No 46 - 2018

DANMAP 2017

This year’s DANMAP report (DANMAP 2017) was published on the DANMAP site on 2 October 2018. The aim of the report is to provide a unique “One Health” platform that presents monitoring and research into the use of antimicrobial drugs and the development of antimicrobial resistance detected in humans, animals and foods in Denmark. Below, we describe the main findings for 2017.

For a more detailed description, please see the annual DANMAP report on the SSI website.

Detailed information about the monitoring programme and the report is available at www.DANMAP.org 

Antimicrobial consumption in animals

The overall consumption of antimicrobials for animals declined for the fourth year running. Since 2013, consumption has decreased by 16 tonnes. From 2016 to 2017, consumption decreased by approx. 3% to 101 tonnes.

Antimicrobial consumption in humans

In 2017, the overall human antimicrobial consumption was 17.55 defined daily doses per 1,000 inhabitants per day (DID), which is lower than the 2016 consumption (18.44 DID) and also lower than the consumption recorded ten years ago (18.09 DID). Generally, about 90% of the prescribed antimicrobials are used in primary healthcare, and the remaining 10% are used in the hospital sector.

The consumption of antimicrobials increased from the first statement in the DANMAP report in 1996 (13.60 DID) and until 2011 (19.80) after which it remained stable for some years until 2013 when consumption started descending, a trend which has been maintained since then. In 2017, penicillins continued being the most consumed antimicrobial group in primary healthcare (67%) and also at hospitals (53%).

In 2017, the three critically important groups of antimicrobials (fluoroquinolones, cephalosporins and carbapenems) comprised 23% of the consumption of antimicrobials at hospitals, which is a slight increase from the 22% used the preceding year, but a drop from the 31% used in 2008. The increase observed in 2017 is probably in part associated with a prolonged supply issue with the combination drug piperacillin with tazobactam. The use of this drug declined from 9.32 defined daily doses per 100 bed days (DBD) in 2016 to 7.75 DBD in 2017 (-17%).

Resistance in clinical bacteria in humans

Since DANMAP was established, and particularly in the past decade, the number of detected invasive infections in humans has increased considerably. From 2016 to 2017, the number of Escherichia coli in invasive infections increased from 4,841 isolates to 5,114 isolates. The same year, cefuroxime resistance in the invasive E. coli isolates increased from 8.6 to 9.7%. An increase observed in E. coli resistance to ciprofloxacin is probably due to the introduction of new threshold values to susceptibility/resistance to ciprofloxacin according to the European laboratory definitions (EUCAST). The number of resistant invasive isolates with Klebsiella pneumoniae has generally declined since 2008, and the decreasing trend for cefuroxime and 3rd generation cephalosporins continued in 2017 (11.1 and 7.1%, respectively), whereas a slight increase was observed in resistance to piperacillin/tazobactam, from 5.8% in 2016 to 7.1% in 2017. For E. coli and K. pneumoniae, the resistance to carbapenems in the invasive isolates remained <1 %.

Resistance in the submitted clinical isolates: For the first time since 2013, a small decrease in the number of vancomycin-resistant enterococci (VRE) was observed (515 cases in 2016, 508 cases in 2017). The number of cases with carbapenemase-producing organisms (CPO) increased from 115 cases in 99 patients in 2016 to 123 cases in 115 patients in 2017, corresponding to a 6% increase in the share of submitted CPO isolates. The share of MRSA in bacteraemias with Staphyloccocus aureus remained at the same level in 2017 (2.2%) as was observed in 2016 (2.1%), and the total number of new MRSA cases observed in 2017 (3,579) was also in line with the level observed in 2016 (3,550). Resistance data for Haemophilus influenzae cases was reported for the first time in DANMAP in 2017 (115 reported cases), and a small increase in the share of cases that were resistant to ampicillin was observed (18% in 2014, 22% in 2017).

For Neisseria gonorrhoeae, which are resistant to ciprofloxacin, an increase was observed from 2016 (18%) to 2017 (28%).

Finally, in 2017, 5% of the Mycoplasma genitalium cases were resistant to fluoroquinolones, and the majority of these were also resistant to macrolides, which means that for these infections there is currently no effective approved antimicrobials in Denmark.

Commentary

The overall consumption of antimicrobials for animals as well as humans is relatively low in Denmark compared with the EU and the rest of the world. International travels and trade are therefore considered important factors when new bacteria and resistance mechanisms are introduced into and subsequently spread in the Danish population. Nevertheless, unnecessary consumption of antimicrobials does occur in the Danish population; for instance, too many prescriptions are issued for treatment of presumed urinary tract infections. Furthermore, in some population groups, the antimicrobial consumption is naturally high, e.g. in seriously ill hospitalised patients. This may contribute to driving the development of resistance, to maintaining resistance levels and to spreading resistant bacteria in hospitals.

The National Action Plan for Antimicrobials for Humans, published in 2017, aims to reduce the number of antimicrobial prescriptions, to increase the use of narrow-spectrum rather than broad-spectrum antimicrobials and to reduce consumption of the critically important antimicrobials in hospitals. It is currently too early to report the results of the action plan. However, in recent years several initiatives, e.g. by the GPs, have contributed to a favourable development in the number of prescriptions issued in primary healthcare, a development that is expected to continue. Likewise, regional efforts made in hospitals, not least by the national learning and quality teams, are expected to have a beneficial effect on the consumption of antimicrobials in hospitals.

The antimicrobial consumption in any population drives the development of resistance. Monitoring of the consumption of antimicrobials and the occurrence of multi-resistant bacteria like MRSA, ESBL, CPO and VRE therefore provides essential information about when and where more control is needed. The MRSA guideline from 2006 has been instrumental in reducing the spread of MRSA in hospitals. With the National Board of Health’s new guideline on the prevention of spread of CPO, an important step has been taken in the prevention of further development and spreading of these resistant bacteria.
(U.W. Sönksen, K.S.S. Pedersen, S.S. Olsen, S. Skovgaard, A.E. Henius, A. Petersen, A.R. Larsen, M. Torpdal, S. Hoffmann, T. Dalby, E.M. Nielsen, H. Hasman, A.M. Hammerum, J.S. Jensen, Microbiology and Infection Control, M. Laursen, Data Delivery and Medicinal Product Statistics, Danish Health Data Authority)

European Testing Week 23-30 November 2018 – Test. Treat. Prevent.

Next week will see the sixth launching of the European Testing Week. It is still important to focus on having more people tested for HIV and/or hepatitis.

The objective of European HIV Testing Week is to raise awareness of HIV and hepatitis, and to draw attention to the advantages of being tested and initiating treatment early.

Well-treated people who have HIV cannot transmit the infection to anyone else. At the international IAS conference in Amsterdam earlier this year, the PARTNER study’s findings were presented. PARTNER tested nearly 1,000 homosexual couples and close to 78,000 unprotected anal intercourses and did not record a single case of infection. It is also well-documented that the sooner you start treatment, the better are your chances of maintaining good health. Nearly 50% of all the people who test HIV positive in Europe today are tested at a point in time at which their health/immune system has already been damaged.

During the European Testing Week, more than 700 NGOs, hospitals and clinics in Europe join forces to have more people tested. A wide range of activities are celebrated, from testing offered at clubs, in the street and outside of normal opening hours, to information campaigns designed to raise awareness about HIV and hepatitis testing both locally, nationally and among European policy makers. To learn more about the European Testing Week, please see the Success Stories page.

The efforts to support integrated testing are underpinned by the first ever guidelines for integrated testing for viral hepatitis and HIV, which were developed by the European Centre for Disease Prevention and Control (ECDC) (and which will be published in connection with the European Testing Week).

You can register for the European Testing Week at the week's website, where you will also find more information and materials that may be useful in the implementation of activities.

To see which organisations participate in the European Testing Week, take a look at the list of participating organisations.

The European Testing Week is coordinated by HIV in Europe, which is located with CHIP under The Copenhagen University Hospital (Rigshospitalet), Clinic for Infectious Medicine. Feel free to contact CHIP at hie.rigshospitalet@regionh.dk.