1
00:00:00,000 --> 00:00:14,440
Thanks for meeting us at the Canadian Breakpoint, a Canadian infectious disease podcast by infectious

2
00:00:14,440 --> 00:00:15,440
disease physicians.

3
00:00:15,440 --> 00:00:21,040
I'm your host, Summer Stewart, and I'm excited to introduce infectious disease physician and

4
00:00:21,040 --> 00:00:23,760
author Dr. Rupeena Purewal.

5
00:00:23,760 --> 00:00:29,820
Dr. Purewal is a Canadian pediatric infectious disease physician from Edmonton, Alberta.

6
00:00:29,820 --> 00:00:34,420
She completed her medical school at the University of Pecs in Hungary and her three-year residency

7
00:00:34,420 --> 00:00:37,120
program at West Virginia University.

8
00:00:37,120 --> 00:00:42,440
She returned to Canada in 2017 to start a pediatric infectious disease fellowship at

9
00:00:42,440 --> 00:00:44,480
the University of Manitoba.

10
00:00:44,480 --> 00:00:49,000
Upon completing her fellowship, Dr. Purewal moved to Saskatchewan as a clinician and

11
00:00:49,000 --> 00:00:53,160
as an academic physician at the University of Saskatchewan.

12
00:00:53,160 --> 00:00:58,800
For our first episode, Dr. Purewal will present the Canadian Antimicrobial Resistance Surveillance

13
00:00:58,800 --> 00:00:59,800
System update.

14
00:00:59,800 --> 00:01:02,800
Welcome, Dr. Purewal.

15
00:01:02,800 --> 00:01:04,160
Hello everyone.

16
00:01:04,160 --> 00:01:05,800
Thank you, Summer, for that great introduction.

17
00:01:05,800 --> 00:01:13,320
I'm very excited to be here today to start our very first episode of our podcast.

18
00:01:13,320 --> 00:01:17,720
And as Summer mentioned, my name is Rupeena Purewal and I'm a pediatric infectious disease

19
00:01:17,720 --> 00:01:24,080
physician here in Saskatoon, Saskatchewan at the Jim Patterson Children's Hospital.

20
00:01:24,080 --> 00:01:29,160
I've taken the initiative to start a Canadian-based podcast for my Canadian colleagues, whether

21
00:01:29,160 --> 00:01:35,680
it be infectious disease specialists, microbiologists, family physicians, pharmacists, or really

22
00:01:35,680 --> 00:01:41,520
anybody dealing with prescribing antibiotics and the use of antibiotics.

23
00:01:41,520 --> 00:01:45,760
On our podcast, we'll be doing monthly episodes with interesting areas.

24
00:01:45,760 --> 00:01:51,040
I'll be discussing current and up-to-date topics related to antimicrobials, stewardship,

25
00:01:51,040 --> 00:01:54,400
and really all sorts of infectious diseases.

26
00:01:54,400 --> 00:01:58,800
Some of our podcasts will be more informative, while others will be more interactive with

27
00:01:58,800 --> 00:02:01,120
specific guests.

28
00:02:01,120 --> 00:02:03,200
So thank you so much for tuning in.

29
00:02:03,200 --> 00:02:07,800
Today's episode will be a summary of the Canadian Antimicrobial Resistance Surveillance

30
00:02:07,800 --> 00:02:13,160
System, the CARS report that was updated in 2020.

31
00:02:13,160 --> 00:02:19,600
As most of you are aware, CARS is a Canadian national system for reporting on antimicrobial

32
00:02:19,600 --> 00:02:23,120
resistance and antimicrobial use.

33
00:02:23,120 --> 00:02:29,160
And it's one of Public Health Agency of Canada's commitments as a part of the Pan-Canadian

34
00:02:29,160 --> 00:02:33,800
Framework for Action on Antimicrobial Resistance and Use.

35
00:02:33,800 --> 00:02:39,000
And by reporting findings on antimicrobials, it provides really us, decision-makers, with

36
00:02:39,000 --> 00:02:44,920
evidence to support policy and programs to foster prudent antimicrobial use to prevent

37
00:02:44,920 --> 00:02:48,600
and control resistance in Canada.

38
00:02:48,600 --> 00:02:53,220
So our very first episode will be a condensed update with the main focus really on the priority

39
00:02:53,220 --> 00:03:00,000
pathogens listed in the report that are showing a trend in Canada that's getting worse.

40
00:03:00,000 --> 00:03:07,000
Antimicrobial data for certain pathogens and antimicrobial use in humans, along with emerging

41
00:03:07,000 --> 00:03:11,560
threats that are being identified in Canada.

42
00:03:11,560 --> 00:03:16,080
As most of you are aware, antimicrobial resistance is increasing in Canada.

43
00:03:16,080 --> 00:03:21,840
And surveillance is one technique to identify resistance rates and create awareness to reduce

44
00:03:21,840 --> 00:03:26,280
overuse and overprescribing of antibiotics.

45
00:03:26,280 --> 00:03:30,800
The report really highlights some concerning trends in Canada that we should all be aware

46
00:03:30,800 --> 00:03:31,800
of.

47
00:03:31,800 --> 00:03:38,160
And therefore, it's a very important topic, especially for us in the clinical world.

48
00:03:38,160 --> 00:03:41,780
So to begin with, we will be talking about three pathogens.

49
00:03:41,780 --> 00:03:48,040
So there'll be MRSA, methicillin-resistant staph aureus, vancomycin-resistant enterococcus,

50
00:03:48,040 --> 00:03:54,200
also known as VRE, and then also carbapenemase-producing entrobacteriaceae.

51
00:03:54,200 --> 00:04:01,120
So starting off with what the report went through in regards to MRSA, in 2014 to 2018,

52
00:04:01,120 --> 00:04:06,080
it did identify this pathogen as a trend towards getting worse.

53
00:04:06,080 --> 00:04:12,640
So over 65 hospitals reported to the Canadian Nosocomial Infection Surveillance Program,

54
00:04:12,640 --> 00:04:20,400
and 2,900 MRSA bloodstream infection cases were reported, and over 550 deaths were reported

55
00:04:20,400 --> 00:04:25,040
due to MRSA in 2014 to 2018.

56
00:04:25,040 --> 00:04:31,700
Now, whenever we speak about MRSA, we always discuss either healthcare-associated versus

57
00:04:31,700 --> 00:04:36,160
community-associated MRSA bloodstream infections.

58
00:04:36,160 --> 00:04:39,520
And so those are the areas that we will be talking about today that were mentioned in

59
00:04:39,520 --> 00:04:45,320
the reports in regards to their mortality, in regards to their resistance patterns, and

60
00:04:45,320 --> 00:04:50,280
also agents for non-bloodstream MRSA infections.

61
00:04:50,280 --> 00:04:56,160
So starting off with healthcare-associated MRSA, it was noted that the all-cause mortality

62
00:04:56,160 --> 00:05:04,320
during this 2014 to 2018 period was noted to be close to 24%.

63
00:05:04,320 --> 00:05:10,880
They did notice that all the strains were susceptible to vancomycin, and less than 1%

64
00:05:10,880 --> 00:05:13,240
were non-susceptible to daptomycin.

65
00:05:13,240 --> 00:05:19,520
Now, looking at those agents that are used for non-bloodstream MRSA infections and the

66
00:05:19,520 --> 00:05:26,840
healthcare-associated MRSA strains, they noticed no resistance to lenazoline, resistance to

67
00:05:26,840 --> 00:05:33,840
rifampin, trimethypim, sulfamethoxazole, and tetracycline were reported as low, ranging

68
00:05:33,840 --> 00:05:39,600
from anywhere from 1% to 4%, and notably for tetracycline around 4%.

69
00:05:39,600 --> 00:05:45,240
And resistance to clindamycin has decreased from 75% to 50%.

70
00:05:45,240 --> 00:05:49,360
So those are some reassuring numbers for clindamycin.

71
00:05:49,360 --> 00:05:56,720
Now comparably, looking at the community-associated MRSA bloodstream infections, these have increased

72
00:05:56,720 --> 00:06:01,840
by 140% between 2014 to 2018.

73
00:06:01,840 --> 00:06:06,080
And it was reported that this was largely driven by the increase in cases attributed

74
00:06:06,080 --> 00:06:12,480
to the community, so the number of cases overall had increased in the community as well.

75
00:06:12,480 --> 00:06:21,680
Now, all-cause mortality was lower for the community-associated MRSA bloodstream infections

76
00:06:21,680 --> 00:06:27,840
than it was for the healthcare-associated MRSA infections, and notably at 14% as compared

77
00:06:27,840 --> 00:06:30,680
to the 24% we had just mentioned.

78
00:06:30,680 --> 00:06:36,440
Now, in the report, they also went through more details for the community-associated

79
00:06:36,440 --> 00:06:41,360
MRSA infections, and specifically outlining the different strain types.

80
00:06:41,360 --> 00:06:48,920
So, historically based on Canadian standards, strains 7 and 10 were associated with community-associated

81
00:06:48,920 --> 00:06:59,160
MRSA, and strain type 2 was historically associated with healthcare-associated MRSA.

82
00:06:59,160 --> 00:07:05,960
However, they had noticed that strain types 2 and 10 were decreased overall, but the community

83
00:07:05,960 --> 00:07:17,040
MRSA type 7 had increased from 8 to up until 9% between this 2014 to 2018 period.

84
00:07:17,040 --> 00:07:23,600
For the community-associated MRSA, they did state that all isolates were susceptible to

85
00:07:23,600 --> 00:07:31,040
vancomycin, and there was less than 1% non-susceptibility to daptomycin, so very similar to our healthcare-associated

86
00:07:31,040 --> 00:07:34,080
MRSA.

87
00:07:34,080 --> 00:07:40,200
And then comparing the non-bloodstream or agents that we use for non-bloodstream infections

88
00:07:40,200 --> 00:07:46,080
for MRSA, they did note that trimethopram, sulfamethoxazole, and rifampin resistance

89
00:07:46,080 --> 00:07:53,520
rates were low, ranging anywhere again from that 1 to 3 to 4%, but something that was

90
00:07:53,520 --> 00:08:01,320
considerably different was that the tetracycline resistance rates were higher than compared

91
00:08:01,320 --> 00:08:02,320
to the healthcare-associated.

92
00:08:02,320 --> 00:08:09,080
So, like I mentioned before, it was at 4% resistance to tetracycline for the healthcare-associated,

93
00:08:09,080 --> 00:08:15,280
and now for the community-associated MRSA infections, the resistance for tetracycline

94
00:08:15,280 --> 00:08:18,640
was close to 10%.

95
00:08:18,640 --> 00:08:21,520
And so that was important information.

96
00:08:21,520 --> 00:08:29,320
And clindamycin, kind of similar to the healthcare-associated MRSA, had decreased for the community-associated

97
00:08:29,320 --> 00:08:37,440
isolates, as well, down to 30% from 40%.

98
00:08:37,440 --> 00:08:43,480
Now, moving on to our second pathogen that we're talking about today, which is vancomycin-resistant

99
00:08:43,480 --> 00:08:44,680
enterococcus.

100
00:08:44,680 --> 00:08:50,800
It's also notably a priority pathogen, indicated as getting worse for its trend summary.

101
00:08:50,800 --> 00:09:03,040
So similar to MRSA, 62 hospitals reported information to CNISP, and 649 cases of VRE,

102
00:09:03,040 --> 00:09:08,300
vancomycin-resistant enterococcus bloodstream infections were reported, and over 200 deaths

103
00:09:08,300 --> 00:09:12,080
during this time period of 2014 to 2018.

104
00:09:12,080 --> 00:09:18,480
Now, the rates of healthcare-associated vancomycin-resistant enterococcus bloodstream infections more than

105
00:09:18,480 --> 00:09:24,160
doubled between this 2014 and 2018 period.

106
00:09:24,160 --> 00:09:26,460
So those are significant numbers.

107
00:09:26,460 --> 00:09:32,640
The all-cause mortality was also higher for cases with healthcare-associated VRE.

108
00:09:32,640 --> 00:09:41,000
31% of patients died within 30 days of diagnosis between this 2014 to 2018 period.

109
00:09:41,000 --> 00:09:52,040
Now, another important area that notably was mentioned in this report and updated was that

110
00:09:52,040 --> 00:09:59,760
98% of the isolates for VRE were enterococcus faecium, and less than 2% were reported as

111
00:09:59,760 --> 00:10:03,160
or speciated to enterococcus faecalis.

112
00:10:03,160 --> 00:10:10,200
So really goes to show that the numbers of enterococcus faecium were significantly higher.

113
00:10:10,200 --> 00:10:15,880
And there's a rapid emergence of a specific sequence type that was mentioned also in the

114
00:10:15,880 --> 00:10:18,440
report.

115
00:10:18,440 --> 00:10:26,640
The specific sequence type, the ST1478, that was reported for enterococcus faecium, it

116
00:10:26,640 --> 00:10:32,280
was actually initially first reported in 2013 in Canada, but now it's representing over

117
00:10:32,280 --> 00:10:37,600
40% of the isolates between this 2014 to 2018 period.

118
00:10:37,600 --> 00:10:44,040
And the reason why it's important is because this actual sequence type, ST1478, was associated

119
00:10:44,040 --> 00:10:50,240
with rising levels of resistance to important antimicrobials such as gentamicin and daptamicin.

120
00:10:50,240 --> 00:10:55,920
And so I think that was a significant point in the report that they wanted to convey that

121
00:10:55,920 --> 00:11:04,280
these, especially for us clinicians thinking about empiric management or even synergy,

122
00:11:04,280 --> 00:11:12,520
it was an important key point that resistance rates are increasing for these agents.

123
00:11:12,520 --> 00:11:19,960
In terms of antimicrobial susceptibility, so it was available for over 70% of the isolates,

124
00:11:19,960 --> 00:11:26,280
and it was noted that daptamicin non-susceptibility had increased from back in 2014 where it was

125
00:11:26,280 --> 00:11:34,720
0% up to 7 to 8% in 2018.

126
00:11:34,720 --> 00:11:39,000
And so that was a significant change.

127
00:11:39,000 --> 00:11:45,240
Resistance to high-level gent also increased from 9 up until 43%, and resistance to linase

128
00:11:45,240 --> 00:11:52,240
lid also was notably increased from 0 up until 1.3%.

129
00:11:52,240 --> 00:11:57,440
Now finally moving on to our third pathogen, our priority pathogen I should say, that is

130
00:11:57,440 --> 00:12:04,200
showing a trend towards getting worse between this 2014 and 2018 period, the carbapenemies-producing

131
00:12:04,200 --> 00:12:06,700
intrabacteria group.

132
00:12:06,700 --> 00:12:17,000
So again, over 60 hospitals reported around 290 hospital or healthcare-associated colonizations,

133
00:12:17,000 --> 00:12:26,800
73 healthcare-associated infections due to CPE organisms, and a total of 365 healthcare-associated

134
00:12:26,800 --> 00:12:36,840
CPE cases, and 16 deaths in between 2014 to 2018.

135
00:12:36,840 --> 00:12:43,840
So looking at the Canadian hospital data, it reported a nine-fold increase in patients

136
00:12:43,840 --> 00:12:49,520
that have been colonized with healthcare-associated CPE organisms.

137
00:12:49,520 --> 00:12:55,360
And so really, although infection rates remain low and stable, it was disclosed that increased

138
00:12:55,360 --> 00:13:01,200
rates of colonizations were being reported, and this could be due to either heightened

139
00:13:01,200 --> 00:13:07,320
awareness, increased screening, however it's still of concern.

140
00:13:07,320 --> 00:13:14,360
The all-cause mortality was high for cases that had healthcare-associated CPE infections,

141
00:13:14,360 --> 00:13:23,240
ranging at 16% of patients that died within 30 days of the diagnosis between this four

142
00:13:23,240 --> 00:13:25,840
years.

143
00:13:25,840 --> 00:13:31,040
Healthcare-associated CPE cases were reported that often are associated with international

144
00:13:31,040 --> 00:13:35,240
travel and international healthcare exposure, as many of us are aware, and these are kind

145
00:13:35,240 --> 00:13:39,520
of the screening questions and the reasons for screening in Canada.

146
00:13:39,520 --> 00:13:44,280
However, domestic nosocomial transmission also appears to be increasing, and that was

147
00:13:44,280 --> 00:13:47,160
mentioned in the report.

148
00:13:47,160 --> 00:13:56,120
In 2018, around 40% of patients that were identified with healthcare-associated CPE

149
00:13:56,120 --> 00:14:03,880
had traveled outside of Canada within the past 12 months, and 84% of the reported isolates

150
00:14:03,880 --> 00:14:08,680
for these patients, they had received medical care while abroad.

151
00:14:08,680 --> 00:14:17,080
And so an important point again for the reasons that why we screen such high-risk patients.

152
00:14:17,080 --> 00:14:23,600
So the carbapenemase, another interesting kind of report for the CPE was looking at

153
00:14:23,600 --> 00:14:28,600
what types of carbapenemases were identified.

154
00:14:28,600 --> 00:14:34,440
And so when they looked at over 147 isolates, they were all reviewed, the proportion of

155
00:14:34,440 --> 00:14:40,600
the carbapenemase that were identified, majority of them were KPC, so Klebsiella pneumonia

156
00:14:40,600 --> 00:14:47,280
carbapenemase producing in 54% of those isolates.

157
00:14:47,280 --> 00:14:54,600
So 80 out of 147 of them had KPC carbapenemases being produced.

158
00:14:54,600 --> 00:15:01,680
The second highest was the NDM, which is the New Delhi metallo-betalactamase at 23%.

159
00:15:01,680 --> 00:15:08,960
And then in decreasing order was oxalinase, the oxa-48 at around 10% and seracea, MarSense's

160
00:15:08,960 --> 00:15:13,660
enzyme SME at 2%.

161
00:15:13,660 --> 00:15:21,240
So this was the overall kind of trends and some information regarding these three priority

162
00:15:21,240 --> 00:15:23,280
pathogens that I wanted to discuss.

163
00:15:23,280 --> 00:15:32,680
And I think they definitely highlighted significant changes that are important for us as clinicians.

164
00:15:32,680 --> 00:15:40,560
So I'm going to move on to talking about some antibiogram data for specific pathogens that

165
00:15:40,560 --> 00:15:47,480
were discussed in the report because I felt like this was a very crucial point in this

166
00:15:47,480 --> 00:15:55,880
2014 to 2018 report that they wanted to emphasize because these are agents that we are seeing

167
00:15:55,880 --> 00:15:59,340
some worrisome changes.

168
00:15:59,340 --> 00:16:04,560
So the data that was reported by hospitals was both from inpatient and outpatient and

169
00:16:04,560 --> 00:16:08,920
duplicate isolates were removed when this antibiogram data was established.

170
00:16:08,920 --> 00:16:14,420
Now many of us are probably more familiar with having a minimum cutoff point for reporting

171
00:16:14,420 --> 00:16:16,680
around 30 isolates per hospital.

172
00:16:16,680 --> 00:16:24,440
However, as of 2018 or during this report, prior to 2018 that was the minimum cutoff

173
00:16:24,440 --> 00:16:29,480
and now that's changed and there's no longer this minimum cutoff for the number of isolates

174
00:16:29,480 --> 00:16:30,480
and reported.

175
00:16:30,480 --> 00:16:33,240
So just keep that in mind.

176
00:16:33,240 --> 00:16:37,600
So the couple of pathogens we're going to talk about here are E. coli, Acidum abactor

177
00:16:37,600 --> 00:16:41,040
species and then Salmonella species.

178
00:16:41,040 --> 00:16:47,280
So let's start off with what the report kind of emphasized about E. coli.

179
00:16:47,280 --> 00:16:53,340
So between 2015 and 2018 the proportion of E. coli non-susceptible to carbapenems was

180
00:16:53,340 --> 00:16:56,800
less than 1% for both blood and urine isolates.

181
00:16:56,800 --> 00:17:01,200
So that was a reassuring component.

182
00:17:01,200 --> 00:17:08,040
For E. coli specifically looking at the antibiogram data for blood isolates that they reviewed,

183
00:17:08,040 --> 00:17:15,720
non-susceptibility for pipercillin and tasobactam had increased from 26 to 30%.

184
00:17:15,720 --> 00:17:21,800
Our trimethoprim sulfamethoxazole non-susceptibility also increased ranging around the same so

185
00:17:21,800 --> 00:17:24,600
26 up to 30%.

186
00:17:24,600 --> 00:17:30,200
And non-susceptibility however for ciprofloxacin remained unchanged.

187
00:17:30,200 --> 00:17:35,080
Unfortunately like I mentioned the carbapenem remained less than 1%.

188
00:17:35,080 --> 00:17:42,600
Now comparing that with the E. coli urine isolates that were reported from 2016 to 2018,

189
00:17:42,600 --> 00:17:47,920
it was noted that non-susceptibility rates for pipercillin and tasobactam had increased

190
00:17:47,920 --> 00:17:51,160
from 4 up to 6%.

191
00:17:51,160 --> 00:17:59,000
For trimethoprim sulfamethoxazole they actually decreased slightly from 24 to 21%.

192
00:17:59,000 --> 00:18:05,600
P to ciprofloxacin also decreased from anywhere from 19 to 17%.

193
00:18:05,600 --> 00:18:10,400
And then the non-susceptibility to carbapenem as mentioned before was remained less than

194
00:18:10,400 --> 00:18:12,440
1%.

195
00:18:12,440 --> 00:18:19,560
In terms of acinetobacter something that was mentioned in the report was in 2018 the non-susceptibility

196
00:18:19,560 --> 00:18:23,600
to meropenem was close to 5%.

197
00:18:23,600 --> 00:18:30,280
And I think that's an important number in terms of considering what our empiric management

198
00:18:30,280 --> 00:18:35,320
is and taking care of these patients.

199
00:18:35,320 --> 00:18:40,600
In moving on to the salmonella species, so majority of the isolates that were submitted

200
00:18:40,600 --> 00:18:45,240
for lab tests were cultured from blood for salmonella.

201
00:18:45,240 --> 00:18:51,080
We will talk about both typhoidal and non-typhoidal salmonella in Terica.

202
00:18:51,080 --> 00:18:56,520
So the data was restricted to isolates of salmonella and Terica were serovars typhi,

203
00:18:56,520 --> 00:19:00,320
paratyphi and then there were several non-typhoidal serovars.

204
00:19:00,320 --> 00:19:09,120
So overall most antimicrobial resistance remained stable except for the following.

205
00:19:09,120 --> 00:19:14,440
Between 2014 and 2018 the frequency of salmonella typhi and paratyphi that was resistant to

206
00:19:14,440 --> 00:19:24,560
ceftriaxone increased from nearly undetectable, so 0% in 2014 up to levels of 3%.

207
00:19:24,560 --> 00:19:29,440
Between 2014 and 2018 it was also reported that the frequency of typhoidal salmonella

208
00:19:29,440 --> 00:19:35,200
resistance to ciprofloxacin increased by 34%.

209
00:19:35,200 --> 00:19:41,440
I think that was a very very important point and why empiric management has changed as

210
00:19:41,440 --> 00:19:43,080
well.

211
00:19:43,080 --> 00:19:51,200
In 2018 11% of typhoidal salmonella was resistant to either three or more classes of antimicrobial

212
00:19:51,200 --> 00:19:57,120
so really putting it into this multi-class resistant category and of no resistance to

213
00:19:57,120 --> 00:20:00,040
zithromycin was identified.

214
00:20:00,040 --> 00:20:05,360
Now comparing this to the non-typhoidal salmonella species the number of isolates that were submitted

215
00:20:05,360 --> 00:20:14,720
for lab testing overall had decreased from 2500 to close to 2100 and notably 85% of the

216
00:20:14,720 --> 00:20:19,680
non-typhoidal samples were recovered from stool specimens as opposed to blood or urine

217
00:20:19,680 --> 00:20:24,080
which were really only less than 5 to 7%.

218
00:20:24,080 --> 00:20:31,360
In 2018 13% of the non-typhoidal salmonella were resistant to three or more classes and

219
00:20:31,360 --> 00:20:36,680
really looking at resistance to tetracyclines had increased from 11 to 16%.

220
00:20:36,680 --> 00:20:42,520
The other classes like trimethyprim, sulfamethoxazole, and ciprofloxacin had remained stable and

221
00:20:42,520 --> 00:20:47,800
there was no identified resistance to meropenem that was seen and so that was quite reassuring

222
00:20:47,800 --> 00:20:49,960
for that fact.

223
00:20:49,960 --> 00:20:55,960
Now that was the main components that I wanted to discuss from those categories and I think

224
00:20:55,960 --> 00:21:05,640
an important point that we should take from reading this report and reviewing this report

225
00:21:05,640 --> 00:21:11,040
is kind of also focus on not only the resistance patterns that have been predicted because

226
00:21:11,040 --> 00:21:16,420
those are helpful during our clinical practice but also looking at some of the statistics

227
00:21:16,420 --> 00:21:19,200
that are alarming for antimicrobial use in humans.

228
00:21:19,200 --> 00:21:26,200
So for the next section of the podcast I do want to focus on antimicrobial use in humans

229
00:21:26,200 --> 00:21:30,480
and some of the statistics that were quite alarming to me were that one in four Canadians

230
00:21:30,480 --> 00:21:36,960
received at least one antibiotic course in 2018 and when you look at either surveillance

231
00:21:36,960 --> 00:21:46,360
at a global level or even respectively at a regional level it was tremendous to see

232
00:21:46,360 --> 00:21:51,880
kind of the differences and so globally just to kind of give you an overview there is a

233
00:21:51,880 --> 00:21:58,280
European surveillance of antimicrobial consumption network where Canada it was listed in this

234
00:21:58,280 --> 00:22:06,200
report and they had a good graph on that and showing Canada was at the 12th lowest consumer

235
00:22:06,200 --> 00:22:12,300
of listed as the lowest 12th lowest consumer of antimicrobials per capita.

236
00:22:12,300 --> 00:22:19,560
So if you looked at kind of the lowest consumption country which was the Netherlands and you

237
00:22:19,560 --> 00:22:25,480
looked at Greece which is the most consumption Canada fit at the 12th lowest and so just

238
00:22:25,480 --> 00:22:30,640
kind of to put you put that into perspective Canada consumed nearly twice as an amount

239
00:22:30,640 --> 00:22:37,440
of antimicrobials than the Netherlands but half the amount of Greece.

240
00:22:37,440 --> 00:22:43,640
So I think that's an important consideration to see where we are fitting globally but we'll

241
00:22:43,640 --> 00:22:50,520
talk a little bit about the regional differences as well but really kind of pinpointing on

242
00:22:50,520 --> 00:22:55,900
the fact that along with surveillance increasing awareness of antimicrobials I think it also

243
00:22:55,900 --> 00:23:02,040
impacts us as prescribers and just to think about is this appropriate use of this antibiotic

244
00:23:02,040 --> 00:23:09,120
and do we need to be using these antibiotics and I think part of the surveillance understanding

245
00:23:09,120 --> 00:23:16,320
the surveillance numbers and and why we're doing surveillance is to really drive you

246
00:23:16,320 --> 00:23:21,880
know see what the pattern is showing for resistance but antimicrobial use as all of us are aware

247
00:23:21,880 --> 00:23:28,800
is one of the key drivers of the resistance patterns and so I think it's important to

248
00:23:28,800 --> 00:23:34,000
kind of just remind ourselves of what is going on nationally.

249
00:23:34,000 --> 00:23:39,280
So the report identified that the situation in Canada is worsening we talked about some

250
00:23:39,280 --> 00:23:43,320
of the priority pathogens we talked about some of the resistance patterns we talked

251
00:23:43,320 --> 00:23:50,240
about how the anti-biogram data is changing so let's talk a little bit about the prescription

252
00:23:50,240 --> 00:23:51,680
rates overall.

253
00:23:51,680 --> 00:23:59,920
So in the report antimicrobial use and antimicrobial prescription rates whether you know consumption

254
00:23:59,920 --> 00:24:06,000
or dispension of antimicrobials was all discussed so overall our antimicrobial prescription

255
00:24:06,000 --> 00:24:13,520
rates have increased in this 2014 to 2018 period almost close to 6 percent.

256
00:24:13,520 --> 00:24:20,360
In 2018 64 percent of prescriptions originated from other family physicians general physicians

257
00:24:20,360 --> 00:24:28,280
compared to other medical or non-medical specialties prescribing around 35 percent.

258
00:24:28,280 --> 00:24:34,360
Notably antimicrobial purchasing by hospitals increased by nearly 30 percent and the key

259
00:24:34,360 --> 00:24:41,560
example they gave there was Dapdomycin had a 58 percent increase in purchasing by Canadian

260
00:24:41,560 --> 00:24:44,040
hospitals.

261
00:24:44,040 --> 00:24:48,600
It was also reports that there's increase in purchasing of doxycycline and penicillin

262
00:24:48,600 --> 00:24:55,760
G and these are currently being investigated as part of the next report.

263
00:24:55,760 --> 00:25:05,880
There was also mention further of antibiotics and antimicrobials that are put under WHO's

264
00:25:05,880 --> 00:25:11,680
aware category of being reserve antimicrobials and so these are antimicrobial that should

265
00:25:11,680 --> 00:25:18,720
really be reserved for treating multi-drug resistant infections and their overall kind

266
00:25:18,720 --> 00:25:25,720
of purchasing rates had nearly increased to 10 percent although fortunately their use

267
00:25:25,720 --> 00:25:27,360
remained less than 1 percent.

268
00:25:27,360 --> 00:25:33,800
So these some of these reserve antimicrobials would include Dapdomycin, Linazolid, Ceftaz,

269
00:25:33,800 --> 00:25:39,640
Avibactam just to give you a few examples.

270
00:25:39,640 --> 00:25:45,800
It was also mentioned in the report that carbapenem use has increased by more than 120 percent

271
00:25:45,800 --> 00:25:54,280
in the community setting and as most of us are aware Ertapenem being a common carbapenem

272
00:25:54,280 --> 00:26:01,040
used in the community setting there had been reports of doubling in its use during this

273
00:26:01,040 --> 00:26:04,760
2014 to 2018 period.

274
00:26:04,760 --> 00:26:11,600
So I think in order to again really understand the depth and degree of antimicrobial use

275
00:26:11,600 --> 00:26:17,020
we have to remind ourselves and refresh the definition of defined daily dose.

276
00:26:17,020 --> 00:26:23,240
So as most of us are aware that's abbreviated as DDD and this is the assumed average maintenance

277
00:26:23,240 --> 00:26:30,440
dose per day for an antimicrobial drug that's used for its main indication in adults.

278
00:26:30,440 --> 00:26:35,880
So this DDD provides usually a fixed unit of measurement it's independent of the price,

279
00:26:35,880 --> 00:26:42,480
currency, size and strength but really gives us an easy way to assess trends in drug consumption.

280
00:26:42,480 --> 00:26:47,600
So I'm going to use some of those numbers just to give you an overall kind of review

281
00:26:47,600 --> 00:26:49,600
of the consumption.

282
00:26:49,600 --> 00:26:57,680
So in 2014 to 2018 annual antimicrobial consumption so either dispensed by community pharmacies

283
00:26:57,680 --> 00:27:05,520
and purchased by hospitals was close to 17.5 antimicrobial doses were consumed each day

284
00:27:05,520 --> 00:27:14,440
for every thousand population days or that's close to 6300 doses annually consumed every

285
00:27:14,440 --> 00:27:16,040
thousand inhabitants.

286
00:27:16,040 --> 00:27:23,260
So really this trend more likely was listed to be driven by the 29% increase in purchasing

287
00:27:23,260 --> 00:27:32,780
of antimicrobials by hospitals but just to give you kind of an overall consumption data

288
00:27:32,780 --> 00:27:37,040
important to kind of key in these numbers here.

289
00:27:37,040 --> 00:27:43,640
So if we compare that to let's say we were talking about the carbapenem increase so in

290
00:27:43,640 --> 00:27:50,760
the community setting up by 120% for instance if we look at that urtapenem use went from

291
00:27:50,760 --> 00:27:58,400
2.5 ddd's per thousand inhabitants up to close to 5 so that's where that near doubling

292
00:27:58,400 --> 00:28:03,320
in use of urtapenem numbers are reflective.

293
00:28:03,320 --> 00:28:07,800
So like I mentioned in promise we look at a regional perspective of antimicrobial use

294
00:28:07,800 --> 00:28:15,400
so in 2018 as per the report Canadian provinces in the eastern part of Canada so PEI in New

295
00:28:15,400 --> 00:28:20,720
Finland consumed the largest quantity per capita and then the lowest consumption was

296
00:28:20,720 --> 00:28:24,400
in the territories and British Columbia.

297
00:28:24,400 --> 00:28:33,040
So in 2018 90% of the ddd's were dispensed in the community sector and only 10% purchased

298
00:28:33,040 --> 00:28:40,480
by hospitals so I think that gives you kind of the consumption or dispensing rates as

299
00:28:40,480 --> 00:28:48,380
well based on where they're occurring whether in the community or the hospital setting.

300
00:28:48,380 --> 00:28:53,080
And whenever we talk about antimicrobial use I think we always have to bring up the estimated

301
00:28:53,080 --> 00:28:59,900
health care costs because as most of us are aware these are usually directly affected.

302
00:28:59,900 --> 00:29:06,380
So in the report they had indicated that for both community and hospital the estimated

303
00:29:06,380 --> 00:29:12,920
costs of all antimicrobials that were consumed during 2014 to 2018 had gone up from close

304
00:29:12,920 --> 00:29:18,520
to 810 million to 825 million in just four years.

305
00:29:18,520 --> 00:29:28,160
So another kind of component of the antimicrobial use and really focusing on dispensing of antimicrobials

306
00:29:28,160 --> 00:29:34,280
in which classes because I thought that was quite interesting and well laid out in the

307
00:29:34,280 --> 00:29:42,680
report and an important point for us clinicians as well is that in the community setting the

308
00:29:42,680 --> 00:29:48,120
top five antibiotic classes that were dispensed going from the most to the least were the

309
00:29:48,120 --> 00:29:53,480
extended spectrum penicillins, tetracyclines, then macrolides, then fluoroquinols and then

310
00:29:53,480 --> 00:29:58,280
our first generation cephalosporins being the least dispensed.

311
00:29:58,280 --> 00:30:04,960
In the hospital setting for dispensing antimicrobials it really depended on if the patients were

312
00:30:04,960 --> 00:30:13,000
in the ICU or non-ICU and so the report was able to separate those two settings and report

313
00:30:13,000 --> 00:30:15,720
out the most to the least dispensing.

314
00:30:15,720 --> 00:30:23,600
And so in the non-ICU setting the most dispensed were was cefazolin, then pipercelin, tasobactin,

315
00:30:23,600 --> 00:30:27,760
then metronidazole, then ceftriaxin with the least being ciprofloxacin.

316
00:30:27,760 --> 00:30:34,440
Whereas in the ICU setting you had a cephalosin was still the most dispensed but then also

317
00:30:34,440 --> 00:30:41,560
with pipercelin tasobactin being number two and then more of your broader antimicrobials

318
00:30:41,560 --> 00:30:46,240
like vancomycin and then meropenem and then least was cephtriaxin.

319
00:30:46,240 --> 00:30:54,560
So those are just interesting kind of top five antibiotic classes that were dispensed

320
00:30:54,560 --> 00:31:01,760
differently in the two settings that I thought was quite important to share.

321
00:31:01,760 --> 00:31:10,120
So I think for some of the key points there about antimicrobial use and just looking at

322
00:31:10,120 --> 00:31:16,960
those numbers and how they directly affect you know the initial part that we talked about

323
00:31:16,960 --> 00:31:24,160
today which was resistance was important just to kind of key in some of those important

324
00:31:24,160 --> 00:31:26,520
statistics in Canada.

325
00:31:26,520 --> 00:31:34,400
So this we're coming kind of closer to the end of our podcast today or in our episode

326
00:31:34,400 --> 00:31:39,720
so we're going to finish off by just identifying some of the emerging threats because I did

327
00:31:39,720 --> 00:31:47,960
want to convey that information as an important part of the CARS 2020 report.

328
00:31:47,960 --> 00:31:56,280
So as most of us are aware Canada oris back in between 2012 and 2019 there was 24 cases

329
00:31:56,280 --> 00:32:02,960
that were reported of Canada oris to phac and so the public health agency of Canada

330
00:32:02,960 --> 00:32:08,000
and some of which were multi-drug resistant so just keeping that in mind.

331
00:32:08,000 --> 00:32:16,280
Notably we didn't talk a lot about nysere gonorrhea today although an important pathogen

332
00:32:16,280 --> 00:32:25,000
with its increasing rates and also notably the in 2017 and 2018 it was identified as

333
00:32:25,000 --> 00:32:31,200
an emerging threat because the first chef triaxone resistant case of nysere gonorrhea

334
00:32:31,200 --> 00:32:36,240
was reported in Canada and it was associated with travel to Southeast Asia.

335
00:32:36,240 --> 00:32:42,520
So really kind of keying in on importance of empiric management there.

336
00:32:42,520 --> 00:32:48,880
And then finally the carbpennimase genes there was an identified emerging threat that's been

337
00:32:48,880 --> 00:32:56,660
detected in acinetobacter isolate from a patient or from patients in health care settings.

338
00:32:56,660 --> 00:33:06,200
So there was 41 cases that were reported with carbpennimase producing acinetobacter species

339
00:33:06,200 --> 00:33:12,440
between this 2014 to 2018 period and this really represents a threat to the continued

340
00:33:12,440 --> 00:33:20,760
effectiveness of carbpennims against acinetobacter species so just keeping that in mind.

341
00:33:20,760 --> 00:33:27,240
Alright so I want to thank everyone for tuning in today for our very first episode in discussing

342
00:33:27,240 --> 00:33:29,440
the surveillance report.

343
00:33:29,440 --> 00:33:34,520
I hope you found this short segment a great review of antimicrobial resistance use and

344
00:33:34,520 --> 00:33:40,240
some of our common pathogens and priority pathogens that were discussed today.

345
00:33:40,240 --> 00:33:45,480
Please reach out to us via email if you would like to have specific topics discussed or

346
00:33:45,480 --> 00:33:52,080
would like to come on to the podcast and discuss a specific area in infectious diseases.

347
00:33:52,080 --> 00:34:03,040
We would be grateful to have input regarding that and I want to end off today by thanking

348
00:34:03,040 --> 00:34:13,760
Verity Pharmaceuticals for its ongoing support for this podcast and I hope that you enjoyed

349
00:34:13,760 --> 00:34:21,880
this episode and I look forward to creating new up to date episodes in the near future.

350
00:34:21,880 --> 00:34:25,200
Thank you so much for tuning in.

351
00:34:25,200 --> 00:34:28,920
Thank you Dr. Peerwal and to Verity Pharmaceuticals.

352
00:34:28,920 --> 00:34:31,320
Thanks for listening to our very first episode.

353
00:34:31,320 --> 00:34:37,000
Email us at thecanadianbreakpoint.gmail.com if you have any comments or if you have any

354
00:34:37,000 --> 00:34:40,600
infectious disease topics you'd like to hear about and for us to discuss.

355
00:34:40,600 --> 00:34:50,960
We look forward to seeing you again at the Canadian Breakpoint.