The HKSAR Government attaches great importance to the threat of antimicrobial resistance (AMR) and has launched the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2017 – 2022) (Action Plan) in 2017 to combat the problem.
The Action Plan set out monitoring of antibiotics usage as one of the strategic actions. As currently there is no mechanism to obtain territory-wide antibiotics usage data, wholesale supply data of antibiotics may serve as a proxy to reflect the usage. Hence, the Department of Health (DH) conducted an exercise in 2017 to collect the annual wholesale supply quantities of all the registered antibiotics classified under the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) classification code J01, the Antibacterials for Systemic Use, through licensed drug wholesalers.
Methodology and Analysis
DH collected wholesale supply data from 2014 – 2016 through standardised questionnaire from licensed wholesalers who distributed antibiotics. The licensed wholesalers were requested to provide wholesale data of relevant antibiotics to eight sectors including DH, Hospital Authority, private hospitals, private doctors (mutually exclusive with private hospitals), dentists, veterinary surgeons, community pharmacies and farmers. External preparations were excluded according to the instruction by WHO.
Results were analyzed and presented as defined daily dose (DDD), a standardized unit adopted by WHO to facilitate comparison. It is defined as “the assumed average maintenance dose per day for a drug used for its main indication in adults”. Annual DDD per 1,000 inhabitants per day (DID) was calculated to estimate drug use adjusted for population change. DID is commonly adopted by overseas health authorities to reflect the national consumption trend.
The overall local wholesale supply of antibiotics for human use in 2014, 2015 and 2016 were 22.24, 22.63 and 23.74 DID respectively, with an increase of 1.8% (0.39 DID) from 2014 to 2015 and 4.9% (1.11 DID) from 2015 to 2016.
The top three classes of antibiotics with the highest volume of wholesale supply in 2014 – 2016 were: “beta-lactam penicillins” (11.1 – 11.9 DID); “macrolides, lincosamines and streptogramins” (2.9 – 3.3 DID) and “other beta-lactam antibacterials” (2.9 – 3.0 DID). They accounted for about 76 – 77% of overall local antibiotics supply to human in 2014 – 2016.
The top three sectors supplied with the largest proportion of overall antibiotics in 2014 – 2016 were private doctors (51.4 – 51.9%), Hospital Authority (20.8 – 21.4%) and community pharmacies (18.2 – 18.6%).
Eleven locally important broad spectrum antibiotics, normally reserved for resistant infections, only accounted for 0.94 – 1.11% of the total supply in HK in 2014 – 2016, majority of them (99.2 – 99.4%) were supplied to hospitals.
According to the results, the top three classes of antibiotics with the highest volume of wholesale supply were antibiotic groups that are being used to treat common bacterial infections in both community and hospital settings. They are usually prescribed as first-line treatment for suspected bacterial infections.
The broad spectrum antibiotics only accounted for a very small proportion of the total local supply. The majority of them were supplied to Hospital Authority and private hospitals. This distribution is expected as these sectors provide secondary and tertiary care, in which more vulnerable patients and more patients with resistant infections are being taken care of.
Private doctors, Hospital Authority and community pharmacies were the three sectors supplied with the highest volume of antibiotics. As private doctors and Hospital Authority are the major healthcare providers in community and hospital settings, this result is not unexpected. There was about 18% of total antibiotics supplied to community pharmacies and the Department of Health has been closely monitoring the situation
This exercise was based on wholesale supply data, which has not taken into account factors such as natural wastage, disposal of expired products and procurement of non-registered drugs through name-patient basis. Wholesale supply data are neither representative of consumption data nor dispensing data; and contain no information to reflect appropriateness of antibiotic use.
The Way Forward
In view of the survey result, DH has launched a series of health promotion and education campaigns to advocate appropriate use of antibiotics; together with other experts and stakeholders, DH had updated IMPACT guidelines and launched the Antibiotic Stewardship Programme in Primary Care to promote prudent use of antibiotics in both hospitals and community settings. The DH has reminded community pharmacies regarding compliance with the law, and stepped up enforcement actions against illegal sales of antibiotics
Wholesale supply data of antibiotics can only provide part of the information of overall situation of antibiotic use, DH will, in joint effort with other government departments and organizations, initiate other surveillance activities to provide a more comprehensive picture on the overall AMR situation in Hong Kong.
Advice to Public
Advice to community pharmacies
Advice to healthcare workers
Please click here to view the more detailed results.