Trends in antibiotic use in Swedish Intensive Care Units1999-2009 - - PowerPoint PPT Presentation

Trends in antibiotic use in Swedish Intensive Care Units1999-2009

• M. Edström, H. Gill, G. Fransson, S. Walther, H. Hanberger

ICU-Strama and Swedish ICU registry

www.icuregswe.org www.strama.se

Background

• Swedish ICU-Strama started 1999
• ICU-Strama collects aggregated ICU data on

– antibiotic use – antibiotic resistance – infection control procedures.

• From 2005 joint project between ICU-Strama

and the Swedish Intensive Care Registry (SIR)

• SIR collects data from individual patients.

www.icuregswe.org www.strama.se

Members of Swedish Intensive Care Registry (SIR) 2008

• 70 members
• 18 non members
• 52 ICUs reported

number of bed days 2008

www.icuregswe.org

Materials and methods

• Hospital pharmacies provided data on delivered amounts
• f antibiotics to the ICUs.
• ATC-classification of antibiotics were used.
• Annually updated DDDs calculated by WHO Collaborating

Centre for Drug Statics and Methodology were used.

• Number of bed days were based on all admissions to the

ICUs.

• Data were analysed using linear regression and

Spearman’s rank correlation.

www.whocc.no

Mean Total Antibiotic Consumption in Swedish ICUs 1999-2009

• 1999: 1216 defined daily doses per 1,000 occupied bed days (DDD1000)
• 2009: 1425 DDD1000
• P=<0,001
• Trend=31 DDD1000 /year

200 400 600 800 1000 1200 1400 1600 1800 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 DDD1000

www.icuregswe.org www.strama.se

Total antibiotic consumption 2009 - Swedish ICU:s

0,00 500,00 1000,00 1500,00 2000,00 2500,00 3000,00

1 2 3 4 5 6 7 8 9 1 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 3 1 3 2 3 3 3 4 3 5 3 6 3 7 3 8 3 9 4 4 1 4 2 4 3 4 4 4 5 4 6 4 7 4 8

ICUs 1-48 D D D 1 0 0 0 Median

Median: 1354 DDD1000 Range: 680-2698 DDD1000 ICUs 1-48

www.icuregswe.org www.strama.se

Carbapenems

50 100 150 200 250 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 D D D 1 0 0 0

Trend=7.5 DDD1000/year

www.icuregswe.org www.strama.se

P=<0.001

Piperacillin-Tazobactam

20 40 60 80 100 120 140 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 DDD1000

Trend=10 DDD1000/year

www.icuregswe.org www.strama.se

P=<0.001

Triazole

20 40 60 80 100 120 140 160 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 D D D 1 0 0 0

Trend=7 DDD1000/year

www.icuregswe.org www.strama.se

P=0.001

Cephalosporins

STRAMA launches campaign to reduce cephalosporin consumption

50 100 150 200 250 300 350 400 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 D D D 1

P=0.2 (NS)

www.icuregswe.org www.strama.se

Increase in antibiotic consumption

DDD1000 - Average weighted by number of bed days

Trend Antibiotic 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009

(DDD1000 /Year)

p Aminoglycosides 29 26 25 25 32 38 36 36 41 43 43 1,91 <0.001 Beta-lactamase sensitive penicillins 49 51 62 57 63 60 56 59 63 73 79 2,17 0,002 Carbapenems 125 125 130 120 143 150 149 156 178 191 192 7,47 <0.001 Cephalosporins (all) 336 311 317 325 332 362 356 362 333 262 203

• 6,52

0,16 Combinations of penicillins, incl. beta- lactamase inhibitors 22 25 20 27 34 43 46 61 79 102 120 9,58 <0.001 Fluoroquinolones 92 100 104 121 114 118 107 105 101 99 83

• 0,88

0,43 Glycopeptides 27 25 28 25 22 34 31 33 36 40 48 1,94 <0.001 Imidazoles (J01XD) 61 60 64 70 67 70 61 65 62 52 41

• 1,38

0,08 Isoxazolyl-pc 204 224 230 272 248 260 223 197 230 245 211

• 0,5

0,84 Lincosamides 41 39 41 48 48 46 41 44 47 48 44 0,47 0,15 Macrolides 58 52 43 41 32 36 40 42 48 45 42

• 0,77

0,28 Triazole derivatives 73 81 65 84 97 96 99 113 151 130 129 7,22 <0.001

• ther

99 95 120 115 127 146 117 151 175 144 192 Total 1216 1214 1249 1330 1359 1459 1362 1424 1544 1474 1425 30,69 <0.001

Major Findings

• Reduced cephalosporin consumption (last 3 years)
• Increased carbapenem consumption
• Increased piperacillin-tazobactam consumption

What about resistance to these drugs?

Trends in antibiotic use in Swedish Intensive Care Units1999-2009

10 %

2005 2006 2007 2008 2009?

15%

n=3900

10 %

Trends towards increased cephalosporin and pip-tazo resistance among

• E. coli isolated from Swedish ICU patients 2005 - 2008

Correlation between AB consumption and standardised mortality rate (SMR) based on SAPS3 - 31 ICU:s 2009

Correlation of SMR to DDD1000

500 1000 1500 2000 2500 0,2 0,4 0,6 0,8 1 SMR DDD1000

www.icuregswe.org www.strama.se

P=0.95 (NS)

Correlation between AB consumption and standardised mortality rate (SMR) based on SAPS3 - 31 ICU:s 2009

Correlation of SMR to DDD1000

500 1000 1500 2000 2500 0,2 0,4 0,6 0,8 1 SMR DDD1000

www.icuregswe.org www.strama.se

P=0.95 (NS) Conclusion Swedish ICUs with high (upper range) antibiotic consumption may reduce it without increased risk for critically ill patients

Potential errors

• drugs may be delivered but not administered to patients
• dosing in ICU – not always standard WHO doses
• increased dosing due to life-threatening disease

(sepsis/meningitis etc)

• decreased dosing in renal failure
• lower doses in children
• differences in reporting bed days

Antibiotic Use based on drugs delivered by each hospital pharmacy

• Easy access
• Low cost
• Not time consuming
• Sustainable
• Useful for bench marking
• May be used for measuring effect of interventions = Time

series analysis

Why continue to collect data based on drugs delivered by each hospital pharmacy?

• 1. Appropriate antibiotics without delay
• 2. Culture before start of antibiotics
• 3. Narrow spectrum based on culture results
• 4. Compliance to local and national treatment guidelines
• 5. Shorter courses
• 6. Reduce broad spectrum

Measurable goals for antibiotic use in ICUs