Antimicrobial consumption in the WHO Western Pacific Region: early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS)

Antimicrobial Consumption in the WHO Western Pacific Region Early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) One Region One Movement to Fight Antimicrobial Resistance Join the movement http://pledge.antibioticawarenessweek.org

Antimicrobial Consumption in the WHO Western Pacific Region Early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) Antimicrobial consumption in the WHO Western Pacific Region: early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) © World Health Organization 2021 ISBN 978 92 9061 954 3 Some rights reserved. This work is available under the Creative Commons Attribution-NonCommercial-ShareAlike 3.0 IGO licence (CC BY- NC-SA 3.0 IGO; https://creativecommons.org/licenses/by-nc-sa/3.0/igo). Under the terms of this licence, you may copy, redistribute and adapt the work for non-commercial purposes, provided the work is appropriately cited, as indicated below. In any use of this work, there should be no suggestion that WHO endorses any specific organization, products or services. The use of the WHO logo is not permitted. If you adapt the work, then you must license your work under the same or equivalent Creative Commons licence. If you create a translation of this work, you should add the following disclaimer along with the suggested citation: “This translation was not created by the World Health Organization (WHO). WHO is not responsible for the content or accuracy of this translation. The original English edition shall be the binding and authentic edition”. Any mediation relating to disputes arising under the licence shall be conducted in accordance with the mediation rules of the World Intellectual Property Organization. (http://www.wipo.int/amc/en/mediation/rules/) Suggested citation Antimicrobial consumption in the WHO Western Pacific Region: early implementation of the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS). Manila: World Health Organization Regional Office for the Western Pacific; 2021. Licence: CC BY-NC-SA 3.0 IGO. Cataloguing-in-Publication (CIP) data. 1. Drug resistance, Microbial. 2. Sentinel surveillance. I. World Health Organization Regional Office for the Western Pacific. (NLM Classification: WB330). Sales, rights and licensing. To purchase WHO publications, see http://apps.who.int/bookorders. To submit requests for commercial use and queries on rights and licensing, see http://www.who.int/about/licensing. For WHO Western Pacific Regional Publications, request for permission to reproduce should be addressed to Publications Office, World Health Organization, Regional Office for the Western Pacific, P.O. Box 2932, 1000, Manila, Philippines, Fax. No. (632) 8521-1036, email: wpropuballstaff@who.int Third-party materials. If you wish to reuse material from this work that is attributed to a third party, such as tables, figures or images, it is your responsibility to determine whether permission is needed for that reuse and to obtain permission from the copyright holder. The risk of claims resulting from infringement of any third-party-owned component in the work rests solely with the user. General disclaimers. The designations employed and the presentation of the material in this publication do not imply the expression of any opinion whatsoever on the part of WHO concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted and dashed lines on maps represent approximate border lines for which there may not yet be full agreement. The mention of specific companies or of certain manufacturers’ products does not imply that they are endorsed or recommended by WHO in preference to others of a similar nature that are not mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters. All reasonable precautions have been taken by WHO to verify the information contained in this publication. However, the published material is being distributed without warranty of any kind, either expressed or implied. The responsibility for the interpretation and use of the material lies with the reader. In no event shall WHO be liable for damages arising from its use. Photo credit: WHO/Yoshi Shimizu, cover, pp. 5, 11, 38; WHO/Until Chan, p. 42. Contents List of tables and figures ������������������������������������������������������������������������������������������������������������� iv Abbreviations ����������������������������������������������������������������������������������������������������������������������������� vi Executive summary �������������������������������������������������������������������������������������������������������������������� vii Introduction of WPRACSS ������������������������������������������������������������������������������������������������������������ 1 Accelerating action to fight antimicrobial resistance in the Western Pacific Region ��������������������� 1 The role of antimicrobial consumption monitoring in combating AMR��������������������������������������������� 2 The Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) ����� 3 WPRACSS architecture ���������������������������������������������������������������������������������������������������������������������������� 3 Participating countries and areas ���������������������������������������������������������������������������������������������������������� 4 WPRACSS methodology ��������������������������������������������������������������������������������������������������������������� 5 Monitoring of systemic antimicrobials ��������������������������������������������������������������������������������������������������� 5 Data sources to monitor antimicrobial consumption at the national level �������������������������������������� 6 Limitations and strengths of data sources for national consumption monitoring ������������������������� 6 Data collection at the product level (annually or quarterly) �������������������������������������������������������������� 9 Standardization using the ATC/DDD system ���������������������������������������������������������������������������������������� 9 WPRACSS metrics and indicators ������������������������������������������������������������������������������������������������������� 10 Results of early implementation ������������������������������������������������������������������������������������������������� 11 Data collection process �������������������������������������������������������������������������������������������������������������������������� 11 Total national consumption of antimicrobials ������������������������������������������������������������������������������������ 12 Overview of national antimicrobial consumption by country/area ������������������������������������������������� 13 Brunei Darussalam ������������������������������������������������������������������������������������������������������������������������ 13 Hong Kong SAR (China) ������������������������������������������������������������������������������������������������������������������ 17 Japan ������������������������������������������������������������������������������������������������������������������������������������������������� 20 Lao People’s Democratic Republic ������������������������������������������������������������������������������������������������ 23 Malaysia �������������������������������������������������������������������������������������������������������������������������������������������� 26 Mongolia ������������������������������������������������������������������������������������������������������������������������������������������� 29 Philippines ���������������������������������������������������������������������������������������������������������������������������������������� 32 Antimicrobial consumption based on hospital and community monitoring ����������������������������������� 35 Regional analysis ����������������������������������������������������������������������������������������������������������������������������������� 36 Interpretation of results ������������������������������������������������������������������������������������������������������������� 38 Conclusion and way forward ������������������������������������������������������������������������������������������������������ 42 Annex 1: AWaRe classification 2019 ������������������������������������������������������������������������������������������� 43 Annex 2: 2019 ATC/DDD values for antimicrobials ��������������������������������������������������������������������� 48 iii TABLES Table 1� Countries and areas participating in WPRACSS and their official focal points ��������������� 4 Table 2� Antibiotics under surveillance at the national level as part of this report ���������������������� 5 Table 3� Data sources for national AMC monitoring and their strengths and limitations ������������ 7 Table 4� Antimicrobial consumption and antimicrobial use data explained ����������������������������������� 8 Table 5� Comparison of key data elements of various products������������������������������������������������������� 9 Table 6� WPRACSS key indicators to monitor national antimicrobial consumption ������������������� 10 Table 7� Data sources and coverage of countries and areas participating in national consumption monitoring through WPRACSS �������������������������������������������������������������������� 11 Table 8� Total quantity of antibiotics consumed by country or area in DDD and DID based on 2018 data ���������������������������������������������������������������������������������������������������������������������������� 12 Table 9� Overview of national consumption of antibiotics in Brunei Darussalam in 2018 ���������� 13 Table 10� Use of antibiotics for systemic use in DID and in percentage in Brunei Darussalam in 2018 ���������������������������������������������������������������������������������������������� 14 Table 11� Top 10 most consumed oral antibiotics in Brunei Darussalam in 2018 ������������������������� 15 Table 12� Top 10 most consumed parenteral antibiotics in Brunei Darussalam in 2018 �������������� 16 Table 13� Overview of national consumption of antibiotics in Hong Kong SAR (China) in 2018 �������������������������������������������������������������������������������������������������������������������������������������� 17 Table 14� Consumption of antibiotics for systemic use in DID and in percentage in Hong Kong SAR (China) in 2018 ��������������������������������������������������������������������������������������� 17 Table 15� Top 10 most consumed oral antibiotics in Hong Kong SAR (China) in 2018 ������������������ 19 Table 16� Top 10 most consumed parenteral antibiotics in Hong Kong SAR (China) in 2018 ������ 19 Table 17� Overview of national consumption of antibiotics in Japan in 2018 ��������������������������������� 20 Table 18� Consumption of antibiotics for systemic use in DID and in percentage in Japan in 2018 ���������������������������������������������������������������������������������������������������������������������� 20 Table 19� Top 10 most consumed oral antibiotics in Japan in 2018 ������������������������������������������������� 22 Table 20� Top 10 most consumed parenteral antibiotics in Japan in 2018 ������������������������������������� 22 Table 21� Overview of national consumption of antibiotics in the Lao People’s Democratic Republic in 2018 ������������������������������������������������������������������������� 23 Table 22� Use of antibiotics for systemic use in DID and in percentage in the Lao People’s Democratic Republic in 2018 ������������������������������������������������������������������������� 23 Table 23� Top 10 most consumed oral antibiotics in the Lao People’s Democratic Republic in 2018 �������������������������������������������������������������������������������������������������������������������������������������� 25 Table 24� Top 10 most consumed parenteral antibiotics in the Lao People’s Democratic  Republic ����������������������������������������������������������������������������������������������������������������������������������� 25 Table 25� Overview of national consumption of antibiotics in Malaysia in 2018 ���������������������������� 26 Table 26� Use of antibiotics for systemic use in DID and in percentage in Malaysia in 2018 ������� 26 Table 27� Top 10 most consumed oral antibiotics in Malaysia in 2018 �������������������������������������������� 28 Table 28� Top 10 most consumed parenteral antibiotics in Malaysia in 2018 �������������������������������� 28 List of tables and figures iv WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) iv Table 29� Overview of national consumption of antibiotics in Mongolia in 2018���������������������������� 29 Table 30� Use of antibiotics for systemic use in DID and in percentage in Mongolia in 2018 ������ 29 Table 31� Top 10 most consumed oral antibiotics in Mongolia in 2018 ������������������������������������������� 31 Table 32� Top 10 most consumed parenteral antibiotics in Mongolia in 2018 �������������������������������� 31 Table 33� Overview of national consumption of antibiotics in the Philippines in 2018 ����������������� 32 Table 34� Use of antibiotics for systemic use in DID and in percentage in the Philippines in 2018 �������������������������������������������������������������������������������������������������������������������������������������� 32 Table 35� Top 10 most consumed oral antibiotics in the Philippines in 2018 ��������������������������������� 34 Table 36� Top 10 most consumed parenteral antibiotics in the Philippines in 2018 ���������������������� 34 Table 37� Summary of antibiotic consumption of selected countries and areas in the Western Pacific Region by pharmaceutical subgroup (ATC3) in 2018 ����������������� 36 FIGURES Fig� 1� The supply chain of antimicrobials and related data sources to monitor antimicrobial consumption ������������������������������������������������������������������������������������������������������ 6 Fig� 2� Data sources along the supply cycle of medicines, including data sources used by countries and areas to monitor national consumption of antimicrobials ���������������� 12 Fig� 3� National consumption of antibiotics for systemic use in Brunei Darussalam in 2018 �������������������������������������������������������������������������������������������������������������������������������������� 14 Fig� 4� National consumption of antibiotics for systemic use in Brunei Darussalam by AWaRe categorization in 2018 ����������������������������������������������������������������������������������������� 15 Fig� 5� National consumption of antibiotics for systemic use in Hong Kong SAR (China) in 2018 �������������������������������������������������������������������������������������������������������������������������������������� 18 Fig� 6� National consumption of antibiotics for systemic use in Hong Kong SAR (China) by AWaRe categorization in 2018 ����������������������������������������������������������������������������������������� 18 Fig� 7� National consumption of antibiotics for systemic use in Japan in 2018 ������������������������ 21 Fig� 8� National consumption of antibiotics for systemic use in Japan by AWaRe categorization in 2018 ������������������������������������������������������������������������������������������������������������ 21 Fig� 9� National consumption of antibiotics for systemic use in the Lao People’s Democratic Republic in 2018 ������������������������������������������������������������������������� 24 Fig� 10� National consumption of antibiotics for systemic use in the Lao People’s Democratic Republic by AWaRe categorization in 2018 ���������������������������� 24 Fig� 11� National consumption of antibiotics for systemic use in Malaysia in 2018 �������������������� 27 Fig� 12� National consumption of antibiotics for systemic use in Malaysia by AWaRe categorization in 2018 ������������������������������������������������������������������������������������������������������������ 27 Fig� 13� National consumption of antibiotics for systemic use in Mongolia in 2018 ������������������� 30 Fig� 14� National consumption of antibiotics for systemic use in Mongolia by AWaRe categorization in 2018 ������������������������������������������������������������������������������������������������������������ 30 Fig� 15� National consumption of antibiotics for systemic use in the Philippines in 2018 ��������� 33 Fig� 16� National consumption of antibiotics for systemic use in the Philippines by AWaRe categorization in 2018 ����������������������������������������������������������������������������������������� 33 Fig� 17� National consumption of antibiotics for systemic use by country or area by AWaRe categorization in 2018 ����������������������������������������������������������������������������������������� 37 LIST OF TABLES ANd FIGURES V v Abbreviations AMC antimicrobial consumption AMR antimicrobial resistance AMU antimicrobial use ATC Anatomical Therapeutic Chemical DDD Defined Daily Dose DID DDD per 1000 inhabitants per day GAP Global Action Plan on Antimicrobial Resistance NAP National Action Plan OIE World Organisation for Animal Health WPRACSS Western Pacific Regional Antimicrobial Consumption Surveillance System WHO World Health Organization vi WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) vi Executive summary Antimicrobial resistance (AMR) is a major threat to global health and security. It endangers decades of progress made in modern medicine and public health. Although inappropriate use of antimicrobials is regarded as one of the main drivers of AMR, monitoring antimicrobial use is underdeveloped in large parts of the world. In recent years, the World Health Organization (WHO) has supported countries to strengthen the monitoring of antimicrobial consumption (AMC) and to optimize the use of antimicrobials. To this end, the WHO Regional Office for the Western Pacific launched the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) in 2020 to support Member States in the implementation and further development of antimicrobial consumption and use monitoring at the national level, in the hospitals and in the community, in order to provide a regional platform for countries to understand their own consumption patterns to help guide action on stewardship and surveillance. Thus far, 14 countries and areas have enrolled in WPRACSS. This first-ever regional report presents results on national antimicrobial consumption in seven countries and areas based on import, manufacturing or sales data as a proxy indicator for antibiotic use. An additional three countries have provided data on antimicrobial consumption in the hospital or community sector, and their results will be presented separately due to differences in data coverage. The WHO Regional Office is further supporting several countries in the Region to build monitoring capacity, and more countries are expected to start submitting data to WPRACSS soon. Overview of results The results in this report indicate a wide variation in national antimicrobial consumption, ranging from 4.8 to 50.7 Defined Daily Doses (DDDs) per 1000 inhabitants per day in 2018. There were also notable differences in consumption patterns. In four out of seven countries and areas (Brunei Darussalam, Hong Kong SAR (China), the Lao People’s Democratic Republic and Malaysia), almost half of the antimicrobial consumption consisted of narrow- and extended-spectrum penicillins, especially amoxicillin and/or amoxicillin combined with clavulanic acid. In Japan, Mongolia and the Philippines, one third of the consumption consisted of other beta-lactam antibiotics, including cephalosporins and carbapenems. The proportional consumption of macrolides and quinolones, which are in the WHO List of Critically Important Antimicrobials for Human Medicine, varied greatly between countries and was particularly high in countries where the use of penicillin was low. These variations between countries are also reflected in the Access, Watch and Reserve (AWaRe) classification of antibiotics in the WHO Essential Medicines List. WHO has set a general goal that Access antibiotics should comprise 60% of national antibiotic consumption – a target achieved by four countries (Brunei Darussalam, the Lao People’s Democratic Republic, Malaysia and Mongolia) in this report. Among the remaining three countries and areas, the proportional consumption of Access antibiotics ranged from 16% to 57%. Consumption of Reserve antibiotics were limited to 1.2% or less in all reported countries vii and were not identified in the Lao People’s Democratic Republic and Mongolia. Finally, 88–97% of consumption consisted of oral antibiotics in six countries and areas, with the exception of Mongolia, where 45% of the antibiotics were parenteral. Way forward This report provides an overview of the progress made in establishing antimicrobial consumption and use monitoring in the Western Pacific Region. It indicates significant variation in quantities and patterns of antibiotic consumption between countries. The findings from this report must be interpreted in relation to the data sources used as well as country context and health system capacity, including the burden of disease and AMR profile. It is ultimately important that the data are used as local intelligence and a basis for designing interventions that target specific needs and situations on the ground. These baseline results – if indeed reflecting actual antimicrobial use – provide important targets and opportunities for antimicrobial stewardship interventions while emphasizing the need for access to essential drugs. The WHO Regional Office for the Western Pacific continues to work closely with countries and areas to develop monitoring capacity at the national level and intends to report on antibiotic consumption annually to inform policies and actions in countries across the region. WPRACSS includes modules on antimicrobial consumption and use monitoring in hospitals and the community, and the WHO Regional Office is developing a web-based platform and mobile application to this end. viii WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) viii Introduction of WPRACSS Accelerating action to fight antimicrobial resistance in the Western Pacific Region Antimicrobial resistance (AMR) has become one of the biggest threats to global health security and endangers human development. It is a result of continued overuse and misuse of antimicrobials and affects human, animal and environmental health. Countries and areas in the Western Pacific Region recognize the threat of AMR to the health and security of their populations, as well as its impact on progress towards universal health coverage and the Sustainable Development Goals. Consequently, actions to combat AMR are priorities on the development agendas of all Member States in the Region. The World Health Organization (WHO) Regional Committee for the Western Pacific adopted For the Future: Towards the Healthiest and Safest Region (WPR/2020/RDO/001) in 2019 as a vision to guide WHO’s work with Member States on health priorities in the coming years. Health security, including AMR, is one of the four priorities in the vision, which proposes new ways of working to help countries address complex issues relating to health and development. To further guide Member States, the WHO Regional Committee also endorsed in 2019 the Framework for Accelerating Action to Fight Antimicrobial Resistance in the Western Pacific Region (Resolution WPR/RC70/7). The Framework assists Member States in accelerating the implementation of the 2014 Action Agenda for Antimicrobial Resistance in the Western Pacific Region (Resolution WPR/RC65.R4) and national action plans (NAPs) mandated by the World Health Assembly in 2015. The Framework considers a set of operational shifts as new ways of working in the Region to slow the spread of AMR and avert its impact. The Framework will guide countries to implement sustained and future-oriented solutions with actions contextualized to their 1 needs and situation. Specifically, the Framework will guide countries: to strengthen systems as a foundation for sustainable actions; to work beyond health; to take actions today, guided by their vision of the future; and to build solutions from the ground up while ensuring country impact. AMR affects countries differently, and its impact is underpinned by factors relating to local cultures, ways of life, stages of development and the capacity of national health systems. Developing solutions to address AMR should, therefore, take into consideration local contexts and use existing country systems that can be strengthened over time. This would entail generating local intelligence to design interventions that target specific needs and situations on the ground. Monitoring antimicrobial consumption (AMC) provides insights and tools needed to inform therapy decisions, to assess the public health consequences of antimicrobial misuse and to evaluate the impact of resistance containment interventions. To this end, the Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) was set up to provide local intelligence on AMR to countries and areas. The role of antimicrobial consumption monitoring in combating AMR AMR is driven by many complex factors, but overuse and misuse of antibiotics are among the leading causes. Measuring and analysing the consumption and use of antibiotics is a critical step that will inform the development of appropriate strategies to improve the use of antibiotics. Data on AMC in the human sector have been collected and analysed in many high- and middle-income countries,1,2 and global monitoring of AMC in animals is carried out by the World Organisation for Animal Health (OIE), which publishes an annual global report on the use of antimicrobial agents intended for use in animals. All countries and areas collect some data related to the import, procurement, distribution, sales or clinical use of antimicrobials that can serve as a basis for stewardship and monitoring programmes. Aggregated data derived from such data sources can be used to measure AMC and act as a proxy for antimicrobial use (AMU) at the patient level. These aggregated data sources can be an important starting point for countries with limited experience in data collection and a lack of patient level data for monitoring AMU. Data on AMC provide information on which antimicrobials are used and in what quantities and allow for the assessment of trends over time at global, country or health facility levels. Thus, national monitoring of AMC provides important information for national policies and antimicrobial stewardship. 1 WHO report on surveillance of antibiotic consumption: 2016-2018 early implementation. Geneva: World Health Organization; 2018 (https://www.who.int/medicines/areas/rational_use/oms-amr-amc-report-2016-2018/en/). 2 Klein EY, Van Boeckel TP, Martinez EM, Pant S, Gandra S, Levin SA, et al. Global increase and geographic convergence in antibiotic consumption between 2000 and 2015. Proc Natl Acad Sci USA. 2018;15:E3463–70. doi:10.1073/ pnas.1717295115 2 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 2 The Western Pacific Regional Antimicrobial Consumption Surveillance System (WPRACSS) WPRACSS was set up to conduct AMC and AMU monitoring across the Western Pacific Region to increase multistakeholder accountability, strengthen stewardship of antimicrobials and improve health outcomes. The system aims to capture and synthesize information on AMC and AMU across sectors and countries and will be undertaken through: • Establishment of and capacity-building for AMC and AMU monitoring systems in countries and ensuring that information on AMC and AMU will influence national policies, strengthen stewardship and improve clinical management of AMR infections, as well as contribute to the regional database on AMC and AMU. • Establishment of a web-based regional database to capture data from countries at three different levels (that is, national, hospital, community). The database will serve as a basis for regional analysis and technical advice to countries. • Establishment of community monitoring through online and web-based reporting using a mobile application connected to retail outlets across the Region to enable reporting of antibiotic dispensed in the community. • Issuance of an annual strategic and technical report on AMC in the Western Pacific Region. In all, 14 countries and areas are participating thus far. The WHO Regional Office for the Western Pacific is simultaneously working with others to improve their AMC monitoring. Preliminary findings on the levels of national AMC in selected countries and areas in the Region are published in this first-ever regional report. WPRACSS architecture WPRACSS has been designed to capture the richness and complexity of AMC and AMU monitoring in countries. It has three different modules, as data are commonly captured at various levels of the health system and/or pharmaceutical supply chain. They are: • National module • Hospital module • Community module. Depending on the country capacity and available systems, a country can participate in one or more modules. It is important to note that each module is distinct and serves a specific purpose that is connected to a specific methodology to collect, analyse and visualize data. National module: This module aims to capture, analyse and visualize data on the total consumption of antibiotics at the national level. Combining import and local manufacturing data is the most common approach and is especially important for countries with substantial local manufacturing of medicines. To collect national data, a WPRACSS standardized methodology to monitor AMC is being used. This report predominantly focuses on data from the national monitoring of AMC. Hospital module: National consumption data have limitations because they do not provide information on how antibiotics are prescribed and used at the patient level. Data on AMU at the patient level are sparse due to the difficulties associated with collecting prescription data from fragmented data sources. Hospitals are excellent settings for collecting data on INTROdUCTION OF WPRACSS 3 3 and gaining understanding of antibiotic prescribing and use. They have a high concentration of patients with diverse pathologies, often requiring antibiotic treatment. Collecting hospital data and subsequently implementing informed interventions to optimize antibiotic use in hospitals can lower antibiotic resistance at local and higher levels. Community module: WPRACSS aims to capture data at points of sale (such as pharmacies) to better understand the level of exposure of the community to antimicrobials. Pharmacies can join the community monitoring on a voluntary basis. WPRACSS has developed a mobile application for data capturing. Participating countries and areas Upon an official request of the WHO Regional Office for the Western Pacific to its Member States in October 2019, 14 countries and areas officially signed up to participate in WPRACSS (Table 1). Each one nominated a focal point to facilitate the interaction between the Member State and the WHO Regional Office. Participation in WPRACSS does not mean the country has to monitor and report AMC data immediately. While several countries already have a working system in place, others have yet to start developing their national systems to make it possible to capture AMC data. Hence, for some countries, participating in WPRACSS signifies a country’s interest to work with the WHO Regional Office to set up a national AMC monitoring system. For the purpose of this report, data are presented for seven countries and areas in the Western Pacific Region, as their data represent national AMC captured through the analysis of local manufacturing data, import records or sales data. Table 1. Countries and areas participating in WPRACSS and their official focal points Focal point Brunei Darussalam Ministry of Health Cambodia Ministry of Health China National Institute of Hospital Administration Hong Kong SAR (China) Centre of Health Protection (Department of Health) Japan Ministry of Health, Labour and Welfare Lao People’s Democratic Republic Food and Drug Department, Ministry of Health Malaysia Ministry of Health Mongolia Ministry of Health New Zealand Ministry of Health Philippines Department of Health Papua New Guinea Department of Health Republic of Korea Korea Disease Control and Prevention Agency & Ministry of Health and Welfare Singapore National Centre for Infectious Diseases Viet Nam Ministry of Health 4 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 4 WPRACSS methodology To ensure comparability, the WHO Regional Office has developed a WPRACSS methodology for data collection at the national level, based on the WHO Methodology for a Global Programme on Surveillance of Antimicrobial Consumption.3 The key elements of the methodology are as follows: Monitoring of systemic antimicrobials Only antimicrobials for systemic use are monitored and included as part of the national consumption monitoring through WPRACSS, that is, drugs with the following administration routes: oral and parenteral. Antimicrobials for local use, such as on the skin, ears, eyes and vaginal, are excluded. Monitoring of antibacterial substances (antibiotics) for systemic use is mandatory, whereas monitoring of other antimicrobials is optional (Table 2). Table 2. Antibiotics under surveillance at the national level as part of this report Antimicrobial class ATC Antibacterials for systemic use J01 Antibiotics for alimentary tract A07AA Nitroimidazole derivatives for protozoal diseases P01AB ATC, Anatomical Therapeutic Chemical. Antibiotics for systemic use can be found in the Anatomical Therapeutic Chemical (ATC) therapeutic subgroups J01, A07AA and P01AB of the ATC Classification System – a system of alphanumeric codes developed by WHO for the classification of drugs and other medical products. Most monitored antibiotics belong to subgroup J01, which is part of the anatomical group J (Anti-infectives for systemic use). Antifungals, antimycobacterials for tuberculosis, antivirals and antimalarials are not required to be monitored as part of the national consumption monitoring at this point. However, it is envisaged that countries will also monitor these medicines as part of WPRACSS. 3 WHO methodology for a global programme on surveillance of antimicrobial consumption. Geneva: World Health Organization; 2017 (https://www.who.int/medicines/areas/rational_use/WHO_AMCsurveillance_1.0.pdf). 5 Data sources to monitor antimicrobial consumption at the national level To estimate the quantity of AMC, all antimicrobial drugs for systemic use in the country should be included in the analyses and reported. For the purpose of national consumption monitoring through WPRACSS, countries are requested to provide consumption data that are collected from aggregated data sources and/or reported at an aggregated level. Currently, the preferred data source to monitor national consumption to start with is a combination of all locally manufactured antimicrobials and imported antimicrobials, while excluding antimicrobials that are exported to other countries. While every country is different, such data are commonly available through the National Regulatory Authority records of market authorization, licensing and customs records. However, in the Western Pacific Region, not all countries systematically collect data from these sources. Several countries collect national antimicrobial consumption at a different stage along the supply chain of pharmaceuticals, often obtaining data from wholesalers or procurement, either through a process led by relevant government agencies in the Ministry of Health, or buying available data from a commercial provider that tracks the sales of antimicrobials in a given country. Fig. 1 illustrates how sales or procurement data are derived from the total national antimicrobial consumption. Fig. 1. The supply chain of antimicrobials and related data sources to monitor antimicrobial consumption Total supply of antimicrobials in a country each year = locally manufactured antimicrobials + imported antimicrobials – exported antimicrobials Antimicrobial for human use Patients Antimicrobials for non-human use Public sector procurement Public sector distribution Private sector distribution Public sector dispensing Private sector dispensing Private sector procurement Waste Dispensing records (records of pharmacies, reimbursement claims) Procurement (private & public sector) (records of wholesalers, central medical store, sales) National regulatory authority (records of market authorization, licensing, customs records) Supply chain Data sources Limitations and strengths of data sources for national consumption monitoring This report presents the monitoring of antimicrobials using a mixture of data sources. To understand better the data of each country, it is important to understand the limitations as well as the strengths of the various data sources being used. Table 3 provides a general overview of the strengths and limitations of data sources commonly used to monitor AMC. 6 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 6 Table 3. Data sources for national AMC monitoring and their strengths and limitations Data source Strengths Limitations Import of medicines records z Government-owned data: import permits are issued by the government. z Centralized record-keeping z Standardized reporting z Includes over-the-counter medicines z Administrative records may not include the necessary level of details or a suitable format for analysis. z May include parallel trade stock movements z Informal market excluded z Reflects import cycles rather than consumption patterns Domestic production records z Licensed local manufacturers should be easily identifiable. z Products for local sales can be separated from export. z Data can be requested with the necessary level of details and a suitable format for analysis. z Private companies may be unwilling to provide data. z Reflects production rather than consumption patterns Public sector procurement z Government-owned data z Centralized record-keeping z Disaggregation of data by distribution to the type of facility (hospital or health centre) and geographical location may be possible. z Only public sector data z Hospitals and health facilities may procure some medicines separately. z Reflects procurement rather than consumption patterns Wholesalers z Only legal entity importing medicines for distribution z Can provide purchase and distribution data z Disaggregation of data by distribution to the type of health facility and geographical location may be possible. z Distribution data are better at reflecting consumption patterns than other “higher level” data sources. z Private wholesalers may be unwilling to share data. z Complex supply chain networks with a large number of wholesalers, and larger wholesalers supplying to smaller wholesalers, complicates data collection and increases the risk of “double counting” of medicines. z It may be difficult to separate drugs for human and animal use if the wholesaler provides them to both sectors. z In some countries, health facilities, pharmacies and health-care workers may be allowed to import drugs separately. Commercial data sources z Standardized data collection z Able to combine data from multiple sources, including manufacturer records, hospital and pharmacy data, to obtain complete coverage. z Data must be purchased. z Quality of data might differ from country to country. z Disaggregation of data by type of health facility and geographical location may not be possible. z Country has less insight into the data collection and validation process. z Some commercial data sources do not use the ATC/DDD system. WPRACSS METhOdOLOGY 7 7 Critically important is that regardless of the data source used, countries are requested to provide data representing the entire country, making the population under surveillance the total population of that country for a given year. Moreover, it is envisaged that the WHO Regional Office for the Western Pacific will support countries to streamline their data sources for AMC monitoring at the national level. Several countries in the Region conduct AMC monitoring using medical records, reimbursement data from health insurances or prescription data. In the context of WPRACSS, these individual-level data are referred to as AMU data. In these cases, data may be available on characteristics of the individual using the medicine (like age, gender) and the indication, frequency and duration of use. Antimicrobial consumption and use data can answer different questions, and there are pros and cons to both types of data. The main characteristics of the two types of data are presented in Table 4. In the context of national monitoring, data are collected and reported at an aggregated level, and it is therefore referred to as consumption monitoring. Data from countries that have a monitoring system based on use data will be processed through the community and/or hospital modules of WPRACSS. Both modules are an integral part of WPRACSS and will be rolled out in due course. Table 4. Antimicrobial consumption and antimicrobial use data explained AMC data AMU data Definition What is used? How much is used? How are antimicrobials being used? Level Aggregated data Individual-level data Sources In general, import and local manufacture data. In some context, countries could consider central procurement data. May be derived from prescription records, medical records or insurance claims, etc. Estimate Provides a proxy estimate of the actual use of antimicrobials Provides a more accurate estimate of the actual use of antimicrobials Coverage Easy to obtain complete data coverage for the country Can be difficult to obtain complete data coverage for the country Normally a sample of the population Purpose Good for estimating the quantity of antimicrobial medicines Good for assessing how antimicrobial medicines are prescribed or used for stewardship purposes Complexity Good starting point for countries with limited resources or experience in surveillance of medicines use More resource-intense data collection but provides more information Data usage in context of WPRACSS National consumption monitoring Hospital and community consumption monitoring 8 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 8 Data collection at the product level (annually or quarterly) WPRACSS national consumption monitoring tracks the total quantity of antimicrobial substances present in the country. In principle, data are collected at the product level and then converted into standard measures of drug utilization according to the ATC/DDD system. To convert product-level data into standard measures of drug utilization, the following information is needed for each product containing antimicrobial substances for systemic use (see Table 5 for examples): • Name(s) of the substance(s) • Strength per item • Route of administration • Number of items per package • ATC code • Number of packages (specify time period). Table 5. Comparison of key data elements of various products Product A Product B Product C Name of substance(s) Cefepime Cefepime Amoxicillin Strength per item 1 gram 2 grams 500 mg Number of items per package 1 1 21 Route of administration Parenteral Parenteral Oral ATC code J01DE01 J01DE01 J01CA04 Depending on the country’s capacity, the frequency of data collection may vary. While quarterly data collection is encouraged, it might not be feasible for countries just starting with AMC monitoring. Initially, WPRACSS will display and report data for a given calendar year, but as the capacity of countries increases and countries become more familiar with collecting and analysing consumption data, it will be possible to report trends by quarter. For the purpose of the initial data collection, reporting and analysis of consumption in the year 2018 is used in this report. Standardization using the ATC/DDD system To enable comparisons of consumption data across years and within or between countries, antimicrobial products consumed by the population during a given year are aggregated and converted into standardized measures of drug utilization. The standard metrics facilitate comparisons despite differences in nomenclature (such as brand names or generics), package sizes, strengths and customary dosages. WPRACSS uses the ATC classification system to distinguish between pharmacological subgroups and substances of antimicrobials. The ATC system classifies active pharmacological substances based on the organ or system on which they act, and their therapeutic, pharmacological and chemical properties. To measure the consumption of antimicrobials, the methodology uses the number of Defined Daily Doses (DDDs). The DDD is the assumed average maintenance dose per day of an antimicrobial substance(s) used for its main indication in adults. A DDD is assigned to active ingredients with an existing ATC code. As a rule, the DDDs for antimicrobials are based on treatment for infections of moderate severity. WPRACSS METhOdOLOGY 9 9 To adjust for population size, the consumption of antimicrobial medicines expressed in DDDs is divided by the size of the population monitored. The consumption is usually presented as the number of DDDs per 1000  inhabitants per day (DID). This metric can be roughly interpreted as the number of individuals per 1000  inhabitants on antibiotic treatment per day. Thus, in addition to consumption data, countries should report the population size monitored for the given year. In most cases, this will be the national population. The ATC/DDD system is maintained by the WHO Collaborating Centre for Drug Statistics Methodology, which updates the system continuously to account for new pharmaceutical substances entering the market or existing substances that are not yet captured by the system. Because of the continuous revisions, it is essential to report the version of the ATC/ DDD used to calculate consumption when comparisons are made over time and between countries. This report uses the ATC/DDD version for 2019. Consequently, comparisons with estimates from other publications on AMC should be interpreted with caution. Annex 2 summarizes the ATC and DDD values used in this report. WPRACSS metrics and indicators The report analyses the quantity of antibiotics consumed based on the DDD. Antibiotic consumption at the national level is presented in this report using the indicators in Table 6. It remains important to highlight that the data reported are aggregated data derived from import, manufacturing or sales data. The data act as a proxy for AMU at the patient level. Table 6. WPRACSS key indicators to monitor national antimicrobial consumption Indicator Metric Total quantity (J01, A07AA, P01AB category of antimicrobials) DDD Total quantity (J01, A07AA, P01AB category of antimicrobials) adjusted by population size DID = DDD per 1000 inhabitants per day Relative consumption of antimicrobials by import or local manufacturing (J01, A07AA, P01AB category of antimicrobials) % of total DDD Quantity and relative consumption by pharmacological subgroup (ATC level 3) DID and % of total DDD Relative consumption of antibiotics by AWaRe classification % of total DDD Top 10 most consumed antibiotics by route of administration DID and % of total DDD 10 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 10 Results of early implementation Data collection process This report includes estimates of national antibiotic consumption from seven countries and areas in the Western Pacific Region (Table 8). A data call was organized by the WHO Regional Office from June to July of 2020, and data were provided by countries and areas using a standardized template. To allow for comparison, WHO requested 2018 data, which will serve as the baseline data for WPRACSS national consumption monitoring moving forward. An additional three countries were also able to share data, albeit not as part of the national consumption monitoring data call. The consumption data shared by China and Singapore were based on hospital records, whereas the consumption data of the Republic of Korea came from reimbursement data. Their data will be briefly described but not analysed in detail as part of this report. The data collected from these countries will be analysed in detail in future WPRACSS reports that will include hospital and community monitoring. Table 7 describes data coverage and the sources used by the participating countries and areas to obtain consumption data. Table 7. Data sources and coverage of countries and areas participating in national consumption monitoring through WPRACSS Data source Data coveragea Brunei Darussalam Procurement records provided by public and private sectors Nationwide Hong Kong SAR (China) Imports and local manufacturers Nationwide Japan Sales data provided by IQVIA Japan Nationwide Lao People’s Democratic Republic Imports and local manufacturers Nationwide Malaysia Public sector procurement and sales data provided by IQVIA Malaysia (private sector) Nationwide Mongolia Imports and local manufacturers Nationwide Philippines Sales data provided by IQVIA Philippines Nationwide a Nationwide coverage refers to coverage reported from official sources. In practice, there might be an informal market where antimicrobials are procured or imported. It is difficult to estimate the volume of these informal markets. 11 Fig. 2 illustrates the data sources used by the countries and areas providing data to this report. Fig. 2. Data sources along the supply cycle of medicines, including data sources used by countries and areas to monitor national consumption of antimicrobials Imports Manufacturers Wholesalers Central Medical Stores Hospitals Primary health care Pharmacies Insurances Research and development Regulation Selection Procurement and supply Distribution Prescribing of medicines & diagnostics Dispensing Responsible use • Hong Kong SAR (China) • Lao People’s Democratic Republic • Mongolia • Brunei Darussalam • Japan • Malaysia • Philippines Source: WHO report on surveillance of antibiotic consumption: 2016-2018 early implementation. Geneva: World Health Organization; 2018 (https://apps.who.int/iris/handle/10665/277359). Total national consumption of antimicrobials Table 8 presents an initial overview of the consumption of systemic antibiotics in seven countries and areas in the Western Pacific Region. Table 8. Total quantity of antibiotics consumed by country or area in DDD and DID based on 2018 data Total quantity in DDD DID Populationa Local production Imported Brunei Darussalam 1 177 160 7.3 442 400 0% 100% Hong Kong SAR (China) 50 008 965 18.3 7 486 400 – – Japan 595 772 931.8 12.9 126 443 000 – – Lao People’s Democratic Republic 94 688 300 37.1 7 000 000 31% 69% Malaysia 91 727 274 7.8 32 385 000 – – Mongolia 58 785 411 50.7 3 177 899 36% 64% Philippines 187 243 446 4.8 106 651 922 69% 31% a The population size is defined by the countries themselves, as per their national 2018 population data. 12 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 12 Overview of national antimicrobial consumption by country/area BRUNEI DARUSSALAM Country/area capacity The Brunei Darussalam Antimicrobial Resistance National Action Plan was developed by a national multisectoral coordinating committee, the Brunei Darussalam AMR Committee, through four technical working groups in alignment with the principles of the Global Action Plan on Antimicrobial Resistance (GAP) and the One Health approach. The priority actions identified are categorized according to four strategic objectives: improve awareness and education, strengthen surveillance and research, improve infection prevention and control, and optimize the use of antimicrobials. The priority actions focus: on increasing public awareness of AMR; enhancing AMR education among professionals in human, animal and environmental health; strengthening surveillance through a national coordinating centre; and scaling up existing policies and best practices in infection prevention and control and antibiotic stewardship programmes to reach more facilities. Core components to support a national surveillance system for AMR are in place. Accredited laboratory facilities in the country have the necessary capacity to detect and phenotypically categorize drug-resistant microorganisms, collate data trends for common pathogens, and collaborate with established reference laboratories for antibiotic susceptibility testing. In terms of AMC, data collection is ongoing and reported according to the standards set by international organizations such as WHO and OIE. To this end, the WHO Regional Office for the Western Pacific supported capacity-building efforts in 2017. The Department of Pharmaceutical Services, under the Ministry of Health, ensures that data on AMC from both public and private sector health- care providers are available for monitoring and other purposes. National antibiotic consumption data Table 9. Overview of national consumption of antibiotics in Brunei Darussalam in 2018 Total quantity in DDD DID Population Local production Imported Brunei Darussalam 1 177 160a 7.3 442 400 0% 100% a Based on public and private sector data. One Region One Movement to Fight Antimicrobial Resistance Join the movement http://pledge.antibioticawarenessweek.org RESULTS OF EARLY IMPLEMENTATION 13 13 Table 10. Use of antibiotics for systemic use in DID and in percentage in Brunei Darussalam in 2018 ATC3 classification % DID J01A-Tetracyclines 13.1 0.96 J01B-Amphenicols 0 0 J01C-Beta-lactam antibacterials, penicillins 49.8 3.63 J01D-Other beta-lactam antibacterials 17.7 1.29 J01E-Sulfonamides and trimethoprim 1.8 0.13 J01F-Macrolides, lincosamides and streptogramins 9.0 0.66 J01G-Aminoglycoside antibacterials 0.4 0.03 J01M-Quinolone antibacterials 6.6 0.48 J01R-Combination of antibacterials 0 0.00 J01X-Other antibacterials 1.2 0.08 A07AA-Antibiotics for alimentary tract 0.2 0.01 P01AB-Nitroimidazole derivatives for protozoal diseases 0.3 0.03 Total 100 7.29 Fig. 3. National consumption of antibiotics for systemic use in Brunei Darussalam in 2018 13.1% 49.8% 17.7% 1.8% 9.0% 0.4% 6.6% 0.2%0.4%1.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines 14 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 14 Fig. 4. National consumption of antibiotics for systemic use in Brunei Darussalam by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 65.4% Watch 19.0% Reserve 0.1% Other 15.5% The most commonly consumed Access and Watch antibiotics are presented in Table 11 and Table 12. Reserve antibiotics make up 0.14% of the total consumption of antibiotics, and the main antibiotics consumed in this category are linezolid J01XX08 (74% of Reserve antibiotics) and colistin/colismethate J01XB01 (26% of Reserve antibiotics). Oral route of administration Of the total antibiotic consumption, 90.1% is by oral route of administration, equalling to a DID of 6.57. Table 11 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 11. Top 10 most consumed oral antibiotics in Brunei Darussalam in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Amoxicillin 1.69 26.0 23.2 Access Amoxicillin and enzyme inhibitor 1.41 21.8 19.4 Access Doxycycline 0.93 14.2 12.7 Access Cefuroxime 0.78 12.0 10.7 Watch Ciprofloxacin 0.41 6.3 5.6 Watch Azithromycin 0.39 6.1 5.4 Watch Clarithromycin 0.13 2.1 1.9 Watch Sulfamethoxazole and trimethoprim 0.12 1.9 1.7 Access Erythromycin 0.12 1.8 1.6 Watch Sultamicillin 0.11 1.7 1.5 Access Parenteral route of administration Of the total antibiotic consumption, 9.9% is by parenteral route of administration, equalling to a DID of 0.72. Table 12 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. RESULTS OF EARLY IMPLEMENTATION 15 15 Table 12. Top 10 most consumed parenteral antibiotics in Brunei Darussalam in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Amoxicillin and enzyme inhibitor 0.12 21.5 2.1 Access Cefuroxime 0.10 13.2 1.3 Watch Meropenem 0.08 11.1 1.1 Watch Ceftriaxone 0.07 9.3 0.9 Watch Ceftazidime 0.06 8.9 0.9 Watch Cloxacillin 0.06 8.3 0.8 Access Metronidazole 0.05 7.6 0.8 Access Piperacillin and enzyme inhibitor 0.02 3.1 0.3 Watch Ampicillin and enzyme inhibitor 0.02 2.5 0.3 Access Gentamicin 0.01 2.0 0.2 Access 16 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 16 HONG KONG SAR (CHINA) Country/area capacity The AMR national action plan was approved by the Government in 2017 and runs until 2022. It is aligned to GAP as well as the Action Agenda for Antimicrobial Resistance in the Western Pacific Region. A High-Level Steering Committee on Antimicrobial Resistance (HLSC) is in place to formulate strategies in collaboration with all relevant sectors. The HLSC is chaired by the Secretary of Food and Health and includes representatives from public and private sectors, academia and professional bodies. The NAP identifies monitoring of antibiotic use as one of the strategic actions. National AMC monitoring was set up in 2017 with the aim of using territory-wide wholesale supply to serve as a proxy for antimicrobial use. Since 2017, Hong Kong SAR (China) has collected the annual wholesale supply quantities of all the registered antibiotics classified under the WHO ATC classification code J01 (antibacterials for systemic use),  A07AA (antibiotics for alimentary tract), and P01AB (nitroimidazole derivatives for protozoal diseases) through licensed drug wholesalers. National antibiotic consumption data Table 13. Overview of national consumption of antibiotics in Hong Kong SAR (China) in 2018 Total quantity in DDD DID Population Local production Imported Hong Kong SAR (China) 50 008 965 18.3 7 486 400 – – Table 14. Consumption of antibiotics for systemic use in DID and in percentage in Hong Kong SAR (China) in 2018 ATC3 classification % DID J01A-Tetracyclines 10.1 1.84 J01B-Amphenicols <0.01 0.001 J01C-Beta-lactam antibacterials, penicillins 43.6 7.98 J01D-Other beta-lactam antibacterials 11.8 2.16 J01E-Sulfonamides and trimethoprim 1.1 0.21 J01F-Macrolides, lincosamides and streptogramins 15.7 2.87 J01G-Aminoglycoside antibacterials 0.3 0.05 J01M-Quinolone antibacterials 12.7 2.33 J01X-Other antibacterials 1. 7 0.31 A07AA-Antibiotics for alimentary tract 0.6 0.12 P01AB-Nitroimidazole derivatives for protozoal diseases 2.4 0.44 Total 100 18.30 RESULTS OF EARLY IMPLEMENTATION 17 17 Fig. 5. National consumption of antibiotics for systemic use in Hong Kong SAR (China) in 2018 10.1% 43.6% 11.8% 1.1% 15.7% 0.3% 12.7% 0.6%2.4% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines Fig. 6. National consumption of antibiotics for systemic use in Hong Kong SAR (China) by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 57.3% Watch 39.6% Reserve 0.1% Other 3.1% 18 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 18 The most commonly consumed Access and Watch antibiotics are presented in Table 15 and Table 16. Reserve antibiotics make up 0.1% of the total consumption of antibiotics; the main antibiotics consumed in this category are oral and parenteral linezolid J01XX08 (46.4%) and daptomycin J01XX09 (22.9%). Oral route of administration Of the total antibiotic consumption, 94.9% is by oral route of administration, equalling to a DID of 17.38. Table 15 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 15. Top 10 most consumed oral antibiotics in Hong Kong SAR (China) in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Amoxicillin and beta-lactamase inhibitor 4.27 24.6 23.3 Access Amoxicillin 2.32 13.4 12.7 Access Doxycycline 1.55 8.9 8.5 Access Azithromycin 1.47 8.5 8.1 Watch Levofloxacin 1.36 7.8 7.4 Watch Cefuroxime 1.29 7.4 7.1 Watch Clarithromycin 1.19 6.8 6.5 Watch Ciprofloxacin 0.61 3.5 3.3 Watch Ampicillin and cloxacillin 0.46 2.7 2.5 Access Metronidazole 0.44 2.52 2.4 Access Parenteral route of administration Of the total antibiotic consumption, 5.05% is by parenteral route of administration, equalling to a DID of 0.92. Table 16 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. Table 16. Top 10 most consumed parenteral antibiotics in Hong Kong SAR (China) in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Amoxicillin and beta-lactamase inhibitors 0.30 32.2 1.6 Access Piperacillin and beta-lactamase inhibitors 0.14 14.8 0.8 Watch Ceftriaxone 0.09 10.1 0.5 Watch Meropenem 0.06 6.6 0.3 Watch Vancomycin 0.04 4.4 0.2 Watch Metronidazole 0.04 4.0 0.2 Access Cloxacillin 0.03 3.2 0.2 Access Gentamicin 0.03 3.2 0.2 Access Ertapenem 0.03 3.1 0.2 Watch Cefazolin 0.02 2.8 0.1 Access RESULTS OF EARLY IMPLEMENTATION 19 19 JAPAN Country/area capacity Japan’s National Action Plan (NAP) on Antimicrobial Resistance has identified, in line with GAP and the Action Agenda for AMR in the Western Pacific Region, six priority measures over a period of five years (2016–2020): public awareness and education; surveillance and monitoring; infection prevention and control; appropriate use of antimicrobials; research and development; and international cooperation. The NAP is jointly implemented by relevant ministries, agencies and organizations under a One Health approach. Monitoring antibiotic consumption in humans and animals in Japan is an explicit action defined in the NAP and implemented in both sectors. At the national level, consumption of antimicrobials is monitored through both sales and claims records.4 At the hospital level, Japan has introduced the Japan Surveillance for Infection Prevention and Hospital Epidemiology (J-SIPHE) system. J-SIPHE aims to establish a network for identifying the quantity of use of antimicrobials and infection status in Japan over time, and to upgrade the quality of infection control in order to benefit the general public, by providing collected information as materials for enhancing regional collaboration in infection control. Japan publishes the annual Nippon AMR One Health Report, which provides an overview of surveillance data on AMC and AMR in the animal and human health sectors. National antimicrobial consumption data Table 17. Overview of national consumption of antibiotics in Japan in 2018 Total quantity in DDD DID Population Local production Imported Japan 595 772 932 12�9 12 6443 000 – – Table 18. Consumption of antibiotics for systemic use in DID and in percentage in Japan in 2018 ATC3 classification % DID J01A-Tetracyclines 7.0 0.90 J01B-Amphenicols 0.01 0.00 J01C-Beta-lactam antibacterials, penicillins 8.7 1.13 J01D-Other beta-lactam antibacterials 30.2 3.90 J01E-Sulfonamides and trimethoprim 2.8 0.36 J01F-Macrolides, lincosamides and streptogramins 31.0 4.00 J01G-Aminoglycoside antibacterials 0.28 0.04 J01M-Quinolone antibacterials 19.0 2.46 J01X-Other antibacterials 1.1 0.14 A07AA-Antibiotics for alimentary tract - - P01AB-Nitroimidazole derivatives for protozoal diseases - - Total 100 12.91 4 Japan’s insurance claim records for antimicrobial consumption are available at http://amrcrc.ncgm.go.jp/surveillance/ Surveillance_en.html 20 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 20 Fig. 7. National consumption of antibiotics for systemic use in Japan in 2018 7.0% 8.7% 30.2% 2.8% 31.0% 0.3% 19.0% 1.1% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01R-Combination of antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines Fig. 8. National consumption of antibiotics for systemic use in Japan by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 15.8% Watch 82.9% Reserve 1.2% Other 0.2% The most commonly consumed Access and Watch antibiotics are presented in Table 19 and Table 20. Reserve antibiotics make up 1.2% of the total consumption of antibiotics; the main antibiotics consumed in this category are faropenem J01DI03 (72.6%), minocycline J01AA08 (13.5%) and daptomycin J01XX09 (5.7%). RESULTS OF EARLY IMPLEMENTATION 21 21 Oral route of administration Of the total antibiotic consumption, 92.3% is by oral route of administration, equalling to a DID of 11.9. Table 19 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 19. Top 10 most consumed oral antibiotics in Japan in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Clarithromycin 2.79 23.4 21.6 Watch Levofloxacin 1.29 10.8 10.0 Watch Cefcapene 1.27 10.7 9.9 Watch Cefditoren 1.00 8.4 7.7 Watch Amoxicillin 0.65 5.4 5.0 Access Azithromycin 0.53 4.4 4.1 Watch Minocycline 0.50 4.2 3.9 Watch Garenoxacin 0.48 4.1 3.8 Watch Roxithromycin 0.37 3.1 2.8 Watch Doxycycline 0.36 3.1 2.8 Watch Parenteral route of administration Of the total antibiotic consumption, 7.9% is by parenteral route of administration, equalling to a DID of 1.01. Table 20 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. Table 20. Top 10 most consumed parenteral antibiotics in Japan in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Ceftriaxone 0�21 20�8 1�6 Watch Cefazolin 0�15 15�3 1�2 Access Ampicillin and enzyme inhibitor 0�11 11�3 0�9 Access Piperacillin and enzyme inhibitor 0�09 9�4 0�7 Watch Meropenem 0�06 5�8 0�4 Watch Cefmetazole 0�05 4�8 0�4 Watch Levofloxacin 0�03 2�7 0�2 Watch Vancomycin 0�03 2�6 0�2 Watch Flomoxef 0�03 2�6 0�2 Watch Minocycline 0�02 2�0 0�2 Watch 22 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 22 LAO PEOPLE’S DEMOCRATIC REPUBLIC Country/area capacity The National Strategic Plan on Antimicrobial Resistance (2019–2023) has been endorsed by the Ministry of Health and the Ministry of Agriculture and Forestry. The Strategic Plan guides the implementation of an operational plan on AMR in the Lao People’s Democratic Republic. This operational plan targets five strategic objectives: improve awareness and understanding of AMR; strengthen the AMR surveillance system; improve infection prevention and control; optimize the use of antimicrobials in humans and animals; and improve coordination and budget support. The Strategic Plan aims to reduce the use of antimicrobials in both the human and animal sectors by 20% by 2023. With support from WHO over several years, the Lao People’s Democratic Republic has made its first steps towards setting up a national surveillance system on AMR. It is enrolled in the Global Antimicrobial Resistance Surveillance System (GLASS) and contributed data to the GLASS report in 2018. Data collection on AMC at the national level is conducted by the Food & Drug Department of the Ministry of Health, and data on locally manufactured and imported medical products covering both public and private sectors are being collected. In parallel, with the support of WHO, the Lao People’s Democratic Republic is embarking on the monitoring of antimicrobials at selected hospitals in the country. National antibiotic consumption data Table 21. Overview of national consumption of antibiotics in the Lao People’s Democratic Republic in 2018 Total quantity in DDD DID Population Local production Imported Lao People’s Democratic Republic 94 701 074 37.1 7 000 000 31% 69% Table 22. Use of antibiotics for systemic use in DID and in percentage in the Lao People’s Democratic Republic in 2018 ATC3 classification % DID J01A-Tetracyclines 6.6 2.46 J01B-Amphenicols 0.6 0.23 J01C-Beta-lactam antibacterials, penicillins 51.1 18.93 J01D-Other beta-lactam antibacterials 5.3 1.96 J01E-Sulfonamides and trimethoprim 9.1 3.37 J01F-Macrolides, lincosamides and streptogramins 20.7 7.66 J01G-Aminoglycoside antibacterials 2.2 0.80 J01M-Quinolone antibacterials 2.2 0.82 J01R-Combination of antibacterials 0.02 0.01 J01X-Other antibacterials 0.1 0.04 A07AA-Antibiotics for alimentary tract 0 0  P01AB-Nitroimidazole derivatives for protozoal diseases 2.0 0.79 Total 100 37.07 RESULTS OF EARLY IMPLEMENTATION 23 23 Fig. 9. National consumption of antibiotics for systemic use in the Lao People’s Democratic Republic in 2018 P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01R-Combination of antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines 6.6% 0.6% 51.1% 5.3% 9.1% 20.7% 2.2% 2.2% 0.1% 2.0% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Fig. 10. National consumption of antibiotics for systemic use in the Lao People’s Democratic Republic by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 73.9% Watch 26.1% Reserve 0.0% Other 0.0% 24 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 24 The most commonly consumed Access and Watch antibiotics are presented in Table 23 and Table 24. No Reserve antibiotics were consumed in 2018 according to import and production data. Oral route of administration Of the total antibiotic consumption, 91.6% is by oral route of administration, equalling to a DID of 33.95. Table 23 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 23. Top 10 most consumed oral antibiotics in the Lao People’s Democratic Republic in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Amoxicillin 11.20 33.0 30.2 Access Azithromycin 5.44 16.0 14.7 Watch Ampicillin 4.86 14.3 13.1 Access Sulfamethoxazole/trimethoprim 3.37 9.9 9.1 Watch Erythromycin 2.09 6.2 5.6 Access Doxycycline 1.54 4.6 4.2 Access Cefalexin 1.52 4.5 4.1 Access Tetracycline 0.92 2.7 2.5 Access Phenoxymethyl penicillin 0.85 2.5 2.3 Access Metronidazole (oral) 0.79 2.3 2.1 Access Parenteral route of administration Of the total antibiotic consumption, 8.41% is by parenteral route of administration, equalling to a DID of 3.12. Table 24 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. Table 24. Top 10 most consumed parenteral antibiotics in the Lao People’s Democratic Republic Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Ampicillin 1.37 43.9 3.7 Access Kanamycin 0.67 21.4 1.8 Watch Ceftriaxone 0.33 10.5 0.9 Watch Benzylpenicillin 0.29 9.2 0.8 Access Amoxicillin 0.15 4.7 0.4 Access Cloxacillin 0.14 4.4 0.4 Access Streptomycin 0.10 3.2 0.3 Watch Metronidazole 0.04 1.4 0.1 Access Gentamicin 0.03 1.0 0.1 Access Amoxicillin/clavulanic acid <0.01 0.1 0.01 Access RESULTS OF EARLY IMPLEMENTATION 25 25 MALAYSIA Country/area capacity The Malaysian Action Plan on Antimicrobial Resistance (MyAP-AMR) outlines four priority areas: public awareness and education; surveillance and research; infection prevention and control; and appropriate use of antimicrobials. The Ministry of Health Malaysia, in concert with stakeholders from other related agencies, has set up a National Antimicrobial Resistance Committee (NARC) to lead and advise as well as to implement actions in tackling the rapidly increasing rate of AMR. The Action Plan aims for Malaysia to achieve reductions in the national consumption of antibiotics in humans, the quantity of antibiotics used in food production, the prevalence of AMR based on data collected through integrated programmes for surveillance of AMR throughout the country, and the prevalence of preventable infections, in particular the incidence of drug-resistant infections in health-care settings. AMC and AMU monitoring take place at national, hospital and community levels. Surveillance of prescription data in selected hospitals in Malaysia has been established since 2001, covering selected hospitals under the Ministry of Health, the Ministry of Higher Education, the Ministry of Defence, as well as private hospitals. This hospital surveillance system, known as the National Surveillance on Antibiotic Utilisation (NSAU), was expanded to primary care settings in July 2015. In 2018, the Pharmacy Practice and Development Division under the Ministry of Health initiated the National Surveillance on Antimicrobial Consumption (NSAC) which utilized other data sources, including data on the procurement of antimicrobials in the public sector and sales data from the private sector. National antibiotic consumption data Table 25. Overview of national consumption of antibiotics in Malaysia in 2018 Total quantity in DDD DID Population Local production Imported Malaysia 92 564 016 7.8 32 385 000 – – Table 26. Use of antibiotics for systemic use in DID and in percentage in Malaysia in 2018 ATC3 classification % DID J01A-Tetracyclines 10.0 0.78 J01B-Amphenicols 0.02 0.00 J01C-Beta-lactam antibacterials, penicillins 48.2 3.78 J01D-Other beta-lactam antibacterials 19.7 1.54 J01E-Sulfonamides and trimethoprim 3.7 0.29 J01F-Macrolides, lincosamides and streptogramins 13.8 1.08 J01G-Aminoglycoside antibacterials 0.2 0.02 J01M-Quinolone antibacterials 2.9 0.23 J01R-Combination of antibacterials 0 0.00 J01X-Other antibacterials 1.2 0.09 A07AA-Antibiotics for alimentary tract 0 0.00 P01AB-Nitroimidazole derivatives for protozoal diseases 0.3 0.02 Total 100 7.83 26 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 26 Fig. 11. National consumption of antibiotics for systemic use in Malaysia in 2018 P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines10.0% 48.2% 19.7% 3.7% 13.8% 0.2% 2.9% 1.2% 0.3% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Fig. 12. National consumption of antibiotics for systemic use in Malaysia by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 69.6% Watch 30.4% Reserve 0.1% Other 0.0% RESULTS OF EARLY IMPLEMENTATION 27 27 The most commonly consumed Access and Watch antibiotics are presented in Table 27 and Table 28. Reserve antibiotics make up 0.07% of the total antibiotic consumption; the main antibiotics consumed in this category are colistin J01XB01 (37.5%), linezolid J01XX08 (31.3%) and parenteral minocycline J01AA08 (21.3%). Oral route of administration Of the total antibiotic consumption, 87.9% is by oral route of administration, equalling to a DID of 6.9. Table 27 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 27. Top 10 most consumed oral antibiotics in Malaysia in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Amoxicillin 1.52 22.2 19.5 Access Amoxicillin and enzyme inhibitor 1.04 15.2 13.3 Access Doxycycline 0.75 11.0 9.6 Access Cloxacillin 0.69 10.0 8.8 Access Cefuroxime 0.61 8.9 7.8 Watch Cefalexin 0.49 7.1 6.2 Access Azithromycin 0.35 5.2 4.5 Watch Erythromycin 0.32 4.7 4.1 Watch Clarithromycin 0.30 4.4 3.9 Watch Ciprofloxacin 0.15 2.2 1.9 Watch Parenteral route of administration Of the total antibiotic consumption, 12.1% is by parenteral route of administration, equalling to a DID of 0.94. Table 28 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of parenteral and total antibiotic consumption for each one. Table 28. Top 10 most consumed parenteral antibiotics in Malaysia in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Cefuroxime 0.20 21.1 2.5 Watch Cloxacillin 0.10 10.6 1.3 Access Amoxicillin and enzyme inhibitor 0.09 9.1 1.1 Access Azithromycin 0.08 8.9 1.1 Watch Ceftriaxone 0.08 8.6 1.0 Watch Ampicillin 0.06 6.6 0.8 Access Piperacillin and enzyme Inhibitor 0.06 6.4 0.8 Watch Ampicillin and enzyme Inhibitor 0.05 5.6 0.7 Access Cefazolin 0.04 3.7 0.5 Access Benzylpenicillin 0.03 3.5 0.4 Access 28 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 28 MONGOLIA Country/area capacity In Mongolia, the National Multi-Sectoral Action Plan on Combating Antimicrobial Resistance aims to promote the rational use of antibiotics and prevent the emergence and spread of AMR, improve surveillance of AMR and diagnostics, advance the treatment of antimicrobial infections, and enhance the quality of hospital care and outcomes. The National Action Plan includes activities in accordance with the following six areas: establish governance and ensure multisectoral role to combat AMR, sustainable investment and functioning; strengthen surveillance and diagnostic capacity for AMR and research; reduce the spread of infections through better infection prevention and control measures; ensure quality and safety of antimicrobial medicines; optimize the use of antimicrobials in the human and animal sectors; and raise awareness and understanding of AMR and rational use of the general public and health professionals. WHO has provided technical support to set up AMC monitoring in Mongolia. Consumption monitoring at the national level is done through the collection and analysis of import records and local manufacturing data. National antibiotic consumption data Table 29. Overview of national consumption of antibiotics in Mongolia in 2018 Total quantity in DDD DID Population Local production Imported Mongolia 58 785 411 50.7 3 177 899 36% 64% Table 30. Use of antibiotics for systemic use in DID and in percentage in Mongolia in 2018 ATC3 classification % DID J01A-Tetracyclines 3.2 1.64 J01B-Amphenicols 1.3 0.65 J01C-Beta-lactam antibacterials, penicillins 27.7 14.02 J01D-Other beta-lactam antibacterials 31.3 15.84 J01E-Sulfonamides and trimethoprim 3.8 1.94 J01F-Macrolides, lincosamides and streptogramins 5.5 2.78 J01G-Aminoglycoside antibacterials 12.7 6.43 J01M-Quinolone antibacterials 10.0 5.06 J01R-Combination of antibacterials 0 0 J01X-Other antibacterials 2.6 1.34 A07AA-Antibiotics for alimentary tract 0 0 P01AB-Nitroimidazole derivatives for protozoal diseases 1.9 0.97 Total 100 50.68 RESULTS OF EARLY IMPLEMENTATION 29 29 Fig. 13. National consumption of antibiotics for systemic use in Mongolia in 2018 P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines 3.2% 1.3% 27.7% 31.3% 3.8% 5.5% 12.7% 10.0% 1.9% 2.6% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Fig. 14. National consumption of antibiotics for systemic use in Mongolia by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 62.5% Watch 23.2% Reserve 0.0% Other 14.2% 30 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 30 The most commonly consumed Access and Watch antibiotics are presented in Table 31 and Table 32. No Reserve antibiotics were consumed in 2018, according to import and production data. Oral route of administration Of the total antibiotic consumption, 55.2% is by oral route of administration, equalling to a DID of 28.0. Table 31 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 31. Top 10 most consumed oral antibiotics in Mongolia in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Amoxicillin 8.71 31.1 17.2 Access Ciprofloxacin 4.69 16.8 9.3 Watch Amoxicillin and enzyme inhibitor 2.67 9.5 5.3 Access Ampicillin 2.01 7.2 4.0 Access Sulfamethoxazole and trimethoprim 1.94 6.9 3.8 Access Doxycycline 1.64 5.9 3.2 Access Metronidazole 0.92 3.3 1.8 Access Erythromycin 0.88 3.1 1.7 Watch Clarithromycin 0.84 3.0 1.7 Watch Chloramphenicol 0.65 2.3 1.3 Access Parenteral route of administration Of the total antibiotic consumption, 44.82% is by parenteral route of administration, equalling to a DID of 22.72. Table 32 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. Table 32. Top 10 most consumed parenteral antibiotics in Mongolia in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Cefazolin 11.32 49.8 22.3 Access Streptomycin 6.36 28.0 12.5 Watch Cefotaxime 2.62 11.6 5.2 Watch Ceftriaxone 0.99 4.3 2.0 Watch Metronidazole 0.30 1.3 0.6 Access Penicillin (combination) 0.22 0.9 0.4 Access Ampicillin 0.18 0.8 0.4 Access Benzylpenicillin 0.17 0.7 0.3 Access Midecamycin 0.13 0.6 0.2 Watch Vancomycin 0.04 0.2 0.1 Watch RESULTS OF EARLY IMPLEMENTATION 31 31 PHILIPPINES Country/area capacity The Philippine Action Plan to Combat Antimicrobial Resistance serves as the country’s roadmap towards containing, controlling and preventing AMR. It provides an intervention strategy in order to facilitate the mechanisms of combating the growing problem of AMR as one nation through political commitment and leadership, institutionalizing integrated surveillance systems, regulating access to quality antimicrobials, rational use of antimicrobials, establishing measures to prevent and control further spread of AMR, and strengthening research and development initiatives. This comprehensive plan emphasizes the One Health approach. It recognizes that the causation of AMR is interrelated and intersectoral, thereby requiring collaborative multidisciplinary work at local, national and global levels to attain optimal health for humans, animals and the environment. The NAP sets out to improve surveillance and monitoring of drug-resistant pathogens and AMC to help develop evidence-based policies to control and limit the overuse of antimicrobials. Currently, AMC monitoring is being conducted at the national level using sales data. National antibiotic consumption data Table 33. Overview of national consumption of antibiotics in the Philippines in 2018 Total quantity in DDD DID Population Local production Imported Philippines 187 243 446 4.8 106 651 922 69% 31% Table 34. Use of antibiotics for systemic use in DID and in percentage in the Philippines in 2018 ATC3 classification % DID J01A-Tetracyclines 2.9 0.14 J01B-Amphenicols 0.1 0.00 J01C-Beta-lactam antibacterials, penicillins 36.1 1.74 J01D-Other beta-lactam antibacterials 31.1 1.50 J01E-Sulfonamides and trimethoprim 3.4 0.17 J01F-Macrolides, lincosamides and streptogramins 14.5 0.70 J01G-Aminoglycoside antibacterials 0.2 0.01 J01M-Quinolone antibacterials 11.6 0.56 J01R-Combination of antibacterials 0 0 J01X-Other antibacterials 0.2 0.01 A07AA-Antibiotics for alimentary tract 0 0 P01AB-Nitroimidazole derivatives for protozoal diseases 0 0 Total 100 4.81 32 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 32 Fig. 15. National consumption of antibiotics for systemic use in the Philippines in 2018 2.9% 0.1% 36.1% 31.1% 3.4% 14.5% 0.2% 11.6% 0.2% 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% P01AB-Nitroimidazole derivatives for protozoal diseases A07AA-Antibiotics for alimentary tract J01X-Other antibacterials J01M-Quinolone antibacterials J01G-Aminoglycoside antibacterials J01F-Macrolides, lincosamides and streptogramins J01E-Sulfonamides and trimethoprim J01D-Other beta-lactam antibacterials J01C-Beta-lactam antibacterials, penicillins J01B-Amphenicols J01A-Tetracyclines Fig. 16. National consumption of antibiotics for systemic use in the Philippines by AWaRe categorization in 2018 0% 20% 40% 60% 80% 100% 1 Access 46.0% Watch 52.3% Reserve 0.04% Other 1.7% RESULTS OF EARLY IMPLEMENTATION 33 33 The most commonly consumed Access and Watch antibiotics are presented in Table 35 and Table 36. Reserve antibiotics make up 0.05% of the total antibiotic consumption; the main antibiotics consumed in this category are linezolid J01XX08 (44.7%), minocycline J01AA08 (35.7%) and tigecycline J01AA12 (12.8%). Oral route of administration Of the total antibiotic consumption, 97.4% is by oral route of administration, equalling to a DID of 4.69. Table 35 presents the 10 most commonly consumed oral antibiotics in falling order by DID and the proportion of total oral and total antibiotic consumption for each one. Table 35. Top 10 most consumed oral antibiotics in the Philippines in 2018 Antimicrobial DID % (of total oral consumption) % (of total consumption) AWaRe classification Cefuroxime 1.06 22.5 22.0 Watch Amoxicillin 0.89 18.9 18.5 Access Amoxicillin and enzyme inhibitor 0.59 12.6 12.2 Access Azithromycin 0.28 6.0 5.9 Watch Ciprofloxacin 0.28 5.9 5.7 Watch Clarithromycin 0.25 5.3 5.2 Watch Levofloxacin 0.20 4.3 4.2 Watch Cefalexin 0.18 3.7 3.6 Access Sulfamethoxazole and trimethoprim 0.17 3.5 3.4 Access Cefixime 0.16 3.4 3.3 Watch Parenteral route of administration Of the total antibiotic consumption, 2.6% is by parenteral route of administration, equalling to a DID of 0.12. Table 36 presents the 10 most commonly consumed parenteral antibiotics in falling order by DID and the proportion of total parenteral and total antibiotic consumption for each one. Table 36. Top 10 most consumed parenteral antibiotics in the Philippines in 2018 Antimicrobial DID % (of total parenteral consumption) % (of total consumption) AWaRe classification Ceftriaxone 0.023 19.1 0.49 Watch Cefuroxime 0.020 16.4 0.42 Watch Piperacillin and enzyme inhibitor 0.014 11.4 0.29 Access Meropenem 0.008 6.6 0.17 Watch Metronidazole 0.007 5.5 0.14 Access Levofloxacin 0.004 3.7 0.10 Watch Amikacin 0.004 3.7 0.09 Watch Benzylpenicillin 0.004 3.3 0.08 Access Gentamicin 0.004 3.1 0.08 Access Clindamycin 0.003 2.9 0.07 Access 34 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 34 Antimicrobial consumption based on hospital and community monitoring Three countries participating in WPRACSS can paint a picture of their AMC based on hospital data and/or community data. While monitoring of AMC at hospital and community levels goes beyond the scope of this year’s report, the systems of those three countries are briefly described below. China China operates a hospital-level AMC monitoring system that is managed through the Center for Antibacterial Surveillance. The system conducts statistical analysis on the medical records and prescriptions of medical institutions by a retrospective survey of random samples and obtains indicators such as the utilization rate of antimicrobial agents. Consumption is presented as accumulated DDDs and DDDs/100 bed days (use density) for each category of antimicrobial agents in a medical institute, district, city, province or the whole country. Over 3000 hospitals at various levels report to the system. Republic of Korea The Republic of Korea operates a robust community-level AMC monitoring system using the National Health Insurance (NHI) claims data collected through the Health Insurance Review and Assessment (HIRA) service. Systemic antibiotics are available only with a prescription issued by a physician and are dispensed by pharmacies. Therefore, the data of the Republic of Korea can be considered very comprehensive given that the NHI covers 97.1% of the population and the Medical Aid programme covers the other 2.9%. In 2018, the Republic of Korea reported a total consumption of 26.9 DID, covering the entire country. Singapore Singapore currently collects antimicrobial utilization data on selected antimicrobials from hospitals, but not yet from the community or at the national level. Data on selected antibacterial agents of concern are collected from public hospitals only and are therefore limited in nature. It is difficult to get a clear understanding of how antimicrobials are being utilized at the national level. RESULTS OF EARLY IMPLEMENTATION 35 35 Regional analysis Table 37 and Fig. 17 provide an analysis of the various countries and areas providing AMC data at the national level for the year 2018. The three most frequently consumed antibiotic subclasses are highlighted for each country or area. Table 37. Summary of antibiotic consumption of selected countries and areas in the Western Pacific Region by pharmaceutical subgroup (ATC3) in 2018 Br un ei D ar us sa la m Ho ng K on g SA R (C hi na ) Ja pa n La o Pe op le ’s D em oc ra tic Re pu bl ic M al ay si a M on go lia Ph ili pp in es DID 7.3 18.3 12.9 37.1 7.8 50.7 4.8 J01A-Tetracyclines 13.1% 10.0% 7.0% 6.6% 10.0% 3.2% 2.9% J01B-Amphenicols 0% <0.01% 0.01% 0.6% 0.02% 1.3% 0.1% J01C-Beta-lactam antibacterials, penicillins 49.8% 43.6% 8.7% 51.1% 48.2% 27.7% 36.1% J01D-Other beta-lactam antibacterials 17.7% 11.8% 30.2 % 5.3% 19.6% 31.3% 31.1% J01E-Sulfonamides and trimethoprim 1.8% 1.1% 2.8% 9.1% 3.7% 3.8% 3.4% J01F-Macrolides, lincosamides and streptogramins 9.0% 15.7% 31.0% 20.7% 13.8% 5.5% 14.5% J01G-Aminoglycoside antibacterials 0.4% 0.3% 0.3% 2.2% 0.2% 12.7% 0.01% J01M-Quinolone antibacterials 6.6% 12.7% 19.0% 2.2% 2.9% 10.0% 11.6% J01R – Combination of antimicrobials 0% 0% 0% 0.02% 0% 0% 0.1% J01X-Other antibacterials 1.2% 1.7% 1.1% 0.1% 1.2% 2.6% 0.2% A07AA-Antibiotics for alimentary tract 0.1% 0.6% 0% 0% 0% 0% 0% P01AB-Nitroimidazole derivatives for protozoal diseases 0.4% 2.4% 0% 2% 0.3% 1.9% 0% 100% 100% 100% 100% 100% 100% 100% Note: Cells in orange show three pharmaceutical subgroups with highest percentage for each country. 36 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 36 Fig. 17. National consumption of antibiotics for systemic use by country or area by AWaRe categorization in 2018 0.0% 10.0% 20.0% 30.0% 40.0% 50.0% 60.0% 70.0% 80.0% 90.0% 100.0% Brunei Darussalam Hong Kong SAR (China) Japan Lao PDR Malaysia Mongolia Philippines Brunei Darussalam Hong Kong SAR (China) Japan Lao PDR Malaysia Mongolia Philippines Access 65.4% 57.3% 15.8% 73.9% 69.6% 62.5% 46.0% Watch 19.0% 39.6% 82.9% 26.1% 30.4% 23.2% 52.3% Reserve 0.14% 0.10% 1.20% 0.00% 0.07% 0.00% 0.04% Other 15.5% 3.1% 0.2% 0.0% 0.0% 14.2% 1.7% Lao PDR: Lao People’s Democratic Republic RESULTS OF EARLY IMPLEMENTATION 37 37 Interpretation of results This report presents data on national antibiotic consumption for seven countries and areas of the WHO Western Pacific Region: Brunei Darussalam, Hong Kong SAR (China), Japan, Malaysia, Mongolia, the Lao People’s Democratic Republic and the Philippines. In addition, China, the Republic of Korea and Singapore provided either hospital or community monitoring data. For several countries, this was their first time sharing data at the regional level with other countries through WHO. This step forward reflects a growing trend of countries increasingly building national capacity to monitor the consumption of antimicrobials. While community and hospital AMC and AMU monitoring fall beyond the scope of this initial WPRACSS report, the WHO Regional Office for the Western Pacific is working closely with countries to roll out WPRACSS at these levels of the health system. Moreover, the WHO Regional Office is working with several other countries such as Cambodia, Papua New Guinea, Viet Nam and selected Pacific island countries and areas to build monitoring capacity. It is expected that more countries will start sharing data soon. The data in this report provide a baseline of AMC at the national level in selected countries and areas in the Western Pacific Region. Consumption of antimicrobials can be monitored at different levels. It is therefore important to ensure that only countries monitoring antimicrobials in a similar way are being compared. For this reason, only data from the seven countries that provided national consumption estimates are reported in detail in this report. Countries that collect data in the hospital or community sector only have been excluded. There is a large variation across the countries in consumption of antibiotics adjusted for population size, ranging from 4.8 DDD per 1000 inhabitants per day (DID) in the Philippines to 50.7 DID in Mongolia in 2018 (Table 37). A more in-depth analysis of the pharmacological 38 subgroups revealed noticeable differences between the seven countries and areas. In Brunei Darussalam, Hong Kong SAR (China), the Lao People’s Democratic Republic and Malaysia, nearly 50% of all antibiotics consumed were penicillins (J01C). This subgroup, however, made up less than 10% of antibiotic consumption in Japan. A substantial proportion of the consumed penicillin consisted of amoxicillin and/or amoxicillin and clavulanic acid, which are commonly used for respiratory infections. These substances were found among the top three most commonly consumed oral antibiotics in all countries but Japan, where macrolides, mainly clarithromycin and quinolones, seem to be used instead. One third of antibiotics consumed in Japan, Mongolia and the Philippines were other beta- lactam antibiotics (J01D), including cephalosporins and carbapenems. Quinolones (J01M) made up 10% or more of antibiotic consumption in Hong Kong SAR (China), Japan, Mongolia and the Philippines (Table 37). Aminoglycosides (J01G) were rarely used but comprised more than 12% of antibiotic consumption in Mongolia, which is reflected in the high consumption of parenteral streptomycin. As consumption data from Mongolia are collected from import and manufacturing records, import and production cycles strongly impact the consumption estimates and should be interpreted accordingly. In fact, the high consumption of streptomycin in Mongolia was not reflected in consumption data from adjacent years. As expected, the vast majority of antibiotics consumed were administered orally, and the proportion of oral antibiotics ranged from 88% to 97% in six of the seven countries and areas. In Mongolia, 45% of the antibiotics were parenteral. While the high consumption of parenteral streptomycin in 2018 affects these results, parenteral administration of other antibiotics, such as cephalosporins, were abundant and totalled more than 16 DID in 2018. This result may reflect a difference in clinical practice compared to other countries and may provide an opportunity for antimicrobial stewardship interventions, but it merits further exploration of data sources. Improving the use of antibiotics through antibiotic stewardship is one of the key interventions necessary to curb the further emergence and spread of AMR. It is also important for ensuring appropriate treatment. For that reason, WHO, in 2017 introduced the Access, Watch, Reserve (AWaRe) classification of antibiotics (Box 1) in its Essential Medicines List, which was further updated in 2019. The AWaRe classification is a tool for antibiotic stewardship at local, national and global levels with the aim of reducing AMR. Analysis of consumption data by the AWaRe classification can guide countries in their efforts to conduct stewardship at national, hospital and community levels. Brunei Darussalam, the Lao People’s Democratic Republic, Malaysia and Mongolia reported that over 60% of total consumption was composed of Access antibiotics. Japan and the Philippines displayed a different pattern, with a significant proportion of Watch antibiotics being used in the country (Fig. 17), which merits further exploration and opportunities for antibiotic stewardship interventions. Consumption of Reserve antibiotics is limited and comprise ≤0.2% of antibiotic consumption in most countries. RESULTS OF EARLY IMPLEMENTATION 39 39 Box 1: AWaRe classification of antibiotics ACCESS GROUP ANTIBIOTICS This group includes antibiotics that have activity against a wide range of commonly encountered susceptible pathogens while also showing lower resistance potential than antibiotics in the other groups. The Access group includes 48 antibiotics, 19 of which are included individually on the WHO Model List of Essential Medicines as first- or second-choice empiric treatment options for specified infectious syndromes. WATCH GROUP ANTIBIOTICS This group includes antibiotics that have higher resistance potential. It also includes most of the highest priority agents on the WHO List of Critically Important Antimicrobials for Human Medicine and/or antibiotics that are at relatively high risk of selection of bacterial resistance. Antibiotics in the Watch group should be prioritized as key targets of stewardship programmes and monitoring. The Watch group includes 110 antibiotics, 11 of which are included individually on the WHO Model List of Essential Medicines as first- or second-choice empiric treatment options for specified infectious syndromes. RESERVE GROUP ANTIBIOTICS This group includes antibiotics and antibiotic classes that should be reserved for the treatment of confirmed or suspected infections due to multidrug-resistant organisms. Antibiotics in the Reserve group should be treated as “last resort” options, which should be accessible, but their use should be tailored to highly specific patients and settings, when all alternatives have failed or are not suitable. These medicines could be protected and prioritized as key targets of national and international stewardship programmes involving monitoring and utilization reporting, to preserve their effectiveness. The Reserve group comprises 22 antibiotics, seven of which are listed individually on the WHO Model List of Essential Medicines. Limitations While the countries and areas used the WHO methodology on AMC monitoring or a comparable methodology based on the ATC/DDD classification system, some errors and gaps in the data provided cannot be excluded, given that WPRACSS is in an early implementation phase. The methodology also has some inherent limitations that should be taken into account when interpreting the results: • Data source selection: In general, national level consumption data use importation plus local production data minus exportation. • Import and production records are often easily accessible and have already been collected for administrative purposes. As a result, five of the seven countries included in this report used these sources. However, import and production records provide merely a rough estimate of actual antibiotic consumption in a country. Consumption estimates may be affected by import and manufacturing cycles, stocking practices, and parallel trades and reimportation that impacts the consumption estimates between years. • Data coverage: Related to the selection of data sources is the issue of data coverage. It can be more difficult to obtain complete population coverage using data sources that are higher up along the supply cycle of medicines, that is, “closer” to the patient 40 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 40 or end user such as sales data from pharmacies and prescription data, as the number of data providers usually expands. Additionally, some countries may collect data from the hospital or community sector only, or from the public sector alone. To improve comparability, only countries that provided import, manufacturing, procurement or sales data with nationwide coverage were included in this report. Data from countries that collect from the community or hospital sector only are not reported in detail. For this reason, WPRACSS intends to also include community and hospital sector data soon to enable countries to get a full picture of their antimicrobial consumption patterns. • Informal market: In principle, the data sources used to monitor antibiotic consumption do not cover the informal market. Depending on the size of the informal market for antibiotics, the consumption estimates may be more or less underestimated. • ATC/DDD classification system: While the ATC/DDD classification system provides a common approach to measuring drug utilization that allows standardization across countries and over time, there are some limitations to the methodology that can affect the consumption estimates adversely. To be included in the consumption estimates, the pharmaceutical substance must be included in the ATC/DDD classification system and have an assigned DDD value. There are antibiotics, especially fixed-dose combinations, that do not meet these two criteria and have therefore been excluded from the consumption estimates. Depending on the abundance of fixed-dose combinations, this underestimation may affect some countries more than others. Given the limitations, countries should refrain from any direct comparisons, as each country has its unique context and profile of how antibiotics are used and limitations in their data. The comparison between countries in this report is therefore a mere orientation. More importantly, countries are encouraged to continue collecting and comparing data across several years through their surveillance systems in order to monitor antibiotic consumption over time. This allows countries to detect changes to antibiotic consumption patterns that merit further exploration and may have policy implications or lead to stewardship interventions. RESULTS OF EARLY IMPLEMENTATION 41 41 Conclusion and way forward This report provides an initial overview of the progress in establishing AMC monitoring in countries and areas in the WHO Western Pacific Region. The initial report highlights significant differences in the consumption of antibiotics at the national level. When interpreting the results, it is important to consider the local context and existing country systems and capacity. It is ultimately important that the data are used as local intelligence and a basis for designing interventions that target specific needs and situations on the ground. While some countries reported a significant consumption of antibiotics, it is encouraging to note that most countries mainly use antibiotics from the Access group. The report provides the results of seven countries and areas in the Region, while additional countries are already working closely with the WHO Regional Office to monitor consumption at the national, hospital or community levels. Countries without national AMC surveillance should explore means to establish a system to monitor AMC. The WHO Regional Office is building capacity for additional countries to roll out WPRACSS. The support to countries to develop systems to monitor antimicrobial consumption is a prime example of how the WHO Regional Office is using its Framework for Accelerating Action to Fight Antimicrobial Resistance in the Western Pacific Region to strengthen systems in countries as a foundation for sustainable actions and to help countries to design stewardship interventions on the basis of data and evidence to ensure country impact for future generations. The WHO Regional Office for the Western Pacific will continue to work closely with countries to strengthen WPRACSS. This includes providing technical and financial support to low- and middle-income countries without existing surveillance systems on AMC, as well as continued support to countries with recently implemented surveillance systems to sustain their programmes and expand their population coverage where applicable. In addition, the WHO Regional Office will further enhance WPRACSS by rolling out modules for monitoring consumption and use at hospital and community levels. To this end, it is developing a web- based platform and mobile app to further support the work in countries. It is the intention of the WHO Regional Office to report on AMC through an annual report and, in doing so, to minimize the time lag between data collection and reporting. 42 Annex 1: AWaRe classification 2019 To assist in the development of tools for antibiotic stewardship at local, national and global levels and to reduce AMR, the Access, Watch, Reserve (AWaRe) classification of antibiotics was developed – where antibiotics are classified into different groups to emphasize the importance of their appropriate use. This classification is intended to be used as a tool for countries to better support antibiotic monitoring and stewardship activities. It is not intended as a model for the inclusion of antibiotics on national essential medicines lists. Antibiotics classified under AWaRe and also included on the WHO Model Lists of Essential Medicines are indicated in the table below. Antibiotic Class ATC code Category Amikacin Aminoglycosides J01GB06 Access Amoxicillin Penicillins J01CA04 Access Amoxicillin/clavulanic acid Beta-lactam – beta-lactamase inhibitors J01CR02 Access Ampicillin Penicillins J01CA01  Access Ampicillin/sulbactam Beta-lactam – beta-lactamase inhibitors J01CR01 Access Arbekacin Aminoglycosides J01GB12 Watch Azithromycin Macrolides J01FA10 Watch Azlocillin Penicillins J01CA09 Watch Aztreonam Monobactams J01DF01 Reserve Bacampicillin Penicillins J01CA06 Access Benzathine benzylpenicillin Penicillins J01CE08 Access Benzylpenicillin Penicillins J01CE01 Access Biapenem Carbapenems J01DH05 Watch Carbenicillin Carboxypenicillins J01CA03 Watch Cefacetrile First-generation cephalosporins J01DB10 Access Cefaclor Second-generation cephalosporins J01DC04 Watch Cefadroxil First-generation cephalosporins J01DB05 Access Cefalexin First-generation cephalosporins J01DB01 Access Cefalotin First-generation cephalosporins J01DB03 Access Cefamandole Second-generation cephalosporins J01DC03 Watch Cefapirin First-generation cephalosporins J01DB08 Access Cefatrizine First-generation cephalosporins J01DB07 Access Cefazedone First-generation cephalosporins J01DB06 Access Cefazolin First-generation cephalosporins J01DB04 Access Cefbuperazone Second-generation cephalosporins J01DC13 Watch Cefcapene pivoxil Third-generation cephalosporins J01DD17 Watch Cefdinir Third-generation cephalosporins J01DD15 Watch Cefditoren pivoxil Third-generation cephalosporins J01DD16 Watch Cefepime Fourth-generation cephalosporins J01DE01 Watch Cefetamet pivoxil Third-generation cephalosporins J01DD10 Watch Cefixime Third-generation cephalosporins J01DD08 Watch Cefmenoxime Third-generation cephalosporins J01DD05 Watch 43 Antibiotic Class ATC code Category Cefmetazole Second-generation cephalosporins J01DC09 Watch Cefminox Second-generation cephalosporins J01DC12 Watch Cefodizime Third-generation cephalosporins J01DD09 Watch Cefonicid Second-generation cephalosporins J01DC06 Watch Cefoperazone Third-generation cephalosporins J01DD12 Watch Ceforanide Second-generation cephalosporins J01DC11 Watch Cefoselis Fourth-generation cephalosporins to be assigned Watch Cefotaxime Third-generation cephalosporins J01DD01 Watch Cefotetan Second-generation cephalosporins J01DC05 Watch Cefotiam Second-generation cephalosporins J01DC07 Watch Cefotiam hexetil Second-generation cephalosporins J01DC07 Watch Cefoxitin Second-generation cephalosporins J01DC01 Watch Cefozopran Fourth-generation cephalosporins J01DE03 Watch Cefpiramide Third-generation cephalosporins J01DD11 Watch Cefpirome Fourth-generation cephalosporins J01DE02 Watch Cefpodoxime proxetil Third-generation cephalosporins J01DD13 Watch Cefprozil Second-generation cephalosporins J01DC10 Watch Cefradine First-generation cephalosporins J01DB09 Access Cefroxadine First-generation cephalosporins J01DB11 Access Ceftaroline fosamil Fifth-generation cephalosporins J01DI02  Reserve Ceftazidime Third-generation cephalosporins J01DD02 Watch Ceftazidime/avibactam Third-generation cephalosporins J01DD52 Reserve Cefteram pivoxil Third-generation cephalosporins J01DD18 Watch Ceftezole First-generation cephalosporins J01DB12 Access Ceftibuten Third-generation cephalosporins J01DD14 Watch Ceftizoxime Third-generation cephalosporins J01DD07 Watch Ceftobiprole medocaril Fifth-generation cephalosporins J01DI01 Reserve Ceftolozane/tazobactam Fifth-generation cephalosporins J01DI54 Reserve Ceftriaxone Third-generation cephalosporins J01DD04 Watch Cefuroxime Second-generation cephalosporins J01DC02 Watch Chloramphenicol Amphenicols J01BA01 Access Chlortetracycline Tetracyclines J01AA03 Watch Ciprofloxacin Fluoroquinolones J01MA02 Watch Clarithromycin Macrolides J01FA09 Watch Clindamycin Lincosamides J01FF01 Access Clofoctol Phenol derivatives J01XX03 Watch Clometocillin Penicillins J01CE07 Access Cloxacillin Penicillins J01CF02 Access Colistin Polymyxins J01XB01 Reserve Dalbavancin Glycopeptides J01XA04 Reserve Dalfopristin/quinupristin Streptogramins J01FG02 Reserve Daptomycin Lipopeptides J01XX09 Reserve Delafloxacin Fluoroquinolones J01MA23 Watch Dibekacin Aminoglycosides J01GB09 Watch Dicloxacillin Penicillins J01CF01 Access Dirithromycin Macrolides J01FA13 Watch 44 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 44 Antibiotic Class ATC code Category Doripenem Carbapenems J01DH04 Watch Doxycycline Tetracyclines J01AA02 Access Enoxacin Fluoroquinolones J01MA04 Watch Ertapenem Carbapenems J01DH03 Watch Eravacycline Tetracyclines J01AA13 Reserve Erythromycin Macrolides J01FA01 Watch Faropenem Penems J01DI03 Reserve Fleroxacin Fluoroquinolones J01MA08 Watch Flomoxef Second-generation cephalosporins J01DC14 Watch Flucloxacillin Penicillins J01CF05 Access Flumequine Fluoroquinolones J01MB07 Watch Fosfomycin (IV) Phosphonics J01XX01 Reserve Fosfomycin (oral) Phosphonics J01XX01 Watch Fusidic Acid Steroid antibacterials J01XC01 Watch Garenoxacin Fluoroquinolones J01MA19 Watch Gatifloxacin Fluoroquinolones J01MA16 Watch Gemifloxacin Fluoroquinolones J01MA15 Watch Gentamicin Aminoglycosides J01GB03 Access Imipenem/cilastatin Carbapenems J01DH51 Watch Isepamicin Aminoglycosides J01GB11 Watch Josamycin Macrolides J01FA07 Watch Kanamycin Aminoglycosides J01GB04 Watch Latamoxef Third-generation cephalosporins J01DD06 Watch Levofloxacin Fluoroquinolones J01MA12 Watch Lincomycin Macrolides J01FF02 Watch Linezolid Oxazolidinones J01XX08 Reserve Lomefloxacin Fluoroquinolones J01MA07 Watch Lymecycline Tetracyclines J01AA04 Watch Mecillinam Penicillins J01CA11 Access Meropenem Carbapenems J01DH02 Watch Meropenem/vaborbactam Carbapenems J01DH52 Reserve Metacycline Tetracyclines J01AA05 Watch Metronidazole (IV) Imidazoles J01XD01 Access Metronidazole (oral) Imidazoles P01AB01 Access Mezlocillin Penicillins J01CA10 Watch Micronomicin Aminoglycosides to be assigned Watch Midecamycin Macrolides J01FA03 Watch Minocycline (IV) Tetracyclines J01AA08 Reserve Minocycline (oral) Tetracyclines J01AA08 Watch Moxifloxacin Fluoroquinolones J01MA14 Watch Nafcillin Penicillins J01CF06 Access Neomycin Aminoglycosides J01GB05 Watch Netilmicin Aminoglycosides J01GB07 Watch Nitrofurantoin Nitrofurantoin J01XE01 Access Norfloxacin Fluoroquinolones J01MA06 Watch Ofloxacin Fluoroquinolones J01MA01 Watch ANNEx 45 45 Antibiotic Class ATC code Category Oleandomycin Macrolides J01FA05 Watch Omadacycline Tetracyclines to be assigned Reserve Oritavancin Glycopeptides J01XA05 Reserve Oxacillin Penicillins J01CF04 Access Oxytetracycline Tetracyclines J01AA06 Watch Panipenem Carbapenems to be assigned Watch Pazufloxacin Fluoroquinolones J01MA18 Watch Pefloxacin Fluoroquinolones J01MA03 Watch Penamecillin Penicillins J01CE06 Access Pheneticillin Penicillins J01CE05 Watch Phenoxymethyl penicillin Penicillins J01CE02 Access Piperacillin Penicillins J01CA12 Watch Piperacillin/tazobactam Beta-lactam – beta-lactamase inhibitors (anti-pseudomonal) J01CR05 Watch Pivampicillin Penicillins J01CA02 Access Pivmecillinam Penicillins J01CA08 Access Plazomicin Aminoglycosides to be assigned Reserve Polymyxin B Polymyxins J01XB02 Reserve Pristinamycin Streptogramins J01FG01 Watch Procaine benzylpenicillin Penicillins J01CE09 Access Prulifloxacin Fluoroquinolones J01MA17 Watch Ribostamycin Aminoglycosides J01GB10 Watch Rifabutin Rifamycins J04AB04 Watch Rifampicin Rifamycins J04AB02 Watch Rifamycin Rifamycins J04AB03 Watch Rifaximin Rifamycins A07AA11 Watch Roxithromycin Macrolides J01FA06 Watch Rufloxacin Fluoroquinolones J01MA10 Watch Sisomicin Aminoglycosides J01GB08 Watch Sitafloxacin Fluoroquinolones J01MA21 Watch Sparfloxacin Fluoroquinolones J01MA09 Watch Spectinomycin Aminocyclitols J01XX04 Access Spiramycin Macrolides J01FA02 Watch Spiramycin/metronidazole Combination of antibiotics J01RA04 Watch Streptomycin Aminoglycosides J01GA01 Watch Sulbenicillin Penicillins J01CA16 Watch Sulfadiazine/trimethoprim Trimethoprim - sulfonamide combinations J01EE02 Access Sulfamethizole/trimethoprim Trimethoprim - sulfonamide combinations J01EB02 Access Sulfamethoxazole/ trimethoprim Trimethoprim - sulfonamide combinations J01EE01 Access Sulfametrole/trimethoprim Trimethoprim - sulfonamide combinations J01EE03 Access Sulfamoxole/trimethoprim Trimethoprim - sulfonamide combinations J01EE04 Access Sultamicillin Beta-lactam – beta-lactamase inhibitors J01CR04 Access Tebipenem Carbapenems J01DH06 Watch Tedizolid Oxazolidinones J01XX11 Reserve Teicoplanin Glycopeptides J01XA02 Watch 46 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 46 Antibiotic Class ATC code Category Telavancin Glycopeptides J01XA03 Reserve Telithromycin Macrolides J01FA15 Watch Temocillin Carboxypenicillins J01CA17 Watch Tetracycline Tetracyclines J01AA07 Access Thiamphenicol Amphenicols J01BA02 Access Ticarcillin Carboxypenicillins J01CA13 Watch Tigecycline Glycylcyclines J01AA12 Reserve Tobramycin Aminoglycosides J01GB01 Watch Tosufloxacin Fluoroquinolones J01MA22 Watch Trimethoprim Trimethoprim J01EA01 Access Vancomycin (IV) Glycopeptides J01XA01 Watch Vancomycin (oral) Glycopeptides A07AA09 Watch ANNEx 47 47 Annex 2: 2019 ATC/DDD values for antimicrobials Antibiotic ATC5 Route of administration DDD NOTES Amikacin J01GB06 Parenteral 1 G Amoxicillin J01CA04 Oral 1,5 G Amoxicillin J01CA04 Parenteral 3 G Amoxicillin and enzyme inhibitor J01CR02 Oral 1,5 G Refers to amoxicillin Amoxicillin and enzyme inhibitor J01CR02 Parenteral 3 G Refers to amoxicillin Amphotericin B A07AA07 Oral 0,4 G Ampicillin J01CA01 Oral 2 G Ampicillin J01CA01 Parenteral 6 G Ampicillin J01CA01 Rectal 2 G Ampicillin and enzyme inhibitor J01CR01 Parenteral 6 G Refers to ampicillin Arbekacin J01GB12 Parenteral 0,2 G Aspoxicillin J01CA19 Parenteral 4 G Azidocillin J01CE04 Oral 1,5 G Azithromycin J01FA10 Oral 0,3 G Azithromycin J01FA10 Parenteral 0,5 G Azlocillin J01CA09 Parenteral 12 G Aztreonam J01DF01 Inhalation solution 0,225 G Aztreonam J01DF01 Parenteral 4 G Bacampicillin J01CA06 Oral 1,2 G Bekanamycin J01GB13 Parenteral 0,6 G Benzathine benzylpenicillin J01CE08 Parenteral 3,6 G Expressed as benzylpenicillin Benzathine phenoxymethyl penicillin J01CE10 Oral 2 G Benzylpenicillin J01CE01 Parenteral 3,6 G Biapenem J01DH05 Parenteral 1,2 G Brodimoprim J01EA02 Oral 0,2 G Carbenicillin J01CA03 Parenteral 12 G Carindacillin J01CA05 Oral 4 G Carumonam J01DF02 Parenteral 2 G Cefaclor J01DC04 Oral 1 G Cefadroxil J01DB05 Oral 2 G Cefalexin J01DB01 Oral 2 G Cefaloridine J01DB02 Parenteral 3 G Cefalotin J01DB03 Parenteral 4 G Cefamandole J01DC03 Parenteral 6 G Cefapirin J01DB08 Parenteral 4 G Cefatrizine J01DB07 Oral 1 G 48 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 48 Antibiotic ATC5 Route of administration DDD NOTES Cefazedone J01DB06 Parenteral 3 G Cefazolin J01DB04 Parenteral 3 G Cefbuperazone J01DC13 Parenteral 2 G Cefcapene J01DD17 Oral 0,45 G Cefdinir J01DD15 Oral 0,6 G Cefditoren J01DD16 Oral 0,4 G Cefepime J01DE01 Parenteral 4 G Cefetamet J01DD10 Oral 1 G Cefixime J01DD08 Oral 0,4 G Cefmenoxime J01DD05 Parenteral 2 G Cefmetazole J01DC09 Parenteral 4 G Cefminox J01DC12 Parenteral 4 G Cefodizime J01DD09 Parenteral 2 G Cefonicid J01DC06 Parenteral 1 G Cefoperazone J01DD12 Parenteral 4 G Cefoperazone, combinations J01DD62 Parenteral 4 G Refers to cefoperazone Ceforanide J01DC11 Parenteral 4 G Cefotaxime J01DD01 Parenteral 4 G Cefotetan J01DC05 Parenteral 4 G Cefotiam J01DC07 Oral 1,2 G Cefotiam J01DC07 Parenteral 4 G Cefoxitin J01DC01 Parenteral 6 G Cefozopran J01DE03 Parenteral 4 G Cefpiramide J01DD11 Parenteral 2 G Cefpirome J01DE02 Parenteral 4 G Cefpodoxime J01DD13 Oral 0,4 G Cefpodoxime and beta-lactamase inhibitor J01DD64 Oral 0,4 G Refers to cefpodoxime Cefprozil J01DC10 Oral 1 G Cefradine J01DB09 Oral 2 G Cefradine J01DB09 Parenteral 2 G Cefroxadine J01DB11 Oral 2,1 G Cefsulodin J01DD03 Parenteral 4 G Ceftaroline fosamil J01DI02 Parenteral 1,2 G Ceftazidime J01DD02 Parenteral 4 G Ceftazidime, combinations J01DD52 Parenteral 6 G Refers to ceftazidime Cefteram J01DD18 Oral 0,4 G Ceftezole J01DB12 Parenteral 3 G Ceftibuten J01DD14 Oral 0,4 G Ceftizoxime J01DD07 Parenteral 4 G Ceftobiprole medocaril J01DI01 Parenteral 1,5 G Ceftolozane and beta-lactamase inhibitor J01DI54 Parenteral 3 G Refers to ceftolozane Ceftriaxone J01DD04 Parenteral 2 G Ceftriaxone and beta-lactamase inhibitor J01DD63 Parenteral 2 G Refers to ceftriaxone ANNEx 49 49 Antibiotic ATC5 Route of administration DDD NOTES Cefuroxime J01DC02 Oral 0,5 G Cefuroxime J01DC02 Parenteral 3 G Chloramphenicol J01BA01 Oral 3 G Chloramphenicol J01BA01 Parenteral 3 G Chlortetracycline J01AA03 Oral 1 G Cinoxacin J01MB06 Oral 1 G Ciprofloxacin J01MA02 Oral 1 G Ciprofloxacin J01MA02 Parenteral 0,8 G Clarithromycin J01FA09 Oral 0,5 G Clarithromycin J01FA09 Parenteral 1 G Clindamycin J01FF01 Oral 1,2 G Clindamycin J01FF01 Parenteral 1,8 G Clofoctol J01XX03 Rectal 1,5 G Clometocillin J01CE07 Oral 1 G Clomocycline J01AA11 Oral 1 G Cloxacillin J01CF02 Oral 2 G Cloxacillin J01CF02 Parenteral 2 G Colistin A07AA10 Oral 9 MU Colistin J01XB01 Inhalation powder 3 MU Colistin J01XB01 Inhalation solution 3 MU Colistin J01XB01 Parenteral 9 MU Dalbavancin J01XA04 Parenteral 1,5 G Course dose Daptomycin J01XX09 Parenteral 0,28 G Delafloxacin J01MA23 Oral 0,9 G Delafloxacin J01MA23 Parenteral 0,6 G Demeclocycline J01AA01 Oral 0,6 G Dibekacin J01GB09 Parenteral 0,14 G Dicloxacillin J01CF01 Oral 2 G Dicloxacillin J01CF01 Parenteral 2 G Dirithromycin J01FA13 Oral 0,5 G Doripenem J01DH04 Parenteral 1,5 G Doxycycline J01AA02 Oral 0,1 G Doxycycline J01AA02 Parenteral 0,1 G Enoxacin J01MA04 Oral 0,8 G Epicillin J01CA07 Oral 2 G Epicillin J01CA07 Parenteral 2 G Ertapenem J01DH03 Parenteral 1 G Erythromycin J01FA01 Oral 1 G Erythromycin J01FA01 Oral 2 G Erythromycin ethylsuccinate tablets Erythromycin J01FA01 Parenteral 1 G Faropenem J01DI03 Oral 0,75 G Fidaxomycin A07AA12 Oral 0,4 G Fleroxacin J01MA08 Oral 0,4 G 50 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 50 Antibiotic ATC5 Route of administration DDD NOTES Fleroxacin J01MA08 Parenteral 0,4 G Flomoxef J01DC14 Parenteral 2 G Flucloxacillin J01CF05 Oral 2 G Flucloxacillin J01CF05 Parenteral 2 G Flumequine J01MB07 Oral 1,2 G Flurithromycin J01FA14 Oral 0,75 G Fosfomycin J01XX01 Oral 3 G Fosfomycin J01XX01 Parenteral 8 G Furazidin J01XE03 Oral 0,3 G Fusidic Acid J01XC01 Oral 1,5 G Fusidic Acid J01XC01 Parenteral 1,5 G Garenoxacin J01MA19 Oral 0,4 G Gatifloxacin J01MA16 Oral 0,4 G Gatifloxacin J01MA16 Parenteral 0,4 G Gemifloxacin J01MA15 Oral 0,32 G Gentamicin J01GB03 Parenteral 0,24 G Grepafloxacin J01MA11 Oral 0,4 G Hetacillin J01CA18 Oral 2 G Imipenem and enzyme inhibitor J01DH51 Parenteral 2 G Refers to imipenem Isepamicin J01GB11 Parenteral 0,4 G Josamycin J01FA07 Oral 2 G Kanamycin A07AA08 Oral 3 G Kanamycin J01GB04 Parenteral 1 G Latamoxef J01DD06 Parenteral 4 G Levofloxacin J01MA12 Inhalation solution 0,24 G Levofloxacin J01MA12 Oral 0,5 G Levofloxacin J01MA12 Parenteral 0,5 G Lincomycin J01FF02 Oral 1,8 G Lincomycin J01FF02 Parenteral 1,8 G Linezolid J01XX08 Oral 1,2 G Linezolid J01XX08 Parenteral 1,2 G Lomefloxacin J01MA07 Oral 0,4 G Loracarbef J01DC08 Oral 0,6 G Lymecycline J01AA04 Oral 0,6 G Lymecycline J01AA04 Parenteral 0,6 G Mandelic acid J01XX06 Oral 12 G Mecillinam J01CA11 Parenteral 1,2 G Meropenem J01DH02 Parenteral 3 G Metacycline J01AA05 Oral 0,6 G Metampicillin J01CA14 Oral 1,5 G Metampicillin J01CA14 Parenteral 1,5 G Methenamine J01XX05 Oral 2 G Salt hippurate Methenamine J01XX05 Oral 3 G Salt mandelate Meticillin J01CF03 Parenteral 4 G ANNEx 51 51 Antibiotic ATC5 Route of administration DDD NOTES Metronidazole J01XD01 Parenteral 1,5 G Metronidazole P01AB01 Oral 2 G Metronidazole P01AB01 Rectal 2 G Mezlocillin J01CA10 Parenteral 6 G Midecamycin J01FA03 Oral 1,2 G Midecamycin J01FA03 Parenteral 1 G Minocycline J01AA08 Oral 0,2 G Minocycline J01AA08 Parenteral 0,2 G Miocamycin J01FA11 Oral 1,2 G Moxifloxacin J01MA14 Oral 0,4 G Moxifloxacin J01MA14 Parenteral 0,4 G Nafcillin J01CF06 Parenteral 3 G Nalidixic acid J01MB02 Oral 4 G Natamycin A07AA03 Oral 0,3 G Neomycin A07AA01 Oral 5 G Neomycin J01GB05 Oral 1 G Netilmicin J01GB07 Oral 0,35 G Netilmicin J01GB07 Parenteral 0,35 G Nifurtoinol J01XE02 Oral 0,16 G Nimorazole P01AB06 Oral 2 G Nitrofurantoin J01XE01 Oral 0,2 G Nitroxoline J01XX07 Oral 1 G Norfloxacin J01MA06 Oral 0,8 G Nystatin A07AA02 Oral 1,5 MU Ofloxacin J01MA01 Oral 0,4 G Ofloxacin J01MA01 Parenteral 0,4 G Oleandomycin J01FA05 Oral 1 G Omadacycline J01AA15 Oral 0,3 G Omadacycline J01AA15 Parenteral 0,1 G Ornidazole J01XD03 Parenteral 1 G Ornidazole P01AB03 Oral 1,5 G Oxacillin J01CF04 Oral 2 G Oxacillin J01CF04 Parenteral 2 G Oxolinic acid J01MB05 Oral 1 G Oxytetracycline J01AA06 Oral 1 G Oxytetracycline J01AA06 Parenteral 1 G Panipenem and betamipron J01DH55 Parenteral 2 G Refers to panipenem Paromomycin A07AA06 Oral 3 G Pazufloxacin J01MA18 Parenteral 1 G Pefloxacin J01MA03 Oral 0,8 G Pefloxacin J01MA03 Parenteral 0,8 G Penamecillin J01CE06 Oral 1,05 G Pheneticillin J01CE05 Oral 1 G Phenoxymethyl penicillin J01CE02 Oral 2 G Pipemidic Acid J01MB04 Oral 0,8 G 52 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 52 Antibiotic ATC5 Route of administration DDD NOTES Piperacillin J01CA12 Parenteral 14 G Piperacillin and enzyme inhibitor J01CR05 Parenteral 14 G Refers to piperacillin Piromidic acid J01MB03 Oral 2 G Pivampicillin J01CA02 Oral 1,05 G Pivmecillinam J01CA08 Oral 0,6 G Polymyxin B A07AA05 Oral 3 MU Polymyxin B J01XB02 Parenteral 0,15 G Pristinamycin J01FG01 Oral 2 G Procaine benzylpenicillin J01CE09 Parenteral 0,6 G Propicillin J01CE03 Oral 0,9 G Prulifloxacin J01MA17 Oral 0,6 G Quinupristin/dalfopristin J01FG02 Parenteral 1,5 G Ribostamycin J01GB10 Parenteral 1 G Rifaximin A07AA11 Oral 0,6 G Rokitamycin J01FA12 Oral 0,8 G Rolitetracycline J01AA09 Parenteral 0,35 G Rosoxacin J01MB01 Oral 0,3 G Roxithromycin J01FA06 Oral 0,3 G Rufloxacin J01MA10 Oral 0,2 G Sarecycline J01AA14 Oral 0,1 G Secnidazole P01AB07 Oral 2 G Sisomicin J01GB08 Parenteral 0,24 G Sitafloxacin J01MA21 Oral 0,1 G Sparfloxacin J01MA09 Oral 0,2 G Spectinomycin J01XX04 Parenteral 3 G Spiramycin J01FA02 Oral 3 G Streptoduocin J01GA02 Parenteral 1 G Streptomycin J01GA01 Parenteral 1 G Sulbactam J01CG01 Parenteral 1 G Sulbenicillin J01CA16 Parenteral 15 G Sulfadiazine J01EC02 Oral 0,6 G Sulfadimethoxine J01ED01 Oral 0,5 G Sulfadimidine J01EB03 Oral 4 G Sulfafurazole J01EB05 Oral 4 G Sulfafurazole J01EB05 Parenteral 4 G Sulfaisodimidine J01EB01 Oral 4 G Sulfaisodimidine J01EB01 Parenteral 4 G Sulfalene J01ED02 Oral 0,1 G Sulfamazone J01ED09 Oral 1,5 G Sulfamazone J01ED09 Rectal 1,5 G Sulfamerazine J01ED07 Oral 3 G Sulfamethizole J01EB02 Oral 4 G Sulfamethoxazole J01EC01 Oral 2 G Sulfamethoxypyridazine J01ED05 Oral 0,5 G Sulfametoxydiazine J01ED04 Oral 0,5 G ANNEx 53 53 Antibiotic ATC5 Route of administration DDD NOTES Sulfamoxole J01EC03 Oral 1 G Sulfamoxole J01EC03 Parenteral 1 G Sulfaperin J01ED06 Oral 0,5 G Sulfaphenazole J01ED08 Oral 1 G Sulfapyridine J01EB04 Oral 1 G Sulfathiourea J01EB08 Oral 6 G Sultamicillin J01CR04 Oral 1,5 G Talampicillin J01CA15 Oral 2 G Tebipenem pivoxil J01DH06 Oral 0,56 G Tedizolid J01XX11 Oral 0,2 G Tedizolid J01XX11 Parenteral 0,2 G Teicoplanin J01XA02 Parenteral 0,4 G Telithromycin J01FA15 Oral 0,8 G Temafloxacin J01MA05 Oral 0,8 G Temocillin J01CA17 Parenteral 4 G Tetracycline J01AA07 Oral 1 G Tetracycline J01AA07 Parenteral 1 G Thiamphenicol J01BA02 Oral 1,5 G Thiamphenicol J01BA02 Parenteral 1,5 G Ticarcillin J01CA13 Parenteral 15 G Ticarcillin and enzyme inhibitor J01CR03 Parenteral 15 G Refers to ticarcillin Tigecycline J01AA12 Parenteral 0,1 G Tinidazole J01XD02 Parenteral 1,5 G Tinidazole P01AB02 Oral 2 G Tinidazole P01AB02 Rectal 2 G Tobramycin J01GB01 Inhalation powder 0,112 G Tobramycin J01GB01 Inhalation solution 0,3 G Tobramycin J01GB01 Parenteral 0,24 G Tosufloxacin J01MA22 Oral 0,45 G Trimethoprim J01EA01 Oral 0,4 G Trimethoprim J01EA01 Parenteral 0,4 G Troleandomycin J01FA08 Oral 1 G Trovafloxacin J01MA13 Oral 0,2 G Trovafloxacin J01MA13 Parenteral 0,2 G Vancomycin A07AA09 Oral 2 G Vancomycin J01XA01 Parenteral 2 G 54 WESTERN PACIFIC REGIONAL ANTIMICROBIAL CONSUMPTION SURVEILLANCE SYSTEM (WPRACSS) 54

One Region One Movement to Fight Antimicrobial Resistance Join the movement http://pledge.antibioticawarenessweek.org