Release date: 13 January 2022
The HKSAR Government attaches great importance to the threat of antimicrobial resistance (AMR). A High Level Steering Committee (HLSC) chaired by the Secretary for Food and Health has been established to formulate strategies and implement actions to combat AMR in Hong Kong, and the Hong Kong Strategy and Action Plan on Antimicrobial Resistance (2017- 2022) (Action Plan) was launched in July 2017.
The Action Plan sets out monitoring of antimicrobial usage as one of the strategic actions. Activity 3.2.1 of the Action Plan further suggested to collect the antimicrobial dispensing data from Hospital Authority (HA) to monitor antimicrobial usage in public hospitals and clinics. After studying the antimicrobial dispensing data of public hospitals and clinics of HA (including both non-inpatient and inpatient services), AMU surveillance reports were compiled and published at Centre for Health Protection website. This is the fourth report which provides a brief account of the surveillance findings for year 2020. Please click here to view further details.
Following the recommendation of WHO for AMU surveillance[1], the following core set of antimicrobials under WHO’s Anatomical Therapeutic Chemical (ATC) classification system (Year 2020) was adopted for surveillance purpose. Only antimicrobials given for systemic use[2] were included while topical antimicrobials were excluded.
| ATC Code | ATC Group/Subgroup |
| J01 | Antibacterials for systemic use |
| P01AB | Nitroimidazole derivatives, agents against amoebiasis and other protozoal diseases |
| A07AA | Antibiotics, intestinal antiinfectives |
Dispensing data for a total of 15 broad-spectrum antimicrobials identified by experts in HA (also known as ‘Big Guns’) were examined because of their importance on treating resistant infections.
The surveillance period for AMU is defined by calendar year. Results were analysed and presented as Defined Daily Dose (DDD)[3]. The 2020 version of WHO ATC DDD values was adopted in this report. As there has been no change in DDD values for those antimicrobials dispensed in HA captured by this surveillance system, the DDD values adopted for calculation for previous years remained the same as in the last report of 2019.
Since the Action Plan was published in 2017, the situation of 2016 has been chosen as the baseline for comparison.
Following the practice of European Centre for Disease Prevention and Control (ECDC)[4], compound annual growth rate (CAGR) was adopted to illustrate average annual rate of change when comparing antimicrobials dispensed in 2020 with that in 2016.
CAGR = (SU2010 / SU2016)(1/4) - 1
In this equation, SU2020 and SU2016 refer to the total amount of antimicrobials dispensed for year 2020 and 2016 respectively.
Total antimicrobials dispensed in public hospitals and clinics
In 2020, the total antimicrobials dispensed for non-inpatient and inpatient services were 280.98 DDD/1,000 attendances and 900.83 DDD/1,000 patient-days respectively. When comparing with that of 2016, increases for both services were observed (by 14.71 DDD/1,000 attendances or CAGR of 1.35% for non-inpatient service; by 4.42 DDD/1,000 patient-days or CAGR of 0.12% for inpatient service).
Ten Most Dispensed Antimicrobials in Public Hospitals and Clinics
The ten most dispensed antimicrobials (in terms of DDD) accounted for around 80% of all antimicrobials dispensed for HA services in 2020, with almost all of them registered decreases in 2020 in DDD when compared with that of 2019, except doxycycline and co-trimoxazole. Among them, amoxicillin/clavulanate topped the list since 2016, accounted for 42.12% of all antimicrobials dispensed in 2020. Doxycycline showed the largest increase in dispensing quantity from 2016 to 2020 (CAGR: 16.20%), followed by co-trimoxazole (CAGR: 11.07%). Cloxacillin showed the largest decrease in dispensing quantity from 2016 to 2020 (CAGR: -14.74%), followed by clarithromycin (CAGR: -10.85%).
Broad-spectrum antimicrobials (Big Guns) dispensed in public hospitals and clinics
Regarding the broad-spectrum antimicrobials, their dispensing quantities accounted (in terms of DDD) for about 8.90% of total antimicrobials dispensed in HA in 2020. Increased dispensed quantities were observed with meropenem, vancomycin, cefepime, ceftazidime/avibactam, ceftolozane/tazobactam and daptomycin from 2019 to 2020. Majority of these broad-spectrum antimicrobials were dispensed in inpatient services and the most dispensed one from 2016 to 2020 was piperacillin/tazobactam, contributing about half (45.56%) of all broad-spectrum antimicrobials dispensed in 2020, followed by meropenem and then vancomycin.
From 2016 to 2020, the dispensing quantity of these antimicrobials has shown an increase in CAGR of 5.85%. Among them, ceftaroline fosamil and cefepime showed the largest increases (CAGR: 18.74% and 16.84% respectively).
Antimicrobials dispensed in HA by service
The overall dispensing quantity in HA non-inpatient service showed an increase in CAGR of 5.23% (in terms of DDD/1,000 attendances) from 2016 to 2020 when considering those attendances with antimicrobial only. Among attendances with antimicrobials, dispensing quantity of ‘Specialist Out-patient (Clinical)’, ‘Primary Care (GOPC)’ and ‘Accident & Emergency’ showed increases in CAGR of 6.02%, 2.72% and 1.90% respectively.
Among the 10 most dispensed antimicrobials, amoxicillin/clavulanate has been the most dispensed antimicrobial since 2016 and it accounted for around 40% of the total antimicrobials dispensed in HA non-inpatient service.
Among all broad spectrum antimicrobials dispensed in HA, only 0.65% were dispensed in non-inpatient services in 2020 and a minute decrease was observed from 2016 to 2020 (CAGR: - 0.55% in terms of DDD/1,000 attendances).
‘ICU/HDU’ dispensed the highest quantity of antimicrobials (1662.92 DDD/1,000 patient-days), followed by ‘Surgery’, ‘Medicine’, ‘O&T’ and ‘Others’ (1346.71, 923.38, 910.33 and 575.03 DDD/1,000 patient-days) in 2020.
The total antimicrobials dispensed in HA inpatient service (DDD/1,000 patient-days) showed an increase in CAGR of 0.12% from 2016 to 2020. By specialty, ‘Surgery’ showed the largest increase (2.50%), followed by ‘Orthopaedics & Traumatology’ (1.49%), while ‘Medicine’ showed the largest decrease (-1.24%) and followed by ‘Others’ (-0.87%) and then ‘ICU/HDU’ (-0.37%).
In general, an increase in dispensed quantity of broad-spectrum antimicrobials was observed among all inpatient specialties in 2020 compared with previous years. In 2020, ‘ICU/ HDU’ was the specialty with the largest quantity of broad-spectrum antimicrobials dispensed (549.95 DDD/1,000 patient-days), followed by ‘Medicine’, ‘Surgery’, ‘O&T’ and ‘Others’ (157.28, 157.24, 90.36 and 75.80 DDD/ 1,000 patient-days respectively).
For broad-spectrum antimicrobials dispensed, ‘Others’ had the largest increase in CAGR of 11.56% (in terms of DDD/1,000 patient-days), followed by ‘Orthopaedics & Traumatology’ (11.27%), ‘Surgery’ (11.03%), and then ‘Medicine’ (4.84%) from 2016 to 2020. ‘ICU/HDU’ only increased by 1.17% in CAGR.
The key findings in 2020 surveillance included:
Reader are reminded to interpret the 2020 AMU surveillance results with caution, due to the adjustment of non-emergency and non-essential services at public hospitals in 2020 with COVID-19 pandemic.
Nevertheless, the steady increase in total broad-spectrum antimicrobials dispensed necessitates enhancing Antibiotics Stewardship Programmes (ASP) by monitoring and optimizing their use at various levels.
The continuous and steady rising trends of doxycycline and co-trimoxazole (16.20% and 11.07% in CAGR respectively from 2016 to 2020) among the top 10 most dispensed antimicrobials would warrant further exploration.
We would like to acknowledge stakeholders from HA such as Information Technology & Health Informatics Division, Quality and Safety Division, Strategy and Planning Division, Chief Pharmacist’s Office, and various Working Groups for provision of input to facilitate compilation of the AMU surveillance findings for year 2020.
[1] https://apps.who.int/iris/rest/bitstreams/1313107/retrieve
[2] Only antimicrobials given by oral, parenteral, rectal and inhalation were included in the surveillance
[3] DDD is a standardised unit adopted by WHO to facilitate comparison of drug usage.
[4] https://www.ecdc.europa.eu/sites/default/files/documents/Antimicrobial-consumption-in-the-EU-Annual-Epidemiological-Report-2019.pdf