1 00:00:00,000 --> 00:00:13,520 Thanks for joining us at the Canadian Breakpoint, a Canadian infectious diseases podcast by 2 00:00:13,520 --> 00:00:16,340 Canadian infectious diseases physicians. 3 00:00:16,340 --> 00:00:21,340 I'm Summer Stewart, here with Dr. Rupeena Purewal to welcome you to the first episode 4 00:00:21,340 --> 00:00:22,480 of season two. 5 00:00:22,480 --> 00:00:28,600 Dr. PirwalPurewal is a Canadian pediatric infectious diseases physician from Edmonton, Alberta. 6 00:00:28,600 --> 00:00:33,400 She completed her medical school at the University of Pesh in Hungary and her three-year residency 7 00:00:33,400 --> 00:00:36,420 program at West Virginia University. 8 00:00:36,420 --> 00:00:41,600 She returned to Canada in 2017 to start a pediatric infectious diseases fellowship at 9 00:00:41,600 --> 00:00:43,760 the University of Manitoba. 10 00:00:43,760 --> 00:00:48,600 Upon completing her fellowship, Dr. Purewal moved to Saskatchewan as a clinician and 11 00:00:48,600 --> 00:00:52,400 academic physician at the University of Saskatchewan. 12 00:00:52,400 --> 00:00:58,880 In this episode, Dr. Rupeena Purewal will review the Canadian Antimicrobial Resistance Surveillance 13 00:00:58,880 --> 00:01:00,880 System Report for 2022. 14 00:01:00,880 --> 00:01:01,880 Dr. Purewal. 15 00:01:01,880 --> 00:01:07,560 Hi everyone, welcome to another season of our podcast, the Canadian Breakpoint. 16 00:01:07,560 --> 00:01:09,920 I'm your host, Dr. Rupeena Purewal. 17 00:01:09,920 --> 00:01:16,160 I'm looking forward to a great season with new and exciting episodes and to present updates 18 00:01:16,160 --> 00:01:20,520 on antimicrobials, AMR and diagnostics and much more. 19 00:01:20,520 --> 00:01:24,240 Thank you so much for all of your support we received last season and we look forward 20 00:01:24,240 --> 00:01:26,740 to new episodes. 21 00:01:26,740 --> 00:01:32,880 So prior to kicking off season two, I do want to disclose that this podcast is for informational 22 00:01:32,880 --> 00:01:36,680 purposes only and in no way to endorse any products. 23 00:01:36,680 --> 00:01:41,360 So we're going to kick off season two with updates from our CARS report. 24 00:01:41,360 --> 00:01:47,680 So this is the Canadian Antimicrobial Resistance Surveillance System Report 2022 that was released 25 00:01:47,680 --> 00:01:48,680 recently. 26 00:01:48,680 --> 00:01:55,960 And as many of you may know, it provides a five-year trend up to 2021. 27 00:01:55,960 --> 00:02:02,320 Previously in our last season, our first episode, we actually recorded the CARS report that 28 00:02:02,320 --> 00:02:04,260 had updates till 2019. 29 00:02:04,260 --> 00:02:06,060 So a lot of new information. 30 00:02:06,060 --> 00:02:09,540 So you may wonder why are we talking about this today? 31 00:02:09,540 --> 00:02:15,300 So the importance of this is really because globally it's estimated that 4.95 million 32 00:02:15,300 --> 00:02:21,800 deaths in 2019 were associated with antimicrobial resistant bacterial infections. 33 00:02:21,800 --> 00:02:28,880 If the resistance rates grow and they continue to grow to 40% in 2050, the cost of Canadian 34 00:02:28,880 --> 00:02:34,120 healthcare system will be anywhere close to $7.6 billion a year. 35 00:02:34,120 --> 00:02:37,680 So as you can see, this is a very important topic. 36 00:02:37,680 --> 00:02:41,760 We emphasize that in our first season as well. 37 00:02:41,760 --> 00:02:47,600 And we had a lot of discussions around antimicrobial resistance and antibiotic stewardship as well. 38 00:02:47,600 --> 00:02:54,560 Similarly, we'll have some upcoming episodes to discuss similar topics. 39 00:02:54,560 --> 00:02:59,080 So the interesting thing with this report is that it actually captures the effects of 40 00:02:59,080 --> 00:03:02,400 the first full year of the pandemic. 41 00:03:02,400 --> 00:03:09,320 And so there was a lot of information in the report regarding COVID and AMR and what really 42 00:03:09,320 --> 00:03:10,320 happened. 43 00:03:10,320 --> 00:03:16,840 So I think it's a quite exciting release of information for us and important information 44 00:03:16,840 --> 00:03:21,000 for us to actually know kind of what was noticed. 45 00:03:21,000 --> 00:03:26,280 Now majority of this episode, I will be talking about what was mentioned in the report and 46 00:03:26,280 --> 00:03:29,320 summarizing some of the key findings. 47 00:03:29,320 --> 00:03:37,240 Now keeping in mind that this information is available through the CARS report, I do 48 00:03:37,240 --> 00:03:43,440 have some thoughts about some of the information that was presented that I will bring up today. 49 00:03:43,440 --> 00:03:44,880 So stay tuned. 50 00:03:44,880 --> 00:03:52,640 So overall, if we looked at the key findings in this report, in the CARS report 2022, there 51 00:03:52,640 --> 00:03:56,040 was mention that there was sustained decrease in antimicrobial consumption. 52 00:03:56,040 --> 00:03:59,720 And this is something that we will be talking about at the end of this episode. 53 00:03:59,720 --> 00:04:06,120 So stay tuned for more information in regarding to how there was a reduction of antibiotics 54 00:04:06,120 --> 00:04:12,240 in both the healthcare and healthcare centers and community use as well. 55 00:04:12,240 --> 00:04:18,840 Now in terms of overall, there was mention that there was increase in antimicrobial use 56 00:04:18,840 --> 00:04:24,000 in patients that were hospitalized, especially those that were hospitalized with a concomitant 57 00:04:24,000 --> 00:04:25,000 COVID-19 infection. 58 00:04:25,000 --> 00:04:33,640 Now, as all of us clinicians would know, that it was very difficult and is difficult to 59 00:04:33,640 --> 00:04:41,000 be able to differentiate between the respiratory complications that are associated with COVID 60 00:04:41,000 --> 00:04:45,560 infections and really the clinical challenges of diagnosing co-infections. 61 00:04:45,560 --> 00:04:51,160 And so in the report, this was also mentioned that there may be an increased risk for inappropriate 62 00:04:51,160 --> 00:04:52,160 prescribing. 63 00:04:52,160 --> 00:04:57,320 But we'll talk a little bit about that later in the episode as well, because I'm curious 64 00:04:57,320 --> 00:05:03,520 and I do wonder if we'll continue to see some of the aftermath for years to follow. 65 00:05:03,520 --> 00:05:09,920 Now in terms of some of the exciting things that were presented early in the report, where 66 00:05:09,920 --> 00:05:14,320 we're in regards to newer funding that was received in 2021. 67 00:05:14,320 --> 00:05:20,040 So PHAC was able to make progress in a number of areas, which will help us fight this battle 68 00:05:20,040 --> 00:05:21,700 against AMR. 69 00:05:21,700 --> 00:05:31,360 And so for instance, in terms of detection, integrated lab diagnostic data have been incorporated 70 00:05:31,360 --> 00:05:34,800 that are being used to detect changes. 71 00:05:34,800 --> 00:05:36,480 That's AMR-NET. 72 00:05:36,480 --> 00:05:46,120 In terms of analyzing this data, so there is results from a newer survey that was piloted 73 00:05:46,120 --> 00:05:49,520 actually in 2018 and 2019. 74 00:05:49,520 --> 00:05:54,040 And this is the National Antimicrobial Prescribing Survey, which is going to help us expand our 75 00:05:54,040 --> 00:05:57,840 knowledge of appropriateness of prescriptions that are dispensed. 76 00:05:57,840 --> 00:06:02,640 And also Canada is working on other surveillance systems as well to better understand how AMR 77 00:06:02,640 --> 00:06:04,760 is spreading between countries. 78 00:06:04,760 --> 00:06:06,800 So lots of exciting things. 79 00:06:06,800 --> 00:06:11,560 We're going to talk a little bit more about the National Antimicrobial Prescribing Survey 80 00:06:11,560 --> 00:06:14,360 later in this episode as well. 81 00:06:14,360 --> 00:06:19,320 Now in terms of actions, I think improving effectiveness of antimicrobial stewardship 82 00:06:19,320 --> 00:06:25,360 programs and infection control interventions and using that data is really important. 83 00:06:25,360 --> 00:06:31,200 And that was mentioned in this new funding proposal as well. 84 00:06:31,200 --> 00:06:37,440 And something that's not going to be mentioned much in this report, but will be in upcoming 85 00:06:37,440 --> 00:06:41,720 reports, PHAC did initiate new surveillance activities. 86 00:06:41,720 --> 00:06:47,240 So something to look forward to is, example, environmental surveillance. 87 00:06:47,240 --> 00:06:52,560 So they're monitoring quantity of antimicrobials and wastewater samples from select Canadian 88 00:06:52,560 --> 00:06:59,440 communities, and furthermore, trying to improve the representation of AMR surveillance, not 89 00:06:59,440 --> 00:07:07,560 to just include community and health care sectors, but also long-term care facilities 90 00:07:07,560 --> 00:07:08,560 as well. 91 00:07:08,560 --> 00:07:10,080 So I think there's a lot of updates. 92 00:07:10,080 --> 00:07:15,120 There is a lot of new and exciting things that may not be in this report, but upcoming 93 00:07:15,120 --> 00:07:16,400 next report. 94 00:07:16,400 --> 00:07:19,640 But some of the things that we want to talk about today. 95 00:07:19,640 --> 00:07:23,920 So we're going to go into doing the key findings that were seen in 2016 and 2020. 96 00:07:23,920 --> 00:07:30,960 So I'm going to do the next portion of this podcast episode will include some information 97 00:07:30,960 --> 00:07:34,960 regarding our common pathogens that are under surveillance. 98 00:07:34,960 --> 00:07:41,960 So we'll start off by talking a little bit about MRSA, then VRE, and then go on to discuss 99 00:07:41,960 --> 00:07:48,680 carbamase producing, intrabacterialase, and some of the other targets that were under 100 00:07:48,680 --> 00:07:49,680 surveillance. 101 00:07:49,680 --> 00:07:56,880 So without further ado, so in terms of the report this year, the NACAR's 2022 report, 102 00:07:56,880 --> 00:08:04,440 when they looked at the trend from 2016 to 2020, in terms of MRSA bloodstream infections, 103 00:08:04,440 --> 00:08:07,080 the overall trend had increased. 104 00:08:07,080 --> 00:08:15,300 So this data was reported to CNS with 62 out of 80 hospitals in 10 provinces and one territory. 105 00:08:15,300 --> 00:08:24,560 So overall, they did see an increase since 2017 from the community-acquired, community-associated 106 00:08:24,560 --> 00:08:26,680 MRSA infections. 107 00:08:26,680 --> 00:08:33,320 In terms of why that would be, there was some speculation of increased frequency of at-risk 108 00:08:33,320 --> 00:08:40,280 behaviors in our Canadian population, examples being injection drug use and the ongoing opioid 109 00:08:40,280 --> 00:08:41,280 epidemic. 110 00:08:41,280 --> 00:08:48,240 Now, the overall incidence of MRSA bloodstream infections increased by 33%, of which, which 111 00:08:48,240 --> 00:08:54,880 was a bit alarming, was that 75% of the rise was in the community-associated MRSA bloodstream 112 00:08:54,880 --> 00:08:56,240 infections. 113 00:08:56,240 --> 00:09:01,840 And overall, looking at the samples that were submitted for, and the isolates submitted 114 00:09:01,840 --> 00:09:09,600 for bloodstream infections, MRSA accounted for 16% of the staff-orious bloodstream isolates. 115 00:09:09,600 --> 00:09:17,000 Now, in terms of, when speaking of healthcare-associated MRSA isolates, the bloodstream infections 116 00:09:17,000 --> 00:09:20,960 were down, so there was a downtrend there, by 2.3%. 117 00:09:20,960 --> 00:09:27,080 It was interesting to see that pediatric hospital rates peaked in 2019 for MRSA bloodstream 118 00:09:27,080 --> 00:09:31,880 infections and then stabilized thereafter, whereas in the adult and hospitals and mixed 119 00:09:31,880 --> 00:09:35,600 hospitals, these rates remain stable. 120 00:09:35,600 --> 00:09:42,080 Now, going on to something that was also mentioned in the report was regarding susceptibility 121 00:09:42,080 --> 00:09:47,800 patterns, and I think for us clinicians, this is really important and something that we 122 00:09:47,800 --> 00:09:49,440 always need to keep in mind. 123 00:09:49,440 --> 00:09:57,840 So looking at their data in terms of healthcare-associated MRSA isolates, I was pleased to see that trimethylamine 124 00:09:57,840 --> 00:10:04,720 sulfamethoxazole resistance remained low, so that was below 7%. 125 00:10:04,720 --> 00:10:10,920 Arithromycin resistance decreased from 78% to 65%, and our clindamycin and erythromycin 126 00:10:10,920 --> 00:10:17,200 resistance rates remained stable, so clinda being around 30% to 50%, and then for erythromycin 127 00:10:17,200 --> 00:10:19,960 around 70% to 80%. 128 00:10:19,960 --> 00:10:24,760 Now the, I think something that was very alarming, now this is both in the healthcare-associated 129 00:10:24,760 --> 00:10:32,360 and the community-associated MRSA isolates, but for the first time ever, there was non-susceptibility 130 00:10:32,360 --> 00:10:34,880 to daptomycin that was identified. 131 00:10:34,880 --> 00:10:42,080 So two isolates were from the healthcare-associated MRSA, two isolates in 2020, and similarly 132 00:10:42,080 --> 00:10:48,840 from the community-associated MRSA isolates, again, there was another two isolates for 133 00:10:48,840 --> 00:10:52,480 the first time that had non-susceptibly to daptomycin, so this was quite alarming to 134 00:10:52,480 --> 00:10:57,400 myself, and something that we should all be keeping in mind. 135 00:10:57,400 --> 00:11:03,440 In terms of the healthcare-associated MRSA isolates, all the isolates tested susceptible 136 00:11:03,440 --> 00:11:07,240 to Linazolid, Tigacycline, and Vancomycin. 137 00:11:07,240 --> 00:11:14,280 Just some quick reports on susceptibilities and sensitivities for the community-associated 138 00:11:14,280 --> 00:11:21,560 MRSA isolates, though very similar rates for clindamycin and erythromycin. 139 00:11:21,560 --> 00:11:28,560 Similarly TMP, sulfamethoxazole, rates remained low, less than 3%, and then as previously 140 00:11:28,560 --> 00:11:33,160 mentioned there were two isolates that were non-susceptible to daptomycin, and all of 141 00:11:33,160 --> 00:11:39,760 the community-acquired and associated MRSA isolates were also tested susceptibility, 142 00:11:39,760 --> 00:11:45,160 all were susceptible to Linazolid, Tigacycline, and Vancomycin. 143 00:11:45,160 --> 00:11:53,040 So definitely something that stuck out to me was the daptomycin non-susceptibility patterns 144 00:11:53,040 --> 00:11:58,040 and then the ongoing resistance that we're seeing with clindamycin and erythromycin, 145 00:11:58,040 --> 00:12:03,760 something that I took back from the report for the MRSA bloodstream infections. 146 00:12:03,760 --> 00:12:09,960 And moving on to VREs, so vancomycin resistant enterococcus, bloodstream infections overall 147 00:12:09,960 --> 00:12:17,080 trend in this report was also trending up, so has increased, although since 2018 the 148 00:12:17,080 --> 00:12:19,880 rate has slightly decreased. 149 00:12:19,880 --> 00:12:25,220 There was some speculation that the increase in majority of the years was due to emergence 150 00:12:25,220 --> 00:12:31,480 of a new sequence type, infection control policies, and likely related to our COVID-19 151 00:12:31,480 --> 00:12:32,480 pandemic. 152 00:12:32,480 --> 00:12:42,280 Now, the overall rate that peaked in 2018 increased by 72%, 99% of the isolates, so 153 00:12:42,280 --> 00:12:49,680 there were 683 isolates and 99% of them were enterococcus thesium, and 93% were acquired 154 00:12:49,680 --> 00:12:51,720 in healthcare facility. 155 00:12:51,720 --> 00:12:58,200 Now, the most common sequence types were mentioned in the report, so the sequence type, which 156 00:12:58,200 --> 00:13:06,240 was done for ST17, 1478, and ST80 were the three most common types, and the largest increase 157 00:13:06,240 --> 00:13:13,920 that we did see was in our Canadian report was the sequence type 17, which went from 158 00:13:13,920 --> 00:13:21,800 3% previously to up to 36% from 2016 to 2020. 159 00:13:21,800 --> 00:13:28,840 In terms of our susceptibility patterns, there was some low level resistance detected to 160 00:13:28,840 --> 00:13:34,440 Tigacycline, Linazolid, and Daptomycin, but really only less than 9%, and actually has 161 00:13:34,440 --> 00:13:40,280 for Daptomycin has even further declined to 3.5% in 2020, but just keeping in caution 162 00:13:40,280 --> 00:13:45,120 that only a small number of isolates were actually evaluated, and all of them were resistant 163 00:13:45,120 --> 00:13:48,480 to ciprofloxacin. 164 00:13:48,480 --> 00:13:55,360 Moving on to our other pathogens, so carbapenemies producing enterobacterioles, the overall trend 165 00:13:55,360 --> 00:14:01,240 varied, so they did see an initial increase, but then decreased in the latter part of the 166 00:14:01,240 --> 00:14:08,960 report, so 2019 to 2020, and likely related to infection control practices that were increased, 167 00:14:08,960 --> 00:14:14,640 keeping in mind that colonization rates were not included in this report. 168 00:14:14,640 --> 00:14:25,240 And looking at the CPE, so the carbapenemies producing enterobacterioles rates were the 169 00:14:25,240 --> 00:14:31,880 highest in central and western Canada and remain low in eastern Canada, of mention of 170 00:14:31,880 --> 00:14:39,680 which genes were the most prevalent, so KPC, Cllebsiella pneumoniae, carbapenemies, NDM, 171 00:14:39,680 --> 00:14:47,720 New Delhi metallo-betalactamase, and Oxa 48 in kind of the highest to least prevalence 172 00:14:47,720 --> 00:14:50,520 were reported still in Canada. 173 00:14:50,520 --> 00:14:58,000 Now over 60% of the CPE isolates were resistant to septazidine, cipromeropenem, piptazo, and 174 00:14:58,000 --> 00:15:00,360 trimethylamosulfamethoxazole. 175 00:15:00,360 --> 00:15:07,900 We did see that with trimethylamosulfamethoxazole, resistance did increase by 13%, so something 176 00:15:07,900 --> 00:15:13,040 to keep in mind, and was mentioned in the report. 177 00:15:13,040 --> 00:15:20,880 Now moving on, so they did talk in the report and speak about osteoides difficile, so C. 178 00:15:20,880 --> 00:15:28,960 diff infections, and the overall trend actually decreased initially, but then they saw an 179 00:15:28,960 --> 00:15:35,880 increase in 2019 to 2020, now I'm sure why, again, likely related to the number of antibiotics 180 00:15:35,880 --> 00:15:37,680 being prescribed. 181 00:15:37,680 --> 00:15:40,640 And as we know, it had increased early in the pandemic. 182 00:15:40,640 --> 00:15:46,360 In terms of what the report did mention that stuck out to me about C. diff infections, 183 00:15:46,360 --> 00:15:51,280 so there was one hospital acquired C. diff infection that was noted to be resistant to 184 00:15:51,280 --> 00:15:56,000 metronidazole, but no isolates were resistant to vancomycin. 185 00:15:56,000 --> 00:16:02,800 And in terms of the community acquired and associated C. diff infections, metronidazole 186 00:16:02,800 --> 00:16:08,640 and vancomycin, there was no resistance found to those antimicrobials. 187 00:16:08,640 --> 00:16:14,520 In terms of in Canada, what they noticed the trend for C. diff infections ribotypes, so 188 00:16:14,520 --> 00:16:16,160 what was the most common? 189 00:16:16,160 --> 00:16:27,280 It was ribotypes RT106, 15% of over 330 isolates were of this ribotype, and this was similar 190 00:16:27,280 --> 00:16:31,600 both in the hospital and community setting. 191 00:16:31,600 --> 00:16:37,640 Now moving on to other organisms that were discussed in the report. 192 00:16:37,640 --> 00:16:44,520 So something that was brought up was data around the Nicere gonorrhea isolates. 193 00:16:44,520 --> 00:16:51,680 Now if any of you tuned into our previous season, our last episode discussed disseminated 194 00:16:51,680 --> 00:16:57,280 gonococcal infections, and even in that episode, we talked a lot about how these gonococcal 195 00:16:57,280 --> 00:16:59,440 infections have continued to rise. 196 00:16:59,440 --> 00:17:05,840 And this report was quite fitting with the data that was presented there similarly because 197 00:17:05,840 --> 00:17:10,640 this same surveillance program in Canada, so GASC Canada, Gonococcal Antimicrobial 198 00:17:10,640 --> 00:17:17,760 Surveillance Program Canada, is where the CARS report obtained this data and Alberta, 199 00:17:17,760 --> 00:17:24,360 Manitoba, Northwest Territories and Nova Scotia, the provinces providing such data to see the 200 00:17:24,360 --> 00:17:29,280 trends of AMR with Nicere gonorrhea isolates in Canada. 201 00:17:29,280 --> 00:17:37,880 So the data here in the report did coincide with the concerns with the gonococcal infections 202 00:17:37,880 --> 00:17:39,080 continuing to rise. 203 00:17:39,080 --> 00:17:42,560 They did see that they were higher in males. 204 00:17:42,560 --> 00:17:48,640 The rate increased by 44% during this duration of the five-year period. 205 00:17:48,640 --> 00:17:56,160 Globally and in Canada, there were isolates with decreased sensitivity and susceptibility 206 00:17:56,160 --> 00:17:59,440 to extended spectrum cephalosporins. 207 00:17:59,440 --> 00:18:06,840 And between 2016 and 2020, resistance of these strains to zithromycin remains threatened. 208 00:18:06,840 --> 00:18:12,480 And that was a concerning factor brought up in the CARS report 2022. 209 00:18:12,480 --> 00:18:17,680 In terms of multidrug resistance strains, so this is when there's decreased susceptibility 210 00:18:17,680 --> 00:18:22,640 to one currently recommended therapy, like a zithromycin or cephalosporin group, plus 211 00:18:22,640 --> 00:18:29,440 two other antimicrobials and this ranges for Nicere gonorrhea anywhere from 6 to 12%. 212 00:18:29,440 --> 00:18:34,440 There were warnings from WHO in regards to XDR strains. 213 00:18:34,440 --> 00:18:39,920 So as many of you may know, this is resistance to two current recommended therapies and two 214 00:18:39,920 --> 00:18:43,280 other antimicrobials. 215 00:18:43,280 --> 00:18:49,840 And XDR strains do exist and that gonococcal infections could become untreatable due to 216 00:18:49,840 --> 00:18:51,960 the resistance to all antimicrobials. 217 00:18:51,960 --> 00:18:59,760 So in this five-year period of the report, 11 cases of XDR were identified and there 218 00:18:59,760 --> 00:19:03,080 was mention that further surveillance was needed. 219 00:19:03,080 --> 00:19:08,840 Something that was quite alarming was that seven of the cases were actually in 2018. 220 00:19:08,840 --> 00:19:16,300 When looking at the report, it was mentioned that in 2020, the highest resistance for antimicrobials 221 00:19:16,300 --> 00:19:19,920 was to ciprofloxacin at 57%. 222 00:19:19,920 --> 00:19:23,720 So something to keep in mind. 223 00:19:23,720 --> 00:19:29,720 It is notable that there was a slight decline to decrease susceptibility to ceftraxone in 224 00:19:29,720 --> 00:19:34,720 2020, went from 1.8 to 0.9%. 225 00:19:34,720 --> 00:19:42,040 So in Canada, there were three cases of ceftraxone-resistant gonococcal strains that have been reported 226 00:19:42,040 --> 00:19:45,160 in 2017 and 2018. 227 00:19:45,160 --> 00:19:48,320 And two of these were associated with international travel. 228 00:19:48,320 --> 00:19:55,240 And then a third that was detected in December of 2021 was not related to international travel. 229 00:19:55,240 --> 00:20:02,200 So I think there's a lot of moving parts with the nicaraguanaria and gonococcal infections. 230 00:20:02,200 --> 00:20:09,600 GAS continues to provide this information and surveillance around antimicrobial resistance. 231 00:20:09,600 --> 00:20:16,480 There really is this enhanced surveillance of antimicrobial resistance that was actually 232 00:20:16,480 --> 00:20:18,920 established back in 2013. 233 00:20:18,920 --> 00:20:24,240 And the goal is really to understand the current trends and report them to prescribing physicians. 234 00:20:24,240 --> 00:20:28,240 So I think it's really important for us to keep this in mind. 235 00:20:28,240 --> 00:20:36,240 I think for more details, it would be nice to listen to the disseminated gonococcal infections 236 00:20:36,240 --> 00:20:37,320 episode. 237 00:20:37,320 --> 00:20:42,320 So tune into that just to see what was discussed. 238 00:20:42,320 --> 00:20:45,080 Moving on to other pathogens that were discussed. 239 00:20:45,080 --> 00:20:48,320 So there were reports about tuberculosis. 240 00:20:48,320 --> 00:20:55,720 I for obvious reasons left tuberculosis out of this podcast episode today. 241 00:20:55,720 --> 00:20:58,040 Although there's probably some likely changes. 242 00:20:58,040 --> 00:21:03,080 They did mention that TB trends were stable in Canada. 243 00:21:03,080 --> 00:21:09,200 Now we know some provinces are experiencing higher outbreaks in certain areas. 244 00:21:09,200 --> 00:21:13,080 And so for time purposes, I'll not review this during this episode. 245 00:21:13,080 --> 00:21:18,240 Really we'll need to discuss and provide more inter-provincial data in the near future. 246 00:21:18,240 --> 00:21:23,680 We did have an episode in our first season in terms of TB and the complicated presentations. 247 00:21:23,680 --> 00:21:28,000 And so I think this season we will bring you some updates. 248 00:21:28,000 --> 00:21:32,440 Now moving on to other organisms and pathogens that were discussed. 249 00:21:32,440 --> 00:21:33,560 So strep pneumoniae. 250 00:21:33,560 --> 00:21:41,600 So invasive pneumococcal disease or invasive pneumococcal infections due to strep pneumoniae. 251 00:21:41,600 --> 00:21:47,160 All trend in the report showed that we are seeing a trending up. 252 00:21:47,160 --> 00:21:53,120 So there is a rate of infection increase and the rate of infection by vaccine preventable 253 00:21:53,120 --> 00:21:55,960 serotypes actually increased by 45%. 254 00:21:55,960 --> 00:22:01,280 And this was something that really stuck out to me while reviewing this report and really 255 00:22:01,280 --> 00:22:05,680 emphasize the importance of vaccinations in children. 256 00:22:05,680 --> 00:22:12,720 So when we saw between 2015 to 2019, the rate of invasive pneumococcal disease increased 257 00:22:12,720 --> 00:22:15,360 by 11%. 258 00:22:15,360 --> 00:22:22,160 And when we looked, when CARS report surveillance looked at the isolates that were submitted 259 00:22:22,160 --> 00:22:30,040 to the National Micro Lab, so NML, between 2016 and 2020, where they received over 21 260 00:22:30,040 --> 00:22:39,080 to 3600 strep pneumo isolates, of which two thirds were non-PCV13 isolates and a third 261 00:22:39,080 --> 00:22:42,480 of them were PCV13 isolates. 262 00:22:42,480 --> 00:22:49,880 So something to consider and I think it directly can reflect some of the rate increases that 263 00:22:49,880 --> 00:22:53,920 are alarming because of the vaccine preventable serotypes going up. 264 00:22:53,920 --> 00:22:57,760 And again, emphasizing the importance of these primary vaccines. 265 00:22:57,760 --> 00:23:03,760 So the report also mentioned some other concerning factors in terms of resistance of the strep 266 00:23:03,760 --> 00:23:06,360 pneumonia isolates that were submitted. 267 00:23:06,360 --> 00:23:13,960 So overall, multiple antibiotics were tested in terms of some of the increases that they 268 00:23:13,960 --> 00:23:14,960 saw. 269 00:23:14,960 --> 00:23:20,360 So doxycycline, trimethylamine, sulfamethoxicill, both that increased around two to three percent, 270 00:23:20,360 --> 00:23:24,640 clarithromycin up to 25% resistance patterns. 271 00:23:24,640 --> 00:23:28,040 Something that was alarming to me was the penicillin rates. 272 00:23:28,040 --> 00:23:33,040 Now, considering that we know that there are penicillin resistant strep pneumonia isolates, 273 00:23:33,040 --> 00:23:39,920 but the rates have increased to 10 to 15% as per the CARS 2022 report. 274 00:23:39,920 --> 00:23:45,520 Now in terms of clindamycin resistance, it had initially increased up to 8% and then 275 00:23:45,520 --> 00:23:48,120 slightly down in 2020. 276 00:23:48,120 --> 00:23:53,160 Fortunately, resistance to ceftraxin remained low and stable. 277 00:23:53,160 --> 00:23:58,800 Lowest 0.2 to 0.7% from 2016 to 2020. 278 00:23:58,800 --> 00:24:05,400 Similarly alongside carbapenem resistance also remained low, 0 to 2%. 279 00:24:05,400 --> 00:24:09,840 It was mentioned that all isolates for strep pneumonia that were submitted were susceptible 280 00:24:09,840 --> 00:24:13,560 to vancomycin and linesalid. 281 00:24:13,560 --> 00:24:19,360 Now things that also were mentioned in the report that came across to me as very alarming 282 00:24:19,360 --> 00:24:27,480 was in 2016 and 2020, the multi-drug resistance rates were looked at for all age groups and 283 00:24:27,480 --> 00:24:33,520 the highest increase of multi-drug resistance strep pneumoniae was seen in those aged less 284 00:24:33,520 --> 00:24:35,080 than one year of age. 285 00:24:35,080 --> 00:24:41,200 So this went from anywhere 3% up to 27.8%. 286 00:24:41,200 --> 00:24:46,000 I think I've mentioned this a couple of times during this episode, but really emphasizing 287 00:24:46,000 --> 00:24:50,760 the importance of the primary vaccinations in this age group to really prevent these 288 00:24:50,760 --> 00:24:51,760 infections. 289 00:24:51,760 --> 00:24:56,120 And the highest proportion of the multi-drug resistance strains were seen in serotypes 290 00:24:56,120 --> 00:25:00,800 that can be covered by the PCV13 vaccine. 291 00:25:00,800 --> 00:25:04,880 So serotypes 19A for instance and 19F. 292 00:25:04,880 --> 00:25:08,640 Prevalence was anywhere from 25 to 35%. 293 00:25:08,640 --> 00:25:14,080 So something to keep in mind, I talked a little bit about the penicillin resistance. 294 00:25:14,080 --> 00:25:23,000 I did mention that amoxicillin clavulinate resistance also rose from zero up to 3.4%. 295 00:25:23,000 --> 00:25:30,400 Now moving on from strep pneumoniae, in the report there were discussions regarding invasive 296 00:25:30,400 --> 00:25:37,920 group A strep infections, likely because we are seeing an increased rate of these infections. 297 00:25:37,920 --> 00:25:42,520 So group A strep infects 18 million people globally. 298 00:25:42,520 --> 00:25:48,920 And recently there's increased rates from anywhere from 4 to 6.7 cases per 100,000 between 299 00:25:48,920 --> 00:25:51,280 2010 and 2017. 300 00:25:51,280 --> 00:25:58,080 So PHAC had enhanced its surveillance to keep an eye on invasive group A strep infections. 301 00:25:58,080 --> 00:26:04,760 And overall the key findings from the report, so between 2015 to 2019, was reported that 302 00:26:04,760 --> 00:26:11,280 the incident rate of invasive group A strep increased by 52.8%. 303 00:26:11,280 --> 00:26:18,600 So for the right reasons we had enhanced our surveillance, detecting these increased rates. 304 00:26:18,600 --> 00:26:23,600 Other details in regards to susceptibility patterns were released. 305 00:26:23,600 --> 00:26:31,880 So erythromycin resistance to group A strep was the highest, went from 8 to 11.5%. 306 00:26:31,880 --> 00:26:34,600 Clindamycin overall remained stable. 307 00:26:34,600 --> 00:26:41,600 There was a slight increase in 2017 for resistance for these isolates, but remained stable otherwise 308 00:26:41,600 --> 00:26:42,600 around 3%. 309 00:26:42,600 --> 00:26:45,520 So that was reassuring. 310 00:26:45,520 --> 00:26:52,840 All isolates remained susceptible to penicillin and vancomycin during this five year period. 311 00:26:52,840 --> 00:26:59,600 Now finally in terms of the pathogens that were discussed, so I didn't go too much into 312 00:26:59,600 --> 00:27:07,840 detail about the next set of organisms, only because I think there's a lot of moving parts, 313 00:27:07,840 --> 00:27:09,880 but also further discussions. 314 00:27:09,880 --> 00:27:18,680 But in the report, in CARS 2022 report, there were isolates submitted and evaluated in surveillance 315 00:27:18,680 --> 00:27:22,580 for salmonella, both typhoidal and non-typhoidal. 316 00:27:22,580 --> 00:27:27,780 So some things to keep in mind as travel is increasing, but also what our local patterns 317 00:27:27,780 --> 00:27:34,080 are showing for salmonella and terecacerovir typhi, the number of isolates that were submitted 318 00:27:34,080 --> 00:27:37,320 for testing nearly doubled. 319 00:27:37,320 --> 00:27:44,880 In 2019, 78% of the isolates that were submitted were cerevarityphi. 320 00:27:44,880 --> 00:27:49,320 Majority of these isolates are coming from Ontario at 50% and then BC and then mostly 321 00:27:49,320 --> 00:27:52,120 Alberta at 14%. 322 00:27:52,120 --> 00:28:00,880 In 2016 to 2019, in terms of the typhoidal salmonella, there was reports of ceftraxone 323 00:28:00,880 --> 00:28:06,160 resistance that had increased from 0.5 up to 4.5%. 324 00:28:06,160 --> 00:28:12,640 So that's something that we should all be aware of, especially for prescribers, considering 325 00:28:12,640 --> 00:28:17,280 that empiric treatment can include ceftraxone. 326 00:28:17,280 --> 00:28:25,160 Now for non-typhoidal salmonella, azithromycin resistance increased from 0.5 to 2.3%, but 327 00:28:25,160 --> 00:28:30,120 it was noted that cyprofloxacin resistance remained stable during this period for these 328 00:28:30,120 --> 00:28:32,840 non-typhoidal strains. 329 00:28:32,840 --> 00:28:41,040 The other kind of alarming finding was in 2019 for the salmonella and tereca isolates 330 00:28:41,040 --> 00:28:47,200 that 12% of the typhoidal and 17% of the non-typhoidal were resistant to three or more classes of 331 00:28:47,200 --> 00:28:48,200 antimicrobial. 332 00:28:48,200 --> 00:28:54,400 So obviously emphasizing the importance of susceptibility testing, surveillance, and 333 00:28:54,400 --> 00:28:59,520 hospitals submitting these isolates for testing as well. 334 00:28:59,520 --> 00:29:07,440 So those were the main pathogens that I wanted to discuss today in terms of the surveillance 335 00:29:07,440 --> 00:29:12,480 and trends that were seen in the CARS 2022 report. 336 00:29:12,480 --> 00:29:18,360 Now I just wanted to shift gears a bit to antimicrobial use in humans because as we 337 00:29:18,360 --> 00:29:24,080 know that part of the CARS report, there is data around antimicrobial use and there was 338 00:29:24,080 --> 00:29:29,200 a lot of national, provincial, and international data that was provided in the CARS report 339 00:29:29,200 --> 00:29:33,120 this year or over this five-year trend. 340 00:29:33,120 --> 00:29:39,520 So just to remind everybody, when we're talking about antimicrobial use in humans, so PHAC 341 00:29:39,520 --> 00:29:44,240 uses data from hospital purchases of antibiotics and this really reflects consumption in the 342 00:29:44,240 --> 00:29:46,520 healthcare sector. 343 00:29:46,520 --> 00:29:53,600 Alongside that, antibiotics that are dispensed in retail pharmacies, this data is used to 344 00:29:53,600 --> 00:29:56,920 reflect antibiotic consumption in the community sector. 345 00:29:56,920 --> 00:30:00,760 So that is how this information is obtained. 346 00:30:00,760 --> 00:30:06,960 Always keeping in mind that not all hospital purchases of these antimicrobials are used, 347 00:30:06,960 --> 00:30:14,800 but overall gives us a good picture of antimicrobial use and prescribing data. 348 00:30:14,800 --> 00:30:24,760 So nationally in the CARS 2022 report, the overall antibiotic consumption between 2017 349 00:30:24,760 --> 00:30:30,000 and 2021 decreased by 27%. 350 00:30:30,000 --> 00:30:34,160 And this was seen both in the healthcare sector and the community sector that experienced 351 00:30:34,160 --> 00:30:35,680 this decline. 352 00:30:35,680 --> 00:30:39,680 And obviously coinciding with that would be a decline in spending on antimicrobials in 353 00:30:39,680 --> 00:30:41,840 both the sectors. 354 00:30:41,840 --> 00:30:48,640 Now that was important information, but keeping in mind that a part of this data was obtained 355 00:30:48,640 --> 00:30:56,600 during early pandemic times when infection control practices and the changes in care 356 00:30:56,600 --> 00:31:00,480 and providing care were much different as well. 357 00:31:00,480 --> 00:31:03,120 So it would be interesting to see how this trend continues. 358 00:31:03,120 --> 00:31:08,840 But going into nationally what we were seeing, so in the healthcare sector, cephalosporins 359 00:31:08,840 --> 00:31:13,360 like first, second, and third generations were the generation cephalosporins were highest 360 00:31:13,360 --> 00:31:14,360 consumed. 361 00:31:14,360 --> 00:31:21,520 When looking at the community sector, tetracyclines and penicillins being the top two all around 362 00:31:21,520 --> 00:31:24,080 antibiotics that were prescribed. 363 00:31:24,080 --> 00:31:31,200 And when we looked at prescriber data, actually it was seen that there was an overall decrease 364 00:31:31,200 --> 00:31:34,880 in prescribing rates amongst all prescribers. 365 00:31:34,880 --> 00:31:39,160 This include family doctors, GPs, specialists, and non-physician specialists, which include 366 00:31:39,160 --> 00:31:41,280 dentists. 367 00:31:41,280 --> 00:31:46,100 And they all had a decrease in prescribing rates, but with general practitioners having 368 00:31:46,100 --> 00:31:52,980 a decline of up to 42.8% during this national five-year report. 369 00:31:52,980 --> 00:32:00,040 Now provincially what we saw, so all provinces experienced a decline in 2017 to 2021, although 370 00:32:00,040 --> 00:32:03,840 Atlantic Canada had the highest consumption in 2021. 371 00:32:03,840 --> 00:32:07,520 They had the second largest decline as well. 372 00:32:07,520 --> 00:32:11,760 Second to the Prairie provinces that included Alberta, Saskatchewan, and Manitoba. 373 00:32:11,760 --> 00:32:16,880 Ontario showed the least decline and Quebec had the lowest consumption of antimicrobials 374 00:32:16,880 --> 00:32:18,680 during this five-year period. 375 00:32:18,680 --> 00:32:22,600 I think it's always important to not only look at provincial and national data, but 376 00:32:22,600 --> 00:32:29,600 how do we compare ourselves, so Canada compared to other countries. 377 00:32:29,600 --> 00:32:35,920 And in terms of this international data, which is provided in the CARS 2022 report, Canada 378 00:32:35,920 --> 00:32:43,520 ranked the 10th lowest consumer of antimicrobials per capita in 2020, when it was compared to 379 00:32:43,520 --> 00:32:45,260 30 European countries. 380 00:32:45,260 --> 00:32:50,960 So just to kind of give you perspective, the Netherlands was the lowest, came at the lowest 381 00:32:50,960 --> 00:33:01,640 consuming country, and we, in comparison to them, consumed 50% more antimicrobials. 382 00:33:01,640 --> 00:33:08,360 So I think for us to talk a little bit about some of the newer things around antimicrobial 383 00:33:08,360 --> 00:33:14,200 prescribing, including the Canadian National Antimicrobial Prescribing Survey, I think 384 00:33:14,200 --> 00:33:20,320 it's important for us to gear attention towards the aware antimicrobial categorizations that 385 00:33:20,320 --> 00:33:23,360 were listed by WHO. 386 00:33:23,360 --> 00:33:29,720 And so these are antimicrobial agents, so antibiotics that are basically placed into 387 00:33:29,720 --> 00:33:38,720 three different categories in terms of their resistance, their first line agents, or last 388 00:33:38,720 --> 00:33:39,720 resort agents. 389 00:33:39,720 --> 00:33:45,800 So for instance, the three categories are, and the reason I'm bringing this up is because 390 00:33:45,800 --> 00:33:52,200 it's important to understand that not all antimicrobials or antibiotics can be categorized 391 00:33:52,200 --> 00:33:53,200 in the same way. 392 00:33:53,200 --> 00:33:57,840 And this was something that was brought up, or something that came up in my mind as I 393 00:33:57,840 --> 00:34:04,200 was reviewing the report in terms of, you know, is this a medication or an antibiotic 394 00:34:04,200 --> 00:34:08,360 that has the, you know, is a reserve category? 395 00:34:08,360 --> 00:34:11,720 So a last resort drug has increased rates. 396 00:34:11,720 --> 00:34:17,400 That's a bit more alarming to me, although keeping in mind that all antimicrobial use 397 00:34:17,400 --> 00:34:20,160 and resistance patterns that are increasing are alarming. 398 00:34:20,160 --> 00:34:29,400 So just going back to kind of defining some of the terms that WHO has set out for these 399 00:34:29,400 --> 00:34:30,400 categories. 400 00:34:30,400 --> 00:34:31,920 So there's three different categories. 401 00:34:31,920 --> 00:34:36,880 There's access drugs, watch drugs, and reserve drugs. 402 00:34:36,880 --> 00:34:41,680 Access drugs count as low risk of resistance, and they're usually used to treat commonly 403 00:34:41,680 --> 00:34:43,740 susceptible organisms. 404 00:34:43,740 --> 00:34:47,000 The watch category obviously is the middle category. 405 00:34:47,000 --> 00:34:50,040 So some may think of it as like borderline. 406 00:34:50,040 --> 00:34:53,800 So these are higher potential for resistance, and these are usually your first or second 407 00:34:53,800 --> 00:34:55,000 line drugs. 408 00:34:55,000 --> 00:34:59,880 And then your final and third category is the reserve or last resort drugs. 409 00:34:59,880 --> 00:35:04,640 And these are antimicrobials listed that treat infections that are caused by multi drug resistant 410 00:35:04,640 --> 00:35:13,880 organisms and really the alarming factor in this report from 2017 to 2021, human consumption 411 00:35:13,880 --> 00:35:19,160 of the reserve antibiotics increased by 25%. 412 00:35:19,160 --> 00:35:25,080 And this was mainly driven by a 43% increase in the use of antimicrobials in the healthcare 413 00:35:25,080 --> 00:35:29,800 sector, although decreased in the community sector. 414 00:35:29,800 --> 00:35:35,280 So of this, just to give you an example, just to put it into perspective, especially for 415 00:35:35,280 --> 00:35:41,920 clinicians, pharmacists, and those that are prescribing, Daptomycin, which counts as a 416 00:35:41,920 --> 00:35:48,060 reserve or last resort drug, was the most commonly consumed drug from the reserve group. 417 00:35:48,060 --> 00:35:52,240 And the use increased by 65.8%. 418 00:35:52,240 --> 00:35:58,320 And 68% of that was in the healthcare sector and 38% in the community. 419 00:35:58,320 --> 00:36:04,840 So I think that's something that when I was reading the report, I was thinking about how 420 00:36:04,840 --> 00:36:12,520 many times we've had to prescribe Daptomycin in our hospital setting, but something to 421 00:36:12,520 --> 00:36:22,080 keep in mind in part for those that are running antimicrobial stewardship programs, informing 422 00:36:22,080 --> 00:36:28,680 consumers this information and providing this information, I think is quite valuable. 423 00:36:28,680 --> 00:36:37,740 So in terms of when we looked at consumption overall, in terms of, for instance, another 424 00:36:37,740 --> 00:36:44,160 category of drugs, so carbapenems, they did see a decrease by 33% and 50% decline in the 425 00:36:44,160 --> 00:36:45,160 healthcare sector. 426 00:36:45,160 --> 00:36:48,520 And the community, however, did see a slight increase of 21%. 427 00:36:48,520 --> 00:36:53,920 And this included urtapenem as well as meropenem. 428 00:36:53,920 --> 00:37:01,080 So in order for us to kind of understand that, I think it's important for us to see what 429 00:37:01,080 --> 00:37:07,920 is the ongoing surveillance and really thinking about and talking about one of the newest, 430 00:37:07,920 --> 00:37:13,160 I would say additions or one of the newest additions that was mentioned in the CARS 2022 431 00:37:13,160 --> 00:37:17,360 report was the Canadian National Antimicrobial Prescribing Survey. 432 00:37:17,360 --> 00:37:22,800 And I don't think I'll do justice in explaining everything, but what was mentioned in the 433 00:37:22,800 --> 00:37:25,160 report was quite fascinating. 434 00:37:25,160 --> 00:37:33,920 I think this is definitely a survey that looks at prescribing practices in the healthcare 435 00:37:33,920 --> 00:37:39,480 sector and provides quite valuable information. 436 00:37:39,480 --> 00:37:45,080 Initially when it was piloted, so it's referred to as NAPS, and when it was piloted in 2018 437 00:37:45,080 --> 00:37:48,120 and 2019, they had some good response. 438 00:37:48,120 --> 00:37:55,160 And as of 2022, over 119 healthcare facilities across Canada, so across the 10 provinces, 439 00:37:55,160 --> 00:38:01,080 including actually the 12 pediatric academic hospitals, are currently involved in reporting 440 00:38:01,080 --> 00:38:10,700 information and involved in for allow PHAC to obtain data from the prescribing information. 441 00:38:10,700 --> 00:38:17,520 So keeping in mind that participation is voluntary for the hospitals in terms of this data. 442 00:38:17,520 --> 00:38:24,280 But overall, just to give you kind of an overview of really what was presented in the report 443 00:38:24,280 --> 00:38:31,340 and what is the role of NAPS, it was mentioned that it provides qualitative and quantitative 444 00:38:31,340 --> 00:38:33,380 information. 445 00:38:33,380 --> 00:38:40,000 So for instance, it can give you kind of the insights on prescribing behaviors, helps identify 446 00:38:40,000 --> 00:38:44,720 clinical indications and antimicrobial use patterns. 447 00:38:44,720 --> 00:38:51,320 It also looked at if hospitals followed guidelines for antibiotic choice, dosage, route and duration 448 00:38:51,320 --> 00:38:52,320 and benchmarking. 449 00:38:52,320 --> 00:38:58,880 So a lot of this information led to figuring out appropriateness and inappropriateness 450 00:38:58,880 --> 00:39:07,240 of antibiotic use, which I think coincides with helping us reduce antimicrobial resistance. 451 00:39:07,240 --> 00:39:14,720 So the key findings from the CARS 2022 report, which are obtained from these 90 NAPS audits 452 00:39:14,720 --> 00:39:24,080 in 2018 and 2019 from 64 hospitals, showed that 77.5% of hospital antibiotic prescriptions 453 00:39:24,080 --> 00:39:26,880 were deemed appropriate across Canada. 454 00:39:26,880 --> 00:39:31,520 That was something that I was pleased to see. 455 00:39:31,520 --> 00:39:33,960 Overall, based on the aware category. 456 00:39:33,960 --> 00:39:39,800 So we talked about those, the access drugs and then the watch drugs and finally, reserved 457 00:39:39,800 --> 00:39:40,800 drugs. 458 00:39:40,800 --> 00:39:49,480 37% of the antibiotics were from, in terms of looking at the antibiotic prescriptions, 459 00:39:49,480 --> 00:39:52,280 were from the access category. 460 00:39:52,280 --> 00:39:57,640 There was a higher percentage from the watch categories, around 61%. 461 00:39:57,640 --> 00:40:01,880 And then only 1.8% from the reserved drugs. 462 00:40:01,880 --> 00:40:06,760 Now among the 20 antibiotics that were prescribed that they looked at, only four had appropriateness 463 00:40:06,760 --> 00:40:08,440 levels of less than 70%. 464 00:40:08,440 --> 00:40:14,640 And that was nitrofra-antoine, sephiroxime, levofloxine and moxifloxacin. 465 00:40:14,640 --> 00:40:20,240 They did look at specialties as well and break it down in terms of which specialties had 466 00:40:20,240 --> 00:40:22,960 the highest level of appropriateness. 467 00:40:22,960 --> 00:40:29,320 And with pediatrics, hematology, gynecology, infectious disease and emergency medicine, 468 00:40:29,320 --> 00:40:33,800 taking the top five for appropriateness. 469 00:40:33,800 --> 00:40:39,200 And then finally, also, we're able to provide this data across the provinces and comparing 470 00:40:39,200 --> 00:40:46,400 the provinces and regions with the highest level of appropriate antibiotic use or prescribing 471 00:40:46,400 --> 00:40:51,700 in Western region, which included BC, Alberta, Saskatchewan and Manitoba. 472 00:40:51,700 --> 00:40:57,680 So that was quite, I think that was very different information that was provided from our previous 473 00:40:57,680 --> 00:41:03,400 reports and it was nice to see that there's ongoing surveillance there. 474 00:41:03,400 --> 00:41:10,120 And so for those that were not aware, just like myself, that was quite informational. 475 00:41:10,120 --> 00:41:17,600 Now lastly, before I end this episode, because obviously we've talked about so many numbers 476 00:41:17,600 --> 00:41:24,040 and such great data that was presented in the CARS 2022 report that I could probably 477 00:41:24,040 --> 00:41:26,560 talk about this more and more. 478 00:41:26,560 --> 00:41:31,720 But if there is anything in terms of detailed information that you would want, this is obviously 479 00:41:31,720 --> 00:41:37,400 just a summary of the report, but the CARS 2022 report is available online. 480 00:41:37,400 --> 00:41:43,440 Now before I end this episode, I did want to talk a little bit about, I think it's kind 481 00:41:43,440 --> 00:41:49,680 of something that everybody was wondering about, was the antibiotic use and human antibiotic 482 00:41:49,680 --> 00:41:54,840 use in the community sector kind of before and during the pandemic. 483 00:41:54,840 --> 00:42:02,000 And so some of the data that was released in the CARS 2022 report, which was quite interesting, 484 00:42:02,000 --> 00:42:04,120 was looked at nationally. 485 00:42:04,120 --> 00:42:11,680 So the national data in terms of the average monthly prescriptions, if we look at, I think 486 00:42:11,680 --> 00:42:16,440 the easiest way to do this is looking at before the pandemic, when we looked at the average 487 00:42:16,440 --> 00:42:23,760 monthly prescriptions in Canada, they would range from 45 to 66 per thousand inhabitants, 488 00:42:23,760 --> 00:42:29,280 always having a peak, kind of in our highest rates of prescribing months were May to October, 489 00:42:29,280 --> 00:42:35,480 peaking in January and kind of coincides with respiratory infections and their complications. 490 00:42:35,480 --> 00:42:41,800 And then the lowest infection or prescribing rates in summertime, so June and July. 491 00:42:41,800 --> 00:42:46,320 So looking at that was 45 to 66 per thousand inhabitants. 492 00:42:46,320 --> 00:42:52,160 Now comparing this to when the pandemic started, so reminding ourselves that March to April 493 00:42:52,160 --> 00:43:00,440 2020 was the start of the pandemic and community scripts had declined by 31 percent during 494 00:43:00,440 --> 00:43:01,440 the pandemic. 495 00:43:01,440 --> 00:43:03,080 So rates remained low. 496 00:43:03,080 --> 00:43:10,680 And so the that prescribing average monthly prescriptions in Canada now only ranged from 497 00:43:10,680 --> 00:43:15,400 anywhere around 37 per thousand inhabitants. 498 00:43:15,400 --> 00:43:20,700 So we did see a decline and not only a decline in the community scripts themselves, but also 499 00:43:20,700 --> 00:43:24,680 in the hospital sector, there was a decline by 25 percent. 500 00:43:24,680 --> 00:43:31,400 We looked at the overall trend in 2017 to 2021 and eight percent of which was between 501 00:43:31,400 --> 00:43:33,760 2019 and 2020. 502 00:43:33,760 --> 00:43:41,280 So some of that information, when I took that information, you know, it's hard to correlate, 503 00:43:41,280 --> 00:43:45,800 was this really due to the new and modified means of accessing health care, which the 504 00:43:45,800 --> 00:43:47,960 report also mentioned? 505 00:43:47,960 --> 00:43:51,720 And that's exactly what I was thinking because of public health measures. 506 00:43:51,720 --> 00:43:55,200 Are we going to continue to see this decline? 507 00:43:55,200 --> 00:44:01,160 Obviously there are, you know, initially some of the rates were different in terms of what 508 00:44:01,160 --> 00:44:05,960 we were seeing early on when we didn't know much about COVID-19. 509 00:44:05,960 --> 00:44:13,400 But it would be interesting to see how these trends continue now that we have data from 510 00:44:13,400 --> 00:44:20,360 before the pandemic, the start of the pandemic and some data years around, so years later. 511 00:44:20,360 --> 00:44:27,520 So I think it would be interesting for all of us to stay tuned to see what the next CARS 512 00:44:27,520 --> 00:44:30,480 report reporting period. 513 00:44:30,480 --> 00:44:35,600 I think there's a lot of exciting surveillance going on and there was a lot of important 514 00:44:35,600 --> 00:44:37,760 information that was presented in this report. 515 00:44:37,760 --> 00:44:43,560 So I'm happy to give everybody a summary on this report and if you guys have any questions, 516 00:44:43,560 --> 00:44:51,520 ideas, topics, or other topics that you would want to discuss this season, please feel free 517 00:44:51,520 --> 00:44:58,400 to reach out to us through Twitter, email, and share this information because I think 518 00:44:58,400 --> 00:45:04,520 it's really important and for not only prescribers alone, but I think anybody in the health care 519 00:45:04,520 --> 00:45:05,520 sector. 520 00:45:05,520 --> 00:45:07,080 So thanks for tuning in. 521 00:45:07,080 --> 00:45:09,200 Really appreciate it. 522 00:45:09,200 --> 00:45:16,880 And like I mentioned, we're looking forward to a great list of speakers this season. 523 00:45:16,880 --> 00:45:23,480 If you have the desire to come on to the podcast as a guest, we're more than happy to host 524 00:45:23,480 --> 00:45:24,480 you as well. 525 00:45:24,480 --> 00:45:25,480 Thanks for tuning in. 526 00:45:25,480 --> 00:45:26,480 Take care. 527 00:45:26,480 --> 00:45:29,560 Thank you, Dr. Pirwal. 528 00:45:29,560 --> 00:45:30,920 Thanks for joining us. 529 00:45:30,920 --> 00:45:37,200 If you have a topic suggestion, email us at thecanadianbreakpoint at gmail.com or tweet 530 00:45:37,200 --> 00:45:39,840 us at cabreakpoint. 531 00:45:39,840 --> 00:46:08,400 See you again soon at the Canadian Breakpoint.