Antimicrobial Use Data Research Articles

Canadian Collaboration to Identify a Minimum Dataset for Antimicrobial Use Surveillance for Policy and Intervention Development across Food Animal Sectors.

Surveillance of antimicrobial use (AMU) and antimicrobial resistance (AMR) is a core component of the 2017 Pan-Canadian Framework for Action. There are existing AMU and AMR surveillance systems in Canada, but some stakeholders are interested in developing their own AMU monitoring/surveillance systems. It was recognized that the establishment of core (minimum) AMU data elements, as is necessary for policy or intervention development, would inform the development of practical and sustainable AMU surveillance capacity across food animal sectors in Canada. The Canadian Animal Health Surveillance System (CAHSS) AMU Network was established as a multisectoral working group to explore the possibility of harmonizing data inputs and outputs. There was a consensus that a minimum AMU dataset for AMU surveillance (MDS-AMU-surv) should be developed to guide interested parties in initiating AMU data collection. This multisectoral collaboration is an example of how consultative consensus building across relevant sectors can contribute to the development of harmonized approaches to AMU data collection and reporting and ultimately improve AMU stewardship. The MDS-AMU-surv could be used as a starting point for the progressive development or strengthening of AMU surveillance programs, and the collaborative work could serve as a model for addressing AMR and other shared threats at the human–animal–environment interface.

Antimicrobial resistance at the livestock-human interface: implications for Veterinary Services.

The emergence of antimicrobial resistance (AMR) is a major global public health issue, but it also jeopardises the effectiveness of antimicrobials as a means of curing infections in animals that threaten their health, welfare and productivity. Several reports show that infections in humans caused by antimicrobial-resistant pathogens may be linked to antimicrobial use (AMU) and AMR in food-producing animals; however, to what extent this happens is unknown. Use of antimicrobials drives the emergence of AMR, therefore, their extensive over-use and misuse in livestock is of concern. Robust AMU and AMR data are important to monitor the progress of interventions aiming to reduce AMR in the livestock sector. However, not all countries have complete data on antibiotic sales or use, so our current knowledge of global AMU is primarily based on modelling estimates. Antimicrobial resistance prevalence data are limited, particularly in low- and middle-income countries, but in some high-income regions fairly robust data are available. It should also be noted that monitoring guidelines and protocols are available to provide globally harmonised AMR data. Using antimicrobials rationally and not using them for disease prevention purposes is key to reducing AMU. To ensure that these drugs are used appropriately we must ensure that: a) veterinary services are accessible and affordable for farmers; b) antibiotics are only sold on prescription; c) veterinarians earn no revenue linked to the sale or prescription of antibiotics; d) veterinarians have substantial skills in preventive medicine (good animal husbandry, efficient biosecurity and vaccinology); and e) the benefits of preventive measures must appeal to farmers so that they are willing to pay for them.

Feasibility study of a field survey to measure antimicrobial usage in humans and animals in the Mekong Delta region of Vietnam.

BackgroundDevelopment of antimicrobial use (AMU) surveillance systems in humans and animals is a priority for many low- and middle-income countries; however accurate estimations are hampered by a diversity of animal production systems and metrics. The Mekong Delta region of Vietnam is a ‘hotspot’ of antimicrobial resistance and is home to a high density of humans and animal populations.ObjectivesTo measure and compare AMU using different metrics (standing population, biomass and population correction unit) in the Mekong Delta, and to explore the potential of field-based data collection methods in the design of AMU surveillance systems.MethodsWe collected AMU data from humans and animals (chickens, ducks, Muscovy ducks, pigs) from 101 small-scale farms in the Mekong Delta over a fixed period (90 days in humans, 7 days in animals).ResultsHumans used 7.1 DDDkg, or 175.9 mg of antimicrobial active ingredients (AAIs) per kg of standing body mass annually; animals consumed 60.9 ADDkg or 1324 mg. In the Mekong Delta humans represented 79.3% of the total body mass but consumed 29.6% of AAIs by weight. AAIs regarded of critical importance by WHO represented 56.9% and 50.2% of doses consumed by animals and humans, respectively.ConclusionsUsing a One Health approach, we show that AMU can potentially be estimated from cross-sectional surveys, although results are hypothetical due to small sample size and are sensitive to the chosen population denominator. The methodology proposed here can potentially be scaled up be applied to design AMU surveillance in low-resource settings, allowing AMU reduction efforts to be focused on particular animal species.

Measuring Antimicrobial Use Needs Global Harmonization.

Global health and global economies are predicted to be severely affected by antimicrobial resistance (AMR). The three organizations World Health Organization/World Organisation for Animal Health/Food and Agriculture Organization (WHO/OIE/FAO) are working in their domains to prevent any future AMR crisis. Antimicrobial use (AMU), especially in food animals, is contributing to the development and dissemination of AMR bacteria and genes. AMU monitoring is a strategic objective of the global and national action plans on AMR. However, the AMU reporting metrics at different levels are not harmonized yet, posing difficulties in comparisons among AMU data from different sources. A tripartite WHO/OIE/FAO collaboration is urgently required to develop and implement a globally accepted AMU metric system to ensure reliable comparisons among various data sets.

Reducing Antimicrobial Use by Implementing Evidence-Based, Management-Related Prevention Strategies in Dairy Cows in Switzerland

The aim of this study was to reduce antimicrobial use (AMU) on dairy farms that implemented evidence-based management strategies. The study not only examined whether these strategies led to a reduction in AMU in practice, but also examined the influence of the level of their implementation on AMU. For data analysis, practice software recordings of the farm veterinarians were used. The AMU data of 50 farms with prevention strategies applied (intervention group, IG) over 3 years (2017–2019) and of 74 farms without prevention strategies (control group, CG) over 2 years (2018–2019) were analyzed. Project participation was supported with 500 Swiss francs (~545 USD) per farmer per year. The AMU was compared between the IG and CG using the treatment incidence. In December 2017/January 2018, the farmers of the IG had chosen at least one of the proposed 17 prevention strategies from one of three sectors, i.e., udder health, uterine health and/or replacement calf health. The prevention strategies, were developed in a standard operating procedure protocol and were discussed in detail with the farmers before the implementation. Forty-eight farms chose at least one udder strategy, 10 farms at least one uterine strategy and 37 farms at least one calf strategy. By choosing an udder health strategy or a uterine health strategy, the corresponding systemically administered AMU could be significantly reduced (p < 0.04) in the IG compared with the CG. In addition, udder strategies that were well-implemented led to a significant reduction (p = 0.05) of intramammary “highest priority critically important antimicrobials (HPCIA)” (quinolones, cephalosporins 3rd and higher generation, macrolides and ketolides, glycopeptides, and polymyxins). The level of implementation was significantly lower in 2019 compared to 2018 (p < 0.05, Fisher's exact test). No significant reduction in AMU could be achieved for the calf sector. A reduction of AMU in dairy farms is possible by implementing evidence-based management-related prevention strategies. The level of implementation has only an influence on the consumption of HPCIA. The reduction of AMU in practice by means of evidence-based measures requires supportive human resources instead of financial support, because financial support for farmers seems not to motivate them sufficiently.

223. Difference in Carbapenem Use by ASP Intervention in Japanese Healthcare Facilities

BackgroundAntimicrobial stewardship program (ASP) interventions have been reported to reduce unnecessary antimicrobial use (AMU). In this study, we investigated the difference in the use of carbapenems by ASP intervention in Japanese healthcare facilities.MethodsData on two components of AMU and ASP registered in Japan Surveillance for Infection Prevention and Healthcare Epidemiology (J-SIPHE) from January to December 2019, were used. Facilities with an infection control team in addition to an antimicrobial stewardship team responsible for the proper use of antimicrobial agents were included in the study. AMU data (such as DOT [Days of Therapy / 100 patient days]) are entered semi-automatically from medical fee statement (receipt) file at each facility. ASP intervention is divided into four categories 1) pre-authorization, 2) prospective audit and feedback (PAF), 3) PAF and required notification (RN), 4) RN. The Kruskal-Wallis test is performed to see overall difference and the Dunn test with the Bonferroni correction is done for each pair of categories.ResultsA total of 114 hospitals were included in the analysis. The median number of beds at participating facilities were 430 [IQR: 281–602], the median average hospital stay was 13.0 days [IQR: 11.4–15.2] and total number of inpatients per month was 10087 [6247–14536]. PAF and RN were the most common ASP interventions for carbapenems (62.5%), followed by RN (33.6%). The median DOT [IQR] of participating facilities were 2.1 [1.2–3.1] and 1) 0.7 [0.2–1.1], 2) 2.7 [2.1–3.4], 3) 2.1 [1.4–3.1] and 4) 2.0 [1.2–3.5] by ASP categories. There are significant differences between 1) and 2), 1) and 3), and 1) and 4) (p=0.014, p< 0.01 and p< 0.01, respectively) while the differences between 2) and 3), 2) and 4), and 3) and 4) are not significant (p=1.00).Table 1. Summary statistics of healthcare facilities by ASP Interventions Figure 1. DOT by ASP Interventions ConclusionOnly 3.5% of ASP interventions belong to 1) pre-authorization category and this might be due to the complexity of registration process. This category was found to have the lowest DOT among all ASP interventions in Japanese healthcare facilities. The variances of DOT were especially large in categories 3) and 4), and more detailed analyses would be necessary to evaluate their efficacies accurately.Disclosures All Authors: No reported disclosures

Sources of variation of antimicrobial use in Charolaise and Limousine beef breeds in Veneto region (Italy)

Sources of variation of antimicrobial use in Charolaise and Limousine beef breeds in Veneto region (Italy)

Feedlot Cattle Antimicrobial Use Surveillance Network: A Canadian Journey.

Antimicrobial drugs are important tools for maintaining human and animal health. Globally, antimicrobial use (AMU) in food-producing animals is under increasing scrutiny due to its potential to promote antimicrobial resistance (AMR). Historically, comprehensive Canadian data related to the types of antimicrobial drugs used, extent of use, common indicators of use and the demographics of the cattle populations receiving antimicrobial drugs have been limited, in part due to segmentation in the cattle industry and fragmentation of the drug distribution system. Appropriate AMU estimates are required to understand AMU practices, to interpret AMR levels and patterns, to meaningfully assess associated public health risks, and to inform stewardship activities. The Canadian beef cattle industry has a long history of collaboration in AMU and AMR research. Prior research projects identified both opportunities and challenges in the collection of AMU data. Cornerstone projects provided insight into the complexity of collecting AMU data in Canada's feedlot sector. This paper will discuss how the lessons learned from past work have contributed to the formation of a Canadian fed-cattle antimicrobial surveillance program that was initiated in 2019. This important surveillance program will allow feedlot cattle AMU to improve management decisions and support AMU best practices in the evolving Canadian AMR landscape.

Antibiotic Use in Organic and Non-organic Swedish Dairy Farms: A Comparison of Three Recording Methods.

Biases of antimicrobial use (AMU) reporting systems pose a challenge to monitoring of AMU. Our study aimed to cross-compare three data sources of AMU in Swedish dairy herds to provide an account of the validity of AMU reports. We studied AMU differences between two production systems, to investigate how the reporting system affected this comparison. On-farm quantification of AMU via a manual collection of empty drug containers (BIN) took place in organic (n = 30) and conventional (n = 30) dairy herds during two periods between February 2016 and March 2017. A data extract mirroring these periods was obtained from two linked datasets that contain AMU data as reported by the prescribing veterinarians. These included data from the Swedish Board of Agriculture system (SBA) and Växa milk recording system (VXA). Using the European Medicines Agency technical units, the total number of defined daily doses (DDDvet), and defined course doses (DCDvet) per animal/year were calculated for each herd/period/dataset. Descriptive statistics and Bland–Altman plots were used to evaluate the agreement and systematic bias between the datasets. Mixed models for repeated measures were used to assess AMU differences between production systems. We found consistent numerical differences for the calculated AMU metrics, with BIN presenting higher usage compared to the SBA and VXA. This was driven by a disparity in intramammary tubes (IMt) which appear to be underreported in the national datasets. A statistically significant interaction (BIN dataset) between the production system and drug administration form was found, where AMU for injectable and lactating cow IMt drug forms differed by the production system, but no difference was found for dry-cow IMt. We conclude that calculating AMU using DDDvet and DCDvet metrics at a herd level based on Swedish national datasets is useful, with the caveat of IMt potentially being misrepresented. The BIN method offers an alternative to monitoring AMU, but scaling up requires considerations. The lower disease caseload in organic herds partly explains the lower AMU in particular drug forms. The fact that organic and conventional herds' had equally low AMU for dry-cow IMt, coupled with mismatches in IMt report across herds indicated an area of further research.

Does the Use of Different Indicators to Benchmark Antimicrobial Use Affect Farm Ranking?

The need to reduce antimicrobial use (AMU) in livestock production has led to the establishment of national AMU data collection systems in several countries. However, there is currently no consensus on which AMU indicator should be used and many of the systems have defined their own indicators. This study sought to explore the effect of using different internationally recognized indicators on AMU data collected from Irish pig farms and to determine if they influenced the ranking of farms in a benchmarking system. AMU data for 2016 was collected from 67 pig farms (c. 35% of Irish pig production). Benchmarks were defined using seven AMU indicators: two based on weight of active ingredient; four based on the defined daily doses (DDD) used by the European Medicines Agency and the national monitoring systems of Denmark and the Netherlands; and one based on the treatment incidence (TI200) used in several published studies. An arbitrary “action zone,” characterized by farms above an acceptable level of AMU, was set to the upper quartile (i.e., the top 25% of users, n = 17). Each pair of indicators was compared by calculating the Spearman rank correlation and assessing if farms above the threshold for one indicator were also above it for the comparison indicator. The action zone was broadly conserved across all indicators; even when using weight-based indicators. The lowest correlation between indicators was 0.94. Fifteen farms were above the action threshold for at least 6 of the 7 indicators while 10 farms were above the threshold for all indicators. However, there were important differences noted for individual farms between most pairs of indicators. The biggest discrepancies were seen when comparing the TI200 to the weight-based indicators and the TI200 to the DDDANED (as used by Dutch AMU monitoring system). Indicators using the same numerator were the most similar. All indicators used in this study identified the majority of high users. However, the discrepancies noted highlight the fact that different methods of measuring AMU can affect a benchmarking system. Therefore, careful consideration should be given to the limitations of any indicator chosen for use in an AMU monitoring system.

Variability in Antimicrobial Use Among Hospitals Participating in the Canadian Nosocomial Infection Surveillance Program

Background: The association between antimicrobial use (AMU) and emergence of antimicrobial resistance is well documented. The Canadian Nosocomial Infection Surveillance Program (CNISP) has conducted sentinel surveillance of AMU at participating Canadian hospitals since 2009 resulting in the largest pan-Canadian hospital database of dispensed antimicrobials. Objectives: Describe interhospital variability of AMU across Canada. Methods: Hospitals submit annual AMU data based on patient days (PD). Antimicrobials were measured in defined daily doses (DDD) for adults using the WHO Anatomical Therapeutic Chemical (ATC) system. The AMU data among pediatric patients have been available since 2017 using days of therapy (DOT). Surveillance includes systemic antibacterial agents (J01 ATC codes), oral metronidazole, and oral vancomycin. AMU was assessed using quintiles, interquartile ranges (IQR), and relative IQRs (upper- and lower-quartile values divided by the median). Results: Between 2009 and 2018, 20–26 hospitals participated in adult surveillance each year (35 teaching hospitals and 3 nonteaching hospitals participated in ≥1 year). Over this period, overall AMU decreased by 13% at participating adult hospitals from 645 to 560 DDD per 1,000 PD. AMU varied substantially between hospitals, but this variability decreased over time (Fig. 1). In 2009, the IQRs for overall AMU spanned 309 DDD per 1,000 PD, and in 2018 it spanned only 103 DDD per 1,000 PD. This decrease in variability was due to large decreases in use among hospitals with high use in 2009–2010. Among hospitals in the highest use quintile in 2009–2010, AMU decreased, on average, 44 DDD per 1,000 PD each year. Among hospitals in the lowest use quintile in 2009–2010, AMU increased, on average, 6 DDD per 1,000 PD each year. In 2018, antibiotics with the largest absolute IQR variability were cefazolin (61–113 DDD per 1,000 PD), piperacillin-tazobactam (32–64 DDD per 1,000 PD), and vancomycin (24–49 DDD per 1,000 PD). Among antibiotics with ≥1 DDD per 1,000 PD, antibiotics with the largest relative IQR variability were tobramycin (0.3–6 DDD per 1,000 PD), cefadroxil (0.08–9 DDD per 1,000 PD), and linezolid (0.2–3 DDD per 1,000 PD). In 2018, the IQR for overall pediatric AMU (n = 7 teaching hospitals) was 426–581 DOT per 1,000 PD. Antibiotics with the largest IQRs were vancomycin (0.6–58 DOT per 1,000 PD), cefazolin (33–88 DOT per 1,000 PD), and tobramycin (3–57 DOT per 1,000 PD). Among antibiotics with ≥1 DOT per 1,000 PD in 2018, antibiotics with the largest relative IQRs were tobramycin (3–57 DOT per 1,000 PD), cefuroxime (1–6 DOT per 1,000 PD), and amoxicillin (8–42 DOT per 1,000 PD). Conclusions: There is wide variation in overall antibiotic use across hospitals. Variation between AMU at adult hospitals has decreased between 2009 and 2018; in 2018, antibiotics with the largest IQRs were cefazolin and piperacillin-tazobactam. Benchmarking AMU is crucial for informing antimicrobial stewardship efforts.Funding: CNISP is funded by the Public Health Agency of Canada.Disclosures: Allison McGeer reports funds to her institution from Pfizer and Merck for projects for which she is the principal investigator. She also reports consulting fees from Sanofi-Pasteur, Sunovion, GSK, Pfizer, and Cidara.

Monitoring of Farm-Level Antimicrobial Use to Guide Stewardship: Overview of Existing Systems and Analysis of Key Components and Processes.

The acknowledgment of antimicrobial resistance (AMR) as a major health challenge in humans, animals and plants, has led to increased efforts to reduce antimicrobial use (AMU). To better understand factors influencing AMR and implement and evaluate stewardship measures for reducing AMU, it is important to have sufficiently detailed information on the quantity of AMU, preferably at the level of the user (farmer, veterinarian) and/or prescriber or provider (veterinarian, feed mill). Recently, several countries have established or are developing systems for monitoring AMU in animals. The aim of this publication is to provide an overview of known systems for monitoring AMU at farm-level, with a descriptive analysis of their key components and processes. As of March 2020, 38 active farm-level AMU monitoring systems from 16 countries were identified. These systems differ in many ways, including which data are collected, the type of analyses conducted and their respective output. At the same time, they share key components (data collection, analysis, benchmarking, and reporting), resulting in similar challenges to be faced with similar decisions to be made. Suggestions are provided with respect to the different components and important aspects of various data types and methods are discussed. This overview should provide support for establishing or working with such a system and could lead to a better implementation of stewardship actions and a more uniform communication about and understanding of AMU data at farm-level. Harmonization of methods and processes could lead to an improved comparability of outcomes and less confusion when interpreting results across systems. However, it is important to note that the development of systems also depends on specific local needs, resources and aims.

Antimicrobial use among adult inpatients at hospital sites within the Canadian Nosocomial Infection Surveillance Program: 2009 to 2016

BackgroundAntimicrobial resistance is a growing threat to the world’s ability to prevent and treat infections. Links between quantitative antibiotic use and the emergence of bacterial resistance are well documented. This study presents benchmark antimicrobial use (AMU) rates for inpatient adult populations in acute-care hospitals across Canada.MethodsIn this retrospective surveillance study, acute-care adult hospitals participating in the Canadian Nosocomial Infection Surveillance Program (CNISP) submitted annual AMU data on all systemic antimicrobials from 2009 to 2016. Information specific to intensive care units (ICUs) and non-ICU wards were available for 2014–2016. Data were analyzed using defined daily doses (DDD) per 1000 patient days (DDD/1000pd).ResultsBetween 2009 and 2016, 16–18 CNISP adult hospitals participated each year and provided their AMU data (22 hospitals participated in ≥1 year of surveillance; 11 in all years). From 2009 to 2016, there was a significant reduction in use (12%) (from 654 to 573 DDD/1000pd, p = 0.03). Fluoroquinolones accounted for the majority of this decrease (47% reduction in combined oral and intravenous use, from 129 to 68 DDD/1000pd, p < 0.002). The top five antimicrobials used in 2016 were cefazolin (78 DDD/1000pd), piperacillin-tazobactam (53 DDD/1000pd), ceftriaxone (49 DDD/1000pd), vancomycin (combined oral and intravenous use was 44 DDD/1000pd; 7% of vancomycin use was oral), and ciprofloxacin (combined oral and intravenous use: 42 DDD/1000pd). Among the top 10 antimicrobials used in 2016, ciprofloxacin and metronidazole use decreased significantly between 2009 and 2016 by 46% (p = 0.002) and 26% (p = 0.002) respectively. Ceftriaxone (85% increase, p = 0.0008) and oral amoxicillin-clavulanate (140% increase, p < 0.0001) use increased significantly but contributed only a small component (8.6 and 5.0%, respectively) of overall use.ConclusionsThis study represents the largest collection of dispensed antimicrobial use data among inpatients in Canada to date. Between 2009 and 2016, there was a significant 12% decrease in AMU, driven primarily by a 47% decrease in fluoroquinolone use. Modest absolute increases in parenteral ceftriaxone and oral amoxicillin-clavulanate use were noted but contributed a small amount of total AMU. Ongoing national surveillance is crucial for establishing benchmarks and antimicrobial stewardship guidelines.

Impact of a Comprehensive Antimicrobial Stewardship Program on Institutional Burden of Antimicrobial Resistance: A 14-Year Controlled Interrupted Time-series Study.

Antimicrobial resistance (AMR) constitutes an international public health threat widely believed to result from excessive antimicrobial use (AMU). Numerous authorities have recommended antimicrobial stewardship programs (ASPs) to curb the selection of AMR, but there is a lack of data confirming this benefit. A controlled interrupted time-series study spanning 14 years was performed to assess impact of a comprehensive hospital-based ASP that included pharmacist-led audit and feedback on institutional AMR. Patient-level microbiologic and AMU data were obtained from October 2002 to September 2016. Poisson regression models were used to identify changes in the incidence and trend of hospital-acquired (HA) antibiotic-resistant organisms (AROs) and multidrug-resistant organisms (MDROs). Changes in community-acquired (CA)-ARO, CA-MDRO, and inpatient AMU were assessed as controls and process outcomes. Statistically significant shifts in AMU, HA-ARO, and HA-MDRO trends coinciding with ASP implementation were observed, corresponding with a 9% reduction in HA-ARO burden (incidence rate ratio [IRR], 0.91 [95% confidence interval {CI}, .83-.99]; P = .03) and a 13% reduction in HA-MDRO burden (IRR, 0.87 [95% CI, .73-1.04]; P = .13) in the intervention period. In contrast, CA-ARO and CA-MDRO incidence continued to rise, with 40% (IRR, 1.40 [95% CI, 1.28-1.54]; P < .0001) and 68% (IRR, 1.68 [95% CI, 1.57-1.82]; P < .0001) increases in burden found, respectively. Implementation of a comprehensive ASP resulting in reduced AMU was associated with a significant reduction in institutional AMR, even though community AMR increased during the same period. These results confirm that ASPs play an important role in the fight against AMR.

Pilot study of an online hospital antibiotic use tracking and reporting system.

Antimicrobial use (AMU) varies widely among hospitals, suggesting a need to better monitor usage and evaluate the effectiveness of antimicrobial stewardship programs (ASPs). Our objective was to assess the feasibility of implementing an online voluntary hospital antibiotic use tracking and reporting system. An online survey was sent to ASP clinicians representing hospitals across Ontario. Hospitals that tracked total hospital-wide inpatient antibiotic use in 2017 were asked to submit either days of therapy (DOT) or defined daily doses (DDD), along with separate inpatient days (PD), which were used as the denominator. Respondents who indicated no hospital-wide AMU tracking were asked to describe the barriers to its use. Antibiotic use was displayed on a public website for consenting hospitals. Of 201 eligible hospitals, 66 (33%) provided AMU data representing 10,634 of 25,208 (43%) eligible inpatient beds in the province. DOT and DDD data were provided by 36 hospitals, each. Weighted average antibiotic use was highest in acute teaching hospitals (513 DOT/1,000 PD, 709 DDD/1,000 PD) and lowest in complex continuing care and rehabilitation facilities (158 DOT/1,000 PD, 159 DDD/1,000 PD). Barriers cited for providing hospital-wide AMU data include lack of time and resources to collect and evaluate AMU data and technological limitations preventing data collection. Integrating hospital AMU tracking and reporting as part of a voluntary initiative is feasible, with relatively broad participation. Short of a legislative mandate for participation, opportunities still exist to increase representation, including provision of guidance and technical support to help hospitals track and share AMU.

Implementation and evaluation of an antimicrobial stewardship programme in companion animal clinics: A stepped-wedge design intervention study.

To curb increasing resistance rates, responsible antimicrobial use (AMU) is needed, both in human and veterinary medicine. In human healthcare, antimicrobial stewardship programmes (ASPs) have been implemented worldwide to improve appropriate AMU. No ASPs have been developed for and implemented in companion animal clinics yet. The objective of the present study was to implement and evaluate the effectiveness of an ASP in 44 Dutch companion animal clinics. The objectives of the ASP were to increase awareness on AMU, to decrease total AMU whenever possible and to shift AMU towards 1st choice antimicrobials, according to Dutch guidelines on veterinary AMU. The study was designed as a prospective, stepped-wedge, intervention study, which was performed from March 2016 until March 2018. The multifaceted intervention was developed using previous qualitative and quantitative research on current prescribing behaviour in Dutch companion animal clinics. The number of Defined Daily Doses for Animal (DDDAs) per clinic (total, 1st, 2nd and 3rd choice AMU) was used to quantify systemic AMU. Monthly AMU data were described using a mixed effect time series model with auto-regression. The effect of the ASP was modelled using a step function and a change in the (linear) time trend. A statistically significant decrease of 15% (7%-22%) in total AMU, 15% (5%-24%) in 1st choice AMU and 26% (17%-34%) in 2nd choice AMU was attributed to participation in the ASP, on top of the already ongoing time trends. Use of 3rd choice AMs did not significantly decrease by participation in the ASP. The change in total AMU became more prominent over time, with a 16% (4%-26%) decrease in (linear) time trend per year. This study shows that, although AMU in Dutch companion animal clinics was already decreasing and changing, AMU could be further optimised by participation in an antimicrobial stewardship programme.

Antimicrobial Usage in Animal Production: A Review of the Literature with a Focus on Low- and Middle-Income Countries.

Antimicrobial use (AMU) in animal production is a key contributor to antimicrobial resistance (AMR) worldwide. As consumption of animal protein and associated animal production is forecast to increase markedly over coming years in low- and middle-income countries (LMICs), accurate monitoring of AMU has become imperative. We summarized data from 89 scientific studies reporting AMU data in animal production published in English since 1998, identified through the ‘ISI Web of Knowledge’ search engine. The aims were as follows: (a) to describe methodologies and metrics used to quantify AMU; (b) to summarize qualitative (on-farm prevalence of use) and quantitative (amounts of antimicrobial active principle) data, in order to identify food animal species at the highest risk of AMU; and (c) to highlight data gaps from LMICs. Only 17/89 (19.1%) studies were conducted in LMICs. Sixty (67.3%) reported quantitative data use, with ‘daily doses per animal-time’ being the most common metric. AMU was greatest in chickens (138 doses/1000 animal-days [inter quartile range (IQR) 91.1–438.3]), followed by swine (40.2 [IQR 8.5–120.4]), and dairy cattle (10.0 [IQR 5.5–13.6]). However, per kg of meat produced, AMU was highest in swine, followed by chickens and cattle. Our review highlights a large deficit of data from LMICs, and provides a reference for comparison with further surveillance and research initiatives aiming to reduce AMU in animal production globally.

A cross-sectional survey of the acceptability of data collection processes for validation of a European point prevalence survey of healthcare-associated infections and antimicrobial use.

Statistical measurements alone are insufficient to ensure robust data for point prevalence surveys (PPS) of healthcare-associated infections (HAI). Data quality is determined by the type of data, data collection methods and available resources. Data collectors' views regarding the acceptability of data collection process for validation studies are also important to consider. To explore data collectors' views on the acceptability of data collection processes used for a European validation PPS of HAI and antimicrobial use (AMU). An anonymous online survey was conducted with 67 data collectors from 10 European countries involved in the study. Twenty-five (64.1%) participants viewed AMU data collection as easy/quite easy whereas only five (12.8%) thought HAI data collection was easy/quite easy. Six (17%) participants indicated that incentives and 21 (56.8%) that disincentives were possibly/definitely present for reporting cases of HAI. Engagement of staff was not thought to have adversely affected data collection as only one (2.6%) and five (15.4%) participants thought involvement of hospital PPS teams and administration was low/very low, respectively. Participants believed the approaches used were appropriate but that more training was required prior to data collection, some case definitions should be reviewed and the number of variables reduced.

Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) Farm Program: Results from Finisher Pig Surveillance

In 2006, the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) Farm Program was implemented in sentinel grower-finisher swine herds in Québec, Ontario, Manitoba, Saskatchewan and Alberta. Herds were visited 1-3 times annually. Faecal samples were collected from pens of close-to-market (CTM) weight (>80 kg) pigs and antimicrobial use (AMU) data were collected via questionnaires. Samples were cultured for generic Escherichia coli and Salmonella and tested for antimicrobial susceptibility. This paper describes the findings of this program between 2006 and 2008. Eighty-nine, 115 and 96 herds participated in this program in 2006, 2007 and 2008 respectively. Over the 3 years, antimicrobial resistance (AMR) levels remained consistent. During this period, resistance to one or more antimicrobials was detected in 56-63% of the Salmonella spp. isolates and 84-86% of E. coli isolates. Resistance to five or more antimicrobials was detected in 13-23% of Salmonella and 12-13% of E. coli. Resistance to drugs classified as very important to human health (Category I) by the Veterinary Drug Directorate (VDD), Health Canada, was less than or equal to 1% in both organisms. AMU data were provided by 100 herds in 2007 and 95 herds in 2008. Nine herds in 2007 and five herds in 2008 reported no AMU. The most common route of antimicrobial administration (75-79% of herds) was via feed, predominantly macrolides/lincosamides (66-68% of herds). In both 2007 and 2008, the primary reasons given for macrolide/lincosamide use were disease prevention, growth promotion and treatment of enteric disease. The Category I antimicrobials, ceftiofur and virginiamycin were not used in feed or water in any herds in 2008, but virginiamycin was used in feed in two herds in 2007. Parenteral ceftiofur was used in 29 herds (29%) in 2007 and 20 herds (21%) in 2008. The reasons for ceftiofur use included treatment of lameness, respiratory disease and enteric disease.

Associations Among Antimicrobial Use and Antimicrobial Resistance ofSalmonellaspp. Isolates from 60 Alberta Finishing Swine Farms

The study objectives were to identify potential associations between reported antimicrobial use (AMU) practices and antimicrobial resistance (AMR) of fecal and environmental Salmonella spp. isolates (n = 322 isolates) recovered from 60 Alberta finishing swine farms, and to estimate the amount of pen and farm level variation in AMR. The AMU data were collected through a questionnaire. Separate multilevel logistic regression models were built for six antimicrobials with prevalence of resistance >or=5% using the Generalized Linear Latent and Mixed Model (GLLAMM) procedure. In-feed use of tylosin in finishers was associated with increased odds of resistance in Salmonella isolates to ampicillin (OR = 61.56), streptomycin (OR = 11.70), and multiple antimicrobials (OR = 4.90). Injectable penicillin use in growers was associated with decreased odds of resistance in Salmonella isolates to streptomycin (OR = 0.06), kanamycin (OR = 0.03), and multiple antimicrobials (OR = 0.12). Injectable penicillin use in finishers was associated with decreased odds of resistance in Salmonella isolates to ampicillin (OR = 0.007) and chloramphenicol (OR = 0.04). Overall, these results indicate that AMU in pig production is inconsistently associated with AMR in Salmonella from finishing swine. Variation in AMR prevalence of Salmonella isolates of swine was moderate to high at pen and farm levels for most antimicrobials suggesting that interventions at the pen and farm levels might be beneficial in reducing the emergence of AMR Salmonella in swine populations.