1. v v v v Monitoring antibiotic consumption in hospitals: results from the French nationwide network “ATB-RAISIN” in 2012 April 2014

2. 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 ATB-RAISIN Network: Surveillance of antibiotic consumption in hospitals v v v v 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  ATB-RAISIN steering committee 5 CCLIN* and InVS** Other experts * Coordinating centres for prevention and control of healthcare associated infections ** French Institute for Public Health Surveillance

3. Background Monitoring antibiotic consumption in Healthcare facilities (HCF)  Guidelines : 1996, 2008 (National Authority for Health)  Ministerial circular : 2006 HAI national programmes since 1994 « ATB-RAISIN » set up in 2009 Standardised methodology Antibiotic use national plan since 2001

4. Objectives of ATB-RAISIN To describe antibiotic consumption in French healthcare facilities (HCF) at hospital and at ward level  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

5. 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

6. Results Participation  1411 HCF in 2012  Coverage : 66% PD at national level Number of participating HCF

7. Results: ATB RAISIN, 2012 Total antibiotic use in 1 411 HCF: 374 DDD/1000 PD  Variations in total antibiotic use according to HCF type

8. Results: ATB RAISIN, 2012  Variations in total antibiotic use according to ward/clinical activity

9. Results: ATB-RAISIN, 2012 Most used antibiotics in 1 411 HCF, 2012 Antibiotic DDD / 1 000 PD Amoxiclav 118 Amoxicillin 65 Ceftriaxone 20 Ofloxacin 18 Ciprofloxacin 13 Top 5 67%

10. 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) 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. Fait avec Philcarto - http://philcarto.free.fr 67% 100 % 68% 88% 58% 75% 72% 79% 85% 23% 84% 31% 28% 57% 60% 58% 84% 58% 81% 80% 94% 64% 62% 50% 100 % 44% 401.9 (P75) ≤ consumption < 515.0 (max) 356.5 (P50) ≤ consumption < 401.9 (P75) 331.8 (P25) ≤ consumption < 356.5 (P50) 165.2 (min) ≤ consumption < 331.8 (P25)

11. Fait avec Philcarto - http://philcarto.free.fr 100% 34% 81% 2% 80% 48% 34% 30% 25% 58% 70% 58% 93% 20% 75% 73% 58% 34% 31% 39% 74% 31% 44% 56% 63% 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) 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. Insufficient data 9.6 (P75) ≤ consumption < 16.5 (max) 7.1 (P50) ≤ consumption < 9.6 (P75) 3.3 (P25) ≤ consumption < 7.1 (P50) 0.4 (min) ≤ consumption < 3.3 (P25)

12. Results: ATB-RAISIN, 2012 Proportion of antibiotics according to clinical wards

13. 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 +3.7% +2.5% +0.3%+0.6%

14. 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 Antibiotics2008 2009201020112012 Amoxicillin-clavulanic acid121124125124127 Oral97100 102 Parenteral24 1GC+2GC121314 3GC (J01DD+J01DE+J01DC07) 2628313334 Ceftriaxone1417182021 Carbapenems44555 Fluoroquinolones52 5048 Ciprofloxacin14 1514 Levofloxacin91011 Ofloxacin20 1918 Vancomycin55555 Teicoplanin11111 Total363376386388389

15. 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)

16. Results: ATB-RAISIN, 2008-2012 Incidence of antimicrobial resistance in selected bacteria, in number of strains/1000 PD, in hospitals providing data each year from 2008 to 2012 Contrasted changes in AMR

17. Results: ATB-RAISIN, 2012 Third generation cephalosporins (3GC) consumption and incidence of cefotaxime-resistant Enterobacter cloacae (N=334) Median = 0.18 / 1000 PD Median = 36.8 DDD/ 1000 PD 3GC use in DDD/1000 PD Resistant strains/1000 PD Analysis: High AMR and AB Use Actions: Infection control to prevent spread Prudent use of AB Analysis: High AMR Actions: Infection control, admission screening Prudent use of AB other than 3CG

18. 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 Number of participants Pooled meanMedian Hematology26340201 Intensive care units97163139 Whole HCF239187

19. Results: ATB-RAISIN, 2012 Antimycotics consumption Hematology (n=26) ICU (n=97) Pattern of antimycotic consumption (J02) in hematology and ICUs

20. 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

21. 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?

22. 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