AMR and AM consumption in Denmark
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This document discusses antimicrobial resistance and antibiotic consumption in Denmark. It provides an overview of antibiotic use and resistance trends in Denmark, including: 1) Decreasing antibiotic consumption in pigs and overall in primary healthcare, though consumption is still increasing in hospitals. 2) National surveillance of resistant bacteria finds increasing resistance in E. coli and K. pneumoniae from invasive infections. MRSA rates remain low at 1.6% while carbapenem-resistant Enterobacteriaceae are an emerging issue. 3) Denmark has national strategies and guidelines to continue reducing antibiotic use in animals and humans to tackle the development of antimicrobial resistance.
AMR and AM consumption in Denmark
- 1. Antimicrobial resistance and consumption Anne Kjerulf National Center for Infection Control Statens Serum Institut
- 2. AGENDA Antibiotic resistance – why? The Danish experience - Antibiotic consumption in Denmark - Multidrug resistant microorganisms • Methicillin-resistant Staphylococcus aureus (MRSA) • Carbapenemase-producing organisms (CPO) • Vancomycin-resistant enterococci (VRE) How can we tackle AMR? - Antibiotic stewardship (not included here) - Guidelines – universal precautions and isolation precautions - Specific national guidelines for MRSA and CPO AMR and antibiotic consumption, St Petersburg December 2019 2
- 3. ANTIBIOTIC RESISTANCE – WHY? Wellknown bacteria like E.coli and S. aureus become more and more resistant against the antimicrobial agents that we use for treatment of infections Why? Increasing consumption of antimicrobial agents in the recent years – both animals and human beings globally and on the national level Broad-spectrum antibiotics select for resistance, especially cephalosporins, fluoroquinolones and carbapenems AMR and antibiotic consumption, St Petersburg December 2019 3
- 4. Denmark - 44.000 sq km - 5,5 million inhabitants PIGS: 26 million pigs slaughtered/year. Worlds largest exporter of pork meat (export to EU, Japan, Russia, USA) POULTRY: 130 million broilers slaughtered /year (export to EU and the Middle East) AMR and antibiotic consumption, St Petersburg December 2019 4
- 5. CONSUMPTION OF ANTIMICROBIAL AGENTS IN DENMARK Antimicrobial Resistant Bacteria AMR and antibiotic consumption, St Petersburg December 2019 5
- 6. DANMAP DANISH INTEGRATED ANTIMICROBIAL MONITORING AND RESEARCH PROGRAMME Established in 1995 Cooperation with: - National Food Institute, DTU - National Veterinary Institute, DTU - Danish Medicine Agency - Statens Serum Institut Yearly rapport since 1997 http://www.danmap.org AMR and antibiotic consumption, St Petersburg December 2019 6
- 7. Isolates Samples National Food Institute, DTU Data DANMAP Statens Serum Institut Data Danish Medicine Agency Data Data Private Laboratories Regional hospital laboratories Diagnostic submission Samples Samples Isolates / data Regional food control laboratories Slaughter plants Veterinary practice Samples General practice VetStat, National Veterinary Institute DANMAP – data flow Danish Veterinary and Food Administation Data AMR and antibiotic consumption, St Petersburg December 2019 7
- 8. CONSUMPTION OF ANTIMICROBIAL AGENTS IN DENMARK AMR and antibiotic consumption, St Petersburg December 2019 8
- 9. CONSUMPTION IN PIGS – DECREASE IN TREATMENTS 0 20 40 60 80 100 120 140 09 10 11 12 13 14 15 16 17 18 Sows and piglets Weaners Finishers All age groups, adjusted DAPD(DADDper1000animalsperday) 0 1 2 3 4 5 6 7 8 9 10 11 09 10 11 12 13 14 15 16 17 18 DAPD(DADDper1000animalsperday) Aminoglycosides Amphenicols Lincosamides(a) Macrolides Penicillin's, b-lactamase sensitive Penicillin's, others(b) Pleuromutilins Sulfonamides and trimethoprim Tetracyclines All age groups, adjusted AMR and antibiotic consumption, St Petersburg December 2019 9
- 10. TOTAL CONSUMPTION OF ANTIMICROBIAL AGENTS IN HUMANS Consumption is highest in primary health care (90%) but decreasing Consumption is still increasing in the hospitals AMR and antibiotic consumption, St Petersburg December 2019 10
- 11. TOTAL CONSUMPTION IN EACH OF THE 5 REGIONS AMR and antibiotic consumption, St Petersburg December 2019 11
- 12. CONSUMPTION IN PRIMARY HEALTH CARE Figure 5.3 Consumption of leading antimicrobial groups for systemic use in primary health care, DID, Denmark DANMAP 2018 Data used for this figure is based on total sales in Denmark (individuals and clinics) ATC numbers stem from the 2019 edition of the Anatomical Therapeutic Chemical (ATC) classification system 0 1 2 3 4 5 6 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 DDDper1000inhabitant-day Beta-lactamase sensitive penicillins (J01CE) Penicillins with extended specrum (J01CA) Macrolides (J01FA) Tetracyclines (J01AA) Beta-lactamase resistant penicillins (J01CF) Fluoroquinolones (J01MA) Comb. of penicillins, incl. beta-lactamase inhibitors (J01CR) Penicillins compromise 2/3 of the total consumption in primary health care – but compared to earlier we see an increase in broad-spectrum penicillins and a decrease in small-spectrum penicillins AMR and antibiotic consumption, St Petersburg December 2019 12
- 13. CONSUMPTION IN HOSPITALS Penicillins compromise 54% of the total consumption AMR and antibiotic consumption, St Petersburg December 2019 13
- 14. CONSUMPTION IN HOSPITALS IN THE NORDIC COUNTRIES, 2017 Vidar Möller, Folkhälsomyndigheten, 2018 AMR and antibiotic consumption, St Petersburg December 2019 14
- 15. CONSUMPTION IN HOSPITALS IN EUROPE AMR and antibiotic consumption, St Petersburg December 2019 15
- 16. NATIONAL STRATEGIES IN DENMARK, 2017 Target areas: Continued reduction in use of antimicrobial agents to animals Continued improvement of animal welfare Increased focus on education and knowledge sharing Three concrete goals: 1) Reduction in the total consumption in primary health care 2) Penicillin V shall continue to be the most used antimicrobial agent 3) Reduction in consumption of the critical important antimicrobial agents in hospitals AMR and antibiotic consumption, St Petersburg December 2019 16
- 17. QUESTIONS What are the Russian experiences with consumption of antimicrobial agents? - In animals? The same problem with pigs? - In hospitals? - In primary health care? Prescription of antimicrobial agents or counter sale? Do the doctors earn money on the prescriptions? AMR and antibiotic consumption, St Petersburg December 2019 17
- 18. ANTIBIOTIC RESISTANCE IN DENMARK Antimicrobial Resistant Bacteria AMR and antibiotic consumption, St Petersburg December 2019 18
- 19. National surveillance Full test rapport Data Blood and spinal fluid: E. coli, K. pneumoniae Enterococci, P. aeruginosa, Acinetobacter Urine samples from hospitals and primary health care: E. coli, K. pneumoniae First isolate per patient per year Susceptibility testing data 1. Data based Rutine diagnostics from all 10 departments of clinical microbiology in Denmark AMR and antibiotic consumption, St Petersburg December 2019 19
- 20. Total number of bacteremia 47% 19% 7% 11% 7% 5% 4% E. coli S. aureus S. pneumoniae K. pneumoniae E. faecium E. faecalis P. aeruginosa AMR and antibiotic consumption, St Petersburg December 2019 21
- 21. Bacteremia per 100.000 inhabitants 51% 64% -20% AMR and antibiotic consumption, St Petersburg December 2019 22
- 22. S. aureus, invasive isolates 2018: 2.276 cases with S. aureus bacteremia (2009: 1.466 cases) MRSA 1,6% EARS-Net 2017, MRSA: 16,9% (0% - 57,1%) AMR and antibiotic consumption, St Petersburg December 2019 23
- 23. MRSA IN DENMARK 2018: 3669 new cases AMR and antibiotic consumption, St Petersburg December 2019 24
- 24. MRSA, EPIDEMIOLOGY AMR and antibiotic consumption, St Petersburg December 2019 25
- 25. E. coli, invasive isolates EARS-Net 2017, multiresistente E. coli: 6,3% (1,5% - 24,9%) EARS-Net 2017, 3. gen cephalosporin R E. coli: 14,9% (5,9% - 41,3%) EARS-Net 2017, fluoroquinolon R E. coli: 25,7% (11,6% - 44,9%) AMR and antibiotic consumption, St Petersburg December 2019 26
- 26. K. pneumoniae, invasive isolates Figure 8.6 K. pneumoniae. Resistance (%) in invasive isolates from humans, Denmark EARS-Net 2017, multiresistant K. pneumoniae: 20,5% (0% - 57,1%) EARS-Net 2017, 3. gen cephalosporine R K. pneumoniae: 31,2% (4,6% - 76,3%) AMR and antibiotic consumption, St Petersburg December 2019 27
- 27. CPE, clinical and screening isolates 2018: 156 CPE from 141 patients, 15 fra blood 2017: 104 CPE from 96 patients, 5 from blood 2008-2013: 31 CPE 0 20 40 60 80 100 120 140 160 180 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 OXA-48-group NDM NDM/OXA-48-group KPC VIM More than one isolate was included from the same patient, if the isolates belonged to different bacterial species and/or harboured different carbapenemases Figure 8.13 Numbers of carbapenemase-producing Enterobacterales (CPE), 2008-2018, Denmark AMR and antibiotic consumption, St Petersburg December 2019 28
- 28. Enterococci, invasive isolates EARS-Net 2017, VRE: 14,9% (0% - 43,9%) AMR and antibiotic consumption, St Petersburg December 2019 29
- 29. VRE, clinical isolates Figure 8.14 Numbers of Enterococcus faecium and Enterococcus faecalis isolates carrying vanA and vanB genes from clinical samples submitted to SSI 2009-2018 supplemented with data obtained from MiBa from 2016-2018, Denmark AMR and antibiotic consumption, St Petersburg December 2019 30
- 30. QUESTIONS What are the Russian experiences with surveillance of AMR? - In hospitals? - In primary health care? Where do the AMR come from? And what is the biggest problem? Are there national or regional reference laboratories in Russia? What methods are used for typing of AMR? - Phenotype - Genotype - WGS AMR and antibiotic consumption, St Petersburg December 2019 31
- 31. QUESTIONS What are the Russian experiences with guidelines for infection prevention and control? - Are there common national guidelines? - Are there regional/local guidelines? AMR and antibiotic consumption, St Petersburg December 2019 32
- 32. THANKS FOR ATTENTION – ANY QUESTIONS? 33AMR and antibiotic consumption, St Petersburg December 2019