Usage of Antibiotics and Occurence of Antibiotic Resistance in Switzerland Swiss Antibiotic Resistance Report 2020 ANRESIS ARCH-Vet Publishing details © Federal Office of Public Health FOPH Published by the Federal Office of Public Health FOPH Publication date: November 2020 Editors: Daniela Müller Brodmann, Division of Communicable Diseases, Federal Office of Public Health, and Dagmar Heim, Veterinary Medicinal Products and One Health, Federal Food Safety and Veterinary Office Project coordination: Adrian Heuss, advocacy ag Design and layout: diff. Kommunikation AG, Bern FOPH publication number: 2020-OEG-64 Source: SFBL, Distribution of Publications, CH-3003 Bern www.bundespublikationen.admin.ch Order number: 316.402.20eng www.star.admin.ch Please cite this publication as: Federal Office of Public Health and Federal Food Safety and Veterinary Office. Swiss Antibiotic Resistance Report 2020. Usage of Antibiotics and Occurence of Antibiotic Resistance in Switzerland. November 2020. FOPH publication number: 2020-OEG-64. Table of contents 1 Foreword 6 Vorwort 7 Avant-propos 8 Premessa 9 2 Summary 12 Zusammenfassung 15 Résumé 18 Sintesi 21 3 Introduction 26 3.1 Antibiotic resistance 26 3.2 About ANRESIS 26 3.3 About ARCH-Vet 27 3.4 Guidance for readers 28 3.5 Authors and contributions 29 4 Abbreviations 32 5 Antibacterial consumption in human medicine 36 5.1 Introduction 36 5.2 Hospital care 36 5.3 Outpatient care 41 5.4 Discussion 45 6 Sales of antimicrobials in veterinary medicine 52 6.1 Sales of antimicrobials for use in animals 52 6.2 Sales of antimicrobials for use in livestock animals 52 6.3 Sales of antimicrobials licensed for companion animals 55 6.4 Discussion 56 7 Resistance in bacteria from human clinical isolates 58 7.1 Escherichia coli 58 7.2 Klebsiella pneumoniae 60 7.3 Pseudomonas aeruginosa 63 7.4 Acinetobacter spp 65 7.5 Streptococcus pneumoniae 67 7.6 Enterococci 69 7.7 Staphylococcus aureus 69 Table of contents 1 8 Resistance in zoonotic bacteria from livestock, meat thereof and humans 76 8.1 Campylobacter spp. 76 8.2 Salmonella spp. 85 9 Resistance in indicator bacteria in livestock animals from samples at slaughter 100 9.1 Escherichia coli 101 9.2 ESBL/pAmpC-producing Escherichia coli 108 9.3 Carbapenemase-producing Escherichia coli 116 9.4 Methicillin-resistant Sta phylococcus aureus (MRSA) 116 10 Resistance in indicator bacteria from meat 124 10.1 ESBL/pAmpC- and carbapenemase-producing Escherichia coli 124 10.2 Methicillin-resistant Staphylococcus aureus (MRSA) 128 10.3 Discussion 128 11 Resistance in animal pathogens from animal clinical isolates 132 11.1 Mastitis pathogens 132 11.2 Pathogenic Escherichia coli from poultry 134 11.3 Pathogens from companion animals 135 11.4 Summary and outlook 137 12 Antibiotics in the water cycle 142 12.1 Sources to the environment 142 12.2 Data collection from monitoring programs and independent mea surement campaigns 142 12.3 Antibiotics in treated municipal waste water, surface water and groundwater 143 12.4 Conclusions 144 13 One Health spotlight on carbapenemase-producing Enterobacterales (CPE) 148 13.1 Introduction 148 13.2 Human Medicine 148 13.3 Veterinary Medicine (livestock and meat) 150 13.4 Veterinary Medicine (Small animals) 151 13.5 Discussion 151 2 Table of contents 14 Materials and methods 156 14.1 Data on antibacterial consumption in human medicine 156 14.2 Data on antimicrobial sales in veterinary medicine 157 14.3 Bacterial isolates from humans (clinical probes) 158 14.4 Bacterial isolates from animals and meat thereof 158 14.5 Susceptibility testing, breakpoints, processing antibiotic resistance data from human isolates 160 14.6 Susceptibility testing, cut-offs, breakpoints, processing antimicrobial resistance data from animal isolates 161 Annex I 166 Antibiotics with defined daily dose (DDD) and AWaRe classification according to the WHO Essential Medicines List 166 Annex II 170 Distribution of minimal inhibitory concentrations (MICs) in bacterial isolates from livestock and meat thereof 170 Index 180 Figures, tables and textboxes Table of contents 3 1 Foreword 1 Foreword In recent months, everyone has been focused on COVID-19. This present Swiss Antibiotic Resistance Report (SARR) Although the issue of antibiotic resistance is no longer at the contains substantial improvements. Monitoring data is only forefront of public awareness, this problem must continue to really meaningful when all sectors are represented. The One be tackled vigorously. Antibiotics are essential for treating Health approach for combatting resistance to antibiotics not bacterial infections. When antibiotics are no longer effective only addresses human and veterinary medicine, but also due to antibiotic resistance, vital treatment is often no longer focuses on the environment. For the first time, this SARR successful. Even though COVID-19 is a viral disease, patients also includes a separate chapter on resistance in the envi- have often been given antibiotics to treat the disease’s se- ronment. condary effects. The World Health Organization WHO has expressed the concern that the COVID-19 crisis has made Antibiotic consumption and resistance data from human and the situation of antibiotic resistance even worse, jeopardizing veterinary medicine were first presented in two separate the progress made. chapters; since 2018, specific types of resistance have been examined in detail in a joint chapter across sectors. The re- COVID-19 has also revealed the close connection between port in 2018 specifically addressed methicillin-resistant Sta­ human and animal health. Most health problems hinge on a phylococcus aureus (MRSA); this report specifically address- complexity of factors and can only be effectively addressed es resistance to carbapenems. Carbapenems are antibiotics using a One Health approach. The Swiss antibiotic resistance that are only authorized for human medicine, and not for ve- strategy StAR is also based on this approach. One Health is terinary medicine. Mapping the antibiotic resistance in hu- now recognized worldwide as the leading approach for tack- mans and animals is therefore particularly interesting and ling many health problems, especially antibiotic resistance. demonstrates how important it is to take into account anti- biotic resistance in pets. In a bid to address antibiotic resistance, Switzerland has ta- ken action directed both at human and animal health, and at We would like to thank all those who have been involved in the environment. To measure the impact of the actions ta- the preparation of the SARR report. We hope you enjoy rea- ken, it is essential to monitor antibiotic consumption and an- ding it! tibiotic resistance. The data on antibiotic consumption pro- vide a timely indication of whether improvements have been achieved in the appropriate use of antibiotics. Ultimately, what matters is whether progress has been made in terms of resistance. It has been proven that the improper use of antibiotics has an influence on the development of resis- tance. However, this effect often only becomes apparent with a time delay and is not clear for every type of resistance. Stefan Kuster Katharina Stärk Federal Office of Public Health Federal Food Safety and Veterinary Office 6 Foreword 1 Vorwort In den letzten Monaten war Covid-19 das Thema, das die Im vorliegenden Swiss Antibiotic Resistance Report (SARR) Bevölkerung beschäftigt hat. Obwohl das Thema Anti- gibt es inhaltliche Verbesserungen. Die Überwachungsda- biotikaresistenzen dadurch im Bewusstsein etwas in den ten sind erst dann wirklich aussagekräftig, wenn alle Sekto- Hintergrund geraten ist, muss diese Problematik weiter mit ren abgebildet werden. Im Rahmen des One Health-Ansat- Nachdruck angegangen werden. Antibiotika sind für die The- zes zur Bekämpfung der Resistenzen hat neben Human- und rapie von bakteriellen Infektionen unverzichtbar. Sind Anti- Veterinärmedizin auch die Umwelt eine wichtige Bedeu- biotika wegen Resistenzen nicht mehr wirksam, so fehlen tung. Im vorliegenden SARR wurde erstmals auch ein sepa- oft lebenswichtige Therapien. Obwohl Covid-19 eine virale rates Kapitel über Resistenzen in der Umwelt integriert. Erkrankung ist, mussten Sekundärinfektionen bei Patienten oft mit Antibiotika behandelt werden. Die Weltgesundheits- Nachdem die Antibiotikaverbrauchs- und Resistenzdaten organisation WHO hat Befürchtungen geäussert, dass sich von Human- und Veterinärmedizin anfangs nur in separaten die Situation der Antibiotikaresistenzen wegen der Covid- Kapiteln aufgezeigt wurden, werden seit 2018 in einem 19-Krise noch verschlechtert hat und bereits gemachte Fort- gemeinsamen Kapitel spezifische Resistenzen sektorüber- schritte wieder gefährdet sind. greifend näher beleuchtet. Im Jahr 2018 waren dies Methi- cillin-resistenten Staphylococcus aureus (MRSA), im vorlie- Covid-19 hat auch gezeigt, wie eng die Gesundheit von genden Bericht werden Resistenzen gegen Carbapeneme Mensch und Tier miteinander verbunden sind. Die meisten spezifisch diskutiert. Carbapeneme sind Antibiotika, die nur Gesundheitsprobleme sind von komplexen Faktoren abhän- in der Humanmedizin, nicht aber in der Veterinärmedizin zu- gig und können oft nur mit dem sogenannten One Health- gelassen sind. Die Darstellung der Resistenzlage im Human- Ansatz erfolgreich bekämpft werden. Auf diesem Ansatz und Veterinärbereich ist deswegen besonders interessant beruht auch die Strategie Antibiotikaresistenzen StAR. One und zeigt, wie wichtig es ist, auch die Resistenzsituation bei Health ist mittlerweile als massgebender Ansatz