is relatively high compared with other countries (Figure C). The countries shown in Figure C are good comparators because they have both high data capture and near universal care in the public hospital system. However, because of some limitations in data collection, these comparisons are indicative only.

Figure C Antimicrobial use in Australian hospitals and other countries

Sources: National Antimicrobial Utilisation Surveillance Program (Australia); CIPARS (Canada); DANMAP (Denmark); ESPAUR (England); NethMAP (Netherlands); SAPG (Scotland); NORM (Norway); SWEDRES (Sweden)

Antimicrobial use in the community

Figure D compares Australia’s AU with four northern European countries, England and Canada. These countries have been selected because their data is readily accessible and comparable. AU in the Australian community is higher than any of these countries.

Figure D Community antimicrobial use in Australia and other similar countries

Sources: Pharmaceutical Benefits Scheme (Australia); CIPARS (Canada); DANMAP (Denmark); ESPAUR (England); NethMAP (Netherlands); SWEDRES (Sweden)

Patterns of use of different antimicrobial classes also differ among countries. Australia tends to use more β-lactamase inhibitor combinations and cephalosporins, but fewer narrow-spectrum penicillins (β-lactamase-sensitive penicillins) than Scandinavian countries. Australia also uses far fewer fluoroquinolones than comparator countries – this stems from the conservative restrictions placed on fluoroquinolone prescription on the PBS and RPBS in the 1990s.

Antimicrobial resistance

Comparisons are available from other countries for 4 of the 13 priority organisms: E. coli, K. pneumoniae, Enterococcus faecium and Staphylococcus aureus.

Resistance to some key antimicrobials, including fluoroquinolones, is very low in Australia for E. coli (Figure E) and K. pneumoniae compared with many European countries. The low resistance to fluoroquinolones seen in Australia is partly expected as a result of our restrictions on prescribing this class of antimicrobials.

Figure E Combined resistance to fluoroquinolones, third-generation cephalosporins and aminoglycosides in invasive isolates of Escherichia coli in Australia and European countries, 2014

Note: In Australia, ciprofloxacin resistance (fluoroquinolones), ceftriaxone resistance (cephalosporins) and gentamicin resistance (aminoglycosides) are used to represent resistance to their respective classes.

Sources: Australian Group on Antimicrobial Resistance, 2014; EARS-Net 2014 (Polish data is from 2013)

In contrast, comparative rates of resistance to methicillin in S. aureus and to vancomycin in E. faecium (Figure F) are high to very high in Australia compared with other countries. The reasons for this are not clear, but it is likely that the drivers of resistance in gram-negative bacteria (E. coli and K. pneumoniae) and gram-positive bacteria (S. aureus and E. faecium) are different.

Figure F Vancomycin resistance in Enterococcus faecium in Australia and European countries, 2014

Sources: Australian Group on Antimicrobial Resistance, 2014; EARS-Net, 2014 (Polish data is from 2013)

Chapter 5 of AURA 2016 includes detailed information on international comparisons of AU and AMR.

Future developments

AURA 2016 demonstrates that an effective surveillance system can improve our understanding of how antimicrobials are used in Australia, and increase our knowledge of the priority organisms that are resistant to antimicrobials.

AURA 2016 provides a baseline that will allow trends to be monitored over time. It also reveals current gaps in surveillance and areas where further work is needed. The Australian Commission on Safety and Quality in Health Care is continuing to work with key stakeholders to strengthen the AURA Surveillance System, and to ensure that the data and information provided through AURA can inform action at the local, regional, state and national level to prevent and contain the spread of AMR.

In light of the findings from AURA 2016, future work in relation to surveillance will be needed to:

improve data analysis and interpretation at the national level

increase data coverage across geographical areas (jurisdictional, urban, regional, rural and remote areas), patient settings (primary care, residential aged care and hospitals) and hospital types

improve data collection methods to allow better benchmarking and comparisons between hospitals

increase participation in national data collection surveys such as NAPS, NAUSP and acNAPS

improve data collection and reporting of AMR in all jurisdictions

continue to monitor emerging resistances and changes in patterns of resistance, and ensure they can be rapidly identified and contained to prevent outbreaks.

Other areas that warrant further investigation or action may include:

assessing factors that drive variation in AU and prescribing across jurisdictions

improving appropriateness of prescribing in hospitals (particularly for surgical prophylaxis) and the community (particularly for upper respiratory tract infections)

advancing a response to the issue of inappropriate surgical prophylaxis

promoting the Antimicrobial Stewardship Clinical Care Standard in community and primary care.

AURA 2016 is the first report of its kind in Australia. It is anticipated that regular reports will continue to be produced, with increasing capability to provide greater reach of surveillance, along with improved analyses and data reporting. In turn, this will support the prevention and containment of AMR, and improved health outcomes for all Australians.