Saq065 amrau report Internal V11

Data flow-chart (Record type ‘AMRTEST’)

Table 6: Denominator data for EARS-Net

Laboratory variables	Hospital variables
Laboratory code Town ZIP (post) code Catchment population	Year of report Hospital code Hospital type Catchment population Number of hospital beds Number of intensive care unit beds Number of hospital patient-days Annual occupancy rate Number of admissions Number of blood culture sets

AMR = antimicrobial resistance; TESSy = The European Surveillance System.

Using denominator data allows comparisons to be made between jurisdictions, and institutions of different sizes and activity levels.

Data comparability between laboratories is supported by the participation of contributing laboratories in the UK National External Quality Assurance Scheme. This occurs under a contracted arrangement; the most recent three-year contract was signed in 2010.

Data publication

EARS-Net data are publicly available online through an interactive webpage, where the visitor can select from a number of lists to generate the information of interest. Query results can then be downloaded in a number of formats, including graphs, tables and maps. Three methods of displaying the susceptibility of Enterococcus faecalis isolates to aminopenicillins in participating countries during 2010 are presented in Figure 7.

Annual reports are also produced and are publicly available from the ECDC website. The annual reports contain interpretations and conclusions regarding trends in AMR across Europe.

Program impact

Individual countries, such as Ireland, indicate that EARS-Net data are used ‘to monitor the impact of interventions, such as improved infection control and antibiotic stewardship programmes’.¹⁴² The Irish Health Protection Surveillance Centre website carries a range of information and articles that are based on participation in EARS-Net. For example, revelations from the Enhanced EARS-Net Surveillance: Report for 2011 Data With Special Focus on Enterococcal Bloodstream Infection contains information on the origin of vancomycin-resistant enterococci (VRE):¹⁴³

In a study of the last six years’ enhanced data, most VRE BSIs [bloodstream infections] were hospital-acquired: 87% of the E. faecium VRE and 67% for E. faecalis VRE were acquired in the reporting hospital.

Analysis of the data has also facilitated the elucidation of risk factors for VRE:¹⁴³

The most common risk factors included underlying malignancy/immunosuppression, intensive care unit stay and recent surgery. Recent surgery as risk factor had been increasing in VRE since 2006, however, this decreased sharply in 2011.

Such information, facilitated by the collection of risk factors, sources of infection and patient outcome, is then used to guide changes in clinical guidelines and practice. Planning for the future of EARS-Net has focused on three key questions:¹³⁷

• 
  What will be major public health challenges caused by AMR in Europe within the next 5–10 years?
  
• 
  Are the current surveillance systems capable of providing sufficient data for risk assessment and risk management to control these hazards?
  
• 
  Which changes are needed in order to ascertain such capability?
  

Data generated by EARS-Net and its predecessor, and the systems monitoring antimicrobial usage have demonstrated considerable differences in consumption and correlated this with differences in resistance patterns. In 2008, for example, a four-fold difference in antimicrobial use was demonstrated between the highest (Greece) and lowest (Netherlands and Latvia) consumers. Such findings support a range of initiatives promoting the prudent use of antimicrobials, and Belgium and France have demonstrated declining resistance in S. pneumoniae (penicillin and erythromycin resistance) and S. pyogenes (erythromycin resistance).

The most recent annual report from EARS-Net paints the following picture:¹⁴⁴

• 
  The most alarming evidence of increasing AMR came from data on combined resistance (resistance to third-generation cephalosporins, fluoroquinolones and aminoglycosides) in E. coli and in K. pneumoniae.
  
• 
  The high and increasing percentage of combined resistance observed for K. pneumoniae means that, for some patients with life-threatening infections, only a few therapeutic options remain available (e.g. carbapenems); however, the increasing prevalence of carbapenem resistance in some countries is exacerbating the situation.
  
• 
  Other trends of AMR indicate that national efforts on infection control and containment of resistance are effective, as illustrated by the trends for methicillin-resistant S. aureus (MRSA), antimicrobial-resistant S. pneumoniae and antimicrobial-resistant enterococci, for which the situation appears generally stable or even improving in some countries.
  

Such consolidated information, which can be used to develop and promote strategies to address specific issues, is unobtainable in the absence of a comprehensive system such as EARS-Net.

Figure 7: Available types of European Centre for Disease Prevention and Control (ECDC) reporting data

European Surveillance of Antimicrobial Consumption Network

ESAC-Net was initiated in 2001 as an international network of surveillance systems to collect comparable and reliable data on antimicrobial use in Europe to accompany analogous AMR surveillance programs.

Coordinated by ECDC since 2007, ESAC-Net now collects reference data on the consumption of antimicrobials for systemic use in the European community and hospital sector. Former ESAC subprojects, involving data collection on antimicrobial use in hospitals and in long-term care facilities, are now continued as ECDC-coordinated and/or funded projects within the Healthcare-Associated Infections Surveillance Network (HAI-Net). Specifically, patient-level antimicrobial use prevalence data are provided through a European-wide point survey of healthcare-associated infections (HAIs) and antimicrobial use in acute-care hospitals, and data on the prevalence of antimicrobial use in residents at long-term care facilities is collected by the HALT-2 project.

Data collection and processing

Data sources are national sales and reimbursement data, including information from national drug registers. The WHO Anatomical Therapeutic Chemical (ATC) classification system is used for the allocation of antimicrobials into groups. Data are collected nationally and subnationally based on the Nomenclature of Territorial Units for Statistics (NUTS) classification. Data on antimicrobial consumption is collected at the product level on the following antimicrobials:

• 
  antibacterials for systemic use (ATC group J01)
  
• 
  antimycotics for systemic use (ATC group J02)
  
• 
  antimycobacterials (ATC group J04)
  
• 
  antivirals for systemic use (ATC group J05).
  

In addition, a few other antimicrobials outside of ATC group J are collected to complete the picture of antimicrobial consumption in Europe.

Antimicrobial consumption in Europe is monitored by a network of national surveillance networks in the EU, and European Economic Area and European Free Trade Association countries through annual data calls. Data are uploaded from these national networks to a central database (TESSy). After uploading, each country approves its own data for reporting, and the results are made available on the ECDC website.

Antimicrobial consumption is expressed as the number of WHO defined daily doses (DDD) per 1000 inhabitants per day. The number of packages per 1000 inhabitants per day is also reported, depending on the availability of data. Information on packages improves the understanding and interpretation of differences in the levels and trends in antimicrobial consumption observed between and within countries, as the ATC/DDD data cannot take into account changes in package content. Denominator (population) data are obtained from Eurostat or national statistics reports. When consumption data do not reflect the whole population, contributing countries will provide data on the population covered by antimicrobial consumption surveillance data. The total outpatient antibiotic use in 33 European countries in 2009 is presented in Figure 8.

Data publication

The ECDC maintains and facilitates its data reporting by ensuring:

• 
  validation of community and hospital-sector data, including data from the national drug registers derived from national surveillance networks
  
• 
  analysis of the trends in antimicrobial consumption overall and in the different ATC groups, as well as comparisons between countries and regions
  
• 
  public access to information on antimicrobial consumption in Europe through an ESAC-Net interactive database.
  

Program impact

ESAC-Net data enable countries to audit their antibiotic use by creating and maintaining a comprehensible, comparable and reliable reference database. ESAC data have been shown to be a valuable resource not only for ecological studies on the relationship between antibiotic use and resistance, but also to evaluate adherence to guidelines and policies, and to assess the outcomes of national and regional interventions. Moreover, collating regional data in a meaningful way complements national consumption statistics. For example, subnational data collected for Ireland, Italy, Portugal, Sweden and the UK, using the three-level NUTS classification, found differing rates of penicillin use within Italy, a high-consuming country, with much higher volumes of total outpatient antibiotic (mainly penicillins) use in the south (e.g. 39.9 DDD in Campania and 34.9 DDD in Sicily) compared with the north (e.g. 16.1 DDD in Bolzano). Similar gradients have also been demonstrated in low-consumption countries such as Sweden.¹⁴⁵

Figure 8: Total outpatient antibiotic use in 33 European countries in 2009 in defined daily doses (DDDs)

Relevance to Australia

During consultation, key Australian AMR stakeholders identified that the strengths of the ECDC program comprise a comprehensive, coordinated and publicly funded AMR surveillance and antibiotic consumption program that operates across many international jurisdictions. The majority of respondents felt that limiting AMR surveillance to seven clinically important organisms and samples (e.g. from blood cultures and cerebrospinal fluid) was an asset, while others felt that restricting the scope of pathogens was a limitation. Stakeholders acknowledged that the availability of data at supranational, national or state/provincial levels allowed more targeted and timely identification of emerging issues. Data capture (including denominator data on laboratory/hospital activity and patient characteristics), within both hospital and community settings, was highly regarded by respondents. Stakeholders also noted the program could quantify improvement or maintenance of resistance rates for certain organisms (including Gram-negative organisms). Program strengths also included the availability of external quality assurance support for contributing laboratories, and accessibility of reports to hospitals and the public. The exclusion of animal, food or environmental data was proposed as a program limitation.