Antimicrobial Resistance - OECD
Antimicrobial resistancePolicy insights
Did you know?Antimicrobial resistance (AMR) occurswhen microorganisms develop resistanceto antimicrobials they are exposed to.AMR is a natural phenomenon, enhancedby persistent exposure to selectivepressure enabled by high volume useof antimicrobials. The process may bereversible by reducing inappropriate use -resistance.htm OECD 2016
OECD Antimicrobial resistance - OECD 2016Antimicrobial resistanceis a growing health and economic threatrequiring a multipronged responseAntimicrobial resistance (AMR) is a complexissue of global concern. AMR is not simply aproblem of medical science being beaten bynature; human action and perverse incentivesplay a major role in its development. Themisuse of antibiotics in the medical, veterinaryand agricultural sectors, which include theinappropriate prescribing of antibiotics, theiroveruse in the livestock sector, and insufficienthygiene practices in hospital, all contribute tothe rise of AMR. Global trade and travel are alsoaccelerating the spread. At the same time, thedevelopment pipeline of new antibiotics hasslowed, mainly due to insufficient incentives,allowing microorganisms to outpace thedevelopment of new drugs.AMR poses a significant burden on healthcaresystems and national budgets. The discovery ofantibiotics meant that previously lethal infectionscould be cured and surgical procedures madesafer, allowing for the development of modernmedicine. With the rise of AMR, we are nowheading towards a ‘post-antibiotic era’ wherecommon infections may once again be fatal.Patients infected with resistant infections: require more intensive and expensivecare and are more likely to be admitted tohospital. Hospitals spend, on average, anadditional USD 10 000 to 40 000 to treat apatient infected by resistant bacteria in OECD. suffer from a loss of productivity andincome due to ill-health and additional timeaway from work. At current resistance rates,the total GDP effect in OECD, accounting forincreased healthcare expenditure, wouldamount to 2.9 trillion USD by 2050.OECD, with its distinctive cross-sectoralexpertise and its global outreach, is placed ina unique position to help countries in tacklingAMR. OECD’s economic expertise includessuch diverse areas as health, technologicalinnovation and agriculture. The OECD cantherefore play a critical role in providingcountries a forum where governments cancompare and exchange policy experiences,identify good practices and promote decisionsand recommendations to comprehensivelytackle AMR under the ‘one-health’ framework. show increased risk of complication anddeath. Globally, about 700 000 deaths may becaused each year by AMR. If current resistancerates increase by 40%, up to 9.5 million peoplemay die each year.1
OECD Antimicrobial resistance - OECD 2016Trends across OECD countriesAntibiotic resistance is growingSix high-priority bacterialantimicrobial resistancecombinations were aggregatedwithin each country by useof the arithmetic mean. Theincluded combinations were:E.coli (resistant to 3rd generationcephalosporins), E.coli(resistant to fluoroquinolones),K.pneumoniae (resistant to 3rdgeneration cephalosporins),K.pneumoniae (resistantto carbapenems), S. aureus(resistant to methicillin),S.pneumoniae (resistant topencillin). Data from 2014 (orlatest available data) and 2005(or 2006 if not available).*Greece missing S.pneumoniae(resistant to penicillin) 2005and 2014, Slovakia and Belgiummissing K.pneumoniae (resistantto 3rd generation cephalosporinsand carbapenem) 2005, Portugalmissing K.pneumoniae (resistantto carbapenem) 2005, NewZealand missing MRSA 2014,Australia missing S.pneumoniae(resistant to penicillin) 2014,Iceland missing K.pneumoniae(resistant to carbapenem) 2014. Includes resistant andintermediate dataSource: ESAC-Net Database denSwitzerlandEstoniaAustriaUnited KingdomAustralia* GermanyCanada BelgiumNew ZealandIrelandFranceSloveniaLuxembourgOECD averageLatviaCzech RepublicHungarySpainUnited StatesPolandPortugal*Slovak Republic*ItalyTurkey Greece*Resistance % 2014Resistance % 20050510This graph illustrates the trend in levels ofantibiotic resistance across OECD countries in2014, comparing it with the levels recorded in2005. On average, the probability of identifyinga resistant infection in OECD in 2014 was about15%. The probability of developing a resistantinfection in the three countries with thehighest levels of resistance is 25% higher thanthe OECD average and about 11 times higherthan in the three countries with the lowestlevels of resistance.Between 2005 and 2014 AMR prevalence hasincreased in 23 out of 26 OECD countries by anaverage of 5% (i.e. from an average of 10% in 2005to 15% in 2014). By looking at specific agents, 3rdgeneration cephalosporin-resistant E. Coli andcarbapenem-resistant K. pneumoniae appearto be highest priorities. Recorded prevalence215202530354045%50of these resistant infections increasedbetween 3 and 4 times in OECD countries.If this trend continues we could revert to aworld where simple infections are no longertreatable. This rising level of antimicrobialresistance highlights the urgent need forpolicy interventions to reduce antibioticconsumption, improve hygiene standards anddevelop novel antimicrobials.United Kingdom is one of the few countriesshowing a decrease in AMR. Decreasing trendsin MRSA (methicillin-resistant S. Aureus) area major driver underpinning this decline. TheUK Health Protection Agency suggested thatsustained efforts to tackle MRSA transmissionin hospitals may have played a critical role inachieving this result.
OECD Antimicrobial resistance - OECD 2016Human consumption of antibiotics remainedsubstantially stable between 2005 and h RepublicIcelandPortugalOECD averageUnited KingdomSlovak urgItalyBelgiumFranceKorea* GreeceTurkey* Antibiotic consumption level 2014Defined daily dose per 1000 inhabitants per dayAntibiotic consumption level 2005Defined daily dose per 1000 inhabitants per dayNote: Antibiotic consumption levelsmeasured in defined daily dose (DDD)per 1000 inhabitants per day. The DDDis defined as the assumed averagemaintenance dose per day for a drugused on its main indication in adults.Data from 2014 (or latest availabledata) and 2005. Includes hospital dataSource: Unless specified the data isfrom the EARS-Net database.*Data direct from country0510152025Antibiotic consumption and, in particular,inappropriate use are among the main causesunderpinning the development of antibioticresistance. In 2014, average antibioticconsumption in OECD was about 20.5 defineddaily dose per day (DDD) per 1 000 inhabitants.Antibiotic consumption in the highestconsuming country is more than twice theOECD average and 4.4 times higher than thelowest consuming country. Between 2005 and2014 OECD countries have increased antibioticconsumption by an average of 4%.OECD analyses show that inappropriate usemay account for up to 50% of all antimicrobialsconsumed in human health care. In somehealthcare services (e.g. long-term care andgeneral practice), inappropriate consumptionmay be as high as 90% of total consumption.An even greater proportion of antibiotics aremisused in the livestock sector. Some of themost common factors influencing inappropriate30354045%use of antimicrobials include cognitive biasesand poor information in patients and physiciansas well as organisational factors and perverseeconomic incentives.As part of broader national strategies toprevent AMR, OECD governments are adoptinga comprehensive set of policy actions toaddress inappropriate consumption ofantimicrobials. These include information andeducation policies, organisational changes,including stewardship programmes, use of newtechnologies and economic incentives.Did you know?In 2014, antimicrobials accountedfor about 3% of the total value ofpharmaceutical sales for humans in OECD.3
OECD Antimicrobial resistance - OECD 2016Policies that promote the rational use ofantimicrobialsShare of OECD countries that have implemented policies to promote the rational use of antimicrobialsRapid diagnostic tests available nationwide40 %Guidelines on the rational use of antimicrobials for prophylaxisnationwide60 %Strategies to rationalise the use of antimicrobials60 %Guidelines on the rational use of antimicrobials for treatmentnationwideImplemented antimicrobial stewardship programmesMonitoring system in place for antimicrobial consumptionGovernments are adopting a broad rangeof policy approaches to curb harm relatedto inappropriate use of antimicrobials inhumans. In the majority of cases, actions todecrease ineffective use of antimicrobialsare part of broader strategies to tackle AMR.A recent survey showed that about 60% ofOECD countries have produced strategies torationalise the use of antimicrobials and anadditional 37% are in the process of developingone.Education and information activities are at thecore of most strategies to reduce inappropriateuse of antimicrobials. This type of actionusually targets both the general population,through mass media campaigns, and medicaldoctors. For example, about three in fourOECD countries have implemented nationalguidelines on the rational use of antimicrobialsfor treatment – although national guidelinesfor prophylaxis use are less common.Combining the implementation of guidelineswith training programmes, for example as partof continuing medical education schemes,provides a more effective approach.4Note: 29 OECDcountries responded tothe questionnaire.73 %84 %100 %Organisational changes in the health caresector are an effective option to rationaliseuse of antimicrobials. The implementationof stewardship programmes and greater useof rapid diagnostic tests has been shown toreduce inappropriate use of antimicrobials withno negative impact on the health of patients.The vast majority of OECD countries (84%)implements stewardship programmes but,in about half of the cases, these programmesare only implemented at the sub-nationallevel. Use of rapid diagnostic tests is evenmore limited. Rapid diagnostic tests are onlyavailable nationwide in 40% of OECD countries.Establishing an effective surveillance systemis fundamental for developing and informingany strategy aimed to rationalise antimicrobialprescriptions and to tackle AMR. All OECDcountries have a system in place to monitorantimicrobial consumption, but in a number ofcases the monitoring system can only providedata for specific care providers (hospital data)or financing agents (insurers). Conversely, onlyone in three OECD countries have assessed theextent of overuse of antimicrobials.
OECD Antimicrobial resistance - OECD 2016Consumption of antibiotics in agricultureaccounts for the majority of total antibiotic useSales of antimicrobial agents marketed mainly for food-producing animals in mg/populationcorrection unit (PCU), : European Medicines Agency (2016).Sales of veterinary antimicrobial agents in29 European countries in ted KingdomSlovakiaEstoniaNetherlandsCzech talySpain050100150200Agriculture’s share of global antibioticconsumption is high and rising, as the demandfor animal proteins increase, especially in lowand middle income countries. Overall, agricultureaccounts for over 75% of annual antimicrobialconsumption in the EU and the US. However in24 EU countries, consumption has fallen by 12%between 2011 and 2014, and this trend is expectedto continue as farmers become more aware ofthe downside risks arising from antimicrobialresistance. Globally, antibiotic consumption isconcentrated, with four countries - China, US,Brazil and India - accounting for almost 50% ofglobal usage.250300350400450mg/PCUOf the 27 classes of antibiotics currently available,only seven classes are used exclusively inagriculture, with the remainder used for humanhealth and in animal production. Tetracyclines,penicillins and macrolides account for over threefifths of antibiotic usage in agriculture. With nonew antibiotics developed for more than 40 years,agriculture is using more medically “potent”antibiotics in treating livestock. This raisesserious concerns in the public health arena overthe use of “last resort” antibiotics in agriculture,and consequently the emergence and spread ofresistance, e.g. colistin, macrolides.5
OECD Antimicrobial resistance - OECD 2016The widespread use of antibiotics in agriculturehas significant implications for livestockproductivity and food security as well as humanhealth. Antibiotic usage in animal agricultureis complex as antibiotics are used not only fortherapeutic purposes, but also for the preventionof infectious diseases and to promote animalgrowth. More than 80% of OECD countrieshave banned the use of antibiotics for growthpromotion, but across developed and developingcountries they are widely used to preventdisease, and often when one animal becomessick the whole herd is treated. With the growingawareness and understanding of the risksarising from the excessive use of antimicrobialsin intensive livestock production, farmers are6moving to alternative measures such as improvedhusbandry, improved biosecurity and nutrition, aswell as selective vaccination programmes.There are major data and information gaps onthe use of antibiotics in agricultural productionand on the development and spread of resistance.The lack of registration of antimicrobial salesis a major barrier in many countries, as muchof the sales are “over the counter” with norecords or surveillance of usage. Moreover, it iscritical to have better information on antibioticconsumption by species, farming systems andpurpose in order to design appropriate countryspecific measures to counter the growth in AMR.
OECD Antimicrobial resistance - OECD 2016Stronger action and economic incentives tosupport the development of new antimicrobialsare badly neededThe last major new class of antibiotic wasdiscovered in 1987 and the approval of noveltherapies has fallen eight-fold since then. Since2000, only five new classes of antibiotics havebeen put on the market and none of these targetgram-negative bacteria, which are often deadly.Given current policies, market conditions alonedo not provide sufficient incentives to businessfor the development of new antibiotics as theexpected profitability of investing in this areais significantly lower than for other therapeuticcategories (e.g. cancer).Policy options to support the development ofnew treatments can be divided into two broadcategories. Upstream interventions target theearly phases which are the most uncertainpart of developing any medical technology.Interventions are designed to shift the risk onthe funding body and encourage enterpriseparticipation. Downstream mechanisms aim toboost the reward at the end of the developmentprocess and facilitate the market entry of drugs.These levers reduce the risk to sponsors (becausethey only reward successful research) but theymay inflate the size of the intervention becausecompanies would need strong incentives to investon an uncertain return far in the future.It is crucial that any initiative to incentivisethe development of new antimicrobials isclosely connected with other key interventionsto rationalise use of antimicrobials, includingincreasing access when needed, and to tackleAMR. Failing to do so would only postponethe problem and provide no long-lasting andsustainable solution.Number of new antimicrobials approved by the United States Food and Drug Administrationsince 19832015No. of 20022003200720082012Source: OECD (2015). Antimicrobial resistance in G7 countries and beyond: economic issues, policies and options for action.7
OECD Antimicrobial resistance - OECD 2016ConclusionEffective policy actions are requiredto tackle AMRThe health and economic burden of AMR is significant and has the potential to becomecatastrophic if appropriate action is not taken urgently. AMR can be successfully tackledby:Strengthening existing surveillance and monitoring systems in both thecommunity and hospital setting.Adopting a globally agreed set of measurable targets for reducing AMR incidenceamong humans and livestock.Strengthening ongoing efforts to rationalise the use of antimicrobials andpreventing the spread of AMR in humans and in the livestock sector.Fostering the research and development of new antimicrobial therapies,including improved biosecurity measures in agriculture.Enhancing coordination between countries to develop a true global action plan totackle AMR. These plans should adopt a broader ‘one-health’ approach coveringhuman health, agriculture and the environment.The OECD can provide a forum for discussion and is currently undertaking comprehensivework in AMR including a health economic evaluation to identify the most cost-effectivestrategies to tackle AMR in humans, as well as an economic analysis of the benefitsand costs of antibiotic usage in livestock production and the economic feasibility ofsustainable alternatives. There is an urgent need for greater collaboration to combat theimminent threat of AMR.8
OECD Antimicrobial resistance - OECD 2016For more information, please .htmAcknowledgments: Victoria Simpkin, Laura Suhlrie,Alastair Wood, Michele Cecchini, Michael Ryan,Francesca Colombo and Jonathan Brooks contributed tothe preparation of this document. www.shutterstock.com/3Dalia www.shutterstock.com/Pogorelova Olga www.shutterstock.com/Alexander Kovalenko www.shutterstock.com/Olga Miltsova www.shutterstock.com/Jarun Ontakrai www.shutterstock.com/WhiteDragon www.shutterstock.com/Aha-Soft
and carbapenem) 2005, Portugal missing K.pneumoniae (resistant to carbapenem) 2005, New Zealand missing MRSA 2014, Australia missing S.pneumoniae (resistant to penicillin) 2014, Iceland missing K.pneumoniae (resistant to carbapenem) 2014. Includes resistant and intermediate data Source: ES
2 The Review on Antimicrobial Resistance, Chaired by Jim O’Neill 3 The Review on Antimicrobial Resistance, Chaired by Jim O’Neill The Review The UK Prime Minister announced a Review on Antimicrobial Resistance in July, call
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Antimicrobials, Aspergillus fumigatus, Antimicrobial Peptides 1. Introduction 1.1. Antimicrobial Peptides and Proteins It is notable that antimicrobial peptides particularly cationic ones play a signifi-cant role within the natural immunity of animal defences against topical and general microbes altogether species of life. These antimicrobial .
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Chapter 5: Antimicrobial stewardship education for clinicians 123 Acronyms and abbreviations 126 5.1 Introduction 127 5.2 Key elements of antimicrobial stewardship education 128 5.2.1 Audiences 128 5.2.2 Principles of education on antimicrobial stewardship 129 5.2.3 Antimicrobial stewardship competencies and standards 129
Introduction Antimicrobial resistance rates continue to increase in hospitals across the United States. 1 One of the five CDC core actions to combat the spread of antimicrobial resistance is improving the use of
RIGHTS@oecd.org, OECD, 2 rue André-Pascal, 75775 Paris Cedex 16, France . Belge, aslen OECD tarafından İngilizce olarak aşağıdaki başlık altında yayınlanmıştır: OECD (2016), OECD Position Paper Regarding the Relationship between the OECD Principles of GLP and ISO/IEC 17025, Series on
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