Page last updated: 26-JAN-2010

SAPG

Statistical Publication Notice

26 January 2010

Scottish Antimicrobial Prescribing Group (SAPG) Report on Antimicrobial Resistance and Use in Humans.

INTRODUCTION

This is the first joint annual report from the Scottish Antimicrobial Prescribing Group (SAPG), published by Health Protection Scotland (HPS) in collaboration with Information Services Division (ISD) that combines information from the monitoring of antimicrobial use and resistance in humans in Scotland.
 
Antimicrobial resistance (AMR) is recognised as a major threat to public health and patient safety. It reduces the available treatment options for infection and is associated with increased morbidity (the frequency and severity of illness) and mortality due to a failure of the initial choice of antimicrobial therapy. It is recognised that the way in which antimicrobials are used, sometimes inappropriately, will increase the risk of antimicrobial resistance developing.
 
The information presented covers the period up to the end of calendar year 2008 and sets the baseline against which the emerging trends in antimicrobial use and resistance can be monitored.  The report is intended to support NHS Boards, hospitals and primary care in their long-term planning of antimicrobial prescribing and in particular should be of use to Antimicrobial Management Teams (AMTs), Infection Control Teams (ICTs) and microbiologists.

KEY POINTS

  • The report presents information on the use of systemic antimicrobials within primary care in Scotland. 
  • In 2008 the three most commonly used groups of antimicrobials were tetracyclines, penicillins with extended spectrum and macrolides which made up 25%, 24% and 17% of total use respectively.
  • The report presents information on patterns of antimicrobial resistance for key organisms causing bacteraemia, including the Gram-negatives Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and the Gram-positives Streptococcus pneumoniae, Staphylococcus aureus and Enterococcus sp. in line with data collected by the European Antimicrobial Resistance Surveillance Scheme (EARSS).
  • For the Gram-negative organisms resistance was observed towards a number of important antibiotic groups, including aminopenicillins, second and third generation cephalosporins, fluoroquinolones and aminoglycosides.

INTERPRETATION

Antimicrobial consumption data has been obtained from a database of all NHS prescriptions dispensed in Scotland.  It relates to prescriptions dispensed within the community, but does not take into account medicines dispensed by hospitals or hospital based clinics.
 
Antimicrobial resistance data is gleaned from reports to HPS from the Microbiology laboratory service.  Not all laboratories report/test all the antibiotics of interest and therefore analysis relates to subsets of the total number of bacteraemia isolates recorded.

DETAILED FINDINGS

  • The report presents information on the use of systemic antimicrobials within primary care in Scotland. It shows that between 2004 and 2008 there has been an increase of 18.3% in overall use of antimicrobials when expressed as the number of defined daily doses per 1000 population per day (DDD/1000/day). In 2008 the three most commonly used groups of antimicrobials were tetracyclines, penicillins with extended spectrum and macrolides which made up 25%, 24% and 17% of total use respectively.
  • Guidance published by the Scottish Antimicrobial Prescribing Group (SAPG) in 2009 on management of commonly encountered infections aims to restrict the use of fluoroquinolones, cephalosporins and co-amoxiclav which are known to increase the risk of Clostridium difficile infection (CDI). Whilst the information in this report predates this guidance, in 2008 eight of the ten most commonly used antimicrobials are those recommended by SAPG.
  • Looking more specifically at the use of antimicrobials that increase the risk of CDI, ciprofloxacin, the most commonly used fluoroquinolone, has increased by 30% between 2004 and 2008, co-amoxiclav use has increased by 22% and cephalosporin use has decreased by 4%.
  • The report presents information on patterns of antimicrobial resistance for key organisms causing bacteraemias, including the Gram-negatives Escherichia coli, Klebsiella pneumoniae, Pseudomonas aeruginosa, and the Gram-positives Streptococcus pneumoniae, Staphylococcus aureus and Enterococcus sp. in line with data collected by the European Antimicrobial Resistance Surveillance Scheme (EARSS).
  • For the Gram-negative organisms, resistance was observed towards a number of important antibiotic groups, including aminopenicillins, second and third generation cephalosporins, fluoroquinolones and aminoglycosides. Resistance proportions for the Scottish isolates were in most cases within the same range as reported in previous United Kingdom (UK) reports, but for third generation cephalosporins and fluoroquinolones resistance proportions in the Scottish isolates were above the latest UK figures reported to EARSS for 2008.
  • It has been suggested that the rise in third generation cephalosporin resistance in many countries is caused by dissemination of ESBL-producers (extended spectrum beta-lactamase producers) in hospitals and the community. Substantial proportions of the Scottish E. coli (7.2%) and K. pneumoniae (8.4%) isolates were ESBL-producers.
  • Combined resistance to third generation cephalosporins and fluoroquinolones or aminoglycocides was observed in proportions of E. coli and K. pneumoniae isolates, (10.5% and 5% respectively for E Coli and 9.3%, and 10.2% respectively for K pneumoniae).
  • This development of combined resistance limits the treatment options for Gram-negative infections, and poses the threat of further evolution of multi-drug resistance.
  • Although rare in Scotland, emergence of carbapenem resistance in Gram-negatives has been detected by the UK Reference Laboratory for Antimicrobial Resistance (ARMRL). The emergence of combined resistance needs to be carefully monitored particularly in the context of a shift in prescribing towards Clostridium difficile sparing antibiotics.
  • Based on the data in this report resistance among the Gram-positives is currently less of a concern in Scotland. All but one isolate of Streptococcus pneumoniae was sensitive to penicillin and no resistance to glycopeptides (vancomycin) was detected among MRSA isolates. However, 16.7% resistance to vancomycin was observed among the E. faecium isolates from bacteraemias (also referred to as VRE). This is of particular concern as these resistance mechanisms can be transferred to other pathogens (including MRSA) via plasmids.
  • In looking forward, the ongoing implementation of national standardisation and automation of testing and reporting of antimicrobial susceptibility data will greatly enhance the quality of national data. Alongside developments in antimicrobial use and resistance surveillance, systems to monitor unintended consequences that arise from changes in antimicrobial use will be developed.

CONCLUSIONS

In conclusion, this report presents the baseline data for antimicrobial use and resistance in Scotland. It provides information on which national programmes, commissioned by the Healthcare Associated Infection (HAI) Taskforce and overseen by SAPG and the HPS (HAI) programme board, can be based. The publication of future annual reports from HPS/ISD will help assess the effectiveness of these national programmes in minimising antimicrobial resistance in Scotland and continue to monitor this in the context of the changing international situation.

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MAIN CONTACTS:

Camilla Wiuff (HPS)
Epidemiologist
0141 282 2927
camilla.wiuff@nhs.net

William Malcolm (HPS)
Pharmaceutical Adviser
0141 300 1174
w.malcolm@nhs.net

Tracey Cromwell (ISD)
Principal Information Analyst
0131 275 6179
tracey.cromwell@nhs.net

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GLOSSARY:

AMR: Antimicrobial resistance. In this case, refers to the ability of bacteria to withstand the harmful effects of antibiotics.

ESBL: Extended spectrum beta-lactamase. These are enzymes produced by bacteria that can break down and inactivate beta-lactamase antibiotics.

MIC: Minimum Inhibitory concentration. The concentration of an antibiotic required to inhibit the growth of an organism when measured in laboratory tests.

PCR: Polymerase chain reaction. A method used to amplify DNA in the laboratory often for diagnostic purposes.
 
VRE: Vancomycin resistant enterococci. Bacteria of the genus Enteroccocus which are resistant to vancomycin.

DDD: Defined Daily Dose. This is the internationally recognised technical unit of measurement of medicine consumption.  DDDs are recommended by the World Health Organisation (WHO) as the standard to allow comparative use of medicines over time and between locations. It is the assumed average maintenance dose per day for a medicine used in its main indication in adults.

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PRE-RELEASE ACCESS:

Under terms of the "Pre-Release Access to Official Statistics (Scotland) Order 2008", ISD are obliged to publish information on those receiving Pre-Release Access ("Pre-Release Access" refers to statistics in their final form prior to publication). The standard maximum Pre-Release Access is five working days. Shown below are details of those receiving standard Pre-Release Access and, separately, those receiving extended Pre-Release Access.
 
Standard (five day) Pre-Release Access:
Scottish Government Health Department (Analytical Services Division)
NHS Board Chief Executives
NHS Board Communication leads
 
Extended Pre-Release Access:
Scottish Government Health Department (Analytical Services Division)
This extended Pre-Release Access is given to a small number of named individuals in the Scottish Government Health Department (Analytical Services Division). This Pre-Release Access is for the sole purpose of enabling that department to gain an understanding of the statistics prior to briefing others in Scottish Government (during the period of standard Pre-Release Access).
 
 
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HISTORY OF THIS PUBLICATION:

Last Published: N/A (This is first publication)
Next Due: January 2011 (tbc)
Data Available Since: N/A (This is first publication)