April 13, 2023 • 45 mins
Dr. Rupeena Purewal, Canadian Pediatric Infectious Diseases Physician from Saskatoon, Saskatchewan, summarizes the CARSS report for 2022.
Find the full report here: Canadian Antimicrobial Resistance Surveillance System (CARSS) Report 2022 - Canada.ca
Pan-Canadian Action on Antimicrobial Resistance: www.canada.ca/en/public-health/services/publications/drugs-health-products/pan-canadian-action-plan-antimicrobial-resistance.html
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Episode Transcript
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Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by
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Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal to welcome you to the first episode
of season two.
Dr. PirwalPurewal is a Canadian pediatric infectious diseases physician from Edmonton, Alberta.
She completed her medical school at the University of Pesh in Hungary and her three-year residency
program at West Virginia University.
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She returned to Canada in 2017 to start a pediatric infectious diseases fellowship at
the University of Manitoba.
Upon completing her fellowship, Dr. Purewal moved to Saskatchewan as a clinician and
academic physician at the University of Saskatchewan.
In this episode, Dr. Rupeena Purewal will review the Canadian Antimicrobial Resistance Surveillance
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System Report for 2022.
Dr. Purewal.
Hi everyone, welcome to another season of our podcast, the Canadian Breakpoint.
I'm your host, Dr. Rupeena Purewal.
I'm looking forward to a great season with new and exciting episodes and to present updates
on antimicrobials, AMR and diagnostics and much more.
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Thank you so much for all of your support we received last season and we look forward
to new episodes.
So prior to kicking off season two, I do want to disclose that this podcast is for informational
purposes only and in no way to endorse any products.
So we're going to kick off season two with updates from our CARS report.
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So this is the Canadian Antimicrobial Resistance Surveillance System Report 2022 that was released
recently.
And as many of you may know, it provides a five-year trend up to 2021.
Previously in our last season, our first episode, we actually recorded the CARS report that
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had updates till 2019.
So a lot of new information.
So you may wonder why are we talking about this today?
So the importance of this is really because globally it's estimated that 4.95 million
deaths in 2019 were associated with antimicrobial resistant bacterial infections.
If the resistance rates grow and they continue to grow to 40% in 2050, the cost of Canadian
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healthcare system will be anywhere close to $7.6 billion a year.
So as you can see, this is a very important topic.
We emphasize that in our first season as well.
And we had a lot of discussions around antimicrobial resistance and antibiotic stewardship as well.
Similarly, we'll have some upcoming episodes to discuss similar topics.
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So the interesting thing with this report is that it actually captures the effects of
the first full year of the pandemic.
And so there was a lot of information in the report regarding COVID and AMR and what really
happened.
So I think it's a quite exciting release of information for us and important information
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for us to actually know kind of what was noticed.
Now majority of this episode, I will be talking about what was mentioned in the report and
summarizing some of the key findings.
Now keeping in mind that this information is available through the CARS report, I do
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have some thoughts about some of the information that was presented that I will bring up today.
So stay tuned.
So overall, if we looked at the key findings in this report, in the CARS report 2022, there
was mention that there was sustained decrease in antimicrobial consumption.
And this is something that we will be talking about at the end of this episode.
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So stay tuned for more information in regarding to how there was a reduction of antibiotics
in both the healthcare and healthcare centers and community use as well.
Now in terms of overall, there was mention that there was increase in antimicrobial use
in patients that were hospitalized, especially those that were hospitalized with a concomitant
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COVID-19 infection.
Now, as all of us clinicians would know, that it was very difficult and is difficult to
be able to differentiate between the respiratory complications that are associated with COVID
infections and really the clinical challenges of diagnosing co-infections.
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And so in the report, this was also mentioned that there may be an increased risk for inappropriate
prescribing.
But we'll talk a little bit about that later in the episode as well, because I'm curious
and I do wonder if we'll continue to see some of the aftermath for years to follow.
Now in terms of some of the exciting things that were presented early in the report, where
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we're in regards to newer funding that was received in 2021.
So PHAC was able to make progress in a number of areas, which will help us fight this battle
against AMR.
And so for instance, in terms of detection, integrated lab diagnostic data have been incorporated
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that are being used to detect changes.
That's AMR-NET.
In terms of analyzing this data, so there is results from a newer survey that was piloted
actually in 2018 and 2019.
And this is the National Antimicrobial Prescribing Survey, which is going to help us expand our
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knowledge of appropriateness of prescriptions that are dispensed.
And also Canada is working on other surveillance systems as well to better understand how AMR
is spreading between countries.
So lots of exciting things.
We're going to talk a little bit more about the National Antimicrobial Prescribing Survey
later in this episode as well.
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Now in terms of actions, I think improving effectiveness of antimicrobial stewardship
programs and infection control interventions and using that data is really important.
And that was mentioned in this new funding proposal as well.
And something that's not going to be mentioned much in this report, but will be in upcoming
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reports, PHAC did initiate new surveillance activities.
So something to look forward to is, example, environmental surveillance.
So they're monitoring quantity of antimicrobials and wastewater samples from select Canadian
communities, and furthermore, trying to improve the representation of AMR surveillance, not
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to just include community and health care sectors, but also long-term care facilities
as well.
So I think there's a lot of updates.
There is a lot of new and exciting things that may not be in this report, but upcoming
next report.
But some of the things that we want to talk about today.
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So we're going to go into doing the key findings that were seen in 2016 and 2020.
So I'm going to do the next portion of this podcast episode will include some information
regarding our common pathogens that are under surveillance.
So we'll start off by talking a little bit about MRSA, then VRE, and then go on to discuss
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carbamase producing, intrabacterialase, and some of the other targets that were under
surveillance.
So without further ado, so in terms of the report this year, the NACAR's 2022 report,
when they looked at the trend from 2016 to 2020, in terms of MRSA bloodstream infections,
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the overall trend had increased.
So this data was reported to CNS with 62 out of 80 hospitals in 10 provinces and one territory.
So overall, they did see an increase since 2017 from the community-acquired, community-associated
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MRSA infections.
In terms of why that would be, there was some speculation of increased frequency of at-risk
behaviors in our Canadian population, examples being injection drug use and the ongoing opioid
epidemic.
Now, the overall incidence of MRSA bloodstream infections increased by 33%, of which, which
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was a bit alarming, was that 75% of the rise was in the community-associated MRSA bloodstream
infections.
And overall, looking at the samples that were submitted for, and the isolates submitted
for bloodstream infections, MRSA accounted for 16% of the staff-orious bloodstream isolates.
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Now, in terms of, when speaking of healthcare-associated MRSA isolates, the bloodstream infections
were down, so there was a downtrend there, by 2.3%.
It was interesting to see that pediatric hospital rates peaked in 2019 for MRSA bloodstream
infections and then stabilized thereafter, whereas in the adult and hospitals and mixed
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hospitals, these rates remain stable.
Now, going on to something that was also mentioned in the report was regarding susceptibility
patterns, and I think for us clinicians, this is really important and something that we
always need to keep in mind.
So looking at their data in terms of healthcare-associated MRSA isolates, I was pleased to see that trimethylamine
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sulfamethoxazole resistance remained low, so that was below 7%.
Arithromycin resistance decreased from 78% to 65%, and our clindamycin and erythromycin
resistance rates remained stable, so clinda being around 30% to 50%, and then for erythromycin
around 70% to 80%.
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Now the, I think something that was very alarming, now this is both in the healthcare-associated
and the community-associated MRSA isolates, but for the first time ever, there was non-susceptibility
to daptomycin that was identified.
So two isolates were from the healthcare-associated MRSA, two isolates in 2020, and similarly
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from the community-associated MRSA isolates, again, there was another two isolates for
the first time that had non-susceptibly to daptomycin, so this was quite alarming to
myself, and something that we should all be keeping in mind.
In terms of the healthcare-associated MRSA isolates, all the isolates tested susceptible
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to Linazolid, Tigacycline, and Vancomycin.
Just some quick reports on susceptibilities and sensitivities for the community-associated
MRSA isolates, though very similar rates for clindamycin and erythromycin.
Similarly TMP, sulfamethoxazole, rates remained low, less than 3%, and then as previously
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mentioned there were two isolates that were non-susceptible to daptomycin, and all of
the community-acquired and associated MRSA isolates were also tested susceptibility,
all were susceptible to Linazolid, Tigacycline, and Vancomycin.
So definitely something that stuck out to me was the daptomycin non-susceptibility patterns
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and then the ongoing resistance that we're seeing with clindamycin and erythromycin,
something that I took back from the report for the MRSA bloodstream infections.
And moving on to VREs, so vancomycin resistant enterococcus, bloodstream infections overall
trend in this report was also trending up, so has increased, although since 2018 the
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rate has slightly decreased.
There was some speculation that the increase in majority of the years was due to emergence
of a new sequence type, infection control policies, and likely related to our COVID-19
pandemic.
Now, the overall rate that peaked in 2018 increased by 72%, 99% of the isolates, so
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there were 683 isolates and 99% of them were enterococcus thesium, and 93% were acquired
in healthcare facility.
Now, the most common sequence types were mentioned in the report, so the sequence type, which
was done for ST17, 1478, and ST80 were the three most common types, and the largest increase
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that we did see was in our Canadian report was the sequence type 17, which went from
3% previously to up to 36% from 2016 to 2020.
In terms of our susceptibility patterns, there was some low level resistance detected to
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Tigacycline, Linazolid, and Daptomycin, but really only less than 9%, and actually has
for Daptomycin has even further declined to 3.5% in 2020, but just keeping in caution
that only a small number of isolates were actually evaluated, and all of them were resistant
to ciprofloxacin.
Moving on to our other pathogens, so carbapenemies producing enterobacterioles, the overall trend
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varied, so they did see an initial increase, but then decreased in the latter part of the
report, so 2019 to 2020, and likely related to infection control practices that were increased,
keeping in mind that colonization rates were not included in this report.
And looking at the CPE, so the carbapenemies producing enterobacterioles rates were the
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highest in central and western Canada and remain low in eastern Canada, of mention of
which genes were the most prevalent, so KPC, Cllebsiella pneumoniae, carbapenemies, NDM,
New Delhi metallo-betalactamase, and Oxa 48 in kind of the highest to least prevalence
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were reported still in Canada.
Now over 60% of the CPE isolates were resistant to septazidine, cipromeropenem, piptazo, and
trimethylamosulfamethoxazole.
We did see that with trimethylamosulfamethoxazole, resistance did increase by 13%, so something
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to keep in mind, and was mentioned in the report.
Now moving on, so they did talk in the report and speak about osteoides difficile, so C.
diff infections, and the overall trend actually decreased initially, but then they saw an
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increase in 2019 to 2020, now I'm sure why, again, likely related to the number of antibiotics
being prescribed.
And as we know, it had increased early in the pandemic.
In terms of what the report did mention that stuck out to me about C. diff infections,
so there was one hospital acquired C. diff infection that was noted to be resistant to
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metronidazole, but no isolates were resistant to vancomycin.
And in terms of the community acquired and associated C. diff infections, metronidazole
and vancomycin, there was no resistance found to those antimicrobials.
In terms of in Canada, what they noticed the trend for C. diff infections ribotypes, so
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what was the most common?
It was ribotypes RT106, 15% of over 330 isolates were of this ribotype, and this was similar
both in the hospital and community setting.
Now moving on to other organisms that were discussed in the report.
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So something that was brought up was data around the Nicere gonorrhea isolates.
Now if any of you tuned into our previous season, our last episode discussed disseminated
gonococcal infections, and even in that episode, we talked a lot about how these gonococcal
infections have continued to rise.
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And this report was quite fitting with the data that was presented there similarly because
this same surveillance program in Canada, so GASC Canada, Gonococcal Antimicrobial
Surveillance Program Canada, is where the CARS report obtained this data and Alberta,
Manitoba, Northwest Territories and Nova Scotia, the provinces providing such data to see the
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trends of AMR with Nicere gonorrhea isolates in Canada.
So the data here in the report did coincide with the concerns with the gonococcal infections
continuing to rise.
They did see that they were higher in males.
The rate increased by 44% during this duration of the five-year period.
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Globally and in Canada, there were isolates with decreased sensitivity and susceptibility
to extended spectrum cephalosporins.
And between 2016 and 2020, resistance of these strains to zithromycin remains threatened.
And that was a concerning factor brought up in the CARS report 2022.
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In terms of multidrug resistance strains, so this is when there's decreased susceptibility
to one currently recommended therapy, like a zithromycin or cephalosporin group, plus
two other antimicrobials and this ranges for Nicere gonorrhea anywhere from 6 to 12%.
There were warnings from WHO in regards to XDR strains.
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So as many of you may know, this is resistance to two current recommended therapies and two
other antimicrobials.
And XDR strains do exist and that gonococcal infections could become untreatable due to
the resistance to all antimicrobials.
So in this five-year period of the report, 11 cases of XDR were identified and there
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was mention that further surveillance was needed.
Something that was quite alarming was that seven of the cases were actually in 2018.
When looking at the report, it was mentioned that in 2020, the highest resistance for antimicrobials
was to ciprofloxacin at 57%.
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So something to keep in mind.
It is notable that there was a slight decline to decrease susceptibility to ceftraxone in
2020, went from 1.8 to 0.9%.
So in Canada, there were three cases of ceftraxone-resistant gonococcal strains that have been reported
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in 2017 and 2018.
And two of these were associated with international travel.
And then a third that was detected in December of 2021 was not related to international travel.
So I think there's a lot of moving parts with the nicaraguanaria and gonococcal infections.
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GAS continues to provide this information and surveillance around antimicrobial resistance.
There really is this enhanced surveillance of antimicrobial resistance that was actually
established back in 2013.
And the goal is really to understand the current trends and report them to prescribing physicians.
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So I think it's really important for us to keep this in mind.
I think for more details, it would be nice to listen to the disseminated gonococcal infections
episode.
So tune into that just to see what was discussed.
Moving on to other pathogens that were discussed.
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So there were reports about tuberculosis.
I for obvious reasons left tuberculosis out of this podcast episode today.
Although there's probably some likely changes.
They did mention that TB trends were stable in Canada.
Now we know some provinces are experiencing higher outbreaks in certain areas.
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And so for time purposes, I'll not review this during this episode.
Really we'll need to discuss and provide more inter-provincial data in the near future.
We did have an episode in our first season in terms of TB and the complicated presentations.
And so I think this season we will bring you some updates.
Now moving on to other organisms and pathogens that were discussed.
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So strep pneumoniae.
So invasive pneumococcal disease or invasive pneumococcal infections due to strep pneumoniae.
All trend in the report showed that we are seeing a trending up.
So there is a rate of infection increase and the rate of infection by vaccine preventable
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serotypes actually increased by 45%.
And this was something that really stuck out to me while reviewing this report and really
emphasize the importance of vaccinations in children.
So when we saw between 2015 to 2019, the rate of invasive pneumococcal disease increased
by 11%.
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And when we looked, when CARS report surveillance looked at the isolates that were submitted
to the National Micro Lab, so NML, between 2016 and 2020, where they received over 21
to 3600 strep pneumo isolates, of which two thirds were non-PCV13 isolates and a third
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of them were PCV13 isolates.
So something to consider and I think it directly can reflect some of the rate increases that
are alarming because of the vaccine preventable serotypes going up.
And again, emphasizing the importance of these primary vaccines.
So the report also mentioned some other concerning factors in terms of resistance of the strep
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pneumonia isolates that were submitted.
So overall, multiple antibiotics were tested in terms of some of the increases that they
saw.
So doxycycline, trimethylamine, sulfamethoxicill, both that increased around two to three percent,
clarithromycin up to 25% resistance patterns.
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Something that was alarming to me was the penicillin rates.
Now, considering that we know that there are penicillin resistant strep pneumonia isolates,
but the rates have increased to 10 to 15% as per the CARS 2022 report.
Now in terms of clindamycin resistance, it had initially increased up to 8% and then
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slightly down in 2020.
Fortunately, resistance to ceftraxin remained low and stable.
Lowest 0.2 to 0.7% from 2016 to 2020.
Similarly alongside carbapenem resistance also remained low, 0 to 2%.
It was mentioned that all isolates for strep pneumonia that were submitted were susceptible
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to vancomycin and linesalid.
Now things that also were mentioned in the report that came across to me as very alarming
was in 2016 and 2020, the multi-drug resistance rates were looked at for all age groups and
the highest increase of multi-drug resistance strep pneumoniae was seen in those aged less
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than one year of age.
So this went from anywhere 3% up to 27.8%.
I think I've mentioned this a couple of times during this episode, but really emphasizing
the importance of the primary vaccinations in this age group to really prevent these
infections.
And the highest proportion of the multi-drug resistance strains were seen in serotypes
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that can be covered by the PCV13 vaccine.
So serotypes 19A for instance and 19F.
Prevalence was anywhere from 25 to 35%.
So something to keep in mind, I talked a little bit about the penicillin resistance.
I did mention that amoxicillin clavulinate resistance also rose from zero up to 3.4%.
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Now moving on from strep pneumoniae, in the report there were discussions regarding invasive
group A strep infections, likely because we are seeing an increased rate of these infections.
So group A strep infects 18 million people globally.
And recently there's increased rates from anywhere from 4 to 6.7 cases per 100,000 between
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2010 and 2017.
So PHAC had enhanced its surveillance to keep an eye on invasive group A strep infections.
And overall the key findings from the report, so between 2015 to 2019, was reported that
the incident rate of invasive group A strep increased by 52.8%.
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So for the right reasons we had enhanced our surveillance, detecting these increased rates.
Other details in regards to susceptibility patterns were released.
So erythromycin resistance to group A strep was the highest, went from 8 to 11.5%.
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Clindamycin overall remained stable.
There was a slight increase in 2017 for resistance for these isolates, but remained stable otherwise
around 3%.
So that was reassuring.
All isolates remained susceptible to penicillin and vancomycin during this five year period.
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Now finally in terms of the pathogens that were discussed, so I didn't go too much into
detail about the next set of organisms, only because I think there's a lot of moving parts,
but also further discussions.
But in the report, in CARS 2022 report, there were isolates submitted and evaluated in surveillance
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for salmonella, both typhoidal and non-typhoidal.
So some things to keep in mind as travel is increasing, but also what our local patterns
are showing for salmonella and terecacerovir typhi, the number of isolates that were submitted
for testing nearly doubled.
In 2019, 78% of the isolates that were submitted were cerevarityphi.
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Majority of these isolates are coming from Ontario at 50% and then BC and then mostly
Alberta at 14%.
In 2016 to 2019, in terms of the typhoidal salmonella, there was reports of ceftraxone
resistance that had increased from 0.5 up to 4.5%.
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So that's something that we should all be aware of, especially for prescribers, considering
that empiric treatment can include ceftraxone.
Now for non-typhoidal salmonella, azithromycin resistance increased from 0.5 to 2.3%, but
it was noted that cyprofloxacin resistance remained stable during this period for these
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non-typhoidal strains.
The other kind of alarming finding was in 2019 for the salmonella and tereca isolates
that 12% of the typhoidal and 17% of the non-typhoidal were resistant to three or more classes of
antimicrobial.
So obviously emphasizing the importance of susceptibility testing, surveillance, and
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hospitals submitting these isolates for testing as well.
So those were the main pathogens that I wanted to discuss today in terms of the surveillance
and trends that were seen in the CARS 2022 report.
Now I just wanted to shift gears a bit to antimicrobial use in humans because as we
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know that part of the CARS report, there is data around antimicrobial use and there was
a lot of national, provincial, and international data that was provided in the CARS report
this year or over this five-year trend.
So just to remind everybody, when we're talking about antimicrobial use in humans, so PHAC
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uses data from hospital purchases of antibiotics and this really reflects consumption in the
healthcare sector.
Alongside that, antibiotics that are dispensed in retail pharmacies, this data is used to
reflect antibiotic consumption in the community sector.
So that is how this information is obtained.
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Always keeping in mind that not all hospital purchases of these antimicrobials are used,
but overall gives us a good picture of antimicrobial use and prescribing data.
So nationally in the CARS 2022 report, the overall antibiotic consumption between 2017
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and 2021 decreased by 27%.
And this was seen both in the healthcare sector and the community sector that experienced
this decline.
And obviously coinciding with that would be a decline in spending on antimicrobials in
both the sectors.
Now that was important information, but keeping in mind that a part of this data was obtained
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during early pandemic times when infection control practices and the changes in care
and providing care were much different as well.
So it would be interesting to see how this trend continues.
But going into nationally what we were seeing, so in the healthcare sector, cephalosporins
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like first, second, and third generations were the generation cephalosporins were highest
consumed.
When looking at the community sector, tetracyclines and penicillins being the top two all around
antibiotics that were prescribed.
And when we looked at prescriber data, actually it was seen that there was an overall decrease
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in prescribing rates amongst all prescribers.
This include family doctors, GPs, specialists, and non-physician specialists, which include
dentists.
And they all had a decrease in prescribing rates, but with general practitioners having
a decline of up to 42.8% during this national five-year report.
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Now provincially what we saw, so all provinces experienced a decline in 2017 to 2021, although
Atlantic Canada had the highest consumption in 2021.
They had the second largest decline as well.
Second to the Prairie provinces that included Alberta, Saskatchewan, and Manitoba.
Ontario showed the least decline and Quebec had the lowest consumption of antimicrobials
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during this five-year period.
I think it's always important to not only look at provincial and national data, but
how do we compare ourselves, so Canada compared to other countries.
And in terms of this international data, which is provided in the CARS 2022 report, Canada
ranked the 10th lowest consumer of antimicrobials per capita in 2020, when it was compared to
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30 European countries.
So just to kind of give you perspective, the Netherlands was the lowest, came at the lowest
consuming country, and we, in comparison to them, consumed 50% more antimicrobials.
So I think for us to talk a little bit about some of the newer things around antimicrobial
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prescribing, including the Canadian National Antimicrobial Prescribing Survey, I think
it's important for us to gear attention towards the aware antimicrobial categorizations that
were listed by WHO.
And so these are antimicrobial agents, so antibiotics that are basically placed into
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three different categories in terms of their resistance, their first line agents, or last
resort agents.
So for instance, the three categories are, and the reason I'm bringing this up is because
it's important to understand that not all antimicrobials or antibiotics can be categorized
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in the same way.
And this was something that was brought up, or something that came up in my mind as I
was reviewing the report in terms of, you know, is this a medication or an antibiotic
that has the, you know, is a reserve category?
So a last resort drug has increased rates.
That's a bit more alarming to me, although keeping in mind that all antimicrobial use
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and resistance patterns that are increasing are alarming.
So just going back to kind of defining some of the terms that WHO has set out for these
categories.
So there's three different categories.
There's access drugs, watch drugs, and reserve drugs.
Access drugs count as low risk of resistance, and they're usually used to treat commonly
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susceptible organisms.
The watch category obviously is the middle category.
So some may think of it as like borderline.
So these are higher potential for resistance, and these are usually your first or second
line drugs.
And then your final and third category is the reserve or last resort drugs.
And these are antimicrobials listed that treat infections that are caused by multi drug resistant
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organisms and really the alarming factor in this report from 2017 to 2021, human consumption
of the reserve antibiotics increased by 25%.
And this was mainly driven by a 43% increase in the use of antimicrobials in the healthcare
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sector, although decreased in the community sector.
So of this, just to give you an example, just to put it into perspective, especially for
clinicians, pharmacists, and those that are prescribing, Daptomycin, which counts as a
reserve or last resort drug, was the most commonly consumed drug from the reserve group.
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And the use increased by 65.8%.
And 68% of that was in the healthcare sector and 38% in the community.
So I think that's something that when I was reading the report, I was thinking about how
many times we've had to prescribe Daptomycin in our hospital setting, but something to
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keep in mind in part for those that are running antimicrobial stewardship programs, informing
consumers this information and providing this information, I think is quite valuable.
So in terms of when we looked at consumption overall, in terms of, for instance, another
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category of drugs, so carbapenems, they did see a decrease by 33% and 50% decline in the
healthcare sector.
And the community, however, did see a slight increase of 21%.
And this included urtapenem as well as meropenem.
So in order for us to kind of understand that, I think it's important for us to see what
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is the ongoing surveillance and really thinking about and talking about one of the newest,
I would say additions or one of the newest additions that was mentioned in the CARS 2022
report was the Canadian National Antimicrobial Prescribing Survey.
And I don't think I'll do justice in explaining everything, but what was mentioned in the
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report was quite fascinating.
I think this is definitely a survey that looks at prescribing practices in the healthcare
sector and provides quite valuable information.
Initially when it was piloted, so it's referred to as NAPS, and when it was piloted in 2018
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and 2019, they had some good response.
And as of 2022, over 119 healthcare facilities across Canada, so across the 10 provinces,
including actually the 12 pediatric academic hospitals, are currently involved in reporting
information and involved in for allow PHAC to obtain data from the prescribing information.
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So keeping in mind that participation is voluntary for the hospitals in terms of this data.
But overall, just to give you kind of an overview of really what was presented in the report
and what is the role of NAPS, it was mentioned that it provides qualitative and quantitative
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information.
So for instance, it can give you kind of the insights on prescribing behaviors, helps identify
clinical indications and antimicrobial use patterns.
It also looked at if hospitals followed guidelines for antibiotic choice, dosage, route and duration
and benchmarking.
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So a lot of this information led to figuring out appropriateness and inappropriateness
of antibiotic use, which I think coincides with helping us reduce antimicrobial resistance.
So the key findings from the CARS 2022 report, which are obtained from these 90 NAPS audits
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in 2018 and 2019 from 64 hospitals, showed that 77.5% of hospital antibiotic prescriptions
were deemed appropriate across Canada.
That was something that I was pleased to see.
Overall, based on the aware category.
So we talked about those, the access drugs and then the watch drugs and finally, reserved
(39:39):
drugs.
37% of the antibiotics were from, in terms of looking at the antibiotic prescriptions,
were from the access category.
There was a higher percentage from the watch categories, around 61%.
And then only 1.8% from the reserved drugs.
(40:01):
Now among the 20 antibiotics that were prescribed that they looked at, only four had appropriateness
levels of less than 70%.
And that was nitrofra-antoine, sephiroxime, levofloxine and moxifloxacin.
They did look at specialties as well and break it down in terms of which specialties had
the highest level of appropriateness.
(40:22):
And with pediatrics, hematology, gynecology, infectious disease and emergency medicine,
taking the top five for appropriateness.
And then finally, also, we're able to provide this data across the provinces and comparing
the provinces and regions with the highest level of appropriate antibiotic use or prescribing
(40:46):
in Western region, which included BC, Alberta, Saskatchewan and Manitoba.
So that was quite, I think that was very different information that was provided from our previous
reports and it was nice to see that there's ongoing surveillance there.
And so for those that were not aware, just like myself, that was quite informational.
(41:10):
Now lastly, before I end this episode, because obviously we've talked about so many numbers
and such great data that was presented in the CARS 2022 report that I could probably
talk about this more and more.
But if there is anything in terms of detailed information that you would want, this is obviously
(41:31):
just a summary of the report, but the CARS 2022 report is available online.
Now before I end this episode, I did want to talk a little bit about, I think it's kind
of something that everybody was wondering about, was the antibiotic use and human antibiotic
use in the community sector kind of before and during the pandemic.
(41:54):
And so some of the data that was released in the CARS 2022 report, which was quite interesting,
was looked at nationally.
So the national data in terms of the average monthly prescriptions, if we look at, I think
the easiest way to do this is looking at before the pandemic, when we looked at the average
(42:16):
monthly prescriptions in Canada, they would range from 45 to 66 per thousand inhabitants,
always having a peak, kind of in our highest rates of prescribing months were May to October,
peaking in January and kind of coincides with respiratory infections and their complications.
And then the lowest infection or prescribing rates in summertime, so June and July.
(42:41):
So looking at that was 45 to 66 per thousand inhabitants.
Now comparing this to when the pandemic started, so reminding ourselves that March to April
2020 was the start of the pandemic and community scripts had declined by 31 percent during
the pandemic.
So rates remained low.
(43:03):
And so the that prescribing average monthly prescriptions in Canada now only ranged from
anywhere around 37 per thousand inhabitants.
So we did see a decline and not only a decline in the community scripts themselves, but also
in the hospital sector, there was a decline by 25 percent.
(43:24):
We looked at the overall trend in 2017 to 2021 and eight percent of which was between
2019 and 2020.
So some of that information, when I took that information, you know, it's hard to correlate,
was this really due to the new and modified means of accessing health care, which the
(43:45):
report also mentioned?
And that's exactly what I was thinking because of public health measures.
Are we going to continue to see this decline?
Obviously there are, you know, initially some of the rates were different in terms of what
we were seeing early on when we didn't know much about COVID-19.
(44:05):
But it would be interesting to see how these trends continue now that we have data from
before the pandemic, the start of the pandemic and some data years around, so years later.
So I think it would be interesting for all of us to stay tuned to see what the next CARS
(44:27):
report reporting period.
I think there's a lot of exciting surveillance going on and there was a lot of important
information that was presented in this report.
So I'm happy to give everybody a summary on this report and if you guys have any questions,
ideas, topics, or other topics that you would want to discuss this season, please feel free
(44:51):
to reach out to us through Twitter, email, and share this information because I think
it's really important and for not only prescribers alone, but I think anybody in the health care
sector.
So thanks for tuning in.
Really appreciate it.
And like I mentioned, we're looking forward to a great list of speakers this season.
(45:16):
If you have the desire to come on to the podcast as a guest, we're more than happy to host
you as well.
Thanks for tuning in.
Take care.
Thank you, Dr. Pirwal.
Thanks for joining us.
If you have a topic suggestion, email us at thecanadianbreakpoint at gmail.com or tweet
(45:37):
us at cabreakpoint.
See you again soon at the Canadian Breakpoint.
Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by
(00:13):
Canadian infectious diseases physicians.
I'm Summer Stewart, here with Dr. Rupeena Purewal to welcome you to the first episode
of season two.
Dr. PirwalPurewal is a Canadian pediatric infectious diseases physician from Edmonton, Alberta.
She completed her medical school at the University of Pesh in Hungary and her three-year residency
program at West Virginia University.
(00:36):
She returned to Canada in 2017 to start a pediatric infectious diseases fellowship at
the University of Manitoba.
Upon completing her fellowship, Dr. Purewal moved to Saskatchewan as a clinician and
academic physician at the University of Saskatchewan.
In this episode, Dr. Rupeena Purewal will review the Canadian Antimicrobial Resistance Surveillance
(00:58):
System Report for 2022.
Dr. Purewal.
Hi everyone, welcome to another season of our podcast, the Canadian Breakpoint.
I'm your host, Dr. Rupeena Purewal.
I'm looking forward to a great season with new and exciting episodes and to present updates
on antimicrobials, AMR and diagnostics and much more.
(01:20):
Thank you so much for all of your support we received last season and we look forward
to new episodes.
So prior to kicking off season two, I do want to disclose that this podcast is for informational
purposes only and in no way to endorse any products.
So we're going to kick off season two with updates from our CARS report.
(01:41):
So this is the Canadian Antimicrobial Resistance Surveillance System Report 2022 that was released
recently.
And as many of you may know, it provides a five-year trend up to 2021.
Previously in our last season, our first episode, we actually recorded the CARS report that
(02:02):
had updates till 2019.
So a lot of new information.
So you may wonder why are we talking about this today?
So the importance of this is really because globally it's estimated that 4.95 million
deaths in 2019 were associated with antimicrobial resistant bacterial infections.
If the resistance rates grow and they continue to grow to 40% in 2050, the cost of Canadian
(02:28):
healthcare system will be anywhere close to $7.6 billion a year.
So as you can see, this is a very important topic.
We emphasize that in our first season as well.
And we had a lot of discussions around antimicrobial resistance and antibiotic stewardship as well.
Similarly, we'll have some upcoming episodes to discuss similar topics.
(02:54):
So the interesting thing with this report is that it actually captures the effects of
the first full year of the pandemic.
And so there was a lot of information in the report regarding COVID and AMR and what really
happened.
So I think it's a quite exciting release of information for us and important information
(03:16):
for us to actually know kind of what was noticed.
Now majority of this episode, I will be talking about what was mentioned in the report and
summarizing some of the key findings.
Now keeping in mind that this information is available through the CARS report, I do
(03:37):
have some thoughts about some of the information that was presented that I will bring up today.
So stay tuned.
So overall, if we looked at the key findings in this report, in the CARS report 2022, there
was mention that there was sustained decrease in antimicrobial consumption.
And this is something that we will be talking about at the end of this episode.
(03:59):
So stay tuned for more information in regarding to how there was a reduction of antibiotics
in both the healthcare and healthcare centers and community use as well.
Now in terms of overall, there was mention that there was increase in antimicrobial use
in patients that were hospitalized, especially those that were hospitalized with a concomitant
(04:24):
COVID-19 infection.
Now, as all of us clinicians would know, that it was very difficult and is difficult to
be able to differentiate between the respiratory complications that are associated with COVID
infections and really the clinical challenges of diagnosing co-infections.
(04:45):
And so in the report, this was also mentioned that there may be an increased risk for inappropriate
prescribing.
But we'll talk a little bit about that later in the episode as well, because I'm curious
and I do wonder if we'll continue to see some of the aftermath for years to follow.
Now in terms of some of the exciting things that were presented early in the report, where
(05:09):
we're in regards to newer funding that was received in 2021.
So PHAC was able to make progress in a number of areas, which will help us fight this battle
against AMR.
And so for instance, in terms of detection, integrated lab diagnostic data have been incorporated
(05:31):
that are being used to detect changes.
That's AMR-NET.
In terms of analyzing this data, so there is results from a newer survey that was piloted
actually in 2018 and 2019.
And this is the National Antimicrobial Prescribing Survey, which is going to help us expand our
(05:54):
knowledge of appropriateness of prescriptions that are dispensed.
And also Canada is working on other surveillance systems as well to better understand how AMR
is spreading between countries.
So lots of exciting things.
We're going to talk a little bit more about the National Antimicrobial Prescribing Survey
later in this episode as well.
(06:14):
Now in terms of actions, I think improving effectiveness of antimicrobial stewardship
programs and infection control interventions and using that data is really important.
And that was mentioned in this new funding proposal as well.
And something that's not going to be mentioned much in this report, but will be in upcoming
(06:37):
reports, PHAC did initiate new surveillance activities.
So something to look forward to is, example, environmental surveillance.
So they're monitoring quantity of antimicrobials and wastewater samples from select Canadian
communities, and furthermore, trying to improve the representation of AMR surveillance, not
(06:59):
to just include community and health care sectors, but also long-term care facilities
as well.
So I think there's a lot of updates.
There is a lot of new and exciting things that may not be in this report, but upcoming
next report.
But some of the things that we want to talk about today.
(07:19):
So we're going to go into doing the key findings that were seen in 2016 and 2020.
So I'm going to do the next portion of this podcast episode will include some information
regarding our common pathogens that are under surveillance.
So we'll start off by talking a little bit about MRSA, then VRE, and then go on to discuss
(07:41):
carbamase producing, intrabacterialase, and some of the other targets that were under
surveillance.
So without further ado, so in terms of the report this year, the NACAR's 2022 report,
when they looked at the trend from 2016 to 2020, in terms of MRSA bloodstream infections,
(08:04):
the overall trend had increased.
So this data was reported to CNS with 62 out of 80 hospitals in 10 provinces and one territory.
So overall, they did see an increase since 2017 from the community-acquired, community-associated
(08:24):
MRSA infections.
In terms of why that would be, there was some speculation of increased frequency of at-risk
behaviors in our Canadian population, examples being injection drug use and the ongoing opioid
epidemic.
Now, the overall incidence of MRSA bloodstream infections increased by 33%, of which, which
(08:48):
was a bit alarming, was that 75% of the rise was in the community-associated MRSA bloodstream
infections.
And overall, looking at the samples that were submitted for, and the isolates submitted
for bloodstream infections, MRSA accounted for 16% of the staff-orious bloodstream isolates.
(09:09):
Now, in terms of, when speaking of healthcare-associated MRSA isolates, the bloodstream infections
were down, so there was a downtrend there, by 2.3%.
It was interesting to see that pediatric hospital rates peaked in 2019 for MRSA bloodstream
infections and then stabilized thereafter, whereas in the adult and hospitals and mixed
(09:31):
hospitals, these rates remain stable.
Now, going on to something that was also mentioned in the report was regarding susceptibility
patterns, and I think for us clinicians, this is really important and something that we
always need to keep in mind.
So looking at their data in terms of healthcare-associated MRSA isolates, I was pleased to see that trimethylamine
(09:57):
sulfamethoxazole resistance remained low, so that was below 7%.
Arithromycin resistance decreased from 78% to 65%, and our clindamycin and erythromycin
resistance rates remained stable, so clinda being around 30% to 50%, and then for erythromycin
around 70% to 80%.
(10:19):
Now the, I think something that was very alarming, now this is both in the healthcare-associated
and the community-associated MRSA isolates, but for the first time ever, there was non-susceptibility
to daptomycin that was identified.
So two isolates were from the healthcare-associated MRSA, two isolates in 2020, and similarly
(10:42):
from the community-associated MRSA isolates, again, there was another two isolates for
the first time that had non-susceptibly to daptomycin, so this was quite alarming to
myself, and something that we should all be keeping in mind.
In terms of the healthcare-associated MRSA isolates, all the isolates tested susceptible
(11:03):
to Linazolid, Tigacycline, and Vancomycin.
Just some quick reports on susceptibilities and sensitivities for the community-associated
MRSA isolates, though very similar rates for clindamycin and erythromycin.
Similarly TMP, sulfamethoxazole, rates remained low, less than 3%, and then as previously
(11:28):
mentioned there were two isolates that were non-susceptible to daptomycin, and all of
the community-acquired and associated MRSA isolates were also tested susceptibility,
all were susceptible to Linazolid, Tigacycline, and Vancomycin.
So definitely something that stuck out to me was the daptomycin non-susceptibility patterns
(11:53):
and then the ongoing resistance that we're seeing with clindamycin and erythromycin,
something that I took back from the report for the MRSA bloodstream infections.
And moving on to VREs, so vancomycin resistant enterococcus, bloodstream infections overall
trend in this report was also trending up, so has increased, although since 2018 the
(12:17):
rate has slightly decreased.
There was some speculation that the increase in majority of the years was due to emergence
of a new sequence type, infection control policies, and likely related to our COVID-19
pandemic.
Now, the overall rate that peaked in 2018 increased by 72%, 99% of the isolates, so
(12:42):
there were 683 isolates and 99% of them were enterococcus thesium, and 93% were acquired
in healthcare facility.
Now, the most common sequence types were mentioned in the report, so the sequence type, which
was done for ST17, 1478, and ST80 were the three most common types, and the largest increase
(13:06):
that we did see was in our Canadian report was the sequence type 17, which went from
3% previously to up to 36% from 2016 to 2020.
In terms of our susceptibility patterns, there was some low level resistance detected to
(13:28):
Tigacycline, Linazolid, and Daptomycin, but really only less than 9%, and actually has
for Daptomycin has even further declined to 3.5% in 2020, but just keeping in caution
that only a small number of isolates were actually evaluated, and all of them were resistant
to ciprofloxacin.
Moving on to our other pathogens, so carbapenemies producing enterobacterioles, the overall trend
(13:55):
varied, so they did see an initial increase, but then decreased in the latter part of the
report, so 2019 to 2020, and likely related to infection control practices that were increased,
keeping in mind that colonization rates were not included in this report.
And looking at the CPE, so the carbapenemies producing enterobacterioles rates were the
(14:25):
highest in central and western Canada and remain low in eastern Canada, of mention of
which genes were the most prevalent, so KPC, Cllebsiella pneumoniae, carbapenemies, NDM,
New Delhi metallo-betalactamase, and Oxa 48 in kind of the highest to least prevalence
(14:47):
were reported still in Canada.
Now over 60% of the CPE isolates were resistant to septazidine, cipromeropenem, piptazo, and
trimethylamosulfamethoxazole.
We did see that with trimethylamosulfamethoxazole, resistance did increase by 13%, so something
(15:07):
to keep in mind, and was mentioned in the report.
Now moving on, so they did talk in the report and speak about osteoides difficile, so C.
diff infections, and the overall trend actually decreased initially, but then they saw an
(15:28):
increase in 2019 to 2020, now I'm sure why, again, likely related to the number of antibiotics
being prescribed.
And as we know, it had increased early in the pandemic.
In terms of what the report did mention that stuck out to me about C. diff infections,
so there was one hospital acquired C. diff infection that was noted to be resistant to
(15:51):
metronidazole, but no isolates were resistant to vancomycin.
And in terms of the community acquired and associated C. diff infections, metronidazole
and vancomycin, there was no resistance found to those antimicrobials.
In terms of in Canada, what they noticed the trend for C. diff infections ribotypes, so
(16:14):
what was the most common?
It was ribotypes RT106, 15% of over 330 isolates were of this ribotype, and this was similar
both in the hospital and community setting.
Now moving on to other organisms that were discussed in the report.
(16:37):
So something that was brought up was data around the Nicere gonorrhea isolates.
Now if any of you tuned into our previous season, our last episode discussed disseminated
gonococcal infections, and even in that episode, we talked a lot about how these gonococcal
infections have continued to rise.
(16:59):
And this report was quite fitting with the data that was presented there similarly because
this same surveillance program in Canada, so GASC Canada, Gonococcal Antimicrobial
Surveillance Program Canada, is where the CARS report obtained this data and Alberta,
Manitoba, Northwest Territories and Nova Scotia, the provinces providing such data to see the
(17:24):
trends of AMR with Nicere gonorrhea isolates in Canada.
So the data here in the report did coincide with the concerns with the gonococcal infections
continuing to rise.
They did see that they were higher in males.
The rate increased by 44% during this duration of the five-year period.
(17:48):
Globally and in Canada, there were isolates with decreased sensitivity and susceptibility
to extended spectrum cephalosporins.
And between 2016 and 2020, resistance of these strains to zithromycin remains threatened.
And that was a concerning factor brought up in the CARS report 2022.
(18:12):
In terms of multidrug resistance strains, so this is when there's decreased susceptibility
to one currently recommended therapy, like a zithromycin or cephalosporin group, plus
two other antimicrobials and this ranges for Nicere gonorrhea anywhere from 6 to 12%.
There were warnings from WHO in regards to XDR strains.
(18:34):
So as many of you may know, this is resistance to two current recommended therapies and two
other antimicrobials.
And XDR strains do exist and that gonococcal infections could become untreatable due to
the resistance to all antimicrobials.
So in this five-year period of the report, 11 cases of XDR were identified and there
(18:59):
was mention that further surveillance was needed.
Something that was quite alarming was that seven of the cases were actually in 2018.
When looking at the report, it was mentioned that in 2020, the highest resistance for antimicrobials
was to ciprofloxacin at 57%.
(19:19):
So something to keep in mind.
It is notable that there was a slight decline to decrease susceptibility to ceftraxone in
2020, went from 1.8 to 0.9%.
So in Canada, there were three cases of ceftraxone-resistant gonococcal strains that have been reported
(19:42):
in 2017 and 2018.
And two of these were associated with international travel.
And then a third that was detected in December of 2021 was not related to international travel.
So I think there's a lot of moving parts with the nicaraguanaria and gonococcal infections.
(20:02):
GAS continues to provide this information and surveillance around antimicrobial resistance.
There really is this enhanced surveillance of antimicrobial resistance that was actually
established back in 2013.
And the goal is really to understand the current trends and report them to prescribing physicians.
(20:24):
So I think it's really important for us to keep this in mind.
I think for more details, it would be nice to listen to the disseminated gonococcal infections
episode.
So tune into that just to see what was discussed.
Moving on to other pathogens that were discussed.
(20:45):
So there were reports about tuberculosis.
I for obvious reasons left tuberculosis out of this podcast episode today.
Although there's probably some likely changes.
They did mention that TB trends were stable in Canada.
Now we know some provinces are experiencing higher outbreaks in certain areas.
(21:09):
And so for time purposes, I'll not review this during this episode.
Really we'll need to discuss and provide more inter-provincial data in the near future.
We did have an episode in our first season in terms of TB and the complicated presentations.
And so I think this season we will bring you some updates.
Now moving on to other organisms and pathogens that were discussed.
(21:32):
So strep pneumoniae.
So invasive pneumococcal disease or invasive pneumococcal infections due to strep pneumoniae.
All trend in the report showed that we are seeing a trending up.
So there is a rate of infection increase and the rate of infection by vaccine preventable
(21:53):
serotypes actually increased by 45%.
And this was something that really stuck out to me while reviewing this report and really
emphasize the importance of vaccinations in children.
So when we saw between 2015 to 2019, the rate of invasive pneumococcal disease increased
by 11%.
(22:15):
And when we looked, when CARS report surveillance looked at the isolates that were submitted
to the National Micro Lab, so NML, between 2016 and 2020, where they received over 21
to 3600 strep pneumo isolates, of which two thirds were non-PCV13 isolates and a third
(22:39):
of them were PCV13 isolates.
So something to consider and I think it directly can reflect some of the rate increases that
are alarming because of the vaccine preventable serotypes going up.
And again, emphasizing the importance of these primary vaccines.
So the report also mentioned some other concerning factors in terms of resistance of the strep
(23:03):
pneumonia isolates that were submitted.
So overall, multiple antibiotics were tested in terms of some of the increases that they
saw.
So doxycycline, trimethylamine, sulfamethoxicill, both that increased around two to three percent,
clarithromycin up to 25% resistance patterns.
(23:24):
Something that was alarming to me was the penicillin rates.
Now, considering that we know that there are penicillin resistant strep pneumonia isolates,
but the rates have increased to 10 to 15% as per the CARS 2022 report.
Now in terms of clindamycin resistance, it had initially increased up to 8% and then
(23:45):
slightly down in 2020.
Fortunately, resistance to ceftraxin remained low and stable.
Lowest 0.2 to 0.7% from 2016 to 2020.
Similarly alongside carbapenem resistance also remained low, 0 to 2%.
It was mentioned that all isolates for strep pneumonia that were submitted were susceptible
(24:09):
to vancomycin and linesalid.
Now things that also were mentioned in the report that came across to me as very alarming
was in 2016 and 2020, the multi-drug resistance rates were looked at for all age groups and
the highest increase of multi-drug resistance strep pneumoniae was seen in those aged less
(24:33):
than one year of age.
So this went from anywhere 3% up to 27.8%.
I think I've mentioned this a couple of times during this episode, but really emphasizing
the importance of the primary vaccinations in this age group to really prevent these
infections.
And the highest proportion of the multi-drug resistance strains were seen in serotypes
(24:56):
that can be covered by the PCV13 vaccine.
So serotypes 19A for instance and 19F.
Prevalence was anywhere from 25 to 35%.
So something to keep in mind, I talked a little bit about the penicillin resistance.
I did mention that amoxicillin clavulinate resistance also rose from zero up to 3.4%.
(25:23):
Now moving on from strep pneumoniae, in the report there were discussions regarding invasive
group A strep infections, likely because we are seeing an increased rate of these infections.
So group A strep infects 18 million people globally.
And recently there's increased rates from anywhere from 4 to 6.7 cases per 100,000 between
(25:48):
2010 and 2017.
So PHAC had enhanced its surveillance to keep an eye on invasive group A strep infections.
And overall the key findings from the report, so between 2015 to 2019, was reported that
the incident rate of invasive group A strep increased by 52.8%.
(26:11):
So for the right reasons we had enhanced our surveillance, detecting these increased rates.
Other details in regards to susceptibility patterns were released.
So erythromycin resistance to group A strep was the highest, went from 8 to 11.5%.
(26:31):
Clindamycin overall remained stable.
There was a slight increase in 2017 for resistance for these isolates, but remained stable otherwise
around 3%.
So that was reassuring.
All isolates remained susceptible to penicillin and vancomycin during this five year period.
(26:52):
Now finally in terms of the pathogens that were discussed, so I didn't go too much into
detail about the next set of organisms, only because I think there's a lot of moving parts,
but also further discussions.
But in the report, in CARS 2022 report, there were isolates submitted and evaluated in surveillance
(27:18):
for salmonella, both typhoidal and non-typhoidal.
So some things to keep in mind as travel is increasing, but also what our local patterns
are showing for salmonella and terecacerovir typhi, the number of isolates that were submitted
for testing nearly doubled.
In 2019, 78% of the isolates that were submitted were cerevarityphi.
(27:44):
Majority of these isolates are coming from Ontario at 50% and then BC and then mostly
Alberta at 14%.
In 2016 to 2019, in terms of the typhoidal salmonella, there was reports of ceftraxone
resistance that had increased from 0.5 up to 4.5%.
(28:06):
So that's something that we should all be aware of, especially for prescribers, considering
that empiric treatment can include ceftraxone.
Now for non-typhoidal salmonella, azithromycin resistance increased from 0.5 to 2.3%, but
it was noted that cyprofloxacin resistance remained stable during this period for these
(28:30):
non-typhoidal strains.
The other kind of alarming finding was in 2019 for the salmonella and tereca isolates
that 12% of the typhoidal and 17% of the non-typhoidal were resistant to three or more classes of
antimicrobial.
So obviously emphasizing the importance of susceptibility testing, surveillance, and
(28:54):
hospitals submitting these isolates for testing as well.
So those were the main pathogens that I wanted to discuss today in terms of the surveillance
and trends that were seen in the CARS 2022 report.
Now I just wanted to shift gears a bit to antimicrobial use in humans because as we
(29:18):
know that part of the CARS report, there is data around antimicrobial use and there was
a lot of national, provincial, and international data that was provided in the CARS report
this year or over this five-year trend.
So just to remind everybody, when we're talking about antimicrobial use in humans, so PHAC
(29:39):
uses data from hospital purchases of antibiotics and this really reflects consumption in the
healthcare sector.
Alongside that, antibiotics that are dispensed in retail pharmacies, this data is used to
reflect antibiotic consumption in the community sector.
So that is how this information is obtained.
(30:00):
Always keeping in mind that not all hospital purchases of these antimicrobials are used,
but overall gives us a good picture of antimicrobial use and prescribing data.
So nationally in the CARS 2022 report, the overall antibiotic consumption between 2017
(30:24):
and 2021 decreased by 27%.
And this was seen both in the healthcare sector and the community sector that experienced
this decline.
And obviously coinciding with that would be a decline in spending on antimicrobials in
both the sectors.
Now that was important information, but keeping in mind that a part of this data was obtained
(30:48):
during early pandemic times when infection control practices and the changes in care
and providing care were much different as well.
So it would be interesting to see how this trend continues.
But going into nationally what we were seeing, so in the healthcare sector, cephalosporins
(31:08):
like first, second, and third generations were the generation cephalosporins were highest
consumed.
When looking at the community sector, tetracyclines and penicillins being the top two all around
antibiotics that were prescribed.
And when we looked at prescriber data, actually it was seen that there was an overall decrease
(31:31):
in prescribing rates amongst all prescribers.
This include family doctors, GPs, specialists, and non-physician specialists, which include
dentists.
And they all had a decrease in prescribing rates, but with general practitioners having
a decline of up to 42.8% during this national five-year report.
(31:52):
Now provincially what we saw, so all provinces experienced a decline in 2017 to 2021, although
Atlantic Canada had the highest consumption in 2021.
They had the second largest decline as well.
Second to the Prairie provinces that included Alberta, Saskatchewan, and Manitoba.
Ontario showed the least decline and Quebec had the lowest consumption of antimicrobials
(32:16):
during this five-year period.
I think it's always important to not only look at provincial and national data, but
how do we compare ourselves, so Canada compared to other countries.
And in terms of this international data, which is provided in the CARS 2022 report, Canada
ranked the 10th lowest consumer of antimicrobials per capita in 2020, when it was compared to
(32:43):
30 European countries.
So just to kind of give you perspective, the Netherlands was the lowest, came at the lowest
consuming country, and we, in comparison to them, consumed 50% more antimicrobials.
So I think for us to talk a little bit about some of the newer things around antimicrobial
(33:08):
prescribing, including the Canadian National Antimicrobial Prescribing Survey, I think
it's important for us to gear attention towards the aware antimicrobial categorizations that
were listed by WHO.
And so these are antimicrobial agents, so antibiotics that are basically placed into
(33:29):
three different categories in terms of their resistance, their first line agents, or last
resort agents.
So for instance, the three categories are, and the reason I'm bringing this up is because
it's important to understand that not all antimicrobials or antibiotics can be categorized
(33:52):
in the same way.
And this was something that was brought up, or something that came up in my mind as I
was reviewing the report in terms of, you know, is this a medication or an antibiotic
that has the, you know, is a reserve category?
So a last resort drug has increased rates.
That's a bit more alarming to me, although keeping in mind that all antimicrobial use
(34:17):
and resistance patterns that are increasing are alarming.
So just going back to kind of defining some of the terms that WHO has set out for these
categories.
So there's three different categories.
There's access drugs, watch drugs, and reserve drugs.
Access drugs count as low risk of resistance, and they're usually used to treat commonly
(34:41):
susceptible organisms.
The watch category obviously is the middle category.
So some may think of it as like borderline.
So these are higher potential for resistance, and these are usually your first or second
line drugs.
And then your final and third category is the reserve or last resort drugs.
And these are antimicrobials listed that treat infections that are caused by multi drug resistant
(35:04):
organisms and really the alarming factor in this report from 2017 to 2021, human consumption
of the reserve antibiotics increased by 25%.
And this was mainly driven by a 43% increase in the use of antimicrobials in the healthcare
(35:25):
sector, although decreased in the community sector.
So of this, just to give you an example, just to put it into perspective, especially for
clinicians, pharmacists, and those that are prescribing, Daptomycin, which counts as a
reserve or last resort drug, was the most commonly consumed drug from the reserve group.
(35:48):
And the use increased by 65.8%.
And 68% of that was in the healthcare sector and 38% in the community.
So I think that's something that when I was reading the report, I was thinking about how
many times we've had to prescribe Daptomycin in our hospital setting, but something to
(36:12):
keep in mind in part for those that are running antimicrobial stewardship programs, informing
consumers this information and providing this information, I think is quite valuable.
So in terms of when we looked at consumption overall, in terms of, for instance, another
(36:37):
category of drugs, so carbapenems, they did see a decrease by 33% and 50% decline in the
healthcare sector.
And the community, however, did see a slight increase of 21%.
And this included urtapenem as well as meropenem.
So in order for us to kind of understand that, I think it's important for us to see what
(37:01):
is the ongoing surveillance and really thinking about and talking about one of the newest,
I would say additions or one of the newest additions that was mentioned in the CARS 2022
report was the Canadian National Antimicrobial Prescribing Survey.
And I don't think I'll do justice in explaining everything, but what was mentioned in the
(37:22):
report was quite fascinating.
I think this is definitely a survey that looks at prescribing practices in the healthcare
sector and provides quite valuable information.
Initially when it was piloted, so it's referred to as NAPS, and when it was piloted in 2018
(37:45):
and 2019, they had some good response.
And as of 2022, over 119 healthcare facilities across Canada, so across the 10 provinces,
including actually the 12 pediatric academic hospitals, are currently involved in reporting
information and involved in for allow PHAC to obtain data from the prescribing information.
(38:10):
So keeping in mind that participation is voluntary for the hospitals in terms of this data.
But overall, just to give you kind of an overview of really what was presented in the report
and what is the role of NAPS, it was mentioned that it provides qualitative and quantitative
(38:31):
information.
So for instance, it can give you kind of the insights on prescribing behaviors, helps identify
clinical indications and antimicrobial use patterns.
It also looked at if hospitals followed guidelines for antibiotic choice, dosage, route and duration
and benchmarking.
(38:52):
So a lot of this information led to figuring out appropriateness and inappropriateness
of antibiotic use, which I think coincides with helping us reduce antimicrobial resistance.
So the key findings from the CARS 2022 report, which are obtained from these 90 NAPS audits
(39:14):
in 2018 and 2019 from 64 hospitals, showed that 77.5% of hospital antibiotic prescriptions
were deemed appropriate across Canada.
That was something that I was pleased to see.
Overall, based on the aware category.
So we talked about those, the access drugs and then the watch drugs and finally, reserved
(39:39):
drugs.
37% of the antibiotics were from, in terms of looking at the antibiotic prescriptions,
were from the access category.
There was a higher percentage from the watch categories, around 61%.
And then only 1.8% from the reserved drugs.
(40:01):
Now among the 20 antibiotics that were prescribed that they looked at, only four had appropriateness
levels of less than 70%.
And that was nitrofra-antoine, sephiroxime, levofloxine and moxifloxacin.
They did look at specialties as well and break it down in terms of which specialties had
the highest level of appropriateness.
(40:22):
And with pediatrics, hematology, gynecology, infectious disease and emergency medicine,
taking the top five for appropriateness.
And then finally, also, we're able to provide this data across the provinces and comparing
the provinces and regions with the highest level of appropriate antibiotic use or prescribing
(40:46):
in Western region, which included BC, Alberta, Saskatchewan and Manitoba.
So that was quite, I think that was very different information that was provided from our previous
reports and it was nice to see that there's ongoing surveillance there.
And so for those that were not aware, just like myself, that was quite informational.
(41:10):
Now lastly, before I end this episode, because obviously we've talked about so many numbers
and such great data that was presented in the CARS 2022 report that I could probably
talk about this more and more.
But if there is anything in terms of detailed information that you would want, this is obviously
(41:31):
just a summary of the report, but the CARS 2022 report is available online.
Now before I end this episode, I did want to talk a little bit about, I think it's kind
of something that everybody was wondering about, was the antibiotic use and human antibiotic
use in the community sector kind of before and during the pandemic.
(41:54):
And so some of the data that was released in the CARS 2022 report, which was quite interesting,
was looked at nationally.
So the national data in terms of the average monthly prescriptions, if we look at, I think
the easiest way to do this is looking at before the pandemic, when we looked at the average
(42:16):
monthly prescriptions in Canada, they would range from 45 to 66 per thousand inhabitants,
always having a peak, kind of in our highest rates of prescribing months were May to October,
peaking in January and kind of coincides with respiratory infections and their complications.
And then the lowest infection or prescribing rates in summertime, so June and July.
(42:41):
So looking at that was 45 to 66 per thousand inhabitants.
Now comparing this to when the pandemic started, so reminding ourselves that March to April
2020 was the start of the pandemic and community scripts had declined by 31 percent during
the pandemic.
So rates remained low.
(43:03):
And so the that prescribing average monthly prescriptions in Canada now only ranged from
anywhere around 37 per thousand inhabitants.
So we did see a decline and not only a decline in the community scripts themselves, but also
in the hospital sector, there was a decline by 25 percent.
(43:24):
We looked at the overall trend in 2017 to 2021 and eight percent of which was between
2019 and 2020.
So some of that information, when I took that information, you know, it's hard to correlate,
was this really due to the new and modified means of accessing health care, which the
(43:45):
report also mentioned?
And that's exactly what I was thinking because of public health measures.
Are we going to continue to see this decline?
Obviously there are, you know, initially some of the rates were different in terms of what
we were seeing early on when we didn't know much about COVID-19.
(44:05):
But it would be interesting to see how these trends continue now that we have data from
before the pandemic, the start of the pandemic and some data years around, so years later.
So I think it would be interesting for all of us to stay tuned to see what the next CARS
(44:27):
report reporting period.
I think there's a lot of exciting surveillance going on and there was a lot of important
information that was presented in this report.
So I'm happy to give everybody a summary on this report and if you guys have any questions,
ideas, topics, or other topics that you would want to discuss this season, please feel free
(44:51):
to reach out to us through Twitter, email, and share this information because I think
it's really important and for not only prescribers alone, but I think anybody in the health care
sector.
So thanks for tuning in.
Really appreciate it.
And like I mentioned, we're looking forward to a great list of speakers this season.
(45:16):
If you have the desire to come on to the podcast as a guest, we're more than happy to host
you as well.
Thanks for tuning in.
Take care.
Thank you, Dr. Pirwal.
Thanks for joining us.
If you have a topic suggestion, email us at thecanadianbreakpoint at gmail.com or tweet
(45:37):
us at cabreakpoint.
See you again soon at the Canadian Breakpoint.
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