UNDERSTANDING SOUTH AFRICA'S CONSUMPTION OF ANTIMICROBIALS

Pharmacy Society of South Africa

Conference 2018

Ruth Lancaster

1. Background

• AMR National Strategic Plan

2. Sources of antimicrobial use in South Africa

3. Analysis

• Defined Daily Doses

4. Results

5. Key learning points

6. Conclusion

Contents

WHA endorses Global Action Plan on AMR in

May 2014

AMR Strategy Framework

October 2015

AMR Implementation plan

Approved in June 2015

AMS One Health Governance Guidelines

Pillars of the South African AMR Strategy Framework

Stra

tegi

c o

bje

ctiv

e

En

able

rs

Antimicrobial resistance Governance

Diagnostic stewardship

Enhance Surveillance

Antimicrobial Stewardship

Prevention including IPC

and vaccination

Health systems strengthening, research, education and communication

Impact: Rational Antimicrobial use and improved patient outcomes

Strategic Objective 2 & 3

5

Improve appropriate use of diagnostics and optimise surveillance

Strengthen passive and active surveillance locally and nationally

• Antimicrobial resistance

• Antimicrobial use

MAC-AMR: Surveillance Working Group co-ordinating the consolidation of data

from private and public sectors on AMR resistance – Goal: advise NDoH on EML

and formularies; yearly report with resistance maps

80-10060-7940-5920-390-9

Figure 1-2: Percentage of extended-spectrum beta-lactamase producing Escherichia coli*, by country (most recent year, 2011-2014)

Source: CDDEP 2015, WHO 2014 and PAHO, forthcoming

No data10-19

Escherichia coli (E coli) – world

benchmark

11

Sources of AMU in SA

6

4 Sources of AMU data in SA for human and animals: 1. South African Revenue Services

• Volume of antimicrobials in kg and rand value

2. South African Animal Health Association

• Volume per antibiotic class

• Represents + 80 pharmaceutical companies

3. Quintiles IMS

• Standard units per 1000 population antimicrobials supplied by

pharmaceutica in the private sector

4. RSA Pharma Database

• Order and procurement data against contracts awarded by the NDoH

• Represents provincial ordering patterns

7

Sources of AMU in SA

Combining the data from all data sources

https://www.whocc.no/ddd/definition_and_general_considera/

8

Assumed average maintenance dose per day for a

medicine used for its main indication in Adults

Sometimes a dose that is rarely prescribed, as it is an

average of two or more commonly used dose sizes

Uses:

•Technical measurement that allows measurement and

comparison of volume of medicine use

•Rough estimate of consumption, not an exact picture of

actual use

Defined Daily Doses

9

NATIONAL ORDER DATA Description ATC 5th level Dec 2015

Ampicillin 500mg/Vial 1 Vial J01CA01 528400

Ciprofloxacin 250mg 10 Tablet J01MA02 25690

Ciprofloxacin 250mg/5ml 100ml J01MA02 1430

Defined Daily Doses

10

Description ATC

Stre

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h

Stre

ngt

h U

nit

Pac

k Si

ze

Pac

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Un

it

DD

D

DD

D u

nit

DD

D (

mg)

DD

D u

nit

mg

Pat

ien

t d

ays

DD

D p

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pac

k

Qu

anti

ty

Issu

ed

DD

D Is

sue

d

Ampicillin 500mg/Vial 1 Vial J01CA0

1 500 mg 1 vial 2000 mg 2000 mg 365 0.25 528400 132100

Ciprofloxacin 250mg 10 Tablet J01MA

02 250 mg 10 tablet 1 g 1000 mg 365 2.5 25690 64225

Ciprofloxacin 250mg/5ml 100ml J01MA

02 250 mg/5ml 100 ml 1 g 1000 mg 365 5 4783 23915

Defined Daily Doses

Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance; 2017

11

Description ATC

Stre

ngt

h

Stre

ngt

h U

nit

Pac

k Si

ze

Pac

k Si

ze

Un

it

DD

D

DD

D u

nit

DD

D (

mg)

DD

D u

nit

mg

Pat

ien

t d

ays

DD

D p

er

pac

k

Qu

anti

ty

Issu

ed

DD

D Is

sue

d

Ampicillin 500mg/Vial 1 Vial J01CA0

1 500 mg 1 vial 2000 mg 2000 mg 365 0.25 528400 132100

Ciprofloxacin 250mg 10 Tablet J01MA

02 250 mg 10 tablet 1 g 1000 mg 365 2.5 25690 64225

Ciprofloxacin 250mg/5ml 100ml J01MA

02 250 mg/5ml 100 ml 1 g 1000 mg 365 5 4783 23915

Defined Daily Doses

Guidelines on Implementation of the Antimicrobial Strategy in South Africa: One Health Approach and Governance; 2017

12

Estimation of AMU internationally • SA use per 1000/population – 21 149

• Higher than other countries but similar to other BRICS

(increasing access to health services, strengthening PHC,

NHI implementation)

Results

Source: IMS data as presented by ResMaps (CDDEP)

13

Results

Source: IMS data as presented by ResMaps (CDDEP)

Estimation of AMU nationally • SA use per 1000/population – 21 149

• 1/3 = cotrimoxazole

• PJP prophylaxis

• Increasing broad spectrum penicillin use

• 1.3 – 3.3 x other BRICS countries

• 0.8 x UK and USA

14 Source: IMS data as presented by ResMaps (CDDEP)

49% 51%

Antibacterials: J01 Pharmadatabase 2015-17

Co-trimoxazole

Antibacterials for systemic useexcluding Co-trimoxazole

Antibacterials: J01 excluding cotrimoxazole RSA Pharmadatabase 2015-2017

Broad spectrum

Narrow spectrum

Carbapenems

Vancomycin

3rd generation cephalosporins

Fluoroquinolones

Macrolides

15

Results

Source: IMS data as presented by ResMaps (CDDEP)

Estimation of AMU: human vs animal • South Africa imported 4.35 tons of antimicrobials (2014)

• Animals = 23%

• USA reported 80% consumption by animal health

16

Results

Source: IMS data as presented by ResMaps (CDDEP)

Estimated consumption: split between human and

animals

17

Key learning points

Source: IMS data as presented by ResMaps (CDDEP)

• Limitations to the data

• Initial overview of the country AMU can be seen:

• Human use > animal use

• Broad spectrum penicillin most used antibiotic class

Community or Hospital?

Public or Private?

Adherence to Standard Treatment Guidelines?

18

Conclusion

Source: IMS data as presented by ResMaps (CDDEP)

• Sustainable and consistent sources of data are critical

• Trend analysis to monitor interventions put into place

http://www.bioethics.net/2018/04/the-end-is-nigh-bioethics-and-antibiotic-resistance/

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Thanks to

Source: IMS data as presented by ResMaps (CDDEP)

• Dr Kim Faure