1. The role of the English Surveillance Programme on Antimicrobial Use & Resistance in improving stewardship
Susan Hopkins
Consultant Infectious Diseases & Microbiology, Royal Free
Healthcare Epidemiologist, Public Health England
Hon Snr Lecturer, UCL

2. UK AMR Strategy: Seven Key Areas for Action
Improving infection prevention and control practices
Optimising prescribing practice
Improving professional education, training and public engagement
Developing new drugs, treatments and diagnostics
Better access to and use of surveillance data
Better identification and prioritisation of AMR research needs
Strengthened international collaboration
Action in all of the above areas is needed simultaneously.
The

3. Antimicrobial stewardship programmes
aim to improve quality of prescribing
usage data required to monitor impact
must be related to AMR epidemiology
BUGS
DRUGS
AMR

4. PHE ESPAUR: English Surveillance Programme for AMU & AMR
Support antimicrobial stewardship by monitoring antimicrobial use
Monitor key drug-bug combinations
Enhance data analysis and advice on use of carbapenemens & critically important drugs
Develop & measure quality measures for optimal antimicrobial prescribing
Develop methods to monitor the clinical outcomes/ unintended consequences
Develop initiatives to change public and professional behaviour
Input into national antimicrobial guidance

5. Top 6 Blood stream infections, Voluntary surveillance, 2002-11

6. Staphylococcus aureus: MRSA & MSSA
Lowest number of MRSA bacteraemias in over 15 years

7. Escherichia coli bacteraemia
Year on year increase over last 10 years – approx 20,000 more than 15 years ago
25% were diagnosed ≥2 days after hospital admission
Increased AMR in hospital associated cases

8. Resistance in E coli, Blood, 2004-2013 N~30,000/year
Resistance in Klebsiella, Blood,
N~8,000/year
Is this change in resistance important – empiric gudielines in hospitals are usually augmentin/ taz/ gent for sepsis. This means 1 in 10 people get an inappropriate first antibiotic – likely 3-4 fold increased risk of death.
Why have these changes occurred – earlier I showed you the graph demosntrating a fall in AMU quinolones and
Declines in resistance to Ciprofloxacin & Ceftriaxone
Increases in resistance to Piperacillin-Tazobactam & Carbapenems
? Ecological Pressure

9. Rapid spread of resistance
AMR is a global problem – and increasing international travel only reinforces this.
This is an example, showing how quickly NDM1 resistance spread around the world within months:
NDM1 is New Delhi metallo-beta-lactamase 1 (an enzyme that makes bacteria resistant to beta lactams like carbopenems)
First found in a patient in New Delhi in December 2009 (in a Swedish national who was visiting India).
Within 12 months, had been detected in 17 further countries: Norway, Finland, Sweden, Holland, UK, France, Spain, Denmark, Belgium, Germany, Austria, Pakistan, Oman, Kenya, Japan, USA and Australia.
---
Original source: Nature, 13th July 2013
Antimicrobial resistance
Image from slides produced by McKinsey & Company,
based on earlier image from Nature, 13th July 2013

10. PHE confirmed carbapenemase producers

11. Changes
Over the last 5 years,
The fall over the last five years in hospital prescribing of cephalosporins and quinolones has been mirrored by a comparable fall in community antibiotic prescriptions.
The number of community prescription items for cephalosporin’s in the last five years has fallen by 55% and that of quinolones by 36% (up to 2012 – 49% & 35% respectively)
In contrast - number of prescriptions for tetracyclines, macrolides, trimethoprim and macrodantin (first line antibiotics recommended by National guidance) have increased.
The reductions in the use of quinolones and cephalosporins are part of the antimicrobial stewardship measures that have been in place nationally, in the drive to reduce Clostridium difficile infections.
Trends in Prescribing of Antibacterials , excluding penicillins, in General Practice in England
AMP Key Trends Diane Ashiru-Oredope

12. AMP Key Trends Diane Ashiru-Oredope

13. AMP Key Trends Diane Ashiru-Oredope

14. Secondary care data from Cooke et al via IMS Health shows that from 2007/8 to 2011/12:
Use of cephalosporins and quinolones have reduced by 38% (1st, 2nd & 3rd generation cephalosporins) and 24% respectively whilst
Use of co-amoxiclav, carbapenems and piperacillin/tazobactam have increased by 56·6%, 94·8% and 142·3% respectively

15. Carbapenem usage for English Hospitals, 2007-2012
Looking a little bit more closely at carbapenem use demonstrates a year on year rise (chicken or egg) – overally use has doubled

16. Carbapenem usage as % of total use in English hospitals in 2011-2012

17. UCLp Hospitals & Point Prevalence Survey
First national prevalence antimicrobial use survey 2011
Many UCLp hospitals participated
Overall England Prevalence 35%
Variation across hospital type
Variation with age, sex, comorbidity, specialty, history of surgery

18. Point prevalence Survey: Antimicrobial use
AMP Key Trends Diane Ashiru-Oredope

19. Variation in AMU prevalence, SAUR
Hospital
Crude AMU Prevalence
% (95% CI) 1
32.3 ( ) 2
39.9 ( ) 3
43.8 ( ) 4
31.5 ( ) 5
41.8 ( )

20. Proportion of AMU by drug
National 1 2 3 4 5
Co-amox
13.8
26.7
23.1
22.8
14.7
Pip-tazo
10.9
5.8
11.5
12.8
11.3
24.1
Gent
4.2
6.7
1.9
2.3
4.5
Mero
5.0 (8th)
0 (>20th)
2.6 (10th)
3.8 (7th)
6.8 (4th)
9.5 (3rd)

21. Can use influence national AMR?
Until 2007, major increases in cephalosporin and quinolone resistance amongst Escherichia coli & Klebsiella spp
Plateau/ fall in resistance was from 2007 (LabBase / BSAC)
Fall in resistance coincides with the large reduction in cephalosporin and quinolone use
due to national antimicrobial stewardship guidance to reduce Clostridium difficile infections nationally
Replacement have been penicillin/b-lactamase inhibitors which may have another impact
Livermore D M et al. J. Antimicrob. Chemother. 2013;jac.dkt212
Until 2007, the UK saw major increases in cephalosporin and quinolone resistance amongst Escherichia coli and Klebsiella spp
Plateau/ fall in resistance was from 2007 (LabBase and BSAC data)
Fall in resistance coincides with the large reduction in cephalosporin and quinolone use due to national antimicrobial stewardship guidance to reduce Clostridium difficile infections nationally
Replacement have been penicillin/b-lactamase inhibitors which may be adding to the selection for carbapenamase producers
Livermore D M et al. J. Antimicrob. Chemother. 2013;jac.dkt212
The UK saw major increases in cephalosporin and quinolone resistance amongst Enterobacteriaceae
from 2001 to 2006, subsequent trends
LabBase and BSAC data showed that rates of non-susceptibility to cephalosporins and quinolones rose
amongst Escherichia coli and Klebsiella spp. until mid-decade (2004–07) before
amongst Escherichia coli and Klebsiella spp. until mid-decade (2004–07) before plateauing or falling
They coincided with large reductions in hospital cephalosporin
and quinolone use, owing to concern about Clostridium difficile, with replacement by penicillin/b-lactamase inhibitor
combinations, which have borderline activity against ESBL producers, but consistently lack activity against
carbapenemase producers.
Non-susceptibility to cephalosporins and quinolones has declined among bloodstream Enterobacteriaceae
in the UK, probably reflecting prescribing shifts.
The penicillin/b-lactamase inhibitor combinations that
have largely replaced cephalosporins and quinolones may add to selection for carbapenemase producers.
have largely replaced cephalosporins and quinolones may add to selection for carbapenemase produce
The changes in prescribing across primary and secondary care may, at least in part, explain the increase of Escherichia coli bacteraemias and emergence of other MDR clones.

22. Conclusion AMR major threat to future healthcare
AMU recognised driver of resistance
ESPAUR a national surveillance programme developed by PHE will
focus on integrating data
develop & measure quality measures
UCLp key role
working across hospitals to support initiative
validate data and
be a national leader
You can’t make an omelette without cracking an egg.

23. Acknowledgements: Diane Ashire-Oredope Jonathan Cooke Sue Faulding
Russell Hope
Alan Johnson
Cliodna McNulty
Pete Stephens
Neil Woodford
GPs, microbiology, pharmacy, infection prevention & control teams