11 July 2019
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 because at that time there was not a mechanism to obtain territory-wide antibiotics usage data, wholesale supply data of antibiotics might 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. The first-ever territory-wide report of antibiotics supplied to different sectors based on the wholesale supply data (2014 - 2016) was published in April 2018 at the CHP website.
Since then, collecting the wholesale supply data of antibiotics through licensed drug wholesalers has been regularised as an ongoing annual surveillance exercise. DH collected the 2017 wholesale supply data and prepared the second wholesale supply report. The 2017 wholesale supply results are put together with the 2014 - 2016 results for easy reference. Some wholesalers reported that minor errors were committed during the first exercise. Such errors have been corrected when the 2017 results were being prepared and the results in this report are the most up-to-date versions.
DH collected wholesale supply data through a standardised electronic 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 (HA), private hospitals, private doctors (mutually exclusive with private hospitals), dentists, veterinary surgeons, community pharmacies and farmers.
Classes of Antibiotics Covered
As suggested in the document, namely, WHO methodology for a global programme on surveillance of antimicrobial consumption (version 1.0, which can be accessed here), a core set of antibiotics should be included in the surveillance:
WHO ATC Code
Classes of Antibiotics
Antibacterials for Systemic Use
Antibiotics for Alimentary Tract
Nitroimidazole Derivates for Protozoal Diseases
Therefore those antibiotics under A07AA, which had not been included in the previous exercise, were also covered in this surveillance. External use topical preparations are excluded in the surveillance as suggested by WHO.
Quantification of Antibiotic Usage
Results were analyzed and presented as defined daily dose (DDD), the most commonly used metric for measurement and reporting of drug utilisation internationally. It is also adopted by WHO to facilitate drug consumption 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 annual difference in population. DID is also 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, 2016 and 2017 were 22.11, 22.47, 23.58 and 21.64 DID respectively, with an increase of 6.7% from 2014 to 2016 but a decrease of 8.2% from 2016 to 2017 was observed.
The top three classes of antibiotics with the highest volume of wholesale supply in 2017 were: “beta-lactam antibacterials, penicillins” (11.11 DID, 51.4% of the overall supply); “macrolides, lincosamides and streptogramins” (2.95 DID, 13.6%) and “other beta-lactam antibacterials” (2.32 DID, 10.7%). They accounted for about 75.7% of overall local antibiotics supply to human in 2017. Similar pattern of distribution of these three classes of antibiotics were observed in 2014 - 2016 as well.
The top three sectors supplied with the largest proportion of overall antibiotics in 2017 were private doctors (51.1%), HA (23.3%) and community pharmacies (12.7%).
Fourteen locally important broad spectrum antibiotics, normally reserved for resistant infections, only accounted for 1.5% of the total supply in HK in 2017, majority of them (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 (1.5%). The majority of them were supplied to HA and private hospitals. This distribution is expected as these sectors provide secondary and tertiary care, in which more vulnerable patients and patients with more resistant infections are being taken care of.
Private doctors, HA and community pharmacies were the three sectors supplied with the highest volume of antibiotics from 2014 to 2017. As private doctors and HA are the major healthcare providers in community and hospital settings, this result is not unexpected. The proportion of antibiotics supplied to community pharmacies dropped from 18.4% to 12.7% in 2017.
In addition, the total wholesale supply of antibiotics in HK was on the rising trend from 2014 to 2016 (increased by 6.7%) but the rising trend was reversed as the total supply decreased by 8.2% (4.9 million DDD decrease) in 2017.
This reversal of the trend was contributed by decrease in supply to community pharmacies (4.3 million DDD reduction) and private doctors (3.0 million DDD reduction) in 2017. It also coincided with the series of publicity campaigns to raise the public awareness of AMR and appeal of judicious use of antibiotics amongst all stakeholders, and the issuance of the Guidance Notes on Antibiotic Use. At the same time DH has also stepped up the enhanced regulatory actions against illegal sale of antibiotics without prescription.
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
DH has disseminated and discussed the wholesale supply results with the relevant stakeholders. DH would continue the health education and promotion through various media to raise the general awareness of AMR and advocate the Guidance Notes on Antibiotic Use through the Antibiotic Stewardship Programme in Primary Care. On the other hand, DH would take the two-pronged approach, education and enhanced enforcement action against illegal sale of antibiotics. Last but not the least, DH would continue the various surveillance exercises and introduce the most appropriate control measures to curb the threat of AMR.
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
• Do not purchase antibiotics without a prescription
• Do not demand antibiotics from your doctor
• Follow your doctor’s advice when taking antibiotics
• To prevent AMR, maintaining good personal hygiene and receiving up-to-date vaccination are equally important
Advice to community pharmacies
• Only supply antibiotics in accordance with the law
• Illegal sale of antibiotics is a criminal offence
– e.g. supply of prescription antibiotics to the general public without the authorization of a prescription
• The maximum penalty is a fine of $30,000 and 12 months of imprisonment
Advice to healthcare workers
Antibiotics are precious resources against infections. Healthcare workers play an essential role
in preserving them:
• Continue to prescribe antibiotics in accordance with therapeutic guidelines in consideration of clinical situations
• Discuss with your patients about the importance of appropriate antibiotic use and the dangers of AMR
• Apply best practice of infection prevention and control
• Talk to your patients about how to prevent infections and their spread
– e.g. vaccination, maintain good personal hygiene and hand hygiene