J Korean Med Sci. 2020 Dec 7;35(47):e390 https://doi.org/10.3346/jkms.2020.35.e390 eISSN 1598-6357·pISSN 1011-8934 Original Article Trend of Antibiotic Usage for Infectious Diseases, Microbiology & Parasitology Hospitalized Community-acquired Pneumonia Cases in Korea Based on the 2010–2015 National Health Insurance Data Bongyoung Kim ,1* Rangmi Myung ,2* Myoung-jae Lee ,2 Jieun Kim ,1 and Hyunjoo Pai 1 1Department of Internal Medicine, College of Medicine, Hanyang University, Seoul, Korea 2Department of Economics, College of Political Science & Economics, Korea University, Seoul, Korea Received: Jun 19, 2020 ► See the editorial “Antimicrobial Consumption as a Key Component of Antimicrobial Stewardship Accepted: Sep 14, 2020 Programs: a Meaningful Movement toward Evidence-based Antimicrobial Stewardship of Validated Outcome Measures” in volume 35, number 47, e412. Address for Correspondence: Hyunjoo Pai, MD, PhD Department of Internal Medicine, Hanyang ABSTRACT University College of Medicine, 232 Wangsimni-ro, Seongdong-gu, Seoul 04763, Korea. Background: This study is to describe the changes in prescribing practices of antibiotics to E-mail: [email protected] treat community-acquired pneumonia (CAP) in Korea during 2010–2015. Methods: The claim database of the Health Insurance Review and Assessment Service in Korea Myoung-jae Lee, PhD was used to select adult patients (≥ 18 years of age) admitted between 2010 and 2015, with the Department of Economics, College of Political Science & Economics, Korea University, 145 International Classification of Diseases, Tenth Revision codes relevant to all-cause pneumonia Anam-ro, Seongbuk-gu, Seoul 02841, Korea. for the first or second priority discharge diagnosis. The episodes with hospital-acquired E-mail: [email protected] or healthcare-associated pneumonia were excluded. Consumption of each antibiotic was converted to defined daily dose (DDD) per episode. The amount of antibiotic consumption was *Bongyoung Kim and Rangmi Myung compared between patients with CAP aged < 65 years and those aged ≥ 65 years. contributed equally to this work. Results: The average amount of antibiotic consumption per episode was 15.5 DDD, © 2020 The Korean Academy of Medical which remained stable throughout the study period (P = 0.635). Patients aged ≥ 65 years Sciences. received more antibiotics than those aged < 65 years (15.7 vs. 15.3 DDD). Third-generation This is an Open Access article distributed cephalosporin (4.9 DDD/episode, 31.4%) was the most commonly prescribed, followed by under the terms of the Creative Commons Attribution Non-Commercial License (https:// macrolide (2.7 DDD/episode, 17.1%) and beta-lactam/beta-lactamase inhibitor (BL/BLI) creativecommons.org/licenses/by-nc/4.0/) (2.1 DDD/episode, 13.6%). The consumption amount of fourth-generation cephalosporin which permits unrestricted non-commercial (4th CEP) (P = 0.001), BL/BLI (P = 0.003) and carbapenem (P = 0.002) increased each year use, distribution, and reproduction in any during the study period. The consumption of 4th CEP and carbapenem was doubled during medium, provided the original work is properly 2010–2015. cited. Conclusion: The prescription of broad-spectrum antibiotics such as 4th CEP and carbapenem ORCID iDs to treat CAP increased in Korea during 2010–2015. Bongyoung Kim https://orcid.org/0000-0002-5029-6597 Keywords: Antibiotics; Pneumonia; Resistance; Stewardship; Korea Rangmi Myung https://orcid.org/0000-0002-5776-1009 Myoung-jae Lee https://orcid.org/0000-0002-3935-7491 https://jkms.org 1/13 Antibiotics Usage for CAP in Korea Jieun Kim INTRODUCTION https://orcid.org/0000-0002-6214-3889 Hyunjoo Pai Antimicrobial-resistant pathogens erode the effectiveness of antibiotics, leading to higher https://orcid.org/0000-0003-4143-035X mortalities, longer hospital stays, and increased medical costs.1 Approximately 2.8 million Funding individuals develop an infection and more than 35,000 people die annually in the U.S. due This work was supported by a grant from the to widespread antimicrobial-resistant pathogens.2 The emergence of antimicrobial-resistant Korea Healthcare Technology R&D Project, organisms is considered to be a serious threat to public health, and the importance of proper Nationwide surveillance system of multidrug- antibiotic usage has been emphasized to cope with the threat.3 resistant pathogens for prevention and control of antimicrobial resistance in Korea (HI12C0756), Ministry of Health and Welfare, Unfortunately, Korea is known to have a high level of antibiotic prescription among the Republic of Korea; BCWorld Pharm. Co. Ltd. Organization for Economic Cooperation and Development countries.4 The use of antibiotics, (2019) also partly funded this research. especially broad-spectrum antibiotics, has been increasing in the last decade in Korean 5,6 Disclosure hospitals. Accordingly, the National Action Plan on Antimicrobial Resistance in Korea The authors have no potential conflicts of set as their primary objective a prudent use of antibiotics and reduction of unnecessary interest to disclose. antibiotics prescriptions.7 The first step toward implementing a proper policy for antimicrobial stewardship is identifying the current situation. Although some quantitative Author Contributions studies have already been conducted, more extensive and far-reaching analyses on antibiotic Conceptualization: Pai H. Data curation: Kim B, Myung R. Formal analysis: Myung R. Funding usage patterns are needed. acquisition: Pai H. Investigation: Kim B, Myung R. Methodology: Kim B, Lee MJ, Pai H. Project Community-acquired pneumonia (CAP) is one of the most common community-acquired administration: Kim B, Pai H. Resources: Kim bacterial infections, which usually requires an antibiotic treatment.8 In Korea, the most B, Myung R, Lee MJ, Kim J, Pai H. Software: causative bacterial pathogen for CAP is Streptococcus pneumoniae, which comprises 27%–69% Myung R. Supervision: Kim B, Myung R, Lee 8 MJ, Kim J, Pai H. Validation: Kim B, Myung of the total isolated bacteria. Fortunately, the resistance rate of S. pneumoniae to ceftriaxone R, Lee MJ, Kim J, Pai H. Visualization: Kim and fluoroquinolone (FQ) is less than 10%.9,10 However, some reports demonstrated that the B, Myung R. Writing - original draft: Kim B. proportion of cases due to gram-negative bacteria and S. aureus was higher in elderly patients, Writing - review & editing: Kim B, Myung R, Lee which raised concern about antimicrobial resistance.11 MJ, Pai H. Although efforts to improve microbiological diagnosis for patients with CAP are still ongoing, the rate of microbiological diagnosis remains around 40% due to difficulties in securing adequate samples.12,13 Hence, selecting antibiotics to treat CAP is highly dependent on the official guidelines based on empirical antibiotic treatments. The treatment guidelines for CAP are developed based on local epidemiology, but individual physicians may not adhere to them due to the governmental policies regarding restrictions on antimicrobial agents, prescription behavior of each physician, etc. Analyzing the antibiotic prescription patterns of CAP may give a clue to the changing patterns in the practices of prescribing antibiotics to treat common bacterial infections in Korea, which is the goal of this study as viewed more broadly. METHODS Data source The National Health Insurance System of Korea covers almost the entire population, including low-income families receiving medical aids; approximately 98% of the population is covered by the system.14 We obtained the National Health Insurance claim data through the Healthcare Big Data Hub, where the Health Insurance Review & Assessment Service provides the health insurance data online. https://jkms.org https://doi.org/10.3346/jkms.2020.35.e390 2/13 Antibiotics Usage for CAP in Korea The data include age, sex, insurer type, clinic/hospital code, area code of clinic/hospital, care type (inpatient/outpatient), treatment start date, treatment duration, admission or visit days, primary discharge diagnosis code, sub-discharge diagnosis code, medical department in charge, medical cost, and prescribed pharmaceuticals. The discharge diagnoses were coded following the International Classification of Diseases, Tenth Revision (ICD-10). To identify the underlying comorbidities of patients and to minimize missing variables due to the lag in billing for health insurance claims, the claim data were obtained from January 2009 to December 2016. Definitions We examined the episodes for adult (≥ 18 years) hospitalized patients with ICD-10 codes for all-cause pneumonia in the first or second priority discharge diagnosis.6,15 All-cause pneumonia codes used in the present study are presented in Supplementary Table 1. We included the codes relevant to viral pneumonia (J10, J11, and J12), because empirical antibiotics are likely to be applied to any type of pneumonia before causative pathogens are revealed. The episodes with zero hospitalization day or zero medical cost, as well as those with antibiotic prescription for less than 3 days were excluded.16 In addition, the episodes with the treatment result “transfer to other medical facilities” and those with 1 day or less between discharge and re-hospitalization were excluded. Importantly, episodes that could be classified as hospital-acquired or healthcare-associated pneumonia were excluded, which had any of the following characteristics. Surgery codes were recorded during admission; patients had tuberculosis or acquired immune deficiency syndrome (AIDS)/human