Transcript SRAS - Institut de veille sanitaire

Monitoring antibiotic consumption in
hospitals: results from the French
nationwide network “ATB-RAISIN” in 2012
April 2014
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ATB-RAISIN Network: Surveillance of
antibiotic consumption in hospitals

ATB-RAISIN steering committee
5 CCLIN* and InVS**
• 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
* Coordinating centres for prevention and control of
healthcare associated infections
** French Institute for Public Health Surveillance
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Other experts
• 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
Background
HAI
national programmes
Antibiotic use
national plan
since 2001
since 1994
Monitoring antibiotic consumption in Healthcare facilities (HCF)


Guidelines : 1996, 2008 (National Authority for Health)
Ministerial circular : 2006
« ATB-RAISIN » set up in 2009
Standardised methodology
Objectives of ATB-RAISIN
•
To describe antibiotic consumption in French healthcare
facilities (HCF) at hospital and at ward level


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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

Number of participating HCF
1 600
1 411
1 400
1 262
1 115
1 200
1 000
997
861
800
600
400
200
0
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
P75
Pooled mean
Median
Number of DDD / 1000 PD
400
600
800 1000
Highest value still within
P75+1,5(P75-P25)
1200
Outlier
0
200
P25
Lowest value still within
P25-1,5(P75-P25)
Teaching
hospital
Non
teaching
public
Non
teaching
public
hospital<=33 hospital>33
N=37
N=73
N=299
Non
teaching
private
hospital
N=418
Cancer
hospital
Military
hospital
Rehab
centre
Local
hospital
Long
term
care
Psychiatric
hospital
N=12
N=7
N=318
N=111
N=18
N=118
Results: ATB RAISIN, 2012
Variations in total antibiotic use according to ward/clinical activity
0
Number of DDD / 1000 PD
1000
2000
3000
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Medicine Hematology Infectious
diseases
N=527
N=25
N=12
Surgery
N=426
Intensive
care
N=179
Gynaecology
N=279
Paediatrics
N=190
Rehabilitation
N=701
Long
Psychiatry
term care
N=282
N=204
Results: ATB-RAISIN, 2012
• Most used antibiotics in 1 411 HCF, 2012
Penicillins with extended spectrum (J01CA)
5%
4%
Amoxicillin+ clavulanic acid (J01CR02)
17%
2%
Beta lactamase resistant penicillins (J01CF)
67%
12%
Top 5
1GC+2GC (J01 DB,DC)
3GC (J01DD, J01DE,J01DC07)
Carbapenems (J01DH)
Antibiotic
Other beta-lactam antibacterials
3%
Sulfamides (J01E)
MLS (J01F)
5%
Aminoglycosides (J01G)
2%
32%
2%
118
Amoxicillin
65
Ceftriaxone
20
Ofloxacin
18
Ciprofloxacin
13
Fluoroquinolones (J01MA)
Glycopeptides (J01XA)
1%
Amoxiclav
DDD /
1 000
PD
Imidazole derivatives (J01XD+P01AB)
8%
4%
Miscellaneous
3%
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)
67%
100
%
401.9 (P75) ≤ consumption < 515.0 (max)
64%
57%
60%
85%
58%
72%
356.5 (P50) ≤ consumption < 401.9 (P75)
68%
331.8 (P25) ≤ consumption < 356.5 (P50)
165.2 (min) ≤ consumption < 331.8 (P25)
94%
79%
75%
84%
62%
31%
84%
81%
58%
44%
88%
80%
58%
50%
23%
28%
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.
100
%
Fait avec Philcarto - http://philcarto.free.fr
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)
44%
34%
9.6 (P75) ≤ consumption < 16.5 (max)
31%
31%
7.1 (P50) ≤ consumption < 9.6 (P75)
39%
74%
56%
3.3 (P25) ≤ consumption < 7.1 (P50)
63%
20%
0.4 (min) ≤ consumption < 3.3 (P25)
93%
75%
73%
Insufficient data
58%
58%
2%
70%
81%
58%
25%
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 casemix may partially explain some of the
variations in this map.
80%
48%
34%
30%
34%
100%
Fait avec Philcarto - http://philcarto.free.fr
Results: ATB-RAISIN, 2012
Proportion of antibiotics according to clinical wards
100%
90%
Miscellaneous
80%
Glycopeptides
70%
Fluoroquinolones
60%
Aminoglycosides
Carbapenems
50%
3GC
40%
1GC+2GC
30%
Beta lactamase resistant penicillins
Amoxicillin + clavulanic acid
20%
Amoxicillin
10%
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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
400
No. DDD / 1 000 PD
•
+0.6%
+2.5%
+3.7%
+0.3%
386
388
389
2010
2011
2012
376
380
363
360
340
320
300
2008
2009
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
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
14
17
18
20
21
4
4
5
5
5
52
52
52
50
48
Ciprofloxacin
14
14
15
14
14
Levofloxacin
9
10
11
11
11
20
20
20
19
18
Vancomycin
5
5
5
5
5
Teicoplanin
1
1
1
1
1
363
376
386
388
389
Amoxicillin-clavulanic acid
Ceftriaxone
Carbapenems
Fluoroquinolones
Ofloxacin
Total
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)
22,0
+48.2%
2008
2009
2010
2011
2012
20,0
Number of DDD / 1000 PD
18,0
16,0
14,0
12,0
10,0
8,0
+72.7%
+3.4%
6,0
+37.4%
+2.0%
4,0
2,0
0,0
Piperacillin
tazobactam
J01CR05
Ceftriaxone
J01DD04
Ceftazidime
J01DD02
Cefotaxime
J01DD01
Carbapenems
J01DH
Results: ATB-RAISIN, 2008-2012
• Contrasted changes in AMR
Incidence of antimicrobial resistance in selected bacteria, in number of
strains/1000 PD, in hospitals providing data each year from 2008 to 2012
0,90
+13%
0,80
Resistant strains / 1000 PD
E. coli / Ciprofloxacin
0,70
Staphylococcus aureus /
Oxacillin
0,60
0,50
-22%
+75%
0,40
E. coli / Cefotaxime or
ceftriaxone
Pseudomonas aeruginosa /
Ciprofloxacin
-17%
0,30
+33%
0,20
-28%
0,10
0,00
2008
2009
2010
2011
2012
Enterobacter cloacae /
Cefotaxime
Pseudomonas aeruginosa /
Ceftazidime
Results: ATB-RAISIN, 2012
Median = 36.8 DDD/ 1000 PD
Analysis: High AMR and AB Use
Actions: Infection control to prevent spread
Prudent use of AB
0.4
0.6
0.8
1.0
Analysis: High AMR
Actions:
• Infection control, admission screening
• Prudent use of AB other than 3CG
0.2
Median = 0.18 / 1000 PD
0.0
Resistant
strains/1000 PD
Souches R / 1000 JH
1.2
Third generation cephalosporins (3GC) consumption and incidence of
cefotaxime-resistant Enterobacter cloacae (N=334)
3GC use in DDD/1000 PD
0
20
40
60
80
100
120
140
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
Hematology
Number of Pooled mean
participants
Median
26
340
201
Intensive care units
97
163
139
Whole HCF
239
18
7
Results: ATB-RAISIN, 2012
Antimycotics consumption
Pattern of antimycotic consumption (J02) in hematology and ICUs
ICU (n=97)
Hematology (n=26)
Micafungin 0%
Caspofungin 11%
Amphotericin B
5%
Flucytosine 0%
Posaconazole
12%
Liposomal
Amphotericin B
25%
Flucytosine
0%
Posaconazole
0%
Micafungin
1%
Amphotericin B
1%
Liposomal
Amphotericin B
7%
Voriconazole
5%
Itraconazole
0%
Voriconazole 13%
Itraconazole 2%
Caspofungin
13%
Fluconazole 32%
Fluconazole
73%
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