Protected: Qi05 – AWaRe Access antibiotics

Denominator

The total annual consumption of antibiotics in community and hospital sectors combined, including in long-term care facilities, in DDDs, including (1):

• antibacterials for systemic use (J01)
• neomycin (A07AA01), streptomycin (A07AA04), polymyxin B (A07AA05), kanamycin (A07AA08), vancomycin (A07AA09), colistin (A07AA10), rifaximin (A07AA11), fidaxomicin (A07AA12), rifamycin (A07AA13)
• rifampicin (J04AB02), rifamycin (J04AB03), rifabutin (J04AB04)
• metronidazole (P01AB01), tinidazole (P01AB02), ornidazole (P01AB03)

Numerator

The annual consumption of antibiotics classified as Access -agents (listed below) as per the WHO AWaRe classification (2), in DDDs

Exclusions (Numerator, denominator)

• N/A

Notes

• Consumption is examined in Defined daily doses (DDDs). DDD is the assumed average maintenance dose per day for a medication used for its main indication in adults (3).

Sources of Data

• (Whole)sales data (outpatient and inpatient) or other registers with total consumption.

Purpose

• The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
• Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
• Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

• The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
• Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
• Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
• Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
• ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Similar or related indicators in Nordic or European quality assessment

• European Centre for Disease Prevention and Control (ECDC), antimicrobial consumption dashboard (1)
  • Patterns of consumption of antimicrobials according to the AwaRe classification of antimicrobial agents

Set quality targets

• The WHO 13th General Programme of Work 2019–2023 includes a country-level target of at least 60% of the total antibiotic consumption belonging to the Access group (15).
• The European Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach (2023/C 220/01) has set a target of at least 65% of the total consumption of antibiotics in humans belonging to the Access group by 2030 (4).

Similar or related indicators in international scientific literature

• The relative consumption of AWaRe antibiotics: The proportion of total consumption that comprised Access (vs. Watch and Reserve) agents based on the WHO AWaRe groups of antibiotics  (16)

1. AMC | European Centre for Disease Prevention and Control [Internet]. [cited 2024 May 2]. Available from: https://qap.ecdc.europa.eu/public/extensions/AMC2_Dashboard/AMC2_Dashboard.html#who-aware-tab
2. AWaRe classification of antibiotics for evaluation and monitoring of use, 2023 [Internet]. [cited 2024 May 2]. Available from: https://www.who.int/publications-detail-redirect/WHO-MHP-HPS-EML-2023.04
3. ATCDDD – Definition and general considerations [Internet]. [cited 2024 May 2]. Available from: https://atcddd.fhi.no/ddd/definition_and_general_considera/
4. Council Recommendation on stepping up EU actions to combat antimicrobial resistance in a One Health approach 2023/C 220/01 [Internet]. 2023. Available from: https://eur-lex.europa.eu/legal-content/EN/TXT/?uri=CELEX:32023H0622(01)
5. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, et al. The Relationship between Antimicrobial Use and Antimicrobial Resistance in Europe. Emerg Infect Dis. 2002 Mar;8(3):278–82.
6. Browne AJ, Chipeta MG, Haines-Woodhouse G, Kumaran EPA, Hamadani BHK, Zaraa S, et al. Global antibiotic consumption and usage in humans, 2000–18: a spatial modelling study. Lancet Planet Health. 2021 Dec 1;5(12):e893–904.
7. Coenen S, Ferech M, Haaijer-Ruskamp FM, Butler CC, Vander Stichele RH, Verheij TJM, et al. European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual Saf Health Care. 2007 Dec;16(6):440–5.
8. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet. 2005 Feb 12;365(9459):579–87.
9. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. The Lancet. 2007 Feb 10;369(9560):482–90.
10. Johnson A, Russell L, Perry JD, Slavin M, Tacconelli E. Preface. J Antimicrob Chemother. 2021 Jul 1;76(Supplement_2):ii1.
11. Antimicrobial consumption in the EU/EEA (ESAC-Net) – Annual Epidemiological Report for 2022 [Internet]. 2023 [cited 2024 May 2]. Available from: https://www.ecdc.europa.eu/en/publications-data/surveillance-antimicrobial-consumption-europe-2022
12. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
13. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
14. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
15. Indicator Metadata Registry Details [Internet]. [cited 2024 May 2]. Available from: https://www.who.int/data/gho/indicator-metadata-registry/imr-details/5767
16. Robertson J, Vlahović-Palčevski V, Iwamoto K, Högberg LD, Godman B, Monnet DL, et al. Variations in the Consumption of Antimicrobial Medicines in the European Region, 2014–2018: Findings and Implications from ESAC-Net and WHO Europe. Front Pharmacol [Internet]. 2021 Jun 17 [cited 2024 Apr 5];12. Available from: https://www.frontiersin.org/journals/pharmacology/articles/10.3389/fphar.2021.639207/full