AURA 2016
First Australian report on antimicrobial use and resistance in human health
Summary report
© Commonwealth of Australia 2016
This work is copyright. It may be reproduced in whole or in part for study or training purposes, subject to the inclusion of an acknowledgement of the source.
Address requests and inquiries concerning reproduction and rights for purposes other than those indicated above in writing to:
AURA – Commonwealth Programs, Australian Commission on Safety and Quality in Health Care, GPO Box 5480, Sydney NSW 2001
Or email AURA@safetyandquality.gov.au
Suggested citation: Australian Commission on Safety and Quality in Health Care (ACSQHC). AURA 2016: first Australian report on antimicrobial use and resistance in human health – summary report. Sydney: ACSQHC, 2016.
An online version of this report can be accessed at www.safetyandquality.gov.au.
ISBN: 978-1-925224-47-4 (print) 978-1-925224-48-1 (online)
Acknowledgements
Many individuals and organisations gave their time and expertise over an extended period to this report and the Antimicrobial Use and Resistance in Australia (AURA) project, which were conducted by the Commission. In particular, the Commission wishes to thank the Australian Government Department of Health, the states and territories and their public hospitals, contributing private hospitals, the Australian Group on Antimicrobial Resistance, the National Centre for Antimicrobial Stewardship, SA Health, Queensland Health, Pathology Queensland, Sullivan Nicolaides Pathology, NPS MedicineWise, the National Neisseria Network, the Australian Mycobacterium Reference Laboratory Network and other key experts who have provided their time and considered advice. The involvement and willingness of all concerned to share their experience and expertise are greatly appreciated.
Members of the AURA Project Reference Group are Professor John Turnidge, Dr Phillipa Binns, Professor Marilyn Cruickshank, Dr Jenny Firman, Ms Aine Heaney, Mr Duncan McKenzie, Adjunct Professor Kathy Meleady, Dr Brett Mitchell, Professor Graeme Nimmo, Dr Alicia Segrave, Professor Karin Thursky, Dr Morgyn Warner, Professor Roger Wilson and Associate Professor Leon Worth.
The members of the Commission’s AURA team are also acknowledged for their significant contribution to the development of the AURA Surveillance System and this report.
Disclaimer
This report is based on the best data and evidence available at the time of development.
Edited and designed by Biotext Pty Ltd
Contents
Contents 3
Overview 4
What is antimicrobial resistance? 4
Antimicrobial use and appropriateness of prescribing 4
Antimicrobial resistance 5
International comparisons 5
Using information for action 5
Antimicrobial use and appropriateness 6
Key messages 6
Antimicrobial use in hospitals 6
Antimicrobial use in the community – primary care 8
Antimicrobial use in the community – residential aged care facilities 11
Antimicrobial resistance 13
Key messages 13
Resistance trends of concern 16
International comparisons 18
Key messages 18
Antimicrobial use in hospitals 18
Antimicrobial use in the community 19
Antimicrobial resistance 20
Using information for action 23
Key messages 23
References 26
Overview
AURA 2016: first Australian report on antimicrobial use and resistance in human health provides the most comprehensive picture of antimicrobial resistance (AMR), antimicrobial use (AU) and appropriateness of prescribing in Australia to date. It sets a baseline that will allow trends to be monitored over time. AURA 2016 also highlights areas where future work will inform action to prevent the spread of AMR.
Comprehensive, coordinated and effective surveillance of AMR and AU is a national priority. Surveillance is essential to understand the magnitude, distribution and impact of AMR and AU, as well as to identify emerging issues and trends. It allows the early detection of critical antimicrobial resistances to ensure that effective action can be taken, and provides information on the effectiveness of measures designed to promote appropriate AU and contain AMR. Surveillance is a critical component of Australia’s National Antimicrobial Resistance Strategy.
The Antimicrobial Use and Resistance in Australia (AURA) Surveillance System is the new system to coordinate data from a range of sources, and allow integrated analysis and reporting at a national level. The AURA Surveillance System brings together partner programs such as the Australian Group on Antimicrobial Resistance, the National Antimicrobial Prescribing Survey (NAPS), the National Antimicrobial Utilisation Surveillance Program (NAUSP) and Queensland Health’s OrgTRx system. Data is also sourced from the Pharmaceutical Benefits Scheme and the Repatriation Pharmaceutical Benefits Scheme (PBS/RPBS), NPS MedicineWise, the National Neisseria Network, the National Notifiable Diseases Surveillance System, the Report on government services 2015, and Sullivan Nicolaides Pathology.
The AURA Surveillance System will provide critical information needed by clinicians, policy makers, researchers and health system managers to target efforts to inform antimicrobial stewardship, and AMR policy and program development.
This summary report of AURA 2016 presents the key messages and data from that report.
What is antimicrobial resistance?
AMR is an issue of great importance for health care in Australia. AMR occurs when bacteria change to protect themselves from the effects of antimicrobials. This means that the antimicrobial can no longer eradicate or stop the growth of the bacteria. Antimicrobials can be life-saving agents in the fight against infection, but their effectiveness is diminished by AMR.
AMR has a direct impact on patient care and patient outcomes; it is a critical and immediate challenge to health systems around the world. It increases the complexity of treatment and the duration of hospital stay, and places an additional burden on patients, healthcare providers and the healthcare system.
Antimicrobial use and appropriateness of prescribing
AU is a key driver of AMR – the more we use antimicrobials, the more likely it is that resistance will develop. Appropriate use of antimicrobials can be life-saving, but inappropriate use needs to be monitored and minimised to prevent and contain AMR. Inappropriate use might include prescribing antimicrobials when they are not necessary, prescribing the wrong type of antimicrobial or prescribing for the incorrect duration.
On any given day in 2014, around 38% of patients in Australian hospitals were receiving antimicrobial therapy. Around 23% of these prescriptions were considered inappropriate, and around 24% were noncompliant with guidelines. Prescriptions for surgical prophylaxis are a significant concern – this indication is the most common reason for prescribing antimicrobials in hospitals (13.1% of all prescriptions), but also has the highest proportion of inappropriate use (40.2% of prescriptions were deemed to be inappropriate).
Antimicrobial prescribing is high in the community, with 46% of Australians being dispensed at least one antimicrobial in 2014. High volumes of antimicrobials are prescribed unnecessarily for upper respiratory tract infections.
In residential aged care facilities, 11.3% of the residents were on antimicrobials, but only 4.5% had a suspected or confirmed infection. Antimicrobials are sometimes used unnecessarily in residential aged care facilities for urinary tract infections, and unspecified skin and soft tissue infections.
Antimicrobial resistance
Data from hospitals, residential aged care facilities and the community was reported for priority organisms. Resistances and trends of concern include resistance to third-generation cephalosporins and carbapenems in Enterobacteriaceae, decreased susceptibility to ceftriaxone in Neisseria gonorrhoeae, resistance to ciprofloxacin in Shigella species, and resistance to erythromycin in Streptococcus agalactiae.
International comparisons
AU in the Australian community is higher than in many other countries. Rates of AMR in gram-negative organisms (Escherichia coli and Klebsiella pneumoniae) are lower than in other countries, but high to very high for gram-positive organisms (Staphylococcus aureus and Enterococcus faecium). Australia has low rates of resistance to fluoroquinolones compared with other countries, reflecting the restricted use of this antimicrobial class in Australia.
Using information for action
The information generated through surveillance of AU and AMR more accurately informs and supports strategies to prevent and contain AMR. A national, comprehensive and coordinated surveillance system, such as the AURA Surveillance System, provides data that can be used at many levels – by individuals, healthcare services, jurisdictional health authorities, national bodies and global AMR organisations – to ensure appropriate and effective use of antimicrobials, timely response to emerging resistance and coordinated efforts.
AURA 2016 provides valuable data and comprehensive analyses of AMR, AU and appropriateness of prescribing in Australia, and sets a baseline that will allow AMR and AU trends to be monitored over time. It also highlights areas where additional work would improve understanding and inform further action.
AURA 2016 and a detailed data supplement are available on the AURA website.
Antimicrobial use and appropriateness
Key messages
Hospitals
AU in hospitals was highest in 2010, and has gradually declined since then. However, on any given day in 2014, 38.4% of hospital patients were being treated with an antimicrobial.
There is large variation in the rates of AU between states and territories, but the factors driving this variation are unclear.
Data shows that 23.0% of prescriptions were considered inappropriate and 24.3% were noncompliant with guidelines. Inappropriate use was highest for respiratory tract infections and surgical prophylaxis.
Community
AU in the community is high, with 46% of the population being dispensed at least one systemic antimicrobial prescription in 2014–15. AU is highest in children (0–9 years old) and older people (aged 65 and over).
Prescribing varies across states and territories, and across local areas.
High volumes of antimicrobials are prescribed unnecessarily for respiratory tract infections – more than 50% of people with colds and other upper respiratory tract infections were prescribed an antimicrobial when it was not recommended by guidelines.
Some antimicrobials are prescribed more in winter, which suggests that they are potentially misused to treat viral illnesses such as colds and influenza.
Residential aged care facilities
In residential aged care facilities, 11.3% of the residents were on antimicrobials, but only 4.5% had a suspected or confirmed infection.
One in five antimicrobial prescriptions was written for residents who had no signs or symptoms of infection in the week before starting the antimicrobial. Of patients who did have signs of infection and were prescribed antimicrobials, only one-third of these prescriptions were appropriate.
Antimicrobials are sometimes used unnecessarily in residential aged care facilities for urinary tract infections, and unspecified skin and soft tissue infections.
Inappropriate use of antimicrobials – such as prescribing antimicrobials when they are not necessary, or prescribing the wrong type of antimicrobial – is a key driver of AMR. To prevent and contain AMR, it is important that AU is monitored, and that inappropriate use is minimised.
Antimicrobial use in hospitals
Data on AU in hospitals is sourced from the 2014 NAUSP report.1
Use of antimicrobials in Australian hospitals peaked in 2010, and has declined since then. The rates of use have decreased for some classes of antimicrobials, but have increased for other classes.
There are more than 100 different antimicrobial agents, but 20 of these account for 92% of all antibacterials used in hospitals. Data from NAUSP shows that by far the most commonly prescribed antimicrobial in hospitals is amoxicillin–clavulanate, followed by flucloxacillin, cefazolin and amoxicillin.
Differences in prescribing rates
Antimicrobial usage rates are measured as defined daily doses (DDDs) per 1000 occupied-bed days (OBDs), which allows data to be compared across hospitals, jurisdictions or countries. There is large variation in AU among states and territories – Tasmania has the highest rate of AU, and Queensland has the lowest (Figure 1).
Figure 1 Overall antimicrobial usage rates by jurisdiction, 2014
ACT = Australian Capital Territory; DDD/1000 OBD = defined daily doses per 1000 occupied-bed days; NSW = New South Wales; Qld = Queensland; SA = South Australia; Tas = Tasmania; Vic = Victoria; WA = Western Australia
Data source: National Antimicrobial Utilisation Surveillance Program report, 2014
Aminoglycosides, cephalosporins, fluoroquinolones and macrolides represent the classes of antimicrobials most likely to drive AMR. Overall, the usage rates of these four antimicrobial classes have declined in the large and medium public hospitals, and principal referral hospitals, that participate in NAUSP. Specifically, over the past five years:
rates of gentamicin use (the most commonly used aminoglycoside) have decreased steadily across Australia
use of ceftriaxone (the most commonly prescribed third-generation cephalosporin) and some macrolides appears to be seasonal, reflecting their role in the treatment of lower respiratory tract infections
rates of fluoroquinolone use have remained relatively constant.
Understanding variation in prescribing rates is critical to improving the quality, value and appropriateness of AU. However, there is currently insufficient evidence to identify which factors are driving variation in volumes and patterns of AU in Australian hospitals.
Appropriateness of prescribing
Data on appropriateness of prescribing in hospitals is sourced from the 2014 NAPS report.2
On any given day in an Australian hospital in 2014, 38.4% of patients were being administered an antimicrobial. Of these prescriptions, 24.3% were noncompliant with guidelines and 23.0% were considered to be inappropriate prescriptions. The main reasons why prescriptions were deemed to be inappropriate were that an antimicrobial was not needed, the antimicrobial chosen was incorrect (spectrum too broad), or the duration, dose or frequency of treatment was incorrect.
In 2014, the most common indications (reasons) for antimicrobial prescriptions in hospitals were:
surgical prophylaxis (13.1%)
community-acquired pneumonia (11.3%)
medical prophylaxis (8.3%)
cellulitis or erysipelas (skin infections) (4.4%).
Antimicrobials are often prescribed to patients undergoing surgery to prevent infection during and after the procedure – this is known as surgical prophylaxis. Inappropriate surgical prophylaxis is a major concern – it is the most common reason for antimicrobial prescriptions in hospitals, but also has the highest proportion of inappropriate use. Of all surgical prophylaxis prescriptions, 40.2% were deemed to be inappropriate. Reasons for inappropriateness included incorrect duration, dose or frequency, and there were instances where an antimicrobial was not needed at all.
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