ABSTRACT

Objective.

To assess the compliance in secondary and tertiary level hospitals with monthly reporting of antibiotic consumption to the Colombian National Public Health Surveillance System (SIVIGILA-INS), and to describe reported antibiotic consumption during 2018–2020.

Methods.

This study involved a secondary analysis of antibiotic consumption data reported to SIVIGILA-INS. Frequency of hospital reporting was assessed and compared against expected reports, disaggregated by intensive care units (ICU)/non-ICU wards and geographical regions. Consumption was expressed as defined daily dose (DDD) per 100 occupied beds for seven antibiotics.

Results.

More than 70% of hospitals reported antibiotic consumption at least once in each of the three years (79% in ICU and 71% in non-ICU wards). Of these, ICU monthly reporting was complete (12 monthly reports per year) for 59% in the period 2018–2019 but only 4% in 2020. Non-ICU reporting was complete for 52% in 2019 and for 2% in 2020. Most regions had an overall decrease in reporting in 2020. Analysis of antibiotic consumption showed an increase for piperacillin/tazobactam, ertapenem, and cefepime from 2019 to 2020.

Conclusions.

There were gaps in the consistency and frequency of reporting. Efforts are needed to improve compliance with monthly reporting, which declined in 2020, possibly due to the COVID-19 pandemic. Non-compliance on reporting and data quality issues should be addressed with the hospitals to enable valid interpretation of antibiotic consumption trends.

Keywords
Anti-bacterial agents; prescription drug monitoring programs; patients’ rooms; intensive care units; operations research; Colombia

RESUMEN

Objetivo.

Evaluar el cumplimiento de los hospitales de segundo y tercer nivel en la presentación mensual de información sobre el consumo de antibióticos en el Sistema Nacional de Vigilancia en Salud Pública de Colombia (SIVIGILA-INS) y describir el consumo de antibióticos reportado en el período 2018-2020.

Métodos.

Este estudio incluyó un análisis secundario de los datos del consumo de antibióticos reportado en SIVIGILA-INS. Se evaluó la frecuencia de los informes hospitalarios y se comparó con los informes esperados, desglosados por unidad de cuidados intensivos (UCI) y otros servicios distintos a la UCI, y por región geográfica. El consumo se expresó en dosis diaria definida (DDD) por 100 camas ocupadas para siete antibióticos.

Resultados.

Más del 70% de los hospitales notificaron el consumo de antibióticos al menos una vez en cada uno de los tres años (79% en la UCI y 71% en los servicios distintos a la UCI). De estos, el 59% de las UCI completaron los informes mensuales (12 informes en un año) entre el 2018 y el 2019, pero solo el 4% en el 2020. El 52% de los servicios distintos a la UCI completó los informes en el 2019 y el 2% en el 2020. En la mayoría de las regiones hubo una disminución general de la notificación en el 2020. El análisis del consumo de antibióticos mostró un aumento de piperacilina/tazobactam, ertapenem y cefepima del 2019 al 2020.

Conclusiones.

Se encontraron disparidades en la coherencia y en la frecuencia de la presentación de informes. Es necesario destinar esfuerzos para mejorar el cumplimiento de la notificación mensual, que disminuyó en el 2020 posiblemente debido a la pandemia de COVID-19. La falta de cumplimiento en la presentación de los reportes y los problemas de calidad de los datos deben abordarse con los hospitales para facilitar la interpretación válida de las tendencias de consumo de antibióticos.

Palabras clave
Antibacterianos; programas de monitoreo de medicamentos recetados; habitaciones de pacientes; unidades de cuidados intensivos; investigación operativa; Colombia

RESUMO

Objetivo.

Avaliar o cumprimento da exigência de notificar mensalmente o consumo de antibióticos em hospitais secundários e terciários ao Sistema Nacional de Vigilância em Saúde Pública da Colômbia (SIVIGILA-INS) e descrever o consumo informado de antibióticos de 2018 a 2020.

Métodos.

Este estudo envolveu uma análise secundária dos dados de consumo de antibióticos enviados para o SIVIGILA-INS. A frequência de notificação pelos hospitais foi avaliada e comparada com a frequência esperada. Os dados foram desagregados entre unidades de terapia intensiva (UTIs) e enfermarias gerais e por regiões geográficas. O consumo foi expresso como dose diária definida (DDD) por 100 leitos ocupados para sete antibióticos.

Resultados.

Mais de 70% dos hospitais notificaram consumo de antibióticos pelo menos uma vez em cada um dos três anos (79% na UTI e 71% nas enfermarias gerais). Entre eles, 59% dos hospitais enviaram todas as notificações relativas a UTIs (12 notificações mensais) no período de 2018 a 2019, mas apenas 4% o fizeram em 2020. No caso das enfermarias gerais, 52% dos hospitais enviaram todas as notificações em 2019 e 2% o fizeram em 2020. A maioria das regiões teve uma diminuição geral no número de notificações enviadas em 2020. A análise do consumo de antibióticos revelou um aumento no uso de piperacilina/tazobactam, ertapeném e cefepima de 2019 para 2020.

Conclusões.

Houve lacunas na uniformidade e frequência das notificações. São necessários esforços para melhorar o cumprimento da exigência de notificações mensais, que, possivelmente devido à pandemia de COVID‑19, diminuiu em 2020. Problemas relacionados ao não cumprimento da exigência de notificação e à qualidade dos dados devem ser resolvidos junto aos hospitais para permitir uma interpretação válida das tendências de consumo de antibióticos.

Palavras-chave
Antibacterianos; programas de monitoramento de prescrição de medicamentos; quartos de pacientes; unidades de terapia intensiva; pesquisa operacional; Colômbia

Surveillance of antibiotic consumption for human health is a key element in the global fight against antimicrobial resistance (AMR) (¹1. World Health Organization. Global action plan on antimicrobial resistance. Geneva: WHO; 2015 Available from: https://apps.who.int/iris/handle/10665/193736.
https://apps.who.int/iris/handle/10665/1... ). High-quality consumption data are required to monitor antibiotic stewardship, evaluate progress, and tailor policy at the local and national levels. Antimicrobial consumption monitoring is a relatively new activity in Colombia. A study in 2009 describing 10 Colombian high complexity hospitals showed a decrease in the prescription of ciprofloxacin, the disuse of ceftazidime, and an increasing trend in the prescription of ampicillin/sulbactam, ceftriaxone, meropenem, piperacillin/tazobactam, and vancomycin (²2. Instituto Nacional de Salud. Informe final de evento: Consumo de antibióticos en el ámbito hospitalario, Colombia, 2016. Bogotá: INS; 2016. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/Consumo%20de%20antibiotico%20intrahospitalario%202016.pdf.
https://www.ins.gov.co/buscador-eventos/... ).

In 2012, the Ministry of Health and Social Protection of Colombia launched a national pharmaceutical policy stressing the importance of containing antibacterial resistance and antimicrobial consumption. At that time, it was agreed that there should be gradual and sustained progress by 2021 in the implementation of the prevention and control program for healthcare-associated infections, in controlling AMR, and in reporting antibiotic consumption in 90% of tertiary and secondary level hospitals¹1Health services in Colombia are classified according to their complexity, which is defined based on the resources available, composition, organization, and structural and functional elements. According to the degree of complexity, the services are classified as: low (primary) complexity, medium (secondary) complexity, high (tertiary) complexity and combinations of these. (high and medium complexity institutions) (²2. Instituto Nacional de Salud. Informe final de evento: Consumo de antibióticos en el ámbito hospitalario, Colombia, 2016. Bogotá: INS; 2016. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/Consumo%20de%20antibiotico%20intrahospitalario%202016.pdf.
https://www.ins.gov.co/buscador-eventos/... , ³3. Prada-Ríos SI, Pérez-Castaño AM, Rivera-Triviño AF. Clasificación de instituciones prestadores de servicios de salud según el sistema de cuentas de la salud de la Organización para la Cooperación y el Desarrollo Económico: El caso de Colombia. Rev Gerenc Polit Salud. 2017;16(32):51–65.).

Consequently, the Ministry, with support from the National Institute of Health (INS), implemented surveillance strategies for healthcare-associated infections, antibiotic consumption, and AMR through the National Public Health Surveillance System (Sistema de Vigilancia en Salud Pública—SIVIGILA). The INS has implemented a monitoring program for the consumption of seven antibiotics in secondary and tertiary hospitals at a national level since 2012 (²2. Instituto Nacional de Salud. Informe final de evento: Consumo de antibióticos en el ámbito hospitalario, Colombia, 2016. Bogotá: INS; 2016. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/Consumo%20de%20antibiotico%20intrahospitalario%202016.pdf.
https://www.ins.gov.co/buscador-eventos/... ). The antibiotic consumption surveillance reports from 2013 to 2017 showed variable consumption frequencies in intensive care units (ICU) and non-ICU services throughout the country. In ICUs, the predominant antibiotics used were meropenem, piperacillin/tazobactam, and vancomycin. In non-ICU settings, the consumption of ciprofloxacin and meropenem increased during this time (⁴4. Instituto Nacional de Salud. Informe de evento: Consumo de antibióticos en el ambito hospitalario en Colombia, 2018. Bogotá: INS; 2018. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/CONSUMO%20DE%20ANTIBIÓTICOS%20EN%20ÁMBITO%20HOSPITALARIO_2018.pdf.
https://www.ins.gov.co/buscador-eventos/... ).

Then, aligned with the Global Action Plan on Antimicrobial Resistance,²2The Global Action Plan provides the framework for national action plans to combat antimicrobial resistance. It sets out the key actions that the various actors involved should take, using an incremental approach over the next 5–10 years. Colombia launched a national policy in 2018 that includes strategic interventions related to implementing antimicrobial consumption monitoring mechanisms and an activity named “strengthening surveillance of antimicrobial use at the hospital level” (⁵5. Ministerio de Salud y Protección Social. Plan nacional de respuesta a la resistencia a los antimicrobianos (PNRAM). Bogotá: MSPS; 2018. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/MET/plan-respuesta-resistencia-antimicrobianos.pdf.
https://www.minsalud.gov.co/sites/rid/Li... ). The reports to SIVIGILA implemented previously meet this objective.

SIVIGILA-INS applies the World Health Organization (WHO) methodology to measure the consumption of antimicrobials. This methodology has two key components: i) a common metric to express consumption through a defined daily dose (DDD), and ii) the Anatomical Therapeutic Chemical (ATC) system as a global standard for classifying active ingredients for medical use. This standardized methodology facilitates comparisons between countries or regions. It also allows documentation of the impact of regulatory policies and interventions aimed at preventing excess antimicrobial use. Finally, the DDD consumption indicator can be interpreted as an approximation of the appropriate use of various medicines (⁶6. World Health Organization. GLASS methodology for surveillance of national antimicrobial consumption [Internet]. Geneva: WHO; 2020 [cited 2023 Feb 10]. Available from: https://www.who.int/publications/i/item/9789240012639.
https://www.who.int/publications/i/item/... ).

The same methodology is applied to calculate annual national consumption data. These annual reports include aggregated data on national drug sales for essential antimicrobials. This information is sent to the Ministry of Health and Social Protection by pharmaceutical laboratories and wholesale distributors throughout the country. Colombia began sharing its national consumption data in 2021 based on data collected in 2019. The country reported a total antimicrobial consumption of 18 DDD/1 000 inhabitants per day, corresponding to three ATC codes described as essential antimicrobial medicines: J01 (antibacterials for systemic use), P01AB (nitroimidazole derivatives, for diseases caused by protozoa), and A07AA (intestinal antibacterials). The predominant antibiotics were beta-lactams/penicillin (6%–35%), macrolides/lincosamides (3%–17%), and quinolones (2%–13%) (⁷7. Marin GH, Giangreco L, Dorati C, Mordujovich P, Boni S, Mantilla-Ponte H, et al. Antimicrobial Consumption in Latin American Countries: First Steps of a Long Road Ahead. J Prim Care Community Health. 2022;13:21501319221082346. https://doi.org/10.1177/21501319221082346.
https://doi.org/10.1177/2150131922108234... ).

While the national DDD indicator was comparable to other Latin American countries (Argentina, Chile, Costa Rica, Paraguay, and Peru), the share of macrolides and quinolones was notably higher in Colombia than elsewhere. The intake of these last two antibiotic classes was the highest among the countries involved in the study (⁷7. Marin GH, Giangreco L, Dorati C, Mordujovich P, Boni S, Mantilla-Ponte H, et al. Antimicrobial Consumption in Latin American Countries: First Steps of a Long Road Ahead. J Prim Care Community Health. 2022;13:21501319221082346. https://doi.org/10.1177/21501319221082346.
https://doi.org/10.1177/2150131922108234... ). When analyzed using the WHO AWaRe³3WHO updated its Model List of Essential Medicines in 2017 and grouped antibiotics into Access, Watch, and Reserve (AWaRe) categories based on treatment profile and potential for development of resistance. Access: Indicates the antibiotic of choice for each of the 25 most common infections. These antibiotics should be available at all times, affordable, and quality-assured. Watch: Includes most of the “highest-priority critically important antimicrobials” for human medicine and veterinary use. These antibiotics are recommended only for specific, limited indications. Reserve: Antibiotics that should only be used as a last resort when all other antibiotics have failed. antimicrobial classification, 70% of the antimicrobials consumed belonged to the “Access” category, 29% to the “Watch” category, and 0.12% were “Reserve” antimicrobials. Antibiotics for hospital monitoring are included in the Watch category of this classification. These results by themselves do not place the country at an advantage or disadvantage, as the country-specific epidemiological context and its consumption history must be considered.

While this first report was able to provide national health authorities with a general overview of the country’s antimicrobial consumption profile, the National Response Plan to Antimicrobial Resistance emphasizes the need to complement it with high-quality data from different contexts such as private and public hospitals and the community (²2. Instituto Nacional de Salud. Informe final de evento: Consumo de antibióticos en el ámbito hospitalario, Colombia, 2016. Bogotá: INS; 2016. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/Consumo%20de%20antibiotico%20intrahospitalario%202016.pdf.
https://www.ins.gov.co/buscador-eventos/... , ⁵5. Ministerio de Salud y Protección Social. Plan nacional de respuesta a la resistencia a los antimicrobianos (PNRAM). Bogotá: MSPS; 2018. Available from: https://www.minsalud.gov.co/sites/rid/Lists/BibliotecaDigital/RIDE/VS/MET/plan-respuesta-resistencia-antimicrobianos.pdf.
https://www.minsalud.gov.co/sites/rid/Li... ). The antibiotic consumption data provided by hospitals in the current SIVIGILA system can play a crucial role in this regard, since the use of antimicrobials in healthcare facilities contributes significantly to AMR (⁸8. World Health Organization. WHO Report on Surveillance of Antibiotic Consumption: 2016-2018 early implementation [Internet]. Geneva: WHO; 2018 [cited 2022 Nov 10]. Available from: https://apps.who.int/iris/bitstream/handle/10665/277359/9789241514880-eng.pdf.
https://apps.who.int/iris/bitstream/hand... , ⁹9. Almagor J, Temkin E, Benenson I, Fallach N, Carmeli Y; DRIVE-AB Consortium. The impact of antibiotic use on transmission of resistant bacteria in hospitals: Insights from an agent-based model. PLoS One [Internet]. 2018 May 1 [cited 2023 Feb 10];13(5):e0197111. https://doi.org/10.1371/journal.pone.0197111.
https://doi.org/10.1371/journal.pone.019... ).

The analysis of antibiotic consumption at national and hospital levels should be used as additional information to propose strategies to optimize antimicrobial use in the country or specific regions. However, the usefulness of these data depends on the robustness of the monitoring system and the quality and consistency of the data that are submitted by the hospitals.

This study aimed to assess the compliance in secondary and tertiary level hospitals with monthly reporting of antibiotic consumption over a three-year period. The study also describes reported antibiotic consumption (in DDD/100 occupied beds) according to type of patient service and geographical region.

MATERIALS AND METHODS

Study design

This study was a descriptive secondary analysis of consumption data on seven antibiotics, from secondary and tertiary level Colombian hospitals, submitted via SIVIGILA-INS, from 2018 to 2020, for ICU and non-ICU wards. The database was shared by the Directorate of Epidemiology and Demography of the Ministry of Health and Social Protection of Colombia.⁴4The dataset used in this article can be made available on request to the corresponding author.

Study setting

At present, in the Colombian health system there are approximately 400 hospitals working at the tertiary level of complexity, funded through public or private resources (¹⁰10. Ministerio de Salud y Protección Social. Registro especial de prestadores de servicios de salud [Internet]. Bogotá: MSPS; 2021 [cited 2021 Jul 22]. Available from: https://prestadores.minsalud.gov.co/habilitacion/ingreso.aspx?ets_codigo=11.
https://prestadores.minsalud.gov.co/habi... ). Tertiary level hospitals are obliged to report monthly data on beds available, beds occupied, and units dispensed of seven antimicrobials (cefepime, ceftriaxone, ciprofloxacin, ertapenem, meropenem, piperacillin, and vancomycin) to SIVIGILA, for ICU and non-ICU wards (i.e., maternity, general inpatient, surgery, and other wards, excluding emergency rooms) separately. These antibiotics were selected by the INS for consumption surveillance because they are the main antibiotics for clinical use in adult hospitalization services of high complexity health institutions (¹¹11. Instituto Nacional de Salud. Protocolo de vigilancia en salud pública: Consumo de antibióticos en el ámbito hospitalario. Bogotá: INS; 2019.). Currently, reporting to SIVIGILA is voluntary for secondary level hospitals and mandatory for tertiary level hospitals.

SIVIGILA is a software tool, developed by the INS, that has allowed the implementation of several epidemiological surveillance programs in the country. It is easy to use, and many hospital staff are familiar with it as a result of training efforts by the INS since the system came into operation in 2006. The reporting of antibiotic consumption through this system began in 2013 (²2. Instituto Nacional de Salud. Informe final de evento: Consumo de antibióticos en el ámbito hospitalario, Colombia, 2016. Bogotá: INS; 2016. Available from: https://www.ins.gov.co/buscador-eventos/Informesdeevento/Consumo%20de%20antibiotico%20intrahospitalario%202016.pdf.
https://www.ins.gov.co/buscador-eventos/... ).

The AWaRe (Access, Watch, Reserve) classification of antimicrobials is a WHO initiative launched in 2017. The tool is primarily aimed at low- and middle-income countries and classifies 37 antibiotics that are frequently used to treat 26 common and severe infections. The classification is based on the antibiotics’ potential to induce and propagate resistance, and it also identifies antibiotics that are priorities for monitoring and surveillance (¹¹11. Instituto Nacional de Salud. Protocolo de vigilancia en salud pública: Consumo de antibióticos en el ámbito hospitalario. Bogotá: INS; 2019., ¹²12. World Health Organization. WHO Access, Watch, Reserve (AWaRe) classification of antibiotics for evaluation and monitoring of use [Internet]. Geneva: WHO; 2021 [cited 2023 Feb 10]. Available from: https://www.who.int/publications/i/item/2021-aware-classification.
https://www.who.int/publications/i/item/... ).

Source of data and variables

SIVIGILA reports include details of seven antibiotics (cefepime, ceftriaxone, ciprofloxacin, ertapenem, meropenem, piperacillin, and vancomycin) and their consumption in ICU and non-ICU services for adult patient care in secondary and tertiary hospitals across Colombia. Data for this study were obtained from the SIVIGILA-INS database for the years 2018, 2019, and 2020. The study variables for compliance of hospital submissions were year and month of reporting, by type of patient service, and administrative region of the country. In addition, for the consumption trend analysis from 2018 to 2020, DDD per 100 occupied beds reported for each antibiotic were analyzed as a consumption indicator. Due to system drawbacks, it was not possible to retrieve and use the data for non-ICU services in 2018.

Statistical analysis

Data were provided in a Microsoft Excel spreadsheet. To assess performance of the system, adherence to reporting and data quality were analyzed as parameters of interest. For the reporting parameter, each tertiary level facility was expected to submit one report per month for both ICU and non-ICU services, and each secondary level facility for non-ICU wards only (i.e., 12 reports were expected per facility per service per year). The proportion of reports received was summarized as a percentage. If the same facility had submitted more than one report for a service in a month it was considered a duplicate report, and only the last one was included for the calculation of the number of submitted reports.

For the data quality parameter, the distribution of reported values of monthly DDD/100 occupied beds was summarized for the different antibiotics using medians and interquartile ranges. Box and whisker plots were developed to identify outliers or implausible values. DDD summary statistics were used to explore the changes in antibiotic consumption profile in ICU and non-ICU services over the three-year period, observing how the two parameters, medians with interquartile ranges, affected the measurement and interpretation of DDD.

Ethical considerations

Permission to use the antibiotic consumption data was sought and approved from the Ministry of Health and Social Protection, Colombia. National ethics approval was obtained from the Ethics Review Committee of the Research and Extension Center of the National University of Colombia (B.CIEFO-098-2022). International ethics approval was obtained from the PAHO Ethics Review Committee (PAHOERC-0551-01).

RESULTS

Compliance with reporting

For the period 2018–2020, an average of 79% of ICU wards reported their antibiotic consumption data at least once a year (Table 1). In the period 2018–2019, 59% of the participating hospitals submitted all 12 monthly reports; in 2020, this percentage decreased to 4%.

There was a decrease in compliance in non-ICU wards: 28% of the hospitals never submitted one antibiotic consumption report in 2019, and 31% in 2020. Non-ICU wards also showed a decrease in complete reporting, from 52% of services submitting all 12 reports in 2019 decreasing to 2% submitting all reports in 2020.

Regarding reported beds, a decrease was observed in 2020. On average in 2018 and 2019, 5 375 ICU beds and 33 645 non-ICU beds were reported. In 2020, the number of reported beds dropped to 3 329 in ICU and 4 551 in non-ICU wards.

Regional antibiotic consumption reporting

In most regions there was an overall decrease in reporting in 2020 (Table 2 and 3). However, some regions improved their reporting from 2019 to 2020; for example, Amazonas (non-ICU: 21% to 50%), Nariño (ICU: 31% to 87%; non-ICU: 30% to 83%), and Caquetá (non-ICU: 78% to 92%). Seven regions did not submit a single antibiotic consumption report during the three-year period (Arauca, Córdoba, Guainía, Guaviare, Putumayo, Vaupés, and Vichada).

Trends in antibiotics consumption

Variations were observed in the reporting of DDD/100 occupied beds for specific antibiotics over the study period, such as ceftriaxone in ICU wards (2019: 17 584; 2020: 19 857). In addition, the antibiotic consumption showed an increase for piperacillin/tazobactam (91 606 to 94 076), ertapenem (5 793 to 6 051), and cefepime (26 809 to 38 780) from 2019 to 2020 (Table 4).

However, extreme values of the DDD/100 occupied beds indicator limited its usefulness for analysis, including implausible values such as ICU-DDD/100 occupied beds values of 57 604 for vancomycin in 2018, or 9 752.5 for piperacillin/tazobactam and 16 458 for ceftriaxone in the same year (Table 5). Variable reporting rates also influenced DDD/100 occupied beds values. Monthly median and interquartile ranges for antibiotic consumption remained unchanged for 2018 and 2019 for ICUs, and for 2019 and 2020 for non-ICU wards (Table 5).

DISCUSSION

Antibiotic consumption monitoring programs are essential because they provide information and guide the optimization of antimicrobial use in a country. These programs document patients’ exposure to antibiotics and the potential development of AMR (¹³13. Versporten A, Zarb P, Caniaux I, Gros MF, Drapier N, Miller M, et al. Antimicrobial consumption and resistance in adult hospital inpatients in 53 countries: results of an internet-based global point prevalence survey. Lancet Glob Health [Internet]. 2018 Jun [cited 2022 Nov 11];6(6):e619–29. https://doi.org/10.1016/s2214-109x(18)30186-4.
https://doi.org/10.1016/s2214-109x(18)30... ). Thus, in Colombia, the monthly notification of hospital antibiotic consumption through SIVIGILA-INS has been implemented for nine years. This system is flexible and is adjusted annually according to the country’s needs as a result of information provided by the hospitals and specific situations such as the identification of new mechanisms of AMR. For example, including an antibiotic of pharmaco-epidemiological interest (ertapenem in 2018) due to inappropriate prescriptions, or excluding an antibiotic due to disuse (imipenem in 2020). The selection of monitoring antibiotics should be suitable to broadly represent the consumption preferences in hospital care in the country (¹⁴14. Kim B, Hwang H, Kim J, Lee MJ, Pai H. A few antibiotics can represent the total hospital antibiotic consumption. BMC Infect Dis. 2018;18(1):247. https://doi.org/10.1186/s12879-018-3132-7
https://doi.org/10.1186/s12879-018-3132-... ).

In addition, INS generates annual reports and discloses hospital consumption of seven antibiotics that are subject to surveillance. This study aimed to evaluate the compliance of hospital consumption reports over a three-year period and identified the need to standardize and monitor the methodology of this reporting system to obtain robust and reliable data.

In this regard, there is room for improvement at the interface; that is, where primary data generated in the hospitals are uploaded into the system. For example, the system allows more than one report to be uploaded for a specific period in any moment and does not have a data validation system. These issues directly affect the DDD/100 occupied beds indicator calculated for each drug.

This study has several limitations. First, as the dataset did not include the hospital level of care (tertiary or secondary) and the source of funding (public or private), it was not possible to assess whether some hospitals had more urgent issues with monitoring than others. Second, we detected high variability in the data, which may be explained by duplicate reports, suspected typing mistakes, and/or a lack of compliance with monthly reporting. These issues affected the reliability of the reported data.

Another limitation of this study is related to the health emergency caused by COVID-19 in 2020. This affected the monitoring of antibiotic consumption in hospitals and other surveillance programs. During the pandemic it was observed that health and administrative staff were forced to redesign care models and processes to be available for ICU, emergency, and inpatient care due to low availability of healthcare professionals (¹⁵15. Tomczyk S, Taylor A, Brown A, de Kraker MEA, El-Saed A, Alshamrani M, et al. Impact of the COVID-19 pandemic on the surveillance, prevention and control of antimicrobial resistance: a global survey. J Antimicrob Chemother. 2021;76(11):3045–58. https://doi.org/10.1093/jac/dkab300.
https://doi.org/10.1093/jac/dkab300... ). In ICUs there was a decrease in monthly reporting from 87% in the period 2018 and 2019 to 78% in 2020. Similarly, in 2019, 52% of non-ICU services reported for the whole year (12 months), but only 1.5% did so in 2020 (Table 1). These results could be related to the fact that this reporting was not a priority in 2020, when healthcare professionals in charge of reporting had to turn their attention to documenting the admission, management, and evolution of COVID-19 patients in each hospital (¹⁶16. Rodríguez-Baño J, Rossolini GM, Schultsz C, Tacconelli E, Murthy S, Ohmagari N, et al. Key considerations on the potential impacts of the COVID-19 pandemic on antimicrobial resistance research and surveillance. Trans R Soc Trop Med Hyg. 2021;115(10):1122–9. https://doi.org/10.1093/trstmh/trab048.
https://doi.org/10.1093/trstmh/trab048... ). Overall, the COVID-19 pandemic affected reporting compliance in almost all regions of the country, except for a few areas where reporting was maintained or even improved in 2020, such as Nariño and Caquetá.

Variations in antibiotic consumption (DDD/100 occupied beds per day) are sensitive to hospital reporting performance. According to the INS annual report for 2020, while the number of reporting hospitals increased, the total number of beds was considerably lower, especially for non-ICU (13% of total beds reported during 2018 and 2019, as shown in Table 1). Of the ICU beds, only 61% were notified in 2020, compared to the number of beds included in the previous annual reports (¹⁷17. Instituto Nacional de Salud. Consumo de antibióticos en el ámbito hospitalario, Colombia, 2020. Bogotá: INS; 2020.). The 2020 underreporting is even greater considering that in 2020 adult ICU bed capacity increased from 5 346 to 6 149 beds nationwide (¹⁸18. Ministerio de Salud y Protección Social. Servicios y capacidad instalada de las IPS por departamento o distrito y naturaleza jurídica [Internet]. Bogotá: MSPS; 2022 [cited 2022 Nov 14]. Available from: https://www.sispro.gov.co/central-prestadores-de-servicios/Pages/Servicios-y-capacidad-de-IPS-por-naturaleza-juridica.aspx.
https://www.sispro.gov.co/central-presta... ). This finding could be related to the overwork due to the COVID-19 pandemic in 2020.

Regarding the consumption trends observed between 2018 and 2020, the variations in the consumption of piperacillin/tazobactam, ertapenem, ceftriaxone, and cefepime from 2019 to 2020 could be related to an increase in prescriptions for patients with moderate or severe symptoms related to secondary infection and coinfections in response to SARS-CoV-2 virus, in ICU mainly and non-ICU services (¹⁹19. Chedid M, Waked R, Haddad E, Chetata N, Saliba G, Choucair J. Antibiotics in treatment of COVID-19 complications: a review of frequency, indications, and efficacy. J Infect Public Health. 2021 May;14(5):570–6. https://doi.org/10.1016/j.jiph.2021.02.001.
https://doi.org/10.1016/j.jiph.2021.02.0... ). Regarding the decrease of ciprofloxacin in 2020, although speculative, possible explanations might be adjustments in antibiotic prescriptions through compliance with hospital-specific or national therapeutic guidelines, or a low incidence of infections treated with this antibiotic. This example illustrates the need for each hospital to implement antimicrobial stewardship (AMS) interventions to analyze its consumption data, identify the causes of variation, and improve the use of antibiotics. Such AMS interventions have been shown to reduce treatment costs, resistance rates, and healthcare-associated infections and to improve patient outcomes (²⁰20. Pauwels I, Versporten A, Vermeulen H, Vlieghe E, Goossens H. Assessing the impact of the Global Point Prevalence Survey of Antimicrobial Consumption and Resistance (Global-PPS) on hospital antimicrobial stewardship programmes: results of a worldwide survey. Antimicrob Resist Infect Control [Internet]. 2021 Sep 28 [cited 2022 Nov 14];10(1):138. https://doi.org/10.1186/s13756-021-01010-w.
https://doi.org/10.1186/s13756-021-01010... ).

A way forward could be to provide technical advice to hospitals and to support the INS in order to gradually improve compliance indicators of monthly reporting with reliable data (i.e., the ratio of reports received by SIVIGILA to the expected reports). For example, automated controls such as range checks and validation tools built into data entry and analysis systems could contribute to data quality by highlighting implausible or missing values and reports. Alternatively, a sentinel surveillance approach could help in creating a representative sample of hospitals with high-quality consumption data. Furthermore, data reporting could be made mandatory for secondary level hospitals. It would also be useful to collect data on a few additional variables at service/ward level, such as the number of patients attended and the sources of financing. Finally, knowing the total number of patients treated in ICU and non-ICU services in the hospitals that report to SIVIGILA would allow a comparative analysis of national and hospital consumption.

In conclusion, the progress in the number of ICU and non-ICU services in the country providing the data required by the hospital antibiotic consumption surveillance program is noteworthy. However, the quality of DDD data is sensitive to external factors such as the COVID-19 pandemic in 2020, changes in antibiotic prescription practices, and the accuracy of data-entry work. This highlights the critical need to strengthen the SIVIGILA system for antibiotic consumption, to guarantee data quality, to improve data completeness, and to support hospital staff. In this regard, there is room for improvement at the interface and the issues directly affect the DDD/100 occupied beds indicator calculated for each drug.

Disclaimer.

Authors hold sole responsibility for the views expressed in the manuscript, which may not necessarily reflect the opinion or policy of the RPSP/PAJPH and/or those of the Pan American Health Organization or the Ministry of Health and Social Protection.

Acknowledgment.

This research protocol was developed through the Structured Operational Research and Training Initiative (SORT IT), a global partnership coordinated by TDR—the UNICEF, United Nations Development Programme, World Bank, and World Health Organization (WHO) Special Program for Research and Training in Tropical Diseases, hosted at WHO. The specific SORT IT program that led to this study protocol included an implementation partnership of TDR and the Pan American Health Organization (PAHO), and the PAHO Colombia and Ecuador country offices; the Ministry of Health and Social Protection, Colombia; Food and Agriculture Organization, Sierra Leone; Sustainable Health Systems, Freetown, Sierra Leone; the Tuberculosis Research and Prevention Center non-governmental organization, Armenia; the International Union Against Tuberculosis and Lung Disease, Paris, France, and South East Asia office, India; Institute of Tropical Medicine, Antwerp, Belgium; Damien Foundation, Belgium; Indian Council of Medical Research–National Institute of Epidemiology; Jawaharlal Institute of Postgraduate Medical Education & Research (JIPMER); GMERS Medical College, Gotri Vadodara, India; Medical College Baroda, Vadodara, India; Sri Manakula Vinayagar Medical College, Puducherry, India; Public Health Ontario, Canada; Quadram Institute Bioscience, Norwich, United Kingdom; Universidade Federal de Ciências de Saúde de Porto Alegre, Brazil; Universidade de Brasília, Brazil; Universidad de Concepción, Chile; Universidad de los Andes, Colombia; Universidad Pontificia Bolivariana, Colombia; Universidad Pedagógica y Tecnológica de Colombia; Central University of Ecuador; California State University, Fullerton, United States of America; and the Autonomous University of Yucatán, Mexico. The authors thank the Directorate of Epidemiology and Demography of the Ministry of Health and Social Protection for providing the data used in this study and INS for help in understanding the details of the database. We are grateful to Claudia Vargas, Director of Medicines and Health Technology of the Ministry of Health and Social Protection of Colombia, and Janet Ousley from Médecins Sans Frontières (MSF) for editorial support.

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