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 sets out monitoring of antibiotics usage as one of the strategic actions. As currently there is no mechanism to obtain the actual 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 second and third reports were subsequently published in July 2019 and July 2020 respectively. (Please click here to view the relevant reports)
In the Action Plan, activity 3.2.1 also suggested to collect the antibiotic dispensing data from Hospital Authority (HA) to monitor antimicrobials use in public hospitals and clinics. Therefore, with the assistance from various departments of HA, DH collected the HA antimicrobial dispensing data, including both non-inpatient and inpatient services, for surveillance.
Since the Action Plan was published in 2017, the situation of 2016 has been chosen as the baseline for comparison.
With the assistance of stakeholders from HA such as Chief Pharmacist’s Office, Information Technology & Health Informatics Division, Quality and Safety Division, Strategy and Planning Division and various Working Groups, HA antimicrobial dispensing data and various service statistics were obtained.
Dispensing data of antimicrobials were grouped according to the World Health Organization (WHO) Anatomical Therapeutic Chemical (ATC) classification system of antimicrobials.
Some selected broad-spectrum antimicrobials 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 drug 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.
The overall antimicrobials dispensed in HA increased (in terms of DDD) from 2016 to 2018.
In 2018, after the service volume was taken into account, the antimicrobial dispensed quantity in non-inpatient service decreased by 5.52 DDD per 1,000 attendances (-1.70%) while the antimicrobial dispensed quantity in inpatient service increased by 0.93 DDD per 1,000 patient-days (0.09%) when compared with that of 2016.
The five most dispensed ATC antimicrobial pharmacological subgroups in year 2018 in public hospitals and clinics were beta-lactam antibacterials, penicillins (J01C), quinolone antibacterials (J01M), other beta-lactam antibacterials (J01D), macrolides, lincosamides and streptogramins (J01F) and tetracyclines (J01A). The five most dispensed antimicrobials were amoxicillin/clavulanate (J01CR02), doxycycline (J01AA02), levofloxacin (J01MA12), clarithromycin (J01FA09) and amoxicillin (J01CA04).
When the results were stratified by services, the five most dispensed antimicrobials in 2018 for non-inpatient service were amoxicillin/clavulanate (J01CR02), doxycycline (J01AA02), clarithromycin (J01FA09), amoxicillin (J01CA04) and levofloxacin (J01MA12), while for inpatient service were amoxicillin/clavulanate (J01CR02), levofloxacin (J01MA12), doxycycline (J01AA02), piperacillin/tazobactam (J01CR05) and meropenem (J01DH02). These are antimicrobials commonly used in both hospital and clinic settings for various infections. Detailed figures can be found in the uploaded report by clicking here.
In 2018, there were 15 broad-spectrum antimicrobials, normally given for treatment of resistant infections, selected for monitoring and their dispensed quantities were found with a 15.46% increase in HA inpatient service from 2016 to 2018. The most dispensed broad-spectrum antimicrobial was piperacillin/tazobactam (J01CR05), followed by meropenem (J01DH02) and vancomycin (J01XA01). They together accounted for about 80.98% of the overall selected broad-spectrum antimicrobials dispensed.
When stratified by specialty, Intensive Care Unit (ICU)/ High Dependence Unit (HDU) (616.74 DDD per 1,000 patient-days) was the unit with the highest DDD per 1,000 patient-days of the selected broad-spectrum antimicrobials dispensed in 2018, followed by Medicine (166.82 DDD per 1,000 patient-days) and Surgery (140.68 DDD per 1,000 patient-days). Similar observation was noted in 2016 and 2017.
According to the results, the overall dispensed quantity of antimicrobials in non-inpatient[1] service decreased in 2018 when compared with 2016, while the dispensed quantity of antimicrobials in inpatient[2] service increased.
The five most dispensed ATC antimicrobial pharmacological subgroups in both hospitals and clinics were antimicrobials 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 antimicrobials under monitoring in inpatient service have shown an increasing trend[3] since 2016, in which ICU/HDU had the highest DDD per 1,000 patient-days of these broad-spectrum antimicrobials. 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.
The two relatively new fifth generation cephalosporins, namely, ceftaroline fosamil and ceftolozane/tazobactam showed rapid increase in use since their introduction in HA though the absolute dispensed amount were rather small.
Both cefepime and daptomycin showed an increase of about 40% from 2016 to 2018 though they together only accounted for 3.68% in 2016 and 4.53% in 2018 of the overall use of broad spectrum antimicrobials in inpatient service.
Colistin, being considered as the last resort antimicrobial for treating resistant Gram-negative bacterial infections when all other antimicrobials failed, was found to have decreased by 21.19% in 2018 when compared with that of 2016 in inpatient service.
This exercise was based on antimicrobial dispensing data captured by the HA dispensing system and are only intended to reflect the annual trend of various antimicrobials dispensed at various specialties through this system. It is not meant to gauge the appropriateness of the prescribed antimicrobials for the infectious diseases or whether the right dose and the duration were given.
Antibiotic Stewardship Programme is a useful tool to regularly remind healthcare workers of judicious use of antibiotics. It should be strongly advocated and implemented in all healthcare facilities to raise the awareness on the importance of appropriate use of antibiotics to contain the development of AMR.
Antibiotics are a precious resource for human health and modern medicines and every member of the society should make efforts to preserve it effectiveness against bacterial infections.
Antibiotics are a precious resource and their effectiveness must be preserved to protect us from infections. Healthcare workers play an essential role in preserving them:
Please click here to view the more detailed results.
Please click here to view the full report
Please click here to view the previous reports.
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[1] in DDD per 1,000 attendances
[2] in DDD per 1,000 patient-days
[3] in DDD per 1,000 patient-days