ECDC, EFSA and EMA Joint Scientific Opinion on a list of outcome indicators as regards surveillance of antimicrobial resistance and antimicrobial consumption in humans and food-producing animals

Abstract

ECDC, EFSA and EMA have jointly established a list of harmonised outcome indicators to assist EU Member States in assessing their progress in reducing the use of antimicrobials and antimicrobial resistance (AMR) in both humans and food-producing animals. The proposed indicators have been selected on the basis of data collected by Member States at the time of publication. For humans, the proposed indicators for antimicrobial consumption are: total consumption of antimicrobials (limited to antibacterials for systemic use), ratio of community consumption of certain classes of broad-spectrum to narrow-spectrum antimicrobials and consumption of selected broad-spectrum antimicrobials used in healthcare settings. The proposed indicators for AMR in humans are: meticillin-resistant Staphylococcus aureus and 3rd-generation cephalosporin-resistant Escherichia coli, Klebsiella pneumoniae resistant to aminoglycosides, fluoroquinolones and 3rd-generation cephalosporins, Streptococcus pneumoniae resistant to penicillin and S. pneumoniae resistant to macrolides, and K. pneumoniae resistant to carbapenems. For food-producing animals, indicators for antimicrobial consumption include: overall sales of veterinary antimicrobials, sales of 3rd- and 4th-generation cephalosporins, sales of quinolones and sales of polymyxins. Finally, proposed indicators for AMR in food-producing animals are: full susceptibility to a predefined panel of antimicrobials in E. coli, proportion of samples containing ESBL-/AmpC-producing E. coli, resistance to three or more antimicrobial classes in E. coli and resistance to ciprofloxacin in E. coli. For all sectors, the chosen indicators, which should be reconsidered at least every 5 years, are expected to be valid tools in monitoring antimicrobial consumption and AMR. With the exception of the proposed human AMR indicators, the indicators are in general not suitable to monitor the effects of targeted interventions in a specific sector, such as in a single animal species or animal production sector. Management decisions should never be based on these indicators alone but should take into account the underlying data and their analysis.

Keywords: antimicrobial consumption; antimicrobial resistance; food‐producing animals; humans; indicator.

Figure C.1

Primary indicator: total consumption in humans of antibacterials for systemic use (ATC group J01), expressed in DDD per 1,000 inhabitants and per day (source: ESAC‐Net data) 2015

1. *: Country reported only community data.

   **: Country reported total care data (aggregated data for both sectors).

   EU/EEA: EU/EEA population‐weighted mean consumption.

Figure C.2

Ratio of the community antimicrobial consumption in humans expressed as DDD per 1,000 inhabitants and per day of broad‐spectrum penicillins, cephalosporins, macrolides and fluoroquinolones, macrolides other than erythromycin (J01(CR+DC+DD+(F‐FA01)+MA)) to the consumption of narrow‐spectrum penicillins, cephalosporins and erythromycin (J01(CA+CE+CF+DB+FA01))

1. *: Country reported total care data (aggregated data for both sectors).

   EU/EEA: EU/EEA population‐weighted mean consumption.

Figure C.3

Secondary indicator: Proportion of total hospital AMC that are glycopeptides, 3rd‐ and 4th‐generation cephalosporins, monobactams, carbapenems, fluoroquinolones, polymyxins, piperacillin and enzyme inhibitor, linezolid, tedizolid and daptomycin (DDD per 1,000 inhabitants and per day) (ESAC‐Net, 2015)

Figure D.1

Primary indicator: proportion (%) of meticillin‐resistant Staphylococcus aureus (MRSA) and 3rd‐generation cephalosporin‐resistant E. coli (3GCR E. coli) measured as [% MRSA, % 3GCR E. coli] given as two individual numbers (source: EARS‐Net, 2015)

Figure D.2

Secondary indicator: Proportion (%) of Klebsiella pneumoniae with combined resistance to aminoglycosides, fluoroquinolones and 3rd‐generation cephalosporins

Figure D.3

Secondary indicator: Proportion (%) of penicillin‐resistant Streptococcus pneumoniae and macrolide‐resistant Streptococcus pneumoniae

Figure D.4

Secondary indicator: proportion (%) of carbapenem‐resistant Klebsiella pneumoniae

Figure E.1

Overall sales of veterinary antimicrobial agents for food‐producing species, in mg/PCU, from 2011 to 2014, for 29 European countries

Figure E.2

Sales of veterinary antimicrobial agents for food‐producing species, in mg/PCU, overall (right Y‐axis) and of 3rd‐ and 4th‐generation cephalosporins, quinolones and polymyxins (left Y‐axis), for 2014, for 29 European countries

1. Different axis scale for overall sales and for HCIAs.

Figure E.3

Sales of veterinary antimicrobial agents for food‐producing species, in mg/PCU, fluoroquinolones and other quinolones, for 2014, for 29 European countries

Figure F.1

Results of the calculation of indicator ‘fully susceptible indicator E. coli’ (indicator for AMR in food‐producing animals), as computed with the R code reported in Section F.5

1. The graph shows median and 95% credibility interval. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). No data are shown for Luxembourg (no data available).

Figure F.2

Results of the calculation of indicator ‘ESBL‐/AmpC‐producing indicator E. coli’ (indicator for AMR in food‐producing animals), as computed with the R code reported in Section F.5

1. The graph shows median and 95% credibility interval. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for year 2015 (EFSA and ECDC, 2017), and is therefore restricted to fattening pigs and calves, since in 2014 the specific monitoring for ESBL‐/AmpC‐producing E. coli was not mandatory, and prevalence data was submitted voluntarily by only one country (Italy). No data are shown for Italy (no data available).

Figure F.3

Results of the calculation of indicator ‘multi‐resistant indicator E. coli’ (indicator for AMR in food‐producing animals), as computed with the R code reported in Section F.5

1. The graph shows median and 95% credibility interval. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). No data are shown for Luxembourg (no data available).

Figure F.4

Results of the calculation of indicator ‘ciprofloxacin‐resistant indicator E. coli’ (indicator for AMR in food‐producing animals), as computed with the R code reported in Section F.5

1. The graph shows median and 95% credibility interval. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). No data are shown for Luxembourg (no data available).

Figure F.5

Correlation between possible indicators for AMR in food‐producing animals: selected indicator ‘fully susceptible indicator E. coli’ vs discarded indicator ‘average resistance indicator E. coli’

1. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). For the purpose of this graph, mean values of the indicators are considered.

Figure F.6

Correlation between possible indicators for AMR in food‐producing animals: selected indicator ‘fully susceptible indicator E. coli’ vs selected indicator ‘multi‐resistant indicator E. coli’

1. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). For the purpose of this graph, mean values of the indicators are considered.

Figure F.7

Correlation between possible indicators for AMR in food‐producing animals: selected indicator ‘fully susceptible indicator E. coli’ vs selected indicator ‘ESBL‐/AmpC‐producing indicator E. coli’

1. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for year 2015 (EFSA and ECDC, 2017). For the purpose of this graph, mean values of the indicators are considered. Since the indicator on ESBL‐/AmpC‐producing indicator E. coli can be calculated based on the data collected during 2015 only (fattening pigs and calves), and since data for calves is available for a limited number of countries, this graph shows the correlation between the two indicators (fully susceptible indicator E. coli vs ESBL‐/AmpC‐producing indicator E. coli) calculated only for fattening pigs. This allows investigating better the correlation between the two indicators.

Figure F.8

Correlation between possible indicators for AMR in food‐producing animals: selected indicator ‘fully susceptible indicator E. coli’ vs selected indicator ‘ciprofloxacin‐resistant indicator E. coli’

1. The indicators have been calculated using the available data presented in the EUSR‐AMR reports for years 2014 and 2015 (EFSA and ECDC, 2016, 2017). For the purpose of this graph, mean values of the indicators are considered.