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 3.1.2 of the Action Plan further suggested to collect the antimicrobial supply data from different sectors as proxy to reflect the overall usage and trend of antimicrobial usage. The collection of the wholesale supply data of antimicrobials through respective product registration certificate holders and licensed drug wholesalers has been regularised as an ongoing annual surveillance exercise and reports were compiled and published at Centre for Health Protection website annually. This is the fifth report which provides a brief account of the findings for year 2016 to 2020. Please click here to view further details.
Scope of data
A total of eight sectors, namely Department of Health (DH), Hospital Authority (HA), private hospitals, private doctors (mutually exclusive with private hospitals), dentists, veterinary surgeons, community pharmacies and farmers (who had the Antibiotics Permits issued by the Director of Agriculture, Fisheries and Conservation Department), were included in the surveillance.
Antimicrobials Monitored
Following the recommendation of WHO on surveillance of antimicrobial consumption (AMC)[1], the following core set of antimicrobials under WHO’s Anatomical Therapeutic Chemical (ATC) classification system was adopted for surveillance purpose (DDD values of Year 2021 were adopted for calculations). 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 |
WHO AWaRe Categorisation
Wholesale supply data of antimicrobials was also grouped into three different categories: Access, Watch and Reserve, according to WHO AWaRe categorisation[3] in 2021 and those not listed under WHO AWaRe were grouped as ‘Others’.
Broad-spectrum Antimicrobials (Big Guns)
Wholesale supply for a total of 15 selected broad-spectrum antimicrobials (also known as ‘Big Guns’) were also examined separately in this surveillance exercise for their importance in treatment of resistant bacterial infections. The same are being monitored in AMU surveillance with HA Dispensing Data
Measurement
The surveillance period is defined by calendar year. Results were analysed and presented as Defined Daily Dose (DDD)[4] and DID (DDD per 1,000 inhabitants per day). As mentioned above, the DDD values of Year 2021 were adopted for calculations in this report and as some of the DDD values have been updated by WHO for the recent years[5], the DDD figures of previous years have been re-calculated accordingly which would be different from the figures in the past reports presented a few years ago.
Statistical method
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), compound annual growth rate (CAGR) was adopted to illustrate average annual rate of change when comparing antimicrobials supplied in 2020 with that in 2016.
CAGR = (SU2020 / SU2016)(1/4) - 1
In the above equation, SU2020 and SU2016 refer to the total amount of antimicrobials supplied in 2020 and 2016 respectively.
Overall Antimicrobials Wholesale Supply (2016 – 2020)
The overall antimicrobials supply decreased from 20.37 DID in 2016 to 18.41 DID in 2017 but gradually increased to 19.02 DID in 2019. However, it decreased significantly to 13.63 DID in 2020 during the pandemic of COVID-19. (↓ 5.39 DID or ↓ 28.3% when compared with that of 2019, CAGR from 2016 to 2020: -9.6%).
Distribution by WHO AWaRe Categorisation
Antimicrobials fell under Access constituted 55.8% of all antimicrobials supplied in 2016. The proportion gradually increased to 59.2% in 2019 and increased further to 61.5% in 2020, exceeded the WHO recommended benchmark of 60%. Antimicrobials under Watch decreased steadily from 40.3% in 2016 to 34.5% in 2020, while those under Reserve only constituted around 0.1%-0.15% of the overall supply during 2016 to 2020. Antimicrobials not categorised under the above 3 categories were grouped as ‘Others’ and constituted about 3.4% to 3.9% of all antimicrobial supply.
In terms of DID, the supply of antimicrobials under Access and Watch decreased from 2016 to 2020 with CAGR of -7.3% and -13.0% respectively while those under Reserve had the CAGR increased by 10.7%. However, readers should interpret the results with caution as the total number of antimicrobials under Reserve supplied in Hong Kong increased from five in 2016 to ten in 2020.
Distribution by Sector
In 2020, around half (49.4%) antimicrobials supply went to private doctors, followed by HA (29.0%) and community pharmacies (7.5%). Significant decrease from 2019 to 2020 was observed in private doctors (10.96 to 6.83 DID, ↓ 37.7% ), private hospitals (1.31 to 0.93 DID, ↓ 28.6%) and community pharmacies (1.46 to 1.04 DID, ↓ 28.4%), and relatively mild decrease with Hospital Authority (HA) (4.47 to 4.01 DID, ↓ 10.3%) and dentists (0.64 to 0.61 DID, ↓ 4.4%), while an increase was observed with Department of Health (DH) (0.17 to 0.19 DID, ↑11.7%).
From 2016 to 2020, the proportion of antimicrobials supplied to community pharmacies decreased gradually from 18.5% in 2016 to 7.5% in 2020 with CAGR -27.7%. The proportion of antimicrobials supplied to dentists showed the sharpest increase with CAGR 12.9% from 2016 to 2020 though the absolute amount was small (0.38 DID in 2016 to 0.61 DID in 2020). Increase in supply was also shown in DH (CAGR: 0.3%). Due to the sharp drop in the overall antimicrobial supply in 2020, the CAGR of private doctors, private hospitals and HA from 2016 to 2020 were -10.9%, -3.9% and -0.4% respectively.
Distribution by ATC Pharmacological Subgroup
In 2020, beta-lactam antibacterial, penicillins (J01C) was the most commonly supplied antimicrobial group (44.0%), followed by tetracyclines (J01A) (14.0%), macrolides, lincosamides and streptogramins (J01F) (12.2%), quinolone antibacterials (J01M) (11.8%), and other beta-lactam antibacterials (J01D) (10.0%). Tetracyclines (J01A) has overtaken marcolides, lincosamides and streptogramins (J01F) to become the second most commonly supplied antimicrobial group. Except for other antibacterials (J01X), which the CAGR remained positive (1.8%), the CAGR of every other group was negative from 2016 to 2020 in terms of DID. Other beta-lactam antibacterials (J01D), and marcolides, lincosamides and streptogramins (J01F) had the biggest negative CAGR at -16.9% and -16.0% respectively.
Ten Most Commonly Supplied Antimicrobials
From 2016 to 2020, the ten most commonly supplied antimicrobials contributed to more than 80% of all antimicrobials supplied in the corresponding year. In 2020, amoxicillin and beta-lactamase inhibitor (J01CR02) was the most commonly supplied antimicrobial, accounted for 24.5% of all antimicrobials by wholesale, followed by amoxicillin (J01CA04) (12.8%) and doxycycline (J01AA02) (11.9%).
As the overall supply in 2020 decreased significantly, the CAGR of all the top ten most supplied antimicrobials in 2020 were negative. The CAGR of cefuroxime (J01DC02) and azithromycin (J01FA10) decreased most (↓18.2% and ↓16.8% respectively) from 2016 to 2020.
Wholesale Supply of Selected Broad-spectrum Antimicrobials (‘Big Guns’)
Majority of these broad-spectrum antimicrobials (about 99%) were supplied to HA and private hospitals from 2016 to 2020. In 2020, piperacillin/tazobactam was the most commonly supplied (43.5%) broad-spectrum antimicrobial, followed by meropenem (21.4%) and vancomycin (13.5%). They had been the three most commonly supplied broad-spectrum antimicrobials from 2016 to 2020 accounted for about 78% of all broad-spectrum antimicrobials under monitoring in 2020.
The total wholesale supply of these selected broad-spectrum antimicrobials increased by 7.3% in CAGR from 2016 to 2020 despite the overall CAGR of all antimicrobials supplied was -9.6% in terms of DID.
Defined Daily Dose (DDD) is a technical unit of use that does not necessarily reflect the recommended or average prescribed dose, while there are no separate DDDs for children which makes the DDD estimates for paediatric formulations more difficult to interpret.
Change in DDD[6] values in 2019 by WHO resulted in re-calculating of the past data and hence the figures in this presentation would be different from the figures presented in the past.
The surveillance of antimicrobials by wholesale supply in Hong Kong is a voluntary self-reporting by licensed drug wholesalers and could have reporting errors.
Wholesale supply data is used as a proxy for the amount of antimicrobials supplied to each sector, therefore the figures are not equivalent to dispensing figures and could be affected by marketing strategies, e.g. discount offers which may cause the supply of a particular antimicrobial to increase by a substantial margin when compared with that of last year.
Readers are cautioned not to use the Hong Kong figures to make direct comparison with that of other countries as the health care services provision system and the methodology in collecting the surveillance data may not be the same, e.g. some countries may use dispensing or prescription data as their AMU surveillance data source instead of wholesale supply data and they are different in nature.
The key findings of 2020 surveillance include:
Readers should interpret the 2020 results with caution as the pandemic of COVID-19 might have changed the normal practice and arrangement of medical services in Hong Kong.
As the majority of antimicrobials were supplied to private doctors (49.4%) and HA (29.0%), strengthening the implementation of antibiotic stewardship programme in primary care and public hospitals are recommended
Majority of the broad spectrum antimicrobials (‘Big Guns’) were supplied to HA and private hospitals. The continuous rising trend of these broad spectrum antimicrobials warrants to further explore and enhance the antibiotic stewardship programme in hospitals.
We would like to acknowledge product registration certificate holders and licensed drug wholesalers for provision of wholesale supply data for year 2019, and the Drug Office of DH for facilitating the surveillance exercise.
[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] AWaRe classifies antimicrobials into the above-mentioned three stewardship groups to emphasize the importance of their optimal uses and potential for antimicrobial resistance. WHO encourages countries or regions to work towards to have 60% or more of the overall antimicrobials supplied under Access and reduce the usage of antimicrobials under Watch and Reserve for their higher potential to cause antimicrobial resistance. https://www.who.int/publications/i/item/2021-aware-classification
[4] DDD is a standardised unit adopted by WHO to facilitate comparison of drug usage.
[5] For example, DDD constant for oral use of amoxicillin was changed from 1000mg in 2018 to 1500mg in 2019
[6] WHO ATC 2021 version was adopted for DDD calculation