Research and analysis

HPR volume 17 issues 13 and 14: news (23 November 2023)

Updated 28 December 2023

ESPAUR annual report in summary

The annual English Surveillance Programme for Antimicrobial Utilisation and Resistance (ESPAUR) report, published by the UK Health Security Agency (UKHSA) on 15 November, covers activity up to March 2023 and data on resistances and usage to the end of 2022.

The main findings of the tenth report are summarised below.

Antibiotic resistance

In 2022, with the lifting of pandemic mitigations and the return to pre-pandemic levels of health activity, there were substantial increases in rates of priority pathogens and antibiotic use.

The latest national surveillance data shows that an estimated 58,224 people in England had an antibiotic resistant infection in 2022 – a rise of 4.4% since 2021 (55,792). Deaths due to severe antibiotic resistant infections also increased from 2021 to 2022 (from 2,110 to 2,202). Antibiotic resistant bloodstream infections occurred in 16,643 people in 2022 – a drop of 4.6% since 2018 though this is most likely due to pandemic restrictions rather than a true reduction in antibiotic resistance. The proportion of bloodstream infections that are resistant to one or more antibiotics – 1 in 5 – has remained stable since 2018.

There is considerable regional and demographic variation in England, related to underlying health conditions, deprivation, ethnicity and healthcare delivery. People in the lowest socioeconomic group more likely to acquire a resistant infection compared to the highest socioeconomic group. Asian or British Asian people are the most likely population in England to acquire an antibiotic resistant infection.

In figure 1 (below), the top bar chart shows the overall estimated number of key pathogen bloodstream infections by calendar year 2018 to 2022: infections increased between 2018 and 2019 (86,060 to 88,851), then declined in 2020 (to 79,466) before increasing again in 2022 (to 84,685). 

The lower bar chart in figure 1 shows  the number of resistant key pathogen bloodstream infections by calendar year for the same period. This indicates that resistant key pathogen infections increased between 2018 and 2019 (17,437 to 18,259), then declined in 2020 (to 16,043) before increasing again in 2022 (to 16,643).

Figure 1. The burden of bloodstream infections (BSIs) and resistant BSIs

Antibiotic usage

Total antibiotic use in England had declined each year since ESPAUR was established. However, in 2022 there was an increase of 8.4% compared with 2021 – although this did remain below pre-pandemic levels – highlighting the need for continued efforts to reduce inappropriate antibiotic use.

Primary care accounts for 80.2% of all antibiotics prescribed. Despite a decreasing trend since 2018, there was an increase of 13.0% in primary care antibiotic usage between 2021 and 2022 (from 1.49 to 1.68 items per 1,000 inhabitants per day).

In financial year 2022 to 2023, 29% of NHS England acute trusts (40 out of 137) achieved the NHS Standard Contract expectation to reduce antibiotic prescribing (from WHO ‘Watch’ and ‘Reserve’ categories adapted for England) by 4.5% – from a 2018 baseline – to maintain trajectory towards the NAP 10% reduction target.

Figure 2 (below) shows that secondary care consumption rates – measured using daily defined doses (DDDs) per 1,000 hospital admissions – decreased by 2.9% between 2018 and 2022. There was however an increase of 4.3% in antibiotic consumption between 2021 and 2022. This is likely related to resuming health care services following the COVID-19 pandemic; it was a greater increase than that seen between 2019 and 2020, driven by an increase in inpatient prescribing (6%). Changes in prescribing during the COVID-19 pandemic were expected. Increases in hospital inpatient consumption (DDDs per 1,000 hospital admissions) were thought to be largely related to changes in hospital populations (with cancellations of elective procedures) and reductions in hospital admissions during the COVID-19 pandemic. AMS teams will need to work tirelessly with prescribers in the coming 12 months to reverse this trend.

Figure 2. Antibiotic prescribing increased in secondary care

Antibiotic prescribing continued to be greatest within the general practice setting (72.7%).

Systemic antifungals use decreased by 11.0% from 2018 to 2022, driven by reduced use in the community. There was a large decrease in 2020, as a result of the COVID-19 pandemic, with usage since increasing.

Antibiotic stewardship

The Treat Antibiotics Responsibly, Guidance, Education and Tools (TARGET) website saw the number of views almost double in November 2022 compared to the previous month, coinciding with the TARGET promotional campaign and World Antimicrobial Awareness Week. The significant increase in post-campaign visits to the TARGET website highlights the importance of reminding and raising awareness of AMS to heath care professionals at certain time points. An example of this would be raising awareness of AMS tools and resources available to primary care clinicians on RTIs before the winter.

The TARGET urinary tract infection (UTI) and respiratory tract infection (RTI) leaflets for the community pharmacy setting were included as part of the 2022 to 2023 Community Pharmacy Quality Scheme (PQS). Data was submitted by more than 8,000 community pharmacies, for 104,142 and 115,094 patients presenting with UTI and RTI symptoms respectively.

For World Antimicrobial Awareness Week (WAAW) – 18 to 24 November – the annual WAAW/EAAD/AG Resource toolkit for healthcare professionals was published and is available for download.

GRASP annual report in summary

UKHSA published the annual Gonococcal Resistance to Antimicrobials Surveillance Programme (GRASP) report on 20 November – presenting the latest data on antimicrobial resistance in Neisseria gonorrhoeae in England and Wales.

Between 2021 and 2022, characterisation of 1,460 Neisseria gonorrhoeae isolates collected through GRASP showed:

• the percentage of isolates with reduced susceptibility to ceftriaxone (minimum inhibitory concentration (MIC) >0.03 milligrams per litre (mg/L)), the current first-line therapy, remained low at 0.21% in 2022 compared to 0.07% in 2021
• the modal MIC for ceftriaxone remained at 0.015mg/L
• the modal ceftriaxone MIC for isolates from heterosexual men and women increased to meet that of gay, bisexual and other men who have sex with men (GBMSM) for the first time since 2017; similarly, the modal cefixime MIC for isolates from women increased to that of GBMSM for the first time since 2018
• cefixime resistance (MIC >0.125mg/L) increased slightly from 0.3% to 0.8%
• azithromycin resistance (MIC >0.5mg/L) and ciprofloxacin resistance (MIC >0.06mg/L) continued to increase rapidly (15.1% to 20.4% and 46.8% to 58.6% respectively)
• tetracycline resistance (MIC >1.0mg/L) decreased for the first time since monitoring began (74.8% to 61.8%)
• penicillin resistance (MIC >1.0mg/L) remained stable from 14.2% to 13.6%
• as in previous years, no spectinomycin resistance was detected and the modal gentamicin MIC remained low (4mg/L)
• over two-thirds of the isolates belonged to 10 multi-locus sequence types
• elevated MICs for cephalosporins were associated with expression of mosaic penA alleles, in particular penA-34

Prescribing data demonstrated excellent adherence to the UK guideline for managing infection with N. gonorrhoeae, with 97.7% of individuals receiving the recommended first-line treatment of ceftriaxone 1g intramuscular (IM) monotherapy in 2022.

The effectiveness of first-line treatment for gonorrhoea continues to be threatened by antimicrobial resistance, particularly given the recent reports of mainly travel-associated ceftriaxone resistance in England. Increases in the ceftriaxone and cefixime modal MICs among isolates from heterosexual men and women, as well as the growing number of resistant isolates referred to STIRL, show that continual monitoring is essential.

Sexual health services should report cases of suspected treatment failure to UKHSA via the online HIV and STI web portal. (Note: This has website has restricted access for authorised users only.)

Infection reports

Group A streptococcal infections: report on seasonal activity in England, 2023 to 2024

Disseminated gonococcal infection in England, 2019 to 2023: data from voluntary reporting

Laboratory surveillance of pyogenic and non-pyogenic streptococcal bacteraemia in England: 2022 update

Vaccine coverage

Prenatal pertussis vaccination coverage in England from April to June 2023

Environmental hazards

Lead Exposure in Children Surveillance System (LEICSS) annual report, 2023: summary of 2022 data