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Antimicrobial Use (AMU) Surveillance in Public Hospitals and Clinics - Hospital Authority Antibiotics Dispensing Data (2014 - 2016)

2 October 2019

Background

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) started the collection of wholesale supply data through licensed drug wholesalers in 2017 and published the first territory-wide report in April 2018 in Centre for Health Protection website. Since then collection of wholesale supply data has become an annual exercise and the 2018 report was published in July 2019. (Please click here to view the report)

In the Action Plan, activity 3.2.1 also suggested to collect the antibiotic dispensing data from Hospital Authority (HA) to monitor antibiotics use in public hospitals and clinics. Therefore with the assistance from various departments of HA, DH collected the HA dispensing data, including both non-inpatient and inpatient services, for surveillance.

Data Scopes

With the assistance of HA various departments such as Chief Pharmacist’s Office, Information Technology & Health Informatics Division, Quality and Safety Division, and Statistics & Workforce Planning Department, dispensing data and various service statistics were obtained.

Methodology and Analysis

Dispensing data of antibiotics were grouped according to the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) classification system of antibiotics.

Selected broad spectrum antibiotics dispensed to various specialties were also examined because of their importance for treatment of resistant infections in human.

Results were analysed and presented as defined daily dose (DDD), a standardised unit adopted by WHO to facilitate comparison of antibiotics use. It is defined as “the assumed average maintenance dose per day for a drug used for its main indication in adults”. Results were also presented as DDD per 1,000 attendances and DDD per 1,000 patient-days of various specialties for both non-inpatient and inpatient services respectively.

Key Findings

The overall antimicrobials dispensed in both HA non-inpatient service and inpatient service increased from 2014 to 2016. In 2016, the overall antimicrobials dispensed in non-inpatient service was 323.65 DDD per 1,000 attendances while for the inpatient service was 1,069.38 DDD per 1,000 patient-days. They represented about 6.7% and 2.8% increase respectively when compared with the figures of 2014.

The five most dispensed antibiotic groups in year 2016 in public hospitals and clinics were “beta-lactam antibacterials, penicillins” (J01C), “quinolone antibacterials” (J01M), “macrolides, lincosamides and streptogramins” (J01F), “other beta-lactam antibacterials” (J01D) and “tetracyclines” (J01A). The five most dispensed items were “amoxicillin/ clavulanate” (J01CR02), “levofloxacin” (J01MA12), “clarithromycin” (J01FA09), “doxycycline” (J01AA02) and “cloxacillin” (J01CF02).

When the results were stratified by services, the five most dispensed items in 2016 for non-inpatient service were “amoxicillin/ clavulanate” (J01CR02), “clarithromycin” (J01FA09), “amoxicillin” (J01CA04), “cloxacillin” (J01CF02) and “doxycycline” (J01AA02) while for inpatient service were “amoxicillin/ clavulanate” (J01CR02), “levofloxacin” (J01MA12), “piperacillin/ tazobactam” (J01CR05), “doxycycline” (J01AA02) and “cefuroxime” (J01DC02). These are antibiotics commonly used in both hospital and clinic settings for a wide range of infections. Details figures can be found in the uploaded report by clicking here.

In 2016, eleven selected important broad spectrum antibiotics, normally reserved for resistant infections, accounted for about 9.9% of the total antimicrobials dispensed for inpatient service, while the five most dispensed broad spectrum antibiotics, namely, “piperacillin/ tazobactam” (J01CR05), “meropenem” (J01DH02), “vancomycin” (J01XA01), “cefoperazone/ sulbactam” (J01DD62) and “ceftazidime” (J01DD02), accounted for about 91.3% of the overall selected broad spectrum antibiotics dispensed.

When stratified by specialty, Intensive Care Unit (ICU)/ High Dependence Unit (HDU) was the unit with the highest DDD per 1,000 patient-days of the selected broad spectrum antibiotics dispensed (635.69 DDD per 1,000 patient-days) followed by Medicine (137.22 DDD per 1,000 patient-days) and then Surgery (101.90 DDD per 1,000 patient-days) in 2016. Similar observation was noted in 2014 and 2015.

Discussion

According to the results, overall increase in antimicrobial dispensed in both public hospitals and clinics were observed from 2014-2016 with the percentage increase in non-inpatient1 was greater than that of inpatient2.

The five most dispensed antibiotic groups in both hospitals and clinics were antibiotics commonly used to treat common bacterial infections in both hospitals and clinics. They are usually prescribed as first-line treatment for suspected bacterial infections.

The selected broad spectrum antibiotics under monitoring accounted for about 9.9% of the total antimicrobials dispensed for inpatient service in 2016 and ICU/ HDU had the highest rate of use of these broad spectrum antibiotics. It is not an unexpected observation as ICU/ HDU is the specialty in which more vulnerable patients and more patients with resistant infections are being treated.

Two broad spectrum antibiotics, namely, piperacillin/ tazobactam and meropenem were found to have dispensed around 30% more in 2016 when compared with that of 2014. They were also among the ten most dispensed antibiotics for inpatient service and their use should be closely monitored.

Colistin, the last antibiotics to be deployed for resistant infections if all other antibiotics failed, was found to have a percentage decrease of 18.8% when compared with that of 2014.

Limitations

This exercise was based on the HA dispensing data, which contained no information to reflect appropriateness of antibiotic use. Hence services or specialties with higher rate of dispensing of antibiotics might not mean they are prescribing antibiotics unnecessarily. Hence the results should not be used to gauge the appropriateness of use of antibiotics by various specialties.

The Way Forward

Antibiotic Stewardship Programme should be enhanced to expand its present coverage to advocate further on appropriate use of antibiotics in HA. Antibiotics are precious resources for human health and modern medicines and every member of the society should make efforts to preserve it effectiveness against bacterial infection.

Advice


Advice to the Public

  • Proper use of antibiotics
    • Do not demand antibiotics from your doctor
    • Follow your doctor’s advice when taking antibiotics
    • Do not stop taking antibiotics by yourselves even if you are feeling better
    • Do not take leftover antibiotics
    • Do not share your antibiotics with others
    • Do not self-purchase antibiotics without a prescription
  • Practise frequent hand hygiene, especially before eating and taking medicine, and after going to the toilet
  • Ensure your vaccination is up-to-date
  • Maintain cough etiquette, wear a mask if you have respiratory symptoms


Advice to Healthcare Workers

Antibiotics are precious resources against infections. Healthcare workers play an essential role in preserving them:

  • Prescribe antibiotics in accordance with therapeutic guidelines in consideration of clinical situations
  • Educate your patients
    • To take antibiotics as prescribed and always complete the full course of medication
    • Discuss about the importance of appropriate antibiotic use and the dangers of AMR where appropriate
    • Talk about how to prevent infections and their spread. For example, vaccination, maintain good personal hygiene and hand hygiene
  • Apply best practice of infection prevention and control, and to practise frequent hand hygiene
  • Receive seasonal influenza vaccine

Please click here to view the more detailed results.

Please click here to view the full report.


1 in DDD/1,000 attendances

2 in DDD/1,000 patient-days