Surveys show wide range of antimicrobial use in Europe

A pair of studies today that provide a snapshot of antimicrobial consumption in European hospitals and nursing homes show that use varies widely by country, and that healthcare-associated infections (HAIs)—many caused by multidrug-resistant bacteria—are a big threat.

One example of diverse antimicrobial prescribing: The proportion of broad-spectrum antibiotics used in hospitals ranged from 16% to 62% of all antibiotics.

The reports appear in today's issue of Eurosurveillance and are part of efforts to raise awareness ahead of European Antibiotic Awareness Day on Nov 18, part of global World Antibiotic Awareness Week.

In a statement today, Andrea Ammon, MD, director of the European Centre for Disease Prevention and Control (ECDC), cited an estimate last week that 33,000 deaths occur each year due to antimicrobial-resistant infections and said health officials need to ensure that the drugs are used prudently and that infection prevention and control practices are in place in all European healthcare settings.

"Since the rates of antimicrobial resistance, the rates of antimicrobial consumption as well as infection prevention and control practices vary from country to country, it is essential to tailor strategies to address specific needs," she said. "ECDC calls for continued action at all levels."

Antimicrobial use common in hospitals

Though some European countries track antimicrobial consumption in hospitals at the national level, surveillance methods aren't always consistent across countries, making it hard to compare the findings. Today's reports are point-prevalence surveys, which look at antimicrobial use or HAIs on a single given day, which offers a standardized option for looking at antimicrobial use and HAIs in European health facilities.

Today's reports on antimicrobial use and HAI levels mark the second point-prevalence study for hospitals and the third to focus on nursing homes.

The hospital study covers 28 countries with data collected by trained staff on 1 day per ward during four possible periods in 2016 and 2017 that excluded winter and the summer holiday season. The survey spans 1,209 hospitals and 310,755 patients.

Weighted prevalence of antimicrobial use was 30.5% (95% confidence interval [CI], 29.2% to 31.9%). Overall, one in three patients received one or more antimicrobials on any given day, with one in five prescribed for treatment of an HAI.

Broad-spectrum antimicrobial rates in hospitals varied from 16% in Lithuania to 62% in Bulgaria. Overall observed antimicrobial prevalence ranged from a low of 15.9% in Hungary to a high of 55.6% in Greece.

One in seven prescriptions were for surgical prophylaxis. Among other key findings, the group found that 54% of antimicrobial courses for surgical prophylaxis lasted longer than 1 day, down slightly from the 59% found in the first survey, though continuing them beyond the preoperative dose isn't typically recommended.

The investigators found some shifts in the type of antimicrobials prescribed compared to the last survey. In the new study, the most commonly prescribed antimicrobial agents were amoxicillin combined with a beta-lactamase inhibitor, piperacillin combined with a beta-lactamase inhibitor, and ceftriaxone. Ciprofloxacin dropped from the second most prescribed antimicrobial in the first survey to the fourth in the new one, which the authors say may reflect stewardship efforts targeting Clostridium difficile infections.

Countries varied widely regarding resources available for antimicrobial stewardship, and though some hospitals in all countries had a consultant that led the efforts, most had no or little dedicated staff, which researchers said must be a priority in coming years.

Nursing home results similar to earlier surveys

The nursing home point-prevalence survey included 24 countries and also covered 2016-2017. Overall, 4.9% (95% CI, 2.8% to 5.1%) of nursing home residents received at least one antimicrobial on the day of the survey, very similar to surveys from 2010 (4.3%) and 2013 (4.4%).

As was true with hospitals, prevalence varied by country with the highest levels in Spain and Denmark (10.5%), and Lithuania showing the lowest (0.7%). The most commonly prescribed antimicrobials were penicillins, other antibacterials, quinolones, sulfonamides and trimethoprim, and other beta-lactams.

In nursing homes, 29% of the antimicrobials were prescribed for prophylaxis, with 74% of them given to prevent urinary tract infections. ECDC officials said the practice might reduce the infection risk in women, but there's no evidence about its effectiveness in the wider elderly nursing home population.

When the study authors looked at antimicrobial stewardship indicators, such as end- or review-date documentation on medical charts, levels were comparable to the two earlier surveys, which the authors said is a sign that stewardship improvements are urgently needed in European nursing homes.

In an editorial in the same issue that addressed both of the point-prevalence studies, two experts from the US Centers for Disease Control and Prevention said several important findings from the studies can guide stewardship efforts. For example, they wrote that data on surgical prophylaxis can be used to implement standard protocols in collaboration with surgery and other key stakeholders.

They added that although point prevalence surveys are complicate and time-consuming, they are probably more feasible than surveillance systems for resource-strapped hospitals and nursing homes. With many countries performing the surveys, they wrote, "there is an opportunity for global collaboration in order to share information and knowledge towards the goal of more judicious use of precious, lifesaving antimicrobials."

HAI incidence in hospitals, nursing homes

Meanwhile, a separate analysis looked at the prevalence of HAIs in both types of facilities over the same period and found that, on any given day, 1 in 15 hospital patients (6.5%) and 1 in 26 nursing home residents (39%) had at least one HAI, many caused by multidrug-resistant bacteria.

The authors estimated there were 8.9 million HAI episodes each year—4.5 million in hospitals and 4.4 million in nursing homes.

Based on selected antimicrobial resistance markers, the researchers estimated the percentage of resistant infections at 31.6% in hospital patients and 28% in nursing home residents.

The report appears to be the most accurate and robust estimate of HAIs in European health facilities, the authors wrote, confirming that HAIs and antimicrobial-resistant infections pose a significant public health challenge to the region.

See also:

Nov 15 Eurosurveill study on antimicrobial use in European hospitals

Nov 15 Eurosurveill study on antimicrobial use in European nursing homes

Nov 15 Eurosurveill editorial

Nov 15 Eurosurveill study on healthcare-associated infections

Nov 15 ECDC press release

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