Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS)

Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) 2002 - full report 969 KB, 90 pages, in PDF format  Summary FAQs 2002 Surveillance Report Erratum (August, 2004) For more information please email cipars-picra@hc-sc.gc.ca

Subject: CIPARS 2002 Report: Erratum

Dear Colleague,

Earlier this year, the 2002 Report of the Canadian Integrated Program for Antimicrobial Resistance Surveillance (CIPARS) was published. We are writing to inform you of an erratum to this report that affects the Human Antimicrobial Use Section (pages 38-39, 77) and the References (page 89).

On page 38, in the "Human Antimicrobial Use" section, in the first column, the first two sentences of the third paragraph should read: "Between April 2000 and March 2001, 217.9 [not 234.7] million DDDs of antimicrobials for systemic use were dispensed in community pharmacies in Canada. This is equivalent to 19.9 [not 21.4] DDDs/1,000 inhabitant-days." On this same page, in the first complete paragraph of the second column, the last sentence should read: "While 12 [not 11]% of DDDs of antimicrobials dispensed were in Category I (very high human health importance), the bulk (57 [not 53]%) of the antimicrobials dispensed with in Category II (high human health importance)."

On page 39, in Figure 21 the bar representing the Defined Daily Doses (DDDs) of tetracyclines should be adjusted as shown in the revised Figure 21. Therefore, the most commonly dispensed antimicrobials (based on DDDs) were extended spectrum penicillins followed by macrolides, tetracyclines, fluoroquinolones, and cephalosporins and related substances.

On page 77, section "A.6. Antimicrobial Use - Human," there are three revisions to Table A.6.1. Systemic antimicrobials dispensed by selected pharmacies in Canada, April 2000-March 2001. First, where ATC Group=J01AA and Therapeutic group=Tetracyclines, Total No. DDD=30,224,446 [not 47,101,500] and DDD/1,000 inhabitant-days=2.760 [not 4.301]. Second, where ATC Group=J01DA and Therapeutic group=Cephalosporins and related substances, Total No. DDD=24,857,453 [not 24,857,454]. Third, where ATC Group=J01 and Therapeutic group=Antibacterials for systemic use (Total), Total No. DDD=217,860,325 [not 234,737,379] and DDD/1,000 inhabitant-days=19.891 [not 21.432].

If you have any questions regarding this erratum, please email us at cipars-picra@hc-sc.gc.ca.

Sincerely,

Rebecca Irwin, Kathryn Doré, and Richard Reid-Smith
CIPARS editors

Erratum (2004)

Section Three - Antimicrobial Use

Currently, no comprehensive monitoring of antimicrobial use in human medicine, veterinary medicine, or agriculture occurs in Canada. CIPARS is therefore developing a use monitoring system. As part of this development process, Health Canada and its government, academic, and industry partners have undertaken several projects in order to generate preliminary data on antimicrobial use, evaluate the logistics and feasibility of collecting data from potential sources, and assess the quality/validity of the data collected. Highlights from these exploratory studies are summarized in CIPARS - Background Studies. Information on the distribution system for antimicrobials used in livestock can be found in Appendix A.5.

In this section, we present data on human use of systemic antimicrobials, representative of antimicrobials dispensed by community pharmacies across Canada. This is one significant component of present and future CIPARS antimicrobial use monitoring systems. In some instances, the antimicrobials are categorized according to Guidelines proposed by the VDD (Appendix A.1). The original intent of these guidelines was to classify antimicrobials used in veterinary medicine. However, this classification system provides a useful way to examine the potential human health impact with respect to AMR concern of using these drugs in humans and animals.

Human Antimicrobial Use

Health Canada has been working with Intercontinental Medical Statistics (IMS) Health to quantify and describe antimicrobial drug use in humans. IMS Health collects information on drug use across Canada via several audit programs. This report focuses on the IMS Health CompuScript and Canadian Disease and Therapeutic Index (CDTI) audits for fiscal year 2000-2001. Further information on IMS Health data collection methods are described in Appendix B.3.

As per international standards of measurement, the volume of active ingredient (kg), the number of Defined Daily Doses (DDDs), and number of DDDs/1,000 inhabitant-days were calculated for each product strength and summed for the year (Appendix Table A.6.1). The relative percentage of total use is presented in Figure 21 and diagnoses associated with antimicrobial use are presented in Figure 22 and Appendix A.6.2.

Between April 2000 and March 2001, 217.9 million DDDs of antimicrobials for systemic use were dispensed in community pharmacies in
Canada. This is equivalent to 19.9 DDDs/1,000 inhabitant-days. The most commonly dispensed antimicrobials (based on DDDs) were extended spectrum penicillins (mostly amoxicillin). Other commonly dispensed antimicrobials (based on DDDs) included macrolides (mostly clarithromycin), tetracyclines (mostly minocycline and tetracycline), fluoroquinolones (mostly ciprofloxacin), and cephalosporins (mostly second generation drugs, especially cefuroxime).

Almost half of the antimicrobials prescribed were indicated for respiratory system diseases. Antimicrobials were also commonly prescribed for genitourinary system diseases, nervous system and sense organ diseases (especially otitis), skin and subcutaneous tissue diseases, and infectious and parasitic diseases (Figure 22 and Appendix A.6.2). Approximately 5% of the prescribed antimicrobials were used to treat disorders of the digestive system. While 12% of DDDs of antimicrobials dispensed were in Category I (very high human health importance), the bulk (57%) of the antimicrobials dispensed were in Category II (high human health importance).

Figure 21. Relative use of antimicrobials dispensed by community pharmacies (IMS Health)

Note: ¹1106 units of sulfamethoxazole were dispensed but were not included in this calculation because the product strength was unknown;
²100 254 units of methenamine were dispensed but were not included in this calculation because the product strength was unknown.

Figure 22. Distribution of antimicrobial use by diagnostic classes, based on office-based physician prescription data (IMS Health)

A.6. Antimicrobial Use - Human

Table A.6.1. Systemic antimicrobials dispensed by selected pharmacies in Canada, April 2000-March 2001

Note: * 1106 units of sulfamethoxazole were dispensed but are not included in this calculation because the product strength was unknown;
** 100254 units of methenamine were dispensed but are not included in this calculation because the product strength was unknown;
*** based on 2001 census; To calculate the number of DDDs per 1000 inhabitant days, the division factor was determined by using the population for Canada from the 2001 census; formula: Number of days in fiscal year x (2001 population of Canada / 1,000 inhabitants) Source: IMS Health CompuScript audit.

Appendix C - References

Birnbaum D, Canadian Committee on Antibiotic Resistance (CCAR) (2003). Antimicrobial resistance: a deadly burden no country can afford to ignore. Can Commun Dis Rep. 29(18):157-64.

Canadian Pharmacists Association (2001). Compendium of Pharmaceuticals and Specialties (CPS). The Canadian Drug Reference for Health Professionals. Ottawa, Canada.

Centers for Disease Control and Prevention. Outbreak of Multidrug-Resistant Salmonella Newport - United States, January - April 2002. MMWR 2002;51:545-48.

Danish Integrated Antimicrobial Resistance Monitoring and Research Program (DANMAP) (2002). DANMAP 2001 - Use of antimicrobial agents and occurrence of antimicrobial resistance in bacteria from food animals, foods and humans in Denmark. Copenhagen, Denmark.

Delarocque-Astagneau E, Bouillant C, Vaillant V, Bouvet P, Grimont P, Desenclos, J-C (2000). Risk factors for the occurrence of sporadic Salmonella enterica serotype Typhimurium infections in children in France: a national case-control study. Clin Inf Dis. 31: 488-92.

Demczuk W, Ahmed R, Woodward D, Clark C, Rodgers F (2001). Laboratory surveillance data for enteric pathogens in Canada: 2000 annual summary. Health Canada.

Fone D, Barker R (1994). Associations between human and farm animal infections with Salmonella Typhimurium DT104 in Herefordshire. Communicable Disease Report Rev 4:R136-40.

Glynn M, Reddy S, Fiorentino T. et al. (1998). Antimicrobial agent use increases infections with resistant bacteria: a FoodNet case-control study of sporadic, multiresistant Salmonella Typhimurium DT104 infections, 1996-1997. Program and abstracts of the 36th annual meeting of the infectious diseases society of America; 1998 November 12-15; Denver, CO. Alexandria, VA: Infectious Diseases Society of America, 84 [abstract 52].

Grif K, Dierich M, Karch H, Allerberger F (1998). Strain-specific differences in the amount of Shiga toxin released from enterohemorrhagic Escherichia coli O157 following exposure to subinhibitory concentrations of antimicrobial agents. Eur. J. Clin. Microbiol Infect Dis. 17:761-766.

Health Canada (HC) (2002). Uses of antimicrobials in food animals in Canada: impact on resistance and human health. Report of the Advisory Committee on Animal Uses of Antimicrobials and Impact on Resistance and Human Health. Prepared for the Veterinary Drugs Directorate, Health Canada. 165 p.

Health Canada (HC) (2003). Canadian Integrated Surveillance Report: Salmonella, Campylobacter, pathogenic E. coli and Shigella, from 1996 to 1999. CCDR. 29S1.

Joint Expert Advisory Committee on Antibiotic Resistance (JETACAR) (1999). Report of the Joint Expert Advisory Committee on Antibiotic Resistance. Commonwealth of Australia.

Marano N, Rossiter S, Stamey K, et al. (2000). The National Antimicrobial Resistance Monitoring System (NARMS) for enteric bacteria, 1996-1999: surveillance for action. J Am Vet Med Assoc. 217: 1829-30.

Mølbak K, Baggesen D, Aarestrup F, Ebbesen J, Engberg J, Frydendahl K, Gerner-Smidt P, Petersen A, Wegener H (1999). An outbreak of multidrug-resistant, quinolone-resistant

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