This document summarizes discussions from several sessions of a meeting on antimicrobial resistance and healthcare-associated infections. Key points include: - Most countries submit antimicrobial consumption data close to the deadline, and there are specific rules for who can access and publish the data. - It is important but challenging to compare hospital antimicrobial consumption data between countries due to differences in how data is collected. Both defined daily doses and packages are needed for comparison. - A pilot hospital-based antimicrobial consumption survey was proposed to collect additional data starting in late 2015, but the protocol requires further review and clarification before implementation.

1. 3rd Joint Meeting of the Antimicrobial Resistance and
Healthcare-Associated Infections (ARHAI) Networks
Report from ESAC-Net sessions
Rapporteur: Peter Zarb (Malta)
Organised jointly with

2. Session 5 ESAC-Net Data collection:
collection / deadlines / availability
• Most countries submitted just around deadline (June 2014)
• Who is allowed to access TESSy data?
• nominated users (ecdc/national nominees/EU agencies*Confidentiality declaration
needed, 3rd parties# # more restricted)
• MS can deny authority of own data sharing.
• Any publication must acknowledge MS & ECDC
• Prior to publication  Internal peer review 3 NFP + 2 ECDC experts (for
non-[public information)
• Unlike ESVAC where some countries refuse data sharing ECDC must share.
CONCLUSION
• @ECDC we stop at ATC level 4. So publications must be aggregated at
this level even if shared at ATC 5.
PERSPECTIVE
• When data is by age/gender numbers can be very low and this can be
extremely sensitive. TO BE REVIEWED IN SPECIFIC RARE CASES

3. Experience learnt from National Examples
• Types of hospital AMC data: Bulk/In pt/ out-pt (inc OPAT) etc.
• IMPORTANCE of denominators (especially with short LOS):
• Using bed-days gives a high use whilst using admissions gives a different
(opposing) perspective. So BOTH needed
• Ideal: e-Rx (1/5 hospitals have ‘some’ only 1/12 have 100% e-Rx)
• Hospital TYPE: Acute Hospital/s defined @MS level + Others (eg: FR -
LTCF/Rehab/etc)
CONCLUSION
• Despite difficulties in comparison of Hospital Sector AMC surveillance data
due to differences between MS it is still considered important
(MS should mainly compare OWN trends in AMC)
PERSPECTIVE
• Data report grouped by Hospital type… …by clinical activity…

4. Quality Indicators (Session 9)
• Other ARHAI  HAI-Net Indicators (PPS/SSI/CDI/ICU)
1. Structure (eg: Antimicrobial Stewardship)
2. Process (eg: Surgical Prophylaxis)
3. Outcome (eg: Prescription)
• Unique Hospital Identifier (UID) between ARHAI Networks for
crosslinking
UID must be stable throughout the years
(Perspective) UID for Trusts/mergers? Jury is still out
• ECDC-PPS QI’s ‘proxies’: FTE Antimicrobial Stewardship; BC-sets etc..
• ICU QI’s: Prevention of VAP/CVC Infx, AMC, SP, SSI…
• Upcoming TATFAR Indicators on best ways to measure Antimicrobial
Consumption/Stewardship
Conclusion
• Group favoured inclusion of some new Indicators in ESAC-Net

5. Hospital based AMC surveillance
• Limitations in ESAC-Net HC (19 MS)
• Pilot Hospital-based Survey 2015
• Only acute care hospitals (definition from PPS ‘as defined in the MS’)
• Only for J01, P01AB, A07AA, J04AB02
• @National Level  Yearly data – possibly Quarterly… + … By
specialty/ward…
• At hospital level possibly also monthly?
• Types of data:
Purchase/ pharmacy dispensing /Rx (pt level) /administration (pt level) data
(depends what is available locally)
PLUS REIMBURSEMENT DATA (as recommended by BE)
• @ECDC level DDD by ATC (substance level) + RoA…
• Denominator
Admissions + Bed-days (patient-days)
• Feasibility questionnaire @Hospital & @MS level

6. Hospital based AMC surveillance protocol
• Unresolved issues (Real issues?) TO BE REVIEWED by ESAC-Net Working Group
• In-pts only? (OPAT/Renal/Day Surgery…) …Tx for HAI…
• Should Acute Care Hospitals that cannot exclude day/dialysis cases etc. be excluded?
• Or should OPAT & Renal Tx be included as ‘hospital’?
Depends on what ECDC wants to measure…
Challenges:
• Exclusion of non-acute care wards… (?Must be excluded?)
Conclusions
• This is why: Aims of data collection must be clear so as not to collect complicated
data without any added value.
• The Pilot ESAC-Net hospital based survey data collection WILL be postponed to
Sep-Nov 2015 (Not March). By general request for feasibility reasons (recruitment
of hospitals)
• MS + CC Meeting will be held later (maybe End Nov –Beginning Dec 2015)
• Data shall be 2014 rather than 2013
• Hospital Questionnaire – to characterize hospitals
BUSY questionnaire based on TATFAR QI’s  Needs to be shortened.

7. Community AMC surveillance (Session 10)
• Results from past years  HIGHLIGHT Importance of package data
• Broad vs. Narrow Spectrum AM (Is this the right nomenclature? What is the purpose? Not
wiki-defined)
– ESAC-Net Broad Spectrum J01C(-CE) + J01F (-FA01)
– Amoxicillin is Broad Spectrum in NO but Narrow Spectrum in some other MS
• Importance of data by Age & Gender highlighted
Compare with others  choose targets for Quality Improvement
Eg: (NO) Peaks in Rx 0-2Y (RTI) then 15-18Y (ACNE/UTI/STI) then >65Y (UTI)
TEEN females identified as a Target for Quality Improvement.
• When setting targets these must be followed up (ie. Measure effectiveness of
interventions)
• Need for additional Community QI’s
Conclusion
• Broad vs. Narrow Spectrum should be better delineated
Some MS should be able to include age/gender and/or syrup variable
• J04 should be considered as Total not HC / AC (EN=HC others AC)…and analysed
separately

8. Community AMC surveillance -Indicators
• Syrup (including powder for reconstitution for oral administration!) is a good proxy
for AMC <10YO
HOWEVER - Most countries cannot report ‘syrup’ (ca 60%) even more so by age
group
• Dosing as QI (paediatrics)
• Eg: ceftriaxone Blue Book recommends 50-80mg/kg/q24h (ARPEC range >200-
<10)
• Paediatric ABS need to be developed BOTH for HC & AC – Eg:
Amoxicillin Index 1 (It covers 70-80% of paed infx [except UTI’s]) but only around
60% of ALL Rx
Amoxicillin Index 2 (amoxi: (J01CR+J01D+J01F) {by age group} One can see annual
trends
• Out patient QI’s
• BE data shows  in DDD but stable Packages/Tx/Rx ( in DDD/pack [PID])
Amoxi x ≈50% co-amoxi x ≈70% (54% of AC AMU)
• Change in DDD/Pk varies by country and subgroup (no change for J01MA)
Conclusions
• BOTH Packs/1000-Inhabitant Day and DDD/1000-Inhabitant Day are
needed

9. ESAC-Net Cooperation and outputs
(Fri 13th Feb 2015)
• ESAC-Net cooperation partners
– WHO/Europe  Major difference from ESAC-Net – TOTAL CARE DATA
– TATFAR – Aims for a common valid metric
observed vs expected AMU (similar to what ECDC PPS did)
– ESVAC + AMU in humans and animals
Animal DDD + Animal Defined Course Dose
• Multi-Annual Questionnaire (HC/AC)
– To determine meaning of any annual changes in AMC
– To determine any AMS initiatives influencing AMC
– DO NOT REPEAT OTHER ARHAI QUESTIONS
• Comments on TESSy reports decreasing annually 2010-2013
• Atlas of ID (novel ECDC output format)  faster than the interactive
database
• ESAC-Net report bi-annual