No 46 - 2019

DANMAP 2018

This year’s DANMAP report describes the results from monitoring of antimicrobial resistance and antimicrobial consumption in humans, animals and foods in Denmark for 2018 and for most surveyed bacterial species 10 years retrospectively. The DANMAP cooperation was established in1995 and annual reports have been published as from 1997.

The full report is available from the DANMAP website.

The total consumption of antimicrobials for animals as well as humans is low in Denmark compared with the EU and the rest of the world. Particularly the use of antimicrobials in the animal food production and consumption in primary healthcare are remarkably low. The occurrence of antimicrobial-resistant isolates from human clinical infections is at a corresponding low level in Denmark, and - for most species of bacteria - no major increases have been observed in the rates of resistance. However, the number of treatment-requiring infections (assessed from the number of positive blood cultures taken) follows an increasing trend and in 2018, more patients had an invasive infection detected than ever before. This drives the antimicrobial consumption at hospitals - where consumption is relatively high, even in a European perspective - which in turn will contribute to driving resistance development, maintaining resistance, and in worst case contribute to the spread of resistant bacteria at hospitals. It therefore remains important to focus on reducing the consumption of antimicrobials, whenever this is believed to be possible without causing disease that could otherwise have been avoided. Furthermore, it is essential to focus on a continued proper use of antimicrobials especially in critically ill patient groups.

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 the consumption of critically important antimicrobials at hospitals. Since 2012, primary healthcare has observed a sustained decrease in the number of dispensed prescriptions among GPs, medical specialists and dentists alike. Since the introduction of the action plan, this trend has become even stronger, generating a considerable reduction that is evident in all Danish municipalities and regions. In hospitals, the total consumption has been increasing. Nevertheless, an expedient change of the pattern of consumption has been recorded, particularly the use of the critically important antimicrobials (cephalosporins, fluoroquinolones and carbapenems) has changed, reducing their share of the total consumption.

Below, we describe the main findings for 2018.

Antimicrobial consumption in animals

The overall consumption of antimicrobials for animals declined for the fifth year in a row. Since 2013, consumption has declined by almost 17 tonnes, corresponding to a 14% decrease. In 2018, the total consumption for animals was 100 tonnes.

Antimicrobial consumption in humans

In 2018, the overall human antimicrobial consumption was 15.95 defined daily doses per 1,000 inhabitants per day (DID), which is lower than the 2017 consumption (16.67 DID) and also lower than the consumption recorded ten years ago (17.47 DID). Primary healthcare is responsible for approx. 90% of the antimicrobial consumption, whereas the remaining 10% are used at hospitals. In 2018, penicillins continued being the most consumed antimicrobial group in primary healthcare (66%) and also at hospitals (53%).

In 2018, the three critically important groups of antimicrobials (fluoroquinolones, cephalosporins and carbapenems) comprised 20% of the consumption of antimicrobials at hospitals, measured as DDD per 100 bed days, which is a decline from the 22% they comprised one year earlier, and the 32% recorded for 2009.

Resistance in clinical bacteria in humans

In the past ten years, the number of invasive infections (blood stream infections) in humans, monitored by DANMAP, has increased considerably; a trend that continued in 2018.

Escherichia coli is the bacterium most frequently found in blood stream infections. From 2010 to 2018, the number of blood cultures with E. coli findings increased by 58%. In the same period, the share of E. coli with resistance to cefuroxime increased, from 7.6% resistance in 2009 to 9.8% in 2018.

For Staphylococcus aureus, Klebsiella pneumoniae and enterococci, the number of blood stream infections has also risen significantly in the past ten years. While no general increase was observed for resistance rates in invasive isolates of S. aureus and K. pneumoniae, a substantial increase was seen in the share of Enterococcus faecium from blood cultures with resistance to vancomycin (VRE), from 7% in 2017 to 12% in 2018.

The reference laboratory at SSI receives isolates of gram negative bacteria on suspicion of carbapenem resistance (carbapenemase-producing organisms, CPO), both from rectal screenings and clinical samples for resistance genes. In 2018, the number of these verified CPOs increased to a total of 170 cases in 160 patients, a 44% increase compared with the previous year. Since September 2018, all cases of CPO have been notifiable. The notifications comprise clinical information about the patient, e.g., previous travel activity or hospital admissions abroad.

Resistance in zoonotic bacteria, i.e., bacteria that transmit (directly or indirectly) from animals to humans

As in the preceding years, 2018 recorded a significantly higher level of resistance in Campylobacter jejuni and Salmonella Typhimurium in patients who had recently been travelling abroad compared with infections acquired in Denmark.

No macrolide resistance was observed in C. jejuni isolates in 2018. In contrast, fluoroquinolone resistance was observed frequently. Around one third of the isolates from infections acquired in Denmark were resistant, whereas the corresponding share for isolates from travel-associated cases was 83%

For S. Typhimurium, around two thirds of human infections are caused by a single related clone that has been spreading across Denmark in the past 10 years. The clone is resistant to ampicillin, sulfonamides and tetracycline alike, but resistance to critical antimicrobials, i.e., third-generation cephalosporins, carbapenems, gentamicin and colistin, is only rarely observed (< 1 % for cephalosporins and carbapenems in 2018). Resistance to fluoroquinolones remained at a high level in 2018 for isolates from travel-associated cases (25%) compared with 4% among isolates from infections acquired in Denmark. Less than one percent of S. Typhimurium-isolates were resistant to azithromycin.

(U.W. Sönksen, K.S.S. Pedersen, S. Skovgaard, A.E. Henius, Microbiology and Infection Control)

European Testing Week 22-29 November 2019 – Test. Treat. Prevent.

Next week will be the seventh European Testing Week; once again, the week will focus on increasing the number of people who are tested for HIV and/or hepatitis.

The objective of the European HIV Testing Week (ETW) is to raise awareness of HIV and hepatitis, and not least to draw attention to the advantages of being tested and initiating treatment early. This year’s ETW theme is integrated testing for HIV, hepatitis and venereal diseases, and the campaign focuses on related activities designed to enhance attention on and access to testing - fully in line with the ETW’s main slogan: Test. Treat. Prevent.

It has been demonstrated that the sooner you start treatment, the better are your chances of maintaining good health, and the risk of infecting others decreases.

During the ETW, more than 730 NGOs, hospitals and clinics in Europe join forces to have more people tested. The activities celebrated are many, ranging 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 ETW, please see the Success Stories page.

You can register for the ETW at the 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 ETW 2019, take a look at the list of participating organisations

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

(D. Raben, Centre of Excellence for Health, Immunity and Infections (CHIP), S. Cowan, Department of Infectious Epidemiology and Prevention)