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ESPAUR_executive_summary_and_recommendations

ESPAUR_executive_summary_and_recommendations

ESPAUR

ESPAUR Report 2016: Key facts, summary and recommendations 6. Development and implementation of antifungal resistance surveillance and stewardship This year we have also increased our outputs to look at fungal resistance, antifungal consumption and stewardship, as this is an area of emerging concern highlighted by increasing numbers of Candida auris infections detected in England and elsewhere. Key results Antimicrobial resistance between 2010 and 2014 the rate of bloodstream infections caused by Escherichia coli and Klebsiella pneumoniae increased by 15.6% and 20.8% respectively. Between 2014 and 2015 the number of cases continued to increase; E. coli bloodstream infections increased by a further 4.6% and K. pneumoniae increased by 9%. Tackling these infections is a key government priority the proportions of bloodstream infections resistant to piperacillin/tazobactam (the most frequently used antibiotic for the treatment of sepsis) rose dramatically between 2011 and 2015, from 8.5% to 11.7% for those caused by E. coli and from 12.6% to 18.5% for K. pneumoniae. These increases in resistance will increase the pressure on clinicians to use carbapenems (which are the antibiotics of last resort) unless alternative treatment strategies are developed. Resistance to other antibiotics used for treatment was largely unchanged carbapenem resistance remains low in bloodstream infections in England (E. coli 0.2% and K. pneumoniae 1.1%), though there continue to be year-onyear increases in the numbers of bacteria confirmed to produce carbapenemases (enzymes that break down carbapenems making them ineffective for treatment), with 1,893 positive referred isolates confirmed in 2015 incidence of bloodstream infections and infections caused by resistant bacteria are highest in the extremes of life (the very young and the elderly). Interventions to reduce antibiotic resistance that are focused on the very young and the elderly should be prioritised in this report we present data on resistance to combinations of antibiotics, highlighting that only 2.5% of E. coli and 2.0% of K. pneumoniae tested for susceptibility to co-amoxiclav and amikacin were resistant to both. Combinations of antibiotics are thus possible alternatives to single antibiotics for empiric therapy of sepsis, preserving carbapenems and putting less selection pressure on antibiotics such as piperacillin/tazobactam there is wide variation in the rates of resistance to antibiotics across England. For example by CCG trimethoprim resistance in Gram-negative urinary tract infection (UTI) ranges from 16.3% to 66.7%; this may be related to variation in sending urine samples for laboratory testing. However, 86% of CCGs have resistance rates greater than 25%, highlighting that trimethoprim can no 6

ESPAUR Report 2016: Key facts, summary and recommendations longer be advised as the first-line empiric antibiotic treatment for UTIs in England antimicrobial resistance is stable in pneumococcal and Pseudomonas bloodstream infections and tuberculosis and decreasing in Staphylococcus aureus infections. However, vancomycin resistance in bloodstream infections caused by Enterococcus spp. rose from 10% to 16% between 2011 and 2015 an outbreak of azithromycin-resistant gonorrhoea, initially identified in Leeds, has spread across England. Laboratories have been notified to screen all gonorrhoea isolates for resistance and affected patients should be followed up to ensure clinical cure and have rigorous tracing of all sexual contact Antimicrobial prescribing total antibiotic consumption (measured as defined daily dose [DDD]) declined significantly between 2014 and 2015 by 4.3%, from 22.9 to 21.8 DDD per 1000 inhabitants per day antibiotic prescribing predominantly occurs in general practice (74%), followed by hospital inpatients (11%), and outpatients (7%). The remainder comprised use in dental practice (5%) and other community settings (3%). Decreased antibiotic consumption occurred in general practice, hospitals and dental practices antibiotic prescriptions in primary care, measured as the number of prescriptions dispensed, adjusted for the age and sex distributions in the population (Specific Therapeutic group Age-sex Related Prescribing Units [STAR-PU]), has declined for the last four years and is now lower than the similar measure in 2011 (1.11 items per STAR-PU in 2015 compared to 1.23 items per STAR-PU in 2011) broad-spectrum antibiotic use (antibiotics that are effective against a wide range of bacteria) continues to decrease in primary care. England now uses the lowest amounts of cephalosporins and quinolones in the EU. These antibiotics are more likely to drive antibiotic resistance than narrow-spectrum antibiotics. However, hospitals continue to increase their antibiotics of last resort currently available: Piperacillin/tazobactam, carbapenems and colistin compared with other UK health administrations, England has the lowest primary care prescribing by (items and DDDs). Scotland, however, has the lowest use of last resort antibiotics with England the second lowest use Relationship between prescribing and resistance despite low levels of use of cephalosporins and resistance, the proportion of bloodstream infections resistant to these antibiotics has not changed significantly in the last five years the continued increase (50% over five years) in the use of piperacillin/tazobactam, an antibiotic of last resort, is now associated with a significant increase in resistance of both E. coli and K. pneumoniae bloodstream infections. The proportions of these isolates that are resistant have increased by 50% and 60% respectively, over five years. While this may relate to different antibiotic susceptibility breakpoints used in clinical laboratories, this is nevertheless important as this is the information clinicians use to guide patient treatment 7

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