Variable Syrup used for consumption in children. Mike Sharland (UK)

Quality Measures for Antimicrobial use in

European Children

Prof. Mike Sharland, St George’s University of London

Paediatric and Adult AMR rates are

different between children and adults.

ECDC EARS-Net – Klebsiella data

Diaz-Högberg L et al. Abstract, ESPID annual conference 2013, Milan, Italy.

Distribution of the major HAI categories by country – Paediatric data,

ECDC point prevalence survey 2011-2012 (BSI – 37.2 %)

Zingg W et al ESPID 2014

ARPEC-PPS Oct-Nov 2012 :

Neonates

Most Prescribed Antibiotics to neonates <1month old (%) by UN Region

Proportions >5% are marked in red

Data presented at the ICAAC Conference 2014

Antibiotic use in children is different

from adults Antibiotic group ESAC – 2009

children

ESAC – 2009

adults

ARPEC – EU

2011/2012

Tetracyclines 0.2% 1.9% 0.1%

Amphenicols - 0.1% 0.1%

Beta-lactams – penicillins 35.5% 38.4% 30.0%

Other beta-lactams 24.8% 18.5% 26.6%

Sulfonamides & trimethoprim 4.7% 5.2% 7.4%

Macrolides & lincosamides 5.9% 7.4% 5.8%

Aminoglycosides 15.2% 4.3% 14.2%

Quinolones 3.3% 10.6% 2.0%

• Antibiotic use differs between children and adults

• This is likely to disproportionately affect some

antibiotic classes

Proportion of children on antibiotics per type of paediatric acute

care setting across United Kingdom during the point prevalence

survey in 2011-12 – Not Risk Adjusted for Underlying Disease

QI - Total prescribed antibiotics (DDD/100OBD) per age class and per type of

paediatric acute care setting across United Kingdom - ARPEC PPS 2012

QI - paediatric dosing Ceftriaxone

ESPID Blue book recommended paediatric doses: 50-80 mg/kg/day (lines in graph)

ceftriaxone dosing

[email protected] 10

Frequently occurring doses: 500, 1000, 1500 and 2000mg

driven by vial size?

Mixed dosing: 50% weight-based + 50% irrespective of weight

Adherence to guidelines seems poor:

17% get exact recommended dose34% get recommended dose +/- 5mg

QI - Antibiotic therapy for children with suspected RTI, UTI, SSTI, bone and joint

infection in 80 European paediatric hospitals.

Quality Measures - Hospital

Paediatric Antimicrobial Stewardship

evidence-based standards for routine

antimicrobial use for RIGHT

•Decision – appropriate choice of antibiotic

•Drug – narrow spectrum - meropenem

•Dosing – within RDD bands

Ashiru-Oredope, D et al. J Antimicrob Chemother. 2012; 67 Suppl 1: 51-63.

Quality measures for community

prescribingBroad/

narrow

J01D J01F J01M J01CE_

%

J01CR_

%

J01_B/

N

J01_SV J01M_S

V

1.70 3.56 1.36 6.1 30.2 7.68 29.0 14.2

1.59 2.92 2.69 0.3 30.4 49.72 - -

2.32 3.00 1.99 1.8 13.6 1.4 6.79 - -

1.62 3.47 1.22 11.1 21.7 4.15 16.4 2.8

0.03 2.38 0.51 31.1 4.1 0.44 12.6 5.6

0.88 2.16 0.81 2.3 11.4 8.77 28.2 4.1

2.33 1.47 0.88 7.7 7.4 0.76 - -

2.67 3.75 2.00 0.5 23.4 42.98 - -

2.61 2.35 1.51 5.6 2.2 4.32 31.8 23.8

8.91 8.85 2.89 0.2 16.7 148.41 - -

1.92 3.00 1.97 3.4 29.3 15.85 41.5 21.4

0.62 1.56 1.02 10.8 20.7 1.87 12.9 81.9

1.21 3.66 0.91 4.3 27.0 5.65 10.9 0.6

2.55 5.13 3.45 <0.1 35.4 110.60 - -

0.54 1.06 0.86 0.4 12.1 5.32 - -

0.80 1.48 0.83 1.8 10.2 0.3 5.33 - -

4.18 3.87 2.94 0.3 30.9 35.17 31.3 20.6

5.04 3.15 1.79 0.2 40.4 180.15 - -

0.04 1.45 0.87 3.3 16.1 6.79 - -

0.12 1.79 0.54 23.3 <0.1 0.20 - -

2.44 3.54 1.23 0.7 21.3 37.07 - -

1.81 3.41 2.97 0.2 40.9 28.32 18.0 6.6

0.40 2.10 1.10 12.7 28.8 3.58 17.6 3.7

1.56 1.96 2.54 0.4 38.7 61.37 - -

0.20 0.75 0.77 27.8 1.7 0.17 - -

0.55 2.73 0.46 4.1 6.4 1.02 14.1 5.2

0.03 1.06 0.51 0.2 2.2 0.20 10.9 0.6

0.62 1.79 0.87 0.4 11.9 4.15 14.7 3.9

1.61 2.83 1.22 3.3 21.3 6.79 17.8 6.1

2.41 4.45 2.00 7.7 29.3 36.60 29.0 20.8

8.91 8.85 3.45 31.1 40.9 180.15 41.5 81.9

J01

J01C

J01D

J01F

J01M

J01CE_%

J01CR_%

J01DD+DE

J01MA_%

J01_B/N

J01_SV

J01M_SV

Consumption (DDD per 1000

inhabitants and per day)Relative consumption (%)

Country J01* JO1C J01DD+DE_

%

J01MA_

%

Seasonal

variation

Bulgaria 18.18 8.05 11.0

Austria 14.94 6.64 4.7 9.1

Belgium 28.44 16.28 <0.1 9.5

Czech Republic 17.89 7.60 0.5 6.8

Denmark 16.51 10.29 <0.1 3.1

Estonia 11.06 4.22 <0.1 7.4

Finland 18.50 6.61 <0.1 4.8

France 28.23 15.62 6.4 6.9

Germany 14.46 4.10 3.5 10.4

Greece** 39.37 12.87 0.6 7.3

Hungary 15.67 6.69 2.5 12.4

Iceland** 23.13 12.90 0.3 4.4

Latvia 11.11 5.27 0.5 7.4

Ireland 20.32 10.65 0.5 4.5

Italy 27.43 14.55 7.1 12.1

Lithuania 12.68 6.99 6.0

Luxembourg 28.60 13.96 <0.1 10.3

Malta 21.34 9.80 1.0 8.4

Netherlands 11.21 4.36 <0.1 7.6

Norway 15.77 6.77 <0.1 3.4

Poland 21.03 9.43 <0.1 5.8

Slovenia 14.39 9.67 0.7 7.6

Portugal 22.44 12.08 1.6 13.3

Spain 20.31 12.64 2.6 12.3

Sweden 14.15 7.09 0.2 5.5

Quality indicators

Indicators on consumption of antibacterials for systemic use (ATC group J01) and at ATC group level 3

J01_DID*** Consumption of antibacterials for systemic use (J01) expressed in DDD per 1000 inhabitants and per day

* Denominator for relative consumption; ** Country provided only to tal care data, ‡ Indicators within the fourth quartile (i.e. values > percentile 75 (p75) suggest better

quality than indicator values within the third quartile (i.e. p50 < values < p75) and so on.

J01C_DID Consumption of penicillins (J01C) expressed in DDD per 1000 inhabitants and per day

J01D_DID Consumption of cephalosporins (J01D) expressed in DDD per 1000 inhabitants and per day

J01F_DID Consumption of macrolides, lincosamides and streptogramins (J01F) expressed in DDD per 1000 inhabitants and

per day

J01M_DID Consumption of quinolones (J01M) expressed in DDD per 1000 inhabitants and per day

Indicators on seasonal variation of antibacterials for systemic consumption (ATC group J01, subgroup J01M)

Indicators on the relative consumption of antibacterials for systemic use (ATC group 3)Relative consumption

J01CE_% Consumption of b-lactamase sensitive penicillins (J01CE) expressed as percentage of the total consumption of

antibacterials for systemic use (J01)

J01CR_% Consumption of combination of penicillins, including b-lactamase inhibitor (J01CR) expressed as percentage of the

total consumption of antibacterials for systemic use (J01)

J01DD+DE_% Consumption of third and fourth generation of cephalosporins (J01(DD+DE)) expressed as percentage of the

total consumption of antibacterials for systemic use (J01)

J01_SV Seasonal variation of the total antibiotic consumption (J01) of a year period starting in July and ending the next

calendar year in June, expressed as percentage: [(DDD (winter quarters)/DDD (summer quarters)-1] x 100

Seasonal variation: Overuse in the winter quarters (January–March and October–December) compared with the J01M_SV Seasonal variation of quinolone consumption (J01M) -" -

*** The co lumn displays the original labels of quality indicators described in Qual Saf Health Care 2007;16:440–445.

J01MA_% Consumption of fluoroquinolones (J01MA) expressed as percentage of the total consumption of antibacterials for

systemic use (J01)

Indicators on the ratio of broad and narrow spectrum antibacterials

J01_B/N Ratio of the consumption of broad (J01(CR+DC+DD+(F-FA01))) to the consumption of narrow spectrum

penicillins, cephalosporins and macrolides (J01(CE+DB+FA01))

United Kingdom 18.58 8.56 <0.1 2.5

p0 11.06 4.10 <0.1 3.1

0.46 7.4

p75 22.17 12.50 1.56 10.1

p25 14.46 6.69 0.04 5.8

p50 18.34 9.00

p100 39.37 15.62 7.11 13.3

ARPEC Community data

Limited number of antibiotics used

DU-90%/seasonal variation similar

UK Italy NL

Amoxicillin (44%) Amoxicillin

(25%)

Amoxicillin

(45%)

Penicillin V (13%) Amox/clav acid

(23%)

Amox/clav acid

(13%)

Erythromycin (10%) Azithromycin

(10%)

Azithromycin

(8%)

Flucloxacillin (9%) Cefaclor (9%) Clarithromycin

(7%)

Trimethoprim (5%) Cefixime (7%) Pheneticillin

(6%)

Amox/clav acid (4%) Ceftibuten (3%) Nitrofurantoin

Amoxicillin Index - Percentage of children exposed to amoxicillin on the

total number of children exposed to antibiotics per database and calendar

year

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

IPCI

THIN

PEDIA

Amoxicillin Index 2 - Ratio of users of amoxicillin to users of broad

spectrum penicillins, cephalosporins and macrolides by age (NL

1.6; UK 6.0; IT 0.5)

0

1

2

3

4

5

6

7

8

9

10

11

age 0-1

age 1-2

age 2-3

age 3-4

age 4-5

age 5-6

age 6-7

age 7-8

age 8-9

age 9-10

age10-11

age11-12

age12-13

age13-14

age14-15

age15-16

age16-17

age17-18

IPCI

THIN

PEDIA

Amoxicillin Index 2 - Ratio of users of amoxicillin to users of broad

spectrum penicillins, cephalosporins and macrolides by year

0

1

2

3

4

5

6

7

IPCI

THIN

PEDIA

Quality measures for community• ESAC data – sales/reimbursement –

Syrup/Galenic formulation – limited list 10

antibiotics

• Age weighted prevalence range and trend

• Amoxicillin Index – simple indicator

• Region specific guideline adherence

Possible suggestions from

ARPEC• EARS-net – sub-analysis (biannually) of

paediatric BSI data - 0, 1-4, 5-10, 10-15

(add code NICU)

• ESAC-net – sub-analysis of paediatric

data - Community – Syrup/Galenic

formulation data; Hospital - weight, UD

• HAI-net – sub-analysis of paediatric data -

clarify well newborn and NICU code

Acknowledgements

Liselotte Diaz-

Högberg

Ole Heuer

Klaus Weist

Karl Suetens

Marc Struelens

Julia Bielicki

Tim Planche

Myriam Gharbi

Tatiana Munera

Katja Doerholt

David Cromwell

And all ARPEC

participants!

ARHAI Antimicrobial

Prescribing Measures

recommended to the

sponsor Department of

ARHAI UK National Antimicrobial Prescribing

Quality Measures

Primary care Secondary care

Total antibiotic

prescribing

reductions

Total antibiotic prescribing to be

reduced to 2010 levels at CCG

level as measured by number of

antibiotic prescriptions (“items”) per 100 patients per year

Total antibiotic consumption to be

reduced by 1% per annum 2015-

2019 as measured by DDD per

1000 admissions per year.

Measures to

encourage narrow

spectrum

prescribing

Proportion of antibiotics from

cephalosporin, quinolone or co-

amoxiclav classes to be reduced

to less than the current median for

English CCGs as measured by

the number of prescriptions

(“items”) from target classes in

comparison with the total number

of antibiotic prescriptions per year.

Total carbapenem consumption to

be reduced to 2010 consumption

levels as measured by DDD per

1000 admissions per year.