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Saskia v. Popescu, MPH, MA, CIC, is a hospital epidemiologist and infection preventionist with Phoenix Children's Hospital. During her work as an infection preventionist she performed surveillance for infectious diseases, preparedness, and Ebola-response practices. She is currently a PhD candidate in Biodefense at George Mason University where her research focuses on the role of infection prevention in facilitating global health security efforts. She is certified in Infection Control.

WHO Reports on Global Antibiotic Consumption

NOV 19, 2018 | SASKIA V. POPESCU
While the countries such as the Democratic Republic of Congo battles an Ebola outbreak and influenza season is upon us in the United States, it can be easy to neglect the topic of antibiotic stewardship and the multisectoral roles in facilitating resistance; however, antimicrobial resistance continues to be a threat that we face on an international level. The World Health Organization (WHO) has been working hard to address these surveillance gaps and recently released their report on surveillance of antibiotic consumption.

Each year, resistant infections are responsible for 23,000 deaths in the United States, alone, and it is estimated that the cost for treatment of such infections has doubled since 2002, exceeding $2 billion a year. A report from the Organization for Economic Cooperation and Development (OECD) found that 3 out of 4 deaths from antimicrobial-resistant infections could be averted by spending just $2 per person per year through prevention efforts like hand hygiene and antibiotic stewardship.

Although we have made considerable investments in combatting antimicrobial resistance and continually monitor progress through the US Centers for Disease Control and Prevention (CDC), surveillance on a national level is a struggle. Imagine the challenge of such efforts in a resource-stressed country. The acts of tracking laboratory data for trends in resistance, antibiotic prescribing, and antibiotic consumption are resource-intensive efforts that are challenging for even the most developed country.

The WHO has been working to strengthen national capacity to monitor antimicrobial consumption across 57 low- and middle-income countries. These efforts have focused on workshops and educational sessions, as well as technical support, to help better understand consumption trends on an international level. In the case of this report, the WHO defined consumption as “estimates of aggregated data, mainly derived from import, sales, or reimbursement databases” while use was defined as “data on antibiotics that were taken by individual patients.”

These data come from a range of sources like production records, import records, public sector procurement (medical stores), donation records, dispensing records, etc. Consumption was assessed at national levels, but the WHO also relied on data from other surveillance networks such as the European Centre for Disease Prevention and Control (ECDC)’s European Surveillance of Antimicrobial Consumption Network, Canada’s Antimicrobial Resilience Surveillance System, and more. 

Results were broken down into regions: African, Americas, European, Eastern Mediterranean, and Western Pacific. At a higher level, the consumption data showed pretty substantial variation within and between regions in the total amount and type of antibiotics consumed. The overall consumption of antibiotics ranged from 4.4 to 64.4 Defined Daily Doses (DDD) per 1000 inhabitants per day, with amoxicillin and amoxicillin/clavulanic acid being the most frequently used.

The report included antibiotics categorized within the AWaRe categorization, which utilizes the Model List of Essential Medicines and categorizes them as either Access, Watch, or Reserve, which encourages specific use.

Those listed as reserve—meaning that they should only be used for specific indications—accounted for a smaller percentage of use (2%).

“Antibiotics such as second generation cephalosporins and some tetracyclines, which have so far not been classified in the Access, Watch and Reserve (AWaRe) categories, accounted for a substantial proportion of total consumption, more than 10% in the majority of countries,” wrote the authors.

The results for each region were quite interesting. For example, when looking at the consumption of antibiotics and proportion of total consumption by AWaRe categorization, Brazil had higher uses of Access and Reserve antibiotics, while Paraguay consumed a considerable amount of Watch antibiotics.

In 49 of the observed countries, antibiotics listed in the Access category accounted for more than 50% of antibiotic consumption. In the African region, the United Republic of Tanzania accounted for the most consumption of Watch antibiotics while in Europe, France and Italy had high rates of using Reserve antibiotics. 

Overall, the report reveals considerable variation in antibiotic consumption in amounts and types. In some areas of the world, use is very low, while others, such as Italy, had high rates of use. The variation is not unexpected, but it underscores the importance of antimicrobial stewardship and surveillance at national and more local levels.
      
As AMR prevention efforts continue to build, it will be interesting to see if these consumption trends hold or prove the value of stewardship campaigns.
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