AURA 2017: Second Australian report on antimicrobial use and resistance in human health

238 Pages·2017·10.5 MB·English

AURA 2017
Second Australian report on antimicrobial use
and resistance in human health
AURA 2017 Second Australian report on antimicrobial use and resistance in human health
AURA 2017
Second Australian report on antimicrobial use
and resistance in human health
Published by the Australian Commission on Safety and Quality in Health Care
Level 5, 255 Elizabeth Street, Sydney NSW 2000
Phone: [phone]
Fax: [phone]
Email:
Contents
Summary   v
Chapter 1: Introduction   1
Key messages   1
1.1 Background   2
1.2 Australian healthcare system context   4
1.3 Importance of antimicrobial resistance    6
1.4 Importance of surveillance   7
1.5 AURA 2017 report    10
Chapter 2: Data sources and methods   13
Key messages   13
2.1 Types of data and information collected under the Antimicrobial
Use and Resistance in Australia Surveillance System   14
2.2 Sources of data for antimicrobial use and appropriateness of
prescribing   14
2.3 Sources of data for antimicrobial resistance   15
2.4 Considerations for interpreting the data   19
2.5 Data governance processes   20
Chapter 3: Antimicrobial use and appropriateness    23
Key messages   23
3.1 Antimicrobial use in hospitals   24
3.2 Antimicrobial use in the community – primary care   61
3.3 Developments and future plans   79
Chapter 4: Antimicrobial resistance   87
Key messages   87
4.1 Introduction   88
4.2 Acinetobacter baumannii complex   95
4.3 Enterobacteriaceae    97
4.4 Enterococcus species   110
4.5 Mycobacterium tuberculosis   116
4.6 Neisseria gonorrhoeae   119
4.7 Neisseria meningitidis   122
4.8 Pseudomonas aeruginosa   125
4.9 Salmonella species   127
4.10 Shigella species   129
SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE I N HUMAN HEALTH | 2017 iii
4.11 Staphylococcus aureus   130
4.12 Streptococcus agalactiae   138
4.13 Streptococcus pneumoniae   139
4.14 Streptococcus pyogenes   141
Chapter 5: National Alert System for Critical Antimicrobial
Resistances (CARAlert)   145
Key messages   145
5.1 Overview of the CARAlert system   146
5.2 Results from CARAlert 2016   148
5.3 Conclusion   160
Chapter 6: Focus areas   165
Key messages   165
6.1 The growing problem of vancomycin-resistant enterococci   166
6.2 The Queensland clone of CA-MRSA: a homegrown and
increasing problem   168
6.3 International comparisons    170
6.4 Standardising Australia’s approach to susceptibility testing    181
Chapter 7: Conclusions and future developments    185
Key messages   185
7.1 Lessons from AURA 2017   186
7.2 Next steps for the AURA Surveillance System   188
7.3 Future AURA reports   189
Appendix 1: Data source description   191
A1.1 Antimicrobial use collections   191
A1.2 Antimicrobial resistance collections   196
Appendix 2: Priority organisms    201
Appendix 3: Terminology   203
A3.1 Acronyms   203
A3.2 Common terms   204
References   207
iv SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE I N HUMAN H EALTH | 2017
Summary
AURA 2017: Second Australian report on Key issues identifed in AURA
antimicrobial use and resistance in human
2017 relating to antimicrobial
health provides data and analysis from the
Antimicrobial Use and Resistance in Australia use and appropriateness of
(AURA) Surveilance System, primarily from 2015. prescribing
AURA 2017 includes data about organisms • Australia’s antibacterial use in hospitals
that have been determined to be a priority for peaked in 2010, and has decreased by 9.2%
Australia, the volume of antimicrobial use (AU), between 2010 and 2015.
the appropriateness of antimicrobial prescribing, • Fluoroquinolone usage rates reduced in
key emerging issues for antimicrobial resistance line with strategies to restrict use in most
(AMR), and a comparison of Australia’s situation Australian hospitals.
with other countries.
• In hospitals, 23.3% of prescribing did
This second AURA report provides an expanded not comply with guidelines, and 21.9% of
view of AMR, AU and appropriateness of prescriptions were assessed as inappropriate.
prescribing in Australia. Participation in the Of surgical prophylaxis prescriptions, 27.4%
AURA Surveillance System by both public and were continued for longer than 24 hours (less
private healthcare providers has grown, and the than 5% is considered best practice).
increased volume of data has greatly contributed • The most common reasons that hospital
to the capacity to use the AURA Surveillance prescriptions were deemed to be
System to identify emerging issues and monitor inappropriate were:
trends. AURA now includes the National Alert - an antimicrobial was not needed (19.6%) -
System for Critical Antimicrobial Resistances the antimicrobial chosen was incorrect
(CARAlert), which allows the early detection of (spectrum too broad: 25.2%)
critical antimicrobial resistances and, over time,
- the duration of treatment (17.7%) or the
will provide information on the efectiveness
dose was incorrect (19.5%).
of measures to promote appropriate AU and
• More than 30 million antimicrobial
contain AMR.
prescriptions were dispensed through the
Pharmaceutical Benefts Scheme/Repatriation
Pharmaceutical Benefts Scheme in 2015.
There has been little change in this number
since 2008.
• Prescribing of antimicrobials to treat
respiratory tract infections is common – more
than 60% of patients with these conditions are
prescribed an antimicrobial, but antimicrobials
are usually not recommended for these
conditions.
SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE A ND RESISTANCE I N HUMAN H EALTH | 2017 v
SUMMARY
treatment with parenteral antimicrobials. This
Key issues identifed in AURA
means that more patients will be treated with
2017 relating to antimicrobial
vancomycin and related agents, generating
resistance
increasing selection pressure for other
multidrug-resistant pathogens such as VRE.
• Compared with 2014, there were increases
• A challenge for health care is that, so far, no
in rates of fuoroquinolone resistance in
country has found efective interventions to
Escherichia coli from blood cultures (+2.5%)
control the spread of CA-MRSA; efort in this
and Shigella sonnei (+10.9%).
area is a priority.
• Among gram-negative bacteria, rates of
resistance in the community remain relatively In its second year of operation, AURA is providing
stable compared with 2014, and are low by a greater breadth and diversity of critical
world standards. information needed by clinicians, policy makers,
researchers and health system managers to inform
• Between March and December 2016,
antimicrobial stewardship and AMR policy and
673 results were submitted to CARAlert.
program development. Clinicians have advised the
Carbapenemase-producing Enterobacteriaceae
AURA National Coordination Unit (ANCU) at the
was the most frequently recorded critical
Australian Commission on Safety and Quality in
antimicrobial resistance (48%).
Health Care (the Commission) that AURA expands
• The IMP-type carbapenemase is now endemic
coverage and improves representativeness of both
on the Australian eastern seaboard in multiple
AMR and AU data, and that the data are actively
species of Enterobacteriaceae, but there is
being used to inform decisions about patient care.
no evidence that other carbapenemases have
become established in Australia. AURA 2017 also highlights areas where future
• Vancomycin-resistant enterococci (VRE) work will inform action to improve the use of
have emerged as a major healthcare problem antimicrobials and prevent the spread of AMR.
in Australia. When enterococci are resistant
to vancomycin, only two or three reserved
What is antimicrobial
antimicrobials can be used to treat serious
resistance?
infections.
• The proportion of vancomycin-resistant
AMR continues to be an issue of signifcant
Enterococcus faecium isolates in Australia
importance for health care in Australia, and
increased rapidly from 2005, and is now
globally. AMR occurs when bacteria change
higher than that in any European country.
to protect themselves from the efects of
Reversing the incidence of VRE in Australia
antimicrobials. This means that the antimicrobial
will be extremely challenging.
can no longer eradicate or stop the growth of the
• The Queensland clone of methicillin-resistant bacteria. Sometimes antimicrobials are prescribed
Staphylococcus aureus (MRSA) has become inappropriately, such as when antibacterials are
the dominant community-associated MRSA used to treat a viral infection, or antimicrobials are
(CA-MRSA) clone in Australia. CA-MRSA is prescribed either when they are not indicated or
now a more common cause of bloodstream for longer than necessary. Antimicrobials can be
infection than healthcare-associated MRSA. lifesaving agents in the fght against infection, but
• Community-onset infections caused by strains their efectiveness is diminished by inappropriate
of MRSA are therefore likely to fail treatment use and increasing AMR.
with the usual β-lactams used by community
AMR has a direct efect on patient care and
practitioners, resulting in hospitalisation for
patient outcomes. It increases the complexity
vi SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE AND RESISTANCE IN HUMAN HEALTH | 2017
SUMMARY
Areas for action
Intensify eforts to reduce unnecessary this antimicrobial is for conditions that do
prescribing in the community not require an antimicrobial, or for which
amoxicillin alone is recommended in national
Australia continues to have very high
guidelines.
overall rates of community antimicrobial
use compared with a number of
Implement actions to control carbapenemase-
comparable countries. In 2015, around
producing Enterobacteriaceae
half of the Australian population (44.7%,
about 10.7 million people) had at least Data from the National Alert System for
one antimicrobial dispensed under the Critical Antimicrobial Resistances (CARAlert)
Pharmaceutical Benefts Scheme (PBS) or the show that carbapenemase-producing
Repatriation Pharmaceutical Benefts Scheme Enterobacteriaceae were the most frequently
(RPBS). Many antimicrobial prescriptions recorded critical antimicrobial resistance
in the community are unnecessary because between March and December 2016. The IMP-
antimicrobials are frequently used to treat type carbapenemase is now endemic on the
infections for which they provide little or no Australian eastern seaboard.
beneft.
The Commission has published
AURA 2017 supports the recommendations Recommendations for the Control
of the Australian Atlas of Healthcare Variation of Carbapenemase-producing
with regard to antimicrobial dispensing, and Enterobacteriaceae (CPE): A guide for acute
the Antimicrobial Stewardship Clinical Care care health facilities and will work with health
Standard. These include national benchmarks service organisations to support timely
for prescribing of antimicrobials, examination implementation of these recommendations.
by the Pharmaceutical Benefts Advisory
Committee (PBAC) of use of amoxicillin– Monitor resistant gonococcal infections to
clavulanate, and implementation of inform treatment guidelines
antimicrobial stewardship programs in general
CARAlert reports on isolates of Neisseria
practice to reduce the use of amoxicillin,
gonorrhoeae that are non-susceptible to
amoxicillin–clavulanate and cefalexin.
ceftriaxone or azithromycin. Strains that are
non-susceptible to azithromycin are more
The AURA National Coordination Unit (ANCU)
common than initially thought. CARAlert data
will work with the Australian Government
complement state and territory systems that
Department of Health to develop national
monitor antimicrobial resistance as part of
benchmarks for best-practice prescribing
prevention and control strategies for sexually
of antimicrobial agents. The Australian
transmissible infections. The emergence of
Commission on Safety and Quality in Health
antimicrobial-resistant N. gonorrhoeae at the
Care (the Commission) will also work
same time as continued increases in disease
with the PBAC to examine appropriate
notifcations may lead to treatment failures
access to amoxicillin–clavulanate on the
and disease transmission.
PBS/RPBS, given that most prescribing of
continued
SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE AND RESISTANCE IN HUMAN HEALTH | 2017 vii
SUMMARY
Areas for action: continued
Treatment guidelines for gonococcal infection Australia, and only two or three reserved
should be reviewed in light of emerging antimicrobials can be used to treat serious
non-susceptibility to azithromycin. The infections. Strict adherence to infection
Commission will work with the states and control guidelines and efective cleaning and
territories to provide regular updates on sterilisation in healthcare facilities is essential.
ceftriaxone- or azithromycin-nonsusceptible
N. gonorrhoeae through CARAlert, as well Improve the appropriateness of antimicrobial
as to inform national and local treatment use for surgical prophylaxis
guidelines.
The use of antimicrobials for surgical
prophylaxis is often suboptimal, and
Strengthen infection control practices to
antimicrobials are often used for longer than
minimise spread of vancomycin-resistant
necessary in this setting. The Commission
enterococci
will collaborate with the Royal Australasian
Vancomycin-resistant enterococci are College of Surgeons to progress guidance on
becoming a major healthcare problem in antimicrobial use in surgical prophylaxis.
of treatment and the duration of hospital stay, particularly the Preventing and Controlling
resulting in additional burden to patients, Healthcare Associated Infection Standard.
clinicians and healthcare systems.
AURA enables improved coordination and
integration of data from a range of sources,
About the AURA Surveillance and allows integrated analysis and reporting
System at a national level. The AURA Surveillance
System was established based on a strategy of
AURA has been developed in the context of One engagement with content experts in specialised
Health, which is a coordinated, collaborative, felds where high-quality programs were in
multidisciplinary and cross-sectoral approach place, to more efectively bring together existing
to the development and implementation of and new surveillance in an integrated way.
health strategies for people, animals and the This approach reduced duplication of efort,
environment. maximised existing expertise, and enabled a
focus on enhancing surveillance.
Surveillance is a critical element of Australia’s
National Antimicrobial Resistance Strategy Data for AURA are derived from and analysed
and a priority for healthcare delivery for the by the ANCU and AURA program partners. New
states and territories and the private sector. In components of the surveillance system have also
2016, the Australian Government released an been developed to ensure a more comprehensive
implementation plan to support the National and coordinated approach.
Antimicrobial Resistance Strategy, which
included surveillance as a key objective – AURA
provides the human health elements of this
surveillance. AURA also supports the National
Safety and Quality Health Service Standards,
viii SECOND AUSTRALIAN REPORT ON ANTIMICROBIAL USE AND RESISTANCE IN HUMAN HEALTH | 2017