Antibacterial Usage in Secondary Care in Wales ... - Health in Wales

A Report from Public Health Wales Antimicrobial Resistance Programme Surveillance Unit:

Antibacterial Usage in Secondary Care in Wales 2005-2014

Authors: Maggie Heginbothom & Robin Howe Version: 1 Antibacterial Usage in Secondary Care in Wales 2005 - 2014

Date: 14/04/2015 Page: 1 of 73

Status: Final Antimicrobial Resistance Programme: Surveillance Unit

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Table of Contents Table of Contents .................................................................................................... 2 Section 1: Introduction ........................................................................................... 3 Background ...........................................................................................................................3

Section 2: Key points of interest ............................................................................ 4 Section 3: Methods ................................................................................................. 5 Pharmacy data ......................................................................................................................5 Antimicrobial Groups ...........................................................................................................6 Data Interpretation ................................................................................................................7

Section 4: Antibacterial Usage ............................................................................... 8 Section 4.1: Antibacterial Usage in Secondary care ............................................. 9 All Wales Antibacterial Usage for Secondary Care in 2014 .............................................9 Comparisons between hospitals (Overall Antibacterial Use) ....................................... 15 Comparisons between hospitals (Specific Antibacterial Use) ..................................... 17

Section 4.2: Individual Hospital Usage ................................................................ 23 Morriston Hospital (Abertawe Bro Morgannwg University Health Board)................... 23 Neath Port Talbot Hospital (ABMU Health Board) .......................................................... 26 Princess of Wales Hospital (ABMU Health Board) ......................................................... 29 Singleon Hospital (ABMU Health Board) ........................................................................ 32 Nevill Hall Hospital (Aneurin Bevan Health Board) ........................................................ 34 Royal Gwent Hospital (Aneurin Bevan Health Board) ................................................... 37 Wrexham Maelor Hospital (Betsi Cadwaladr University Health Board) ....................... 40 Ysbyty Glan Clwyd (Betsi Cadwaladr University Health Board) ................................... 43 Ysbyty Gwynedd (Betsi Cadwaladr University Health Board) ...................................... 46 Llandough Hospital (Cardiff and Vale University Health Board) .................................. 49 University Hospital of Wales (CVU Health Board) .......................................................... 52 Prince Charles Hospital (Cwm Taf Health Board) .......................................................... 55 Royal Glamorgan Hospital (Cwm Taf Health Board) ...................................................... 58 Bronglais Hospital (Hywel Dda Health Board) ................................................................ 61 Glangwili Hospital (Hywel Dda Health Board) ................................................................ 64 Prince Philip Hospital (Hywel Dda Health Board) .......................................................... 67 Withybush Hospital (Hywel Dda Health Board) .............................................................. 70

Acknowledgments................................................................................................. 73

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Section 1: Introduction Background Welsh Antimicrobial Resistance Programme Surveillance Unit

This report from the Welsh Antimicrobial Resistance Programme Surveillance Unit regarding antimicrobial usage in secondary care is aimed at providing an overview of hospital antimicrobial usage in Wales. The report has had to be selective in what is presented, and concentrates on the major acute hospitals and district general hospitals in Wales. Surveillance of Antimicrobial Usage in Secondary Care

While the use of antimicrobials has revolutionised our ability to treat infections it is associated inevitably with the risk of development and spread of antimicrobial resistance leading to infections that are increasingly difficult to treat, and antimicrobial-associated adverse events, importantly Clostridium difficile-associated disease (CDAD). It has been estimated that 20-50% of antimicrobial use, both in the Community and in Hospitals, is “inappropriate”. This means that patients and society may be exposed to a significant unnecessary risk of resistant infections and CDAD. In addition there is a financial cost, not only in terms of unnecessary antimicrobial use, but also the additional cost of treating resistant infections and CDAD. A key step in improvement of antimicrobial use is the surveillance and assessment of current antimicrobial usage. This can be achieved using a number of complementary methods including: 

Gross surveillance of antimicrobial usage at hospital, specialty or ward/unit level: This can provide comparative information regarding the choice and quantity of agents used, but does not address the indications or appropriateness of antimicrobial use. This current report provides such data at the hospital level and can be used to stimulate more detailed analysis.



Point Prevalence Survey (PPS): In this type of survey, the prescription chart of every patient in a ward or hospital on a set day is checked to see if an antibiotic has been prescribed, and the reasons for the prescription are recorded. This local information about which antibiotics are used and why can be used to target interventions. The Welsh Antimicrobial Resistance Programme is engaged with ECDC, an EU-funded collaboration that, among other projects, supports hospitals in performing comparative PPSs across Europe.



Local unit/ward audits: Audit can be used to explore in detail the indications, dose, duration etc. of antimicrobial prescriptions in order to identify areas for improvement.

It is hoped that access to this data will support:    

Audit patterns of antimicrobial usage Audit of compliance to guidelines and formularies Monitoring the outcomes of interventions. Educational programs

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Section 2: Key points of interest Antimicrobial Usage in Secondary Care Antimicrobial usage varies between hospitals in Wales with significant changes over the last 10 years in response to the problem of C. difficile.  Total antibacterial use o In 2014, six of the seventeen individual hospitals reported showed a decrease in total antimicrobial usage, five showed an increase in usage, five showed no significant change in usage compared to the previous year. o No trends in usage could be reported for Singleton hospital as no data was available for the years prior to 2014. o In 2014, the general upward trend in the usage of beta-lactam/betalactamase inhibitor combinations (e.g. co-amoxiclav) ceased, due to significant decreases in usage at several major sites. o The downward trend in usage in the cephalosporin group and in the fluoroquinolones levelled off in 2011, and usage remains relatively unchanged for both. o Carbapenem usage (e.g. meropenem) showed a steady upward trend.  In terms of total antimicrobial use in secondary care across Wales in 2014 o The commonest antibacterial type was beta-lactam/beta-lactamase inhibitor combinations (e.g. co-amoxiclav) which represented 27% of use, followed by broad-spectrum penicillins (e.g. amoxicillin) and macrolides (e.g. clarithromycin) both 10%. o Cephalosporins and fluoroquinolones (e.g. ciprofloxacin) which have been implicated as causes of C. difficile infection represented 4.9% and 5.0% of total antibiotic use respectively. 

There was significant inter-hospital variability in gross annual antimicrobial use in 2014; the lowest use was recorded at Neath Port Talbot hospital (238 DDDs/1000 BD) and highest use at Ysbyty Gwynedd (1511 DDDs/1000BD) when using bed days as a denominator.



If admissions were used as a denominator there was less inter-hospital variability with the lowest usage at Singleton hospital (3250 DDDs/1000AD) and the highest use at University Hospital Llandough (7196 DDD/1000AD).

 There was significant inter-hospital variability in the types of antimicrobials used due to local prescribing policies and case mix. For example see Table 1: Table 1: Inter-hospital variability in antimicrobial usage

Broad Spectrum Penicillins (e.g. amoxicillin) Ysbyty Glan Clwyd Royal Glamorgan Hospital

Beta-lactam/betalactamase combinations (e.g. co-amoxiclav)

Fluoroquinolones

17.2%

12.8%

7.4%

6.1%

30.4%

4.6%

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Section 3: Methods Table 2: Codes for hospital and data

Health Board

Abertawe Bro Morgannwg UHB

Aneurin Bevan HB

Betsi Cadwaladr UHB

Cardiff and Vale UHB Cwm Taf HB

Hywel Dda HB

All-Wales

Hospital Princess of Wales

Hospital Code B

Morriston

E

Singleton

S

Neath Port Talbot

T

Royal Gwent

D

Nevill Hall

M

Wrexham Maelor

H

Ysbyty Gwynedd

K

Ysbyty Glan Clwyd

L

University Hospital of Wales

F

University Hospital Llandough

P

Royal Glamorgan

C

Prince Charles Bronglais

N A

Withybush

G

Glangwili

J

Prince Philip All-Wales

R Z

Pharmacy data Data sources Antimicrobial ward stock data was extracted from the MEDUSA database. http://www.wales.nhs.uk/sites3/docmetadata.cfm?orgid=428&id=35766 The ward stock data held on pharmacy systems is not primarily intended for analysis of comparative usage and thus there is significant data processing required to standardize the data. Thus the data presented in this report has been coded and measured using the ATC/DDD system. The measure for antimicrobial usage is Defined Daily Doses per 1000 Bed Days (DDD/1000 BD). Bed days have been calculated using in-patient activity (average daily occupied beds) downloaded from Health Solutions Wales Information and Statistics website: e-Quest. http://eproducts.wales.nhs.uk/ “DDD” stands for Defined Daily Dose. DDDs provide a standard measure of drug usage that can be used for international drug utilisation studies. They are administered by the WHO Collaborating Centre for Drug Statistics Methodology at the Norwegian Institute of Public Health which is linked directly to WHO Headquarters in Geneva. http://www.whocc.no/atcddd/. Note: Due to previous technical difficulties with the Morriston pharmacy system, the data for 2005-2012 did not include RETURNS. From 2013 onwards RETURNS are included in the data set and any apparent reductions in usage in Morriston in 2013 may simply be due to the inclusion of RETURNS – interpret data with caution.

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Antimicrobial Groups Data is presented for the following antimicrobials/antimicrobial groups (ATC code):                          

Tetracyclines e.g. oxytetracycline Amphenicols e.g. chloramphenicol Broad spectrum penicillins (BSP) e.g. amoxicillin Beta-lactamase sensitive penicillins (BLSP) e.g. penicillin V Beta-lactamase resistant penicillins (BLRP) e.g. flucloxacillin Beta-lactam/beta-lactamase inhibitor combinations (BLI) Cephalosporins and carbapenems Cephalosporins alone First generation cephalosporins e.g. cefalexin Second generation cephalosporins e.g. cefuroxime Third generation cephalosporins e.g. cefotaxime Monobactams e.g. aztreonam Carbapenems e.g. imipenem Trimethoprim & sulphonamides Macrolides e.g. erythromycin Lincosamides & streptogramins e.g. clindamycin Streptomycin Aminoglycosides e.g. gentamicin Fluoroquinolones e.g. ciprofloxacin Glycopeptides e.g. vancomycin Polymyxins e.g. colistin Fusidic Acid Imidazole derivatives e.g. metronidazole Nitrofuran derivatives e.g. nitrofurantoin Linezolid Rifampicin

(J01AA) (J01BA) (J01CA) (J01CE) (J01CF) (J01CR) (J01D) (J01D*) (J01DB) (J01DC) (J01DD) (J01DF) (J01DH) (J01E) (J01FA) (J01F) (J01GA) (J01GB) (J01MA) (J01XA) (J01XB) (J01XC) (J01XD) (J01XE) (J01XX) (J04AB)

Data presented

Pharmacy systems are primarily designed to support stock control and distribution and may be differently configured in different Trusts/Hospitals. In order to increase comparability, the antimicrobial usage data presented in this report only includes the following “issue types” from pharmacy:     

In-patient Scripts (IP Scripts) Patients’ Own Medications (POMs) or One Stop Medications Returns To Take Away (TTA)/Discharge Scripts Ward Requisitions

The main objective of this report is to show trends in antimicrobial usage within the hospital. Thus the dataset does not include the issue types A&E scripts, Clinics, Day cases, Day hospital, OP scripts and Sales usage. We are unable to resolve returns against their original issue type, and only present IP scripts, POMs, returns, TTAs and ward requisitions. Therefore, data presented may be an under representation of true hospital usage if returns were for OP scripts etc. Conversely, the data may represent an over estimate of true in hospital use depending on the amount of POMs and TTA medication taken out of hospital.

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Note 1: Only data for oral and parenteral antimicrobial usage are included in this report; it DOES NOT include topical, inhaled, rectal or genital preparation usage. Note 2: Data for Singleton Hospital is INCLUDED in this report from February 2014 onwards. Note 3: The data set for Bronglais hospital is incomplete, and does not include data for the clinical decisions unit (CDU). CDU issues are dispensed to the A&E issue point and cannot be identified and separated from A&E issues. Therefore, the data presented in this report is an UNDERESTIMATE of usage at Bronglais hospital. The data for all other clinical decisions units are included in the relevant hospital data sets.

Data Interpretation In interpreting the data presented in this report it is important to appreciate the ways in which the data is collated and the factors that may drive variability in antimicrobial usage between hospitals. Important issues that should be considered include: 





 

Data applicability. As noted above, the data is drawn from Pharmacy computer systems that are designed primarily for stock control, and which are configured slightly differently in different units. These differences may mean that some antimicrobials that are used out-of-hospital are included in the data. The usage of antimicrobials is standardised against a denominator of patient activity (i.e. 1000 bed days) but may also be influenced by patient case-mix in different hospitals. Thus a hospital which treats significant numbers of immunocompromised patients might be expected to use comparatively larger amounts of broad-spectrum antimicrobials. The usage of antimicrobials should normally reflect the antimicrobial policies of each unit. For example the usage of piperacillin/tazobactam rather than an alternative broad spectrum agent may be a reflection of the hospital policy for the treatment of patients presenting with neutropenic sepsis. The data presented can be used to identify changes in usage and monitor the effect of interventions. When interpreting graphs it is important to note that the y-axis scales vary between graphs and care should be used in interpretation.

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Section 4: Antibacterial Usage This section presents hospital antimicrobial stock data, and dispensed prescription data for primary care. It is important to understand the differences in the two data sets in order to interpret the data: Hospital ward stock data held on pharmacy systems is not primarily intended for analysis of comparative usage and thus there is significant data processing required to standardize the data. The data presented in this report has been coded and measured using the ATC/DDD system. The measure for hospital antimicrobial usage is Defined Daily Doses per 1000 Bed Days (DDD/1000 BD). It is important to remember that changes in DDDs may not only reflect changes in the number of patients receiving antibacterials, but also variance in dosage and duration.

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Section 4.1: Antibacterial Usage in Secondary care All Wales Antibacterial Usage for Secondary Care in 2014 BL inhibitors - J01CR BSP - J01CA Macrolides - J01FA BL resistant penicillins - J01CF Tetracyclines J01AA

Imidizole derivatives - J01XD Trimethoprim & Sulphonamides - J01E Fluoroquinolones - J01MA Carbapenems - J01DH Glycopeptides - J01XA BL sensitive penicillins - J01CE

2011

Aminoglycosides - J01GB

2012

2 Gen Cephs - J01DC

2013 2014

1 Gen Cephs - J01DB Rifampicin - J04AB Lincosamides & Streptogramins - J01F 3 Gen Cephs - J01DD

Nitrofuran derivatives - J01XE Fusidic Acid - J01XC Polymixins - J01XB Linezolid - J01XX 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 1: Comparisons in Antibacterial Usage 2011 - 2014 for All-Wales

Figure 1 shows the pattern of antibacterial usage for All-Wales acute hospitals for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including, tetracyclines (J01AA), trimethoprim group (J01E), carbapenems (J01DH), glycopeptides (J01XA), and aminoglycosides (J01DH); and a decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J01CR),

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Carbapenems - J01DH 3%

BL inhibitors - J01CR 27%

All Cephalosporins 5% Fluoroquinolones J01MA 5%

Trimethoprim & Sulphonamides - J01E 5%

BSP - J01CA 10%

Imidizole derivatives J01XD 6% Tetracyclines J01AA 7%

Macrolides - J01FA 10% BL resistant penicillins - J01CF 9%

Figure 2: Top 10 Antibacterial Usage for 2014

Figure 2 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (27%). Fluoroquinolones (J01MA) accounted for a further 5% of usage, cephalosporins (J01DB, J01DC & J01DD) – 5%, and carbapenems (J01DH) – 3%.

400

DDD/1000 BD per Quarter

350 300 J01CR

250 200 150 100

J01D J01MA

50

J01DH

2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

Figure 3: Trends in Specific Antibacterial Group Usage 2005-2014 (Restricted)

10

Figure 3 shows All-Wales trends in usage from 2005-2014 for antibacterials that have restricted usage in some/all hospitals: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).    

Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) e.g. piperacillin/tazobactam, shows a marked downward trend in 2014. The downward trend cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) levelled off in 2011 and remains unchanged. Carbapenem usage (J01DH) e.g. meropenem, shows a steady upward trend. Total antibacterial usage across Wales shows no significant change over time, except for seasonal variation (see Figure 4).

1600 1500


1400 1300 1200 1100

J01

1000 900

800 700


600

Figure 4: Trends in Total Antibacterial Usage 2005-2014

11

400


350 300 J01CR

250 200 150

J01CA 100

J01FA J01AA

50

J01MA 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

Figure 5: Trends in Antibacterial Group Usage 2005-2014 (Respiratory)

Figure 5 shows the trends in usage for antibacterials that can be used to treat respiratory tract infections: beta-lactam/beta-lactamase inhibitor combinations (J01CR), broad spectrum penicillins (J01CA), fluoroquinolones (J01MA), macrolides (J01FA), and tetracyclines (J01AA):    

Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) shows a downward trend in 2014. Broad spectrum penicillin and macrolide usage (J01CA & J01FA) e.g. amoxicillin and clarithromycin, levelled off, with marked winter peaks. Tetracycline usage (J01AA) e.g. doxycycline, shows an upward trend, with winter peaks suggesting an increased use for respiratory infections. Fluoroquinolones usage (J01MA) e.g. levofloxacin shows a downward trend. 400


350 300 J01CR

250 200 150 100

J01E 50

J01MA J01DB 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

J01XE

Figure 6: Trends in Antibacterial Group Usage 2005-2014 (Urinary)

12

Figure 6 shows the trends in usage for antibacterials that can be used to treat urinary tract infections: beta-lactam/beta-lactamase inhibitor combinations (J01CR), first generation cephalosporins (J01DB), fluoroquinolones (J01MA), nitrofurans (J01XE), and trimethoprim and sulphonamide combinations (J01E):    

Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) shows a downward trend in 2014. First generation cephalosporin usage (J01DB) e.g. cefalexin decreased between 2008/2009 but has levelled off since. Nitrofurantoin usage (J01XE) and trimethoprim and combinations usage (J01E) shows an upward trend. Fluoroquinolones usage (J01MA) e.g. ciprofloxacin shows a downward trend. 400


350 300 J01CR

250 200 150 100

J01XD 50 J01GB J01DC 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

Figure 7: Trends in Antibacterial Group Usage 2005-2014 (Surgery)

Figure 7 shows the trends in usage for antibacterials that can be used for surgical prophylaxis and treatment of intra-abdominal infection: aminoglycosides (J01GB), beta-lactam/beta-lactamase inhibitor combinations (J01CR), second generation cephalosporins (J01DC), and imidazoles (J01XD):    

Aminoglycoside usage (J01GB) e.g. gentamicin shows an upward trend. Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) shows a downward trend in 2014. Second generation cephalosporin usage (J01DC) e.g. cefuroxime shows a marked decreased between 2008/2011 which has levelled off since. Imidazole usage (J01XD) e.g. metronidazole shows a slight downward trend.

13

200 180


160 140 120 100

J01CF

80 60 40

J01XA J01CE

20

J01F 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

Figure 8: Trends in Antibacterial Group Usage 2005-2014 (Skin & Other)

Figure 8 shows the trends in usage for antibacterials that can be used for skin and soft tissue infection, and other agents: beta-lactamase sensitive penicillins (J01CE), beta-lactamase resistant penicillins (J01CF), glycopeptides (J01XA) and lincosamides (J01F):     

Beta-lactamase resistant penicillin usage (J01CF) e.g. flucloxacillin shows an upward trend, with marked summer peaks in usage. Beta-lactamase sensitive penicillin usage (J01CE) e.g. benzylpenicillin shows a downward trend, with marked spring peaks in usage. Glycopeptide usage (J01XA) e.g. vancomycin shows an upward trend. Data from the point prevalence survey suggests that this is largely due to an increase in oral vancomycin. Lincosamide usage (J01F) e.g. clindamycin shows an upward trend. Note: Please note the difference in the y-axis scale which is smaller and finishes at 200 DDD/1000 BD per quarter.

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Comparisons between hospitals (Overall Antibacterial Use) 1600

Key: A: Bronglais B: Princess of Wales C: Royal Glamorgan D: Royal Gwent E: Morriston F: University Hospital of Wales (UHW) G: Withybush H: Wrexham Maelor J: West Wales General (Glangwili) K: Ysbyty Gwynedd L: Ysbyty Glan Clwyd M: Nevill Hall N: Prince Charles P: Llandough R: Prince Philip T: Neath Port Talbot

1511

DDD/1000 Bed Days per Quarter

1400 1200 1000 800

630 600 400 238 200 0 K

C

J

L

D

F

E

M

A

P

N

R

G

H

S

B

T

Figure 9: Total antibacterial usage by hospital – DDD/1000 Bed days

The difference in average total antibacterial usage per quarter between the acute hospitals in Wales for 2014 is shown in Figures 9 and 10. Figure 9 shows usage in defined daily doses per 1000 bed days, and a six-fold variation in antibacterial usage between hospitals at either end of the scale; The hospital at the low end of the scale used 238 DDD/1000 BD (Neath Port Talbot), compared to 1511 DDD/1000 BD for the hospital at the high end of the scale (Ysbyty Gwynedd). Figure 10 shows usage in defined daily doses per 1000 admissions, some of the hospitals that appear at the top end of the table have a higher average length of stay and therefore fewer admissions e.g. University Hospital Llandough (P) with the cystic fibrosis unit, and elective orthopaedic surgery unit (CAVOC) have an average length of stay of 7.4 days compared with the acute hospitals of average of 5.7 days.

DDD/1000 Admissions per Quarter

8000

7196

7000 6000 5000 4000

3250

3000 2000

1000 0 P

R

J

K

C

E

H

A

F

L

G

D

M

N

T

B

S

Figure 10: Total antibacterial usage by hospital – DDD/1000 Admissions

15

55

45 40 35 30

25 20 15

10

37

5

51

Number of Differnt Antibacterials

50

0 F

E

P

L

J

K

D

N

C

H

R

S

M

G

B

A

T

Figure 11: Number of different antibacterials dispensed by each hospital

Figure 11 shows the number of different antibacterial agents dispensed as IP scripts, POMs, returns, TTA or ward requisitions in 2014 varied between hospitals from 37 to 51. The biggest number was used by the University Hospital of Wales (F), and the smallest number by Neath Port Talbot hospital (T).

90

Oral Antimicrobial Usage (%)

80 70 60 50 40 30 20

83

58

10 0 T

K

L

M

J

C

S

R

G

F

N

D

H

A

P

E

B

Figure 12: Proportion of total oral antibacterial usage by hospital

Figure 12 shows the proportion of total oral antibacterial usage by hospital in 2014, which varied between 58% and 83%. The hospital with the lowest proportion of oral antibacterial usage was Princess of Wales hospital (B) and the one with the highest proportion of oral usage was Neath Port Talbot (T).

16

Comparisons between hospitals (Specific Antibacterial Use) 180

14 12%

13

160

12

DDD/1000 Bed Days

10 120

9 8

100

7 80

6 5

60

4 40

3 2

26

167

20

Proportion of Total AB Usage

11

140

0

1 0

C

P

F

L

J

K

N

S

H

R

E

D

G

M

B

A

T

Figure 13: Tetracycline (J01AA) usage by hospital

The difference in average tetracycline (J01AA) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 13. There was >six-fold variation in J01AA usage between hospitals at either end of the scale; the hospital at the low end of the scale used 26 DDD/1000 BD of J01AA compared to 167 DDD/1000 BD for the hospital at the high end of the scale. J01AA as a proportion of total usage varied between 3% at Bronglais (A) to 12% at University Hospital Llandough (P). 280

20 18%

260

18

220

16

200

14

180 12

160 140

10

120

8

100 80

6

60

4

Proportion of Total AB Usage (%)

DDD/1000 Bed Days

240

40 2

32

265

20 0

0 K

L

M

D

P

H

C

J

E

F

A

N

B

S

G

R

T

Figure 14: Broad spectrum penicillin (J01CA) usage by hospital

The difference in average broad spectrum penicillin (J01CA) usage per quarter between the acute hospitals in Wales for 2014, and J01CA usage as a proportion of total antibacterial usage is shown in Figure 14. There was >eight-fold variation in J01CA usage between hospitals; the hospital at the low end of the scale used 32 DDD/1000 BD compared to 265 DDD/1000 BD for the hospital at the high end of the scale. J01CA as a proportion of total usage varied between 5% at Prince Philip (R), to 18% at Ysbyty Gwynedd (K).

17

33%

500

35

450 30 25

DDD/1000 Bed Days

350 300

20

250 15

200 150

10


400

100

64

432

5 50 0

0 C

J

E

F

D

M

K

N

G

R

A

S

H

B

P

L

T

Figure 15: Beta-lactam/beta-lactamase inhibitor combinations (J01CR) usage

The difference in average beta-lactam/beta-lactamase inhibitor combinations (J01CR) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 15. There was >six-fold variation in J01CR usage between hospitals at either end of the scale; the hospital at the low end used 64 DDD/1000 BD of J01CR compared to 432 DDD/1000 BD for the hospital at the high end of the scale. J01CR as a proportion of total usage varied between 13% at Ysbyty Glan Clwyd (L) to 33% at Glangwili hospital (J).

PipTazo

100% 90% 80% 70% 60% 50%

30% 20% 10%

Co-amoxiclav

40%

0% M

C

J

E

N

F

D

G

S

B

P

T

R

A

K

H

L

Figure 16: Beta-lactam/beta-lactamase inhibitor combinations (J01CR) usage by entity (%)

The proportion of beta-lactam/beta-lactamase inhibitor combinations (J01CR) usage at entity level is shown in Figure 16. The proportion of total J01CR usage that was co-amoxiclav varied between hospitals, from 52% at Ysbyty Glan Clwyd (L) to 89% at Nevill Hall (M).

18

90

12 11

10%

80

DDD/1000 Bed Days

9

60

8 7

50

6 40

5

30

4 3

20


10 70

2 10

5

87

1

0 A

L

K

S

J

E

G

N

B

R

P

C

F

D

H

M

0

T

Figure 17: Cephalosporin (J01D) usage by hospital

The difference in average cephalosporin (J01D) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 17. There was a wide variation in J01D usage between hospitals; the hospital at the low end of the scale used 5 DDD/1000 BD compared to 87 DDD/1000 BD for the hospital at the high end of the scale. J01D as a proportion of total usage varied between 2.1% at Neath Port Talbot (T) to 10.0% at Singleton (S).

100

8

7.4%

90

7 6

DDD/1000 Bed Days

70 5

60 50

4

40

3

30 2


80

20 1

3

91

10 0

0 L

K

P

C

F

E

D

J

N

H

A

G

M

R

S

B

T

Figure 18: Fluoroquinolone (J01MA) usage by hospital

The difference in average fluoroquinolone (J01MA) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 18. There was a wide variation in J01MA usage between hospitals; the hospital at the low end of the scale used 3 DDD/1000 BD compared to 91 DDD/1000 BD for the hospital at the high end of the scale. J01MA as a proportion of total usage varied between 1.1 % at Neath Port Talbot (T) to 7.4% at Ysbyty Glan Clwyd (L).

19

6.5

60

6.0

55

5.5

50

5.0

45

4.5

40

4.0

35

3.5

30

3.0

25

2.5

20

2.0

15

1.5

10

1.0

5

0.5

2

0


7.0

6.5%

65

63

DDD/1000 Bed Days

70

0.0 P

F

E

A

J

R

S

K

D

H

G

L

C

N

B

M

T

Figure 19: Carbapenem (J01DH) usage by hospital

The difference in average carbapenem (J01DH) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 19. There was marked variation in J01DH usage between hospitals; the hospital at the low end of the scale used 2 DDD/1000 BD of J01DH compared to 63 DDD/1000 BD for the hospital at the high end of the scale. J01DH as a proportion of total usage varied between 0.6% at Nevill Hall hospital (M) to 6.5% at University Hospital Llandough (P).

Imipenem

100% 90% 80% 70% 60% 50%

30% 20% 10%

Meropenem

40%

0% B

C

G

H

S

N

R

P

K

A

J

F

L

T

E

D

M

Figure 20: Carbapenem (J01DH) usage by entity (%)

The proportion of carbapenem (J01DH) usage at entity level is shown in Figure 20. The proportion of total J01DH usage that was meropenem varied between hospitals, from 72% at Nevill Hall hospital (M) and 79% at Royal Gwent (D) to >98% at all other hospitals.

20

80

7.0

75

6.2%

6.5

70

6.0

65

5.0

DDD/1000 Bed Days

55 50

4.5

45

4.0

40

3.5

35

3.0

30

2.5

25

2.0

20


5.5

60

1.5

15

1.0

5

0.5

9

75

10 0

0.0 C

E

N

H

F

L

D

K

P

B

M

R

S

J

A

G

T

Figure 21: Glycopeptide (J01XA) usage by hospital

The difference in average glycopeptide (J01XA) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 21. There was a wide variation in J01XA usage between hospitals; the hospital at the low end of the scale used 0 DDD/1000 BD of J01XA compared to 75 DDD/1000 BD for the hospital at the high end of the scale. J01XA as a proportion of total usage varied between 1.0% at Withybush (G) to 6.2% at Wrexham Maelor (H).

Teicoplanin

100% 90% 80% 70% 60% 50% 40%

20% 10%

Vancomycin

30%

0% T

R

J

A

K

G

F

L

D

P

E

M

S

B

H

C

N

Figure 22: Glycopeptide (J01XA) usage by entity (%)

The proportion of glycopeptide (J01XA) usage at entity level is shown in Figure 22. The proportion of total J01DH usage that was vancomycin varied between hospitals, from 4% at both Princess Charles (N) and Royal Glamorgan (C) to 100% at Neath Port Talbot (T).

21

5.9%

55

5.5

50

5.0

45

4.5

40

4.0

35

3.5

30

3.0

25

2.5

20

2.0

15

1.5

10

1.0

5

0.5

4


6.0

56

DDD/1000 Bed Days

60

0

0.0 P

M

D

C

F

R

E

J

N

L

K

H

B

G

A

S

T

Figure 23: Aminoglycoside (J01GB) usage by hospital

The difference in average aminoglycoside (J01GB) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 23. There was wide variation in J01GB usage between hospitals; the hospital at the low end of the scale used 4 DDD/1000 BD of J01GB compared to 56 DDD/1000 BD for the hospital at the high end of the scale. J01GB as a proportion of total usage varied between 0.8% in Singleton hospital (S) to 5.9% at University Hospital Llandough (P).

200

20 17%

160

16

140

14

120

12

100

10

80

8

60

6

40

4

20

2

35


18

181

DDD/1000 Bed Days

180

0

0 K

J

R

A

C

L

D

G

M

H

S

F

E

P

N

B

T

Figure 24: Macrolide (J01FA) usage by hospital

The difference in average macrolide (J01FA) usage per quarter between the acute hospitals in Wales for 2014, and as a proportion of total antibacterial usage is shown in Figure 24. There was a five-fold variation in J01FA usage between hospitals at either end of the scale; the hospital at the low end of the scale used 35 DDD/1000 BD compared to 181 DDD/1000 BD for the hospital at the high end of the scale. J01FA as a proportion of total usage varied between 6% at the University Hospital of Wales (F) to 17% at Prince Philip (R).

22

Section 4.2: Individual Hospital Usage Morriston Hospital (Abertawe Bro Morgannwg University Health Board) BL inhibitors - J01CR BL resistant penicillins - J01CF

BSP - J01CA Macrolides - J01FA Imidizole derivatives - J01XD Tetracyclines J01AA Glycopeptides - J01XA

Fluoroquinolones - J01MA Carbapenems - J01DH 2 Gen Cephs - J01DC Trimethoprim & Sulphonamides - J01E

2011

BL sensitive penicillins - J01CE

2012

Rifampicin - J04AB

2013

2014

Aminoglycosides - J01GB Lincosamides & Streptogramins - J01F 1 Gen Cephs - J01DB

3 Gen Cephs - J01DD Fusidic Acid - J01XC Nitrofuran derivatives - J01XE Linezolid - J01XX Polymixins - J01XB 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 25: Morriston Hospital - Antibacterial Usage for 2011 to 2014

Figure 25 shows the pattern of antibacterial usage for Morriston hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including carbapenems (J01DH) and glycopeptides (J01XA). Note: Due to previous technical difficulties with the Morriston pharmacy system, the data for 2005-2012 did not include RETURNS. From 2013 onwards RETURNS are included in the data set and any apparent reductions in usage may simply be due to the inclusion of RETURNS – interpret data with caution.

23

Carbapenems - J01DH 5%


Fluoroquinolones J01MA 5%

Glycopeptides - J01XA 5%

Tetracyclines J01AA 5%

All Cephalosporins 6% Imidizole derivatives J01XD 6% Macrolides - J01FA 6%

BL resistant penicillins - J01CF 11% BSP - J01CA 7%


Figure 26 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials accounting for a nearly a third of total antibacterial usage (32%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 6% of usage, fluoroquinolones (J01MA) - 5%, and carbapenems (J01DH) - 5%.

400 J01CR


350 300 250 200 150 100 J01D 50

J01MA J01DH 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

Figure 27: Trends in Specific Antibacterial Group Usage 2005-2014

24

Figure 27 shows Morriston hospital trends in usage from 2005-2014 for antibacterials that have restricted usage in some/all hospitals in Wales: betalactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) shows a marked upward trend, with some large winter peaks. The downward trend cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) levelled off in 2012. Carbapenem usage (J01DH) shows an upward trend. Total antibacterial usage in Morriston has increased over time, with marked variation in the latter years (see Figure 28). The apparent levelling off of usage in 2013/14 may simply be due to the inclusion of RETURNS in the data (data with RETURNS ). 1600 1500


1400 1300 1200

J01

1100 1000 900 800 700 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

600

Figure 28: Trends in Total Antibacterial Usage 2005-2014 – Morriston Hospital

25

Neath Port Talbot Hospital (ABMU Health Board) BL inhibitors - J01CR Macrolides - J01FA

BSP - J01CA Trimethoprim & Sulphonamides - J01E Tetracyclines J01AA BL resistant penicillins - J01CF Imidizole derivatives - J01XD

Aminoglycosides - J01GB Fluoroquinolones - J01MA 1 Gen Cephs - J01DB 2 Gen Cephs - J01DC

2011

Carbapenems - J01DH

2012


2013

2014

Nitrofuran derivatives - J01XE Polymixins - J01XB 3 Gen Cephs - J01DD

Rifampicin - J04AB Linezolid - J01XX Fusidic Acid - J01XC Glycopeptides - J01XA Lincosamides & Streptogramins - J01F 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 29: Neath Port Talbot Hospital - Antibacterial Usage for 2011 to 2014

Figure 29 shows the pattern of antibacterial usage for Neath Port Talbot hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was a marked decrease in prescribing of all antibacterial groups.

26

Aminoglycosides J01GB 2% All Cephalosporins 2%


Imidizole derivatives J01XD 5%


BL resistant penicillins - J01CF 9%


Macrolides - J01FA 15%

Trimethoprim & Sulphonamides - J01E 13%

BSP - J01CA 14%


Figure 30 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for a more than a quarter of total antibacterial usage (27%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 2% of usage, fluoroquinolones (J01MA) 1% and carbapenems (J01DH) - 1%.

400


350 300 250 200 150 100 J01CR 50 J01D


0

J01DH J01MA


27

Figure 31 shows trends in specific antibacterial group usage in Neath Port Talbot hospital from 2005-14: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combinations usage (J01CR) shows a marked down ward trend from 2012 onwards. Cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) show a downward trend across time. Carbapenem usage (J01DH) decreased in 2014. Total antimicrobial usage shows a marked downward trend (see Figure 32). Note: Please note the difference in the y-axis scale which is wider and starts at 100 DDD/1000 BD per quarter.

1400 1300 1200


1100 1000 900 800 700 600 500 400 300

J01

200 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

100


28

Princess of Wales Hospital (ABMU Health Board) BL inhibitors - J01CR

BL resistant penicillins - J01CF BSP - J01CA Macrolides - J01FA Imidizole derivatives - J01XD Tetracyclines J01AA

2 Gen Cephs - J01DC BL sensitive penicillins - J01CE Trimethoprim & Sulphonamides - J01E Glycopeptides - J01XA 1 Gen Cephs - J01DB

2011


2012

Carbapenems - J01DH

2013 2014

Fluoroquinolones - J01MA 3 Gen Cephs - J01DD

Fusidic Acid - J01XC Lincosamides & Streptogramins - J01F Nitrofuran derivatives - J01XE Polymixins - J01XB Linezolid - J01XX

Rifampicin - J04AB 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 33: Princess of Wales Hospital - Antibacterial Usage for 2011 to 2013

Figure 33 shows the pattern of antibacterial usage for Princess of Wales hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was an increase in prescribing of carbapenems (J01DH), glycopeptides (J01XA) and the imidazole derivatives (J01XD) compared with 2013, but generally usage decreased for the other drug groups.

29

Glycopeptides - J01XA 4% Trimethoprim & Sulphonamides - J01E 4% BL sensitive penicillins - J01CE 4%




All Cephalosporins 8%


BL resistant penicillins - J01CF 15% BSP - J01CA 9%


Figure 34 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (30%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 8% of usage, carbapenems (J01DH) - 2%, and fluoroquinolones (J01MA) - 1%.

400


350 300 250 200

J01CR

150 100 J01D

50

J01DH

-50


0

J01MA


30

Figure 35 shows trends in specific antibacterial group usage in Princess of Wales hospital from 2005-14: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).    

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) appears to have levelled off in 2014. Cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) show a general downward trend. Carbapenem usage (J01DH) decreased in 2012, levelling off in 2013/14. Total antibacterial usage shows a general downward trend over time with seasonal peaks (see Figure 36). 1600 1500


1400 1300 1200 1100 1000 900 800 700 J01


600


31

Singleon Hospital (ABMU Health Board) BL inhibitors - J01CR

Macrolides - J01FA Tetracyclines J01AA Imidizole derivatives - J01XD BSP - J01CA 1 Gen Cephs - J01DB

Carbapenems - J01DH BL resistant penicillins - J01CF Trimethoprim & Sulphonamides - J01E 2 Gen Cephs - J01DC BL sensitive penicillins - J01CE

Fluoroquinolones - J01MA 2014

Glycopeptides - J01XA Aminoglycosides - J01GB Nitrofuran derivatives - J01XE

3 Gen Cephs - J01DD Lincosamides & Streptogramins - J01F Fusidic Acid - J01XC Linezolid - J01XX Polymixins - J01XB

Rifampicin - J04AB -50

0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 37: Princess of Wales Hospital - Antibacterial Usage for 2014

Figure 37 shows the pattern of antibacterial usage for Singleton hospital 2014 (grey bars), there is no comparative data for 2011, 2012, and 2013. First generation cephalosporin use (J01DB) is notably high compared with other hospitals e.g. in 2014, usage in Morriston hospital was 9 DDD/1000 BD compared with 39 DDD/1000 BD in Singleton.

32

BL sensitive penicillins - J01CE 4% Trimethoprim & Sulphonamides - J01E 4% BL inhibitors - J01CR 30%

BL resistant penicillins - J01CF 5% Carbapenems - J01DH 5%

BSP - J01CA 8%

All Cephalosporins 10% Imidizole derivatives J01XD 8%





33

Nevill Hall Hospital (Aneurin Bevan Health Board) BL inhibitors - J01CR BSP - J01CA BL resistant penicillins - J01CF Macrolides - J01FA Imidizole derivatives - J01XD Trimethoprim & Sulphonamides - J01E

Aminoglycosides - J01GB Tetracyclines J01AA BL sensitive penicillins - J01CE Fluoroquinolones - J01MA Glycopeptides - J01XA

2011

1 Gen Cephs - J01DB

2012

Carbapenems - J01DH

2013 2014

2 Gen Cephs - J01DC Nitrofuran derivatives - J01XE 3 Gen Cephs - J01DD Lincosamides & Streptogramins - J01F

Rifampicin - J04AB Fusidic Acid - J01XC Polymixins - J01XB Linezolid - J01XX 0

50

100

150

200

250

300

350

400

450

DDD/1000 Bed Days

Figure 39: Nevill Hall Hospital - Antibacterial Usage for 2011 to 2014

Figure 39 shows the pattern of antibacterial usage for Nevill Hall hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was a marked decrease in prescribing for many antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J01CR), broad spectrum penicillins (J01CA),fluoroquinolones (J01MA), glycopeptides (J01XA), macrolides (J01FA), tetracyclines (J01AA), and the trimethoprim group (J01E).The only increase in prescribing was the aminoglycosides (J01GB).

34



BL sensitive penicillins - J01CE 5%

Tetracyclines J01AA 5% Aminoglycosides J01GB 5%

BSP - J01CA 11%

Trimethoprim & Sulphonamides - J01E 6% Imidizole derivatives J01XD 6%




Figure 40 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (26%). Fluoroquinolones (J01MA) accounted for a further 5% of usage, Cephalosporins (J01DB, J01DC & J01DD) 3%, and carbapenems (J01DH) - 2%.

500 450


400 350 300

J01CR

250 200 150 100 J01D

50

J01MA

0


J01DH


35

Figure 41 shows trends in specific antibacterial group usage in Nevill Hall hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).    

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a marked downward trend in 2013, levelling off in 2014. Cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) shows a general downward trend. Carbapenem usage (J01DH) shows a reduction in 2013, levelling off in 2014. Total antibacterial usage shows a marked downward trend from 2013 onwards (see Figure 42). 1700 1600


1500

1400 1300 1200 1100 1000

J01

900 800


700


36

Royal Gwent Hospital (Aneurin Bevan Health Board) BL inhibitors - J01CR

BSP - J01CA Macrolides - J01FA BL resistant penicillins - J01CF Imidizole derivatives - J01XD Tetracyclines J01AA

Fluoroquinolones - J01MA Trimethoprim & Sulphonamides - J01E BL sensitive penicillins - J01CE Aminoglycosides - J01GB Carbapenems - J01DH

2011

Glycopeptides - J01XA

2012

1 Gen Cephs - J01DB

2013 2014

Rifampicin - J04AB 3 Gen Cephs - J01DD

Nitrofuran derivatives - J01XE Lincosamides & Streptogramins - J01F Fusidic Acid - J01XC 2 Gen Cephs - J01DC Linezolid - J01XX

Polymixins - J01XB 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 43: Royal Gwent Hospital - Antibacterial Usage for 2011 to 2014

Figure 43 shows the pattern of antibacterial usage for Royal Gwent hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including broad spectrum penicillins (J01CA), tetracyclines (J01AA), third generation cephalosporins (J01DD), nitorfurnas (J01XE) and lincosamides (J01F); and a decrease in macrolides (J01FA), beta lactamae resistant penicillins (J01CF), imidazole derivatives (J01XD) and fluoroquinolones (J01MA).

37



BL sensitive penicillins - J01CE 3% Trimethoprim & Sulphonamides - J01E 4% Fluoroquinolones J01MA 5%

Tetracyclines J01AA 5% BSP - J01CA 13% Imidizole derivatives J01XD 7% BL resistant penicillins - J01CF 8%



Figure 44 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (28%). Fluoroquinolones (J01MA) accounted for a further 5% of usage, cephalosporins (J01DB, J01DC & J01DD) - 3%, carbapenems (J01DH) - 3%.

400 J01CR


350 300 250 200 150 100

J01MA

50

J01D J01DH 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0


38

Figure 45 shows trends in specific antibacterial group usage for the Royal Gwent from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).    

The upward trend in beta-lactam/beta-lactamase inhibitor combination usage (J01CR) appears to be levelling off. The downward trend in cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) has levelled off. Carbapenem usage (J01DH) shows an upward trend. Total antibacterial usage shows some seasonal variation with no significant change over time from 2009 onwards (see Figure 46). 1600 1500


1400 1300 J01

1200 1100 1000 900 800 700


600


39

Wrexham Maelor Hospital (Betsi Cadwaladr University Health Board) BL inhibitors - J01CR

BSP - J01CA Macrolides - J01FA Tetracyclines J01AA BL resistant penicillins - J01CF Glycopeptides - J01XA

Fluoroquinolones - J01MA Imidizole derivatives - J01XD Trimethoprim & Sulphonamides - J01E Carbapenems - J01DH Lincosamides & Streptogramins - J01F

2011


2012

2 Gen Cephs - J01DC

2013 2014

1 Gen Cephs - J01DB BL sensitive penicillins - J01CE

3 Gen Cephs - J01DD Nitrofuran derivatives - J01XE Rifampicin - J04AB Linezolid - J01XX Fusidic Acid - J01XC

Polymixins - J01XB -50

0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 47: Wrexham Maelor Hospital - Antibacterial Usage for 2011 to 2014

Figure 47 shows the pattern of antibacterial usage for Wrexham Maelor hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including beta-lactam/beta-lactamase inhibitor combinations (J01CR), macrolides (J01FA), bet-lactamase resistant penicillins (J01CF), glycopeptides (J01XA), trimethoprim group (J01E), and carbapenems (J01DH).

40

All Cephalosporins 4% BL inhibitors - J01CR 26%

Trimethoprim & Sulphonamides - J01E 4% Imidizole derivatives J01XD 6% Fluoroquinolones J01MA 6%

BSP - J01CA 12%


BL resistant penicillins - J01CF 8% Tetracyclines J01AA 8%



Figure 48 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (26%). Fluoroquinolones (J01MA) accounted for a further 6% of usage, cephalosporins (J01DB, J01DC & J01DD) - 4%, and carbapenems (J01DH) - 4%.

400


350 300 250 J01CR

200 150 100

J01MA

50

J01D J01DH 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0


41

Figure 49 shows trends in specific antibacterial group usage in Wrexham Maelor from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows variation in usage over time, with an upward trend from 2010 onwards. Cephalosporin usage (J01D) shows variation in usage over time with no obvious trend. Carbapenem usage (J01DH) shows an increasing trend from 2013 onwards. Fluoroquinolone usage (J01MA) shows a sharp decrease in 2006q3, followed by a slight upward trend from 2006q4 onwards. Total antibacterial usage has increased over time, and shows some seasonal variation (see Figure 50). 1500 1400


1300 1200 1100 1000 900 800

J01

700 600


500


42

Ysbyty Glan Clwyd (Betsi Cadwaladr University Health Board) BSP - J01CA

BL inhibitors - J01CR Macrolides - J01FA BL resistant penicillins - J01CF Trimethoprim & Sulphonamides - J01E Fluoroquinolones - J01MA

Imidizole derivatives - J01XD Tetracyclines J01AA Lincosamides & Streptogramins - J01F 1 Gen Cephs - J01DB Glycopeptides - J01XA

2011

2 Gen Cephs - J01DC

2012

Carbapenems - J01DH

2013 2014

BL sensitive penicillins - J01CE Rifampicin - J04AB Aminoglycosides - J01GB

Nitrofuran derivatives - J01XE 3 Gen Cephs - J01DD Linezolid - J01XX Polymixins - J01XB Fusidic Acid - J01XC

0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 51: Ysbyty Glan Clwyd - Antibacterial Usage for 2011 to 2014

Figure 51 shows the pattern of antibacterial usage for Ysbyty Glan Clwyd for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was a marked increase in prescribing for a number of antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J01CR), macrolides (J01FA), beta-lactamase resistant penicillins (J01CF), fluoroquinolones (J01MA), imidazole derivatives (J01XD), tetracyclines (J01AA), trimethoprim group (J01E), carbapenems (J01DH), second generation cephalosporins (J01DB), lincosamides (J01F), aminoglycosides (J01GB), nitrofurans (J01XE), and third generation cephalosporins (J01DD).

43

Lincosamides & Streptogramins - J01F 4%

BSP - J01CA 17%

All Cephalosporins 6% BL inhibitors - J01CR 13% Tetracyclines J01AA 7%



Fluoroquinolones J01MA 7% Trimethoprim & Sulphonamides - J01E 8%



Figure 52 shows the Top 10 antibacterial group usage for 2014; broad spectrum penicillins (J01CA) were the most used antibacterials, accounting for a sixth of total antibacterial usage (17%). Fluoroquinolones (J01MA) accounted for a further 7% of usage, cephalosporins (J01DB, J01DC & J01DD) - 6%, and carbapenems (J01DH) 2%.

400


350 300 250 200 J01CR

150

J01MA

100

J01D 50 J01DH


0


44

Figure 53 shows trends in specific antibacterial group usage in Ysbyty Glan Clwyd from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) increased in 2014. Cephalosporin usage (J01D) shows a general downward trend. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) decreased in 2012/13 but increased in 2014. The general downward trend in total antibacterial usage reversed in 2014, and an increase in usage was noted (see Figure 54). 1600 1500


1400

J01

1300 1200 1100 1000 900 800


600


45

Ysbyty Gwynedd (Betsi Cadwaladr University Health Board) BL inhibitors - J01CR

BSP - J01CA Macrolides - J01FA BL resistant penicillins - J01CF Imidizole derivatives - J01XD Fluoroquinolones - J01MA

Tetracyclines J01AA Trimethoprim & Sulphonamides - J01E BL sensitive penicillins - J01CE Carbapenems - J01DH 2 Gen Cephs - J01DC

2011

1 Gen Cephs - J01DB

2012


2013 2014

Lincosamides & Streptogramins - J01F BSP - J01CA Aminoglycosides - J01GB

Nitrofuran derivatives - J01XE 3 Gen Cephs - J01DD Fusidic Acid - J01XC Polymixins - J01XB Linezolid - J01XX

0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 55: Ysbyty Glan Clwyd - Antibacterial Usage for 2011 to 2014

Figure 55 shows the pattern of antibacterial usage for Ysbyty Gwynedd for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was a marked increase in prescribing for a number of antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J01CR), macrolides (J01FA), beta-lactamase resistant penicillins (J01CF), fluoroquinolones (J01MA), tetracyclines (J01AA), trimethoprim group (J01E), carbapenems (J01DH), second generation cephalosporins (J01DB), lincosamides (J01F), broad spectrum penicillins (J01CA) an nitrofurans (J01XE).

46

BL sensitive penicillins - J01CE 2% Trimethoprim & Sulphonamides - J01E 5%



Tetracyclines J01AA 5% BSP - J01CA 18%


Imidizole derivatives J01XD 9% BL resistant penicillins - J01CF 11%



Figure 56 shows the Top 10 antibacterial group usage for 2014; broad spectrum penicillins (J01CA) were the most used antibacterials, accounting for nearly a fifth of total antibacterial usage (19%). Fluoroquinolones (J01MA) accounted for a further 5% of usage, cephalosporins (J01DB, J01DC & J01DD) - 5%, and carbapenems (J01DH) - 2%.

400


350 300 250

J01CR

200 150 100

J01D J01MA

50

J01DH


0


47

Figure 57 shows trends in specific antibacterial group usage in Ysbyty Gwynedd from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) increased in 2010 and appears to have levelled off. The downward trend in cephalosporin usage (J01D) levelled off in 2012/13. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) appears to have levelled off. Total antibacterial usage shows a marked upward trend over time (see Figure 58). 1600 1500

J01


1400

1300 1200 1100 1000 900 800


600


48

Llandough Hospital (Cardiff and Vale University Health Board) BL inhibitors - J01CR Tetracyclines J01AA BSP - J01CA BL resistant penicillins - J01CF Fluoroquinolones - J01MA

Trimethoprim & Sulphonamides - J01E Carbapenems - J01DH Macrolides - J01FA Aminoglycosides - J01GB Glycopeptides - J01XA Rifampicin - J04AB

2011

2 Gen Cephs - J01DC

2012

Polymixins - J01XB

2013 2014

3 Gen Cephs - J01DD Nitrofuran derivatives - J01XE Imidizole derivatives - J01XD Lincosamides & Streptogramins - J01F

BL sensitive penicillins - J01CE Linezolid - J01XX Fusidic Acid - J01XC 1 Gen Cephs - J01DB 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 59: University Hospital Llandough Hospital - Antibacterial Usage for 2011 to 2014

Figure 59 shows the pattern of antibacterial usage for Llandough hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was an increase in prescribing broad spectrum penicillins (J01CA), and glycopeptides, and a marked decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J01CR), beta-lactamase resistance penicillins (J01CF), macrolides (J01FA), second generation cephalosporins (J01DC) and third generation cephalosporins (J01DD); and a marked decrease in beta-lactam/beta-lactamase inhibitor combinations (J01CR).

49

BL inhibitors - J01CR 18% All Cephalosporins 5%

Aminoglycosides J01GB 6%



Carbapenems - J01DH 6% Trimethoprim & Sulphonamides - J01E 7%

BSP - J01CA 10%




Figure 60 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a sixth of total antibacterial usage. Fluoroquinolones (J01MA) accounted for a further 7% of usage, carbapenems (J01DH) - 6%, and cephalosporins (J01DB, J01DC & J01DD) – 5%.

400


350 300 250 200 150 J01CR

100

J01MA 50

J01DH J01D


0


50

Figure 61 shows trends in specific antibacterial group usage in Llandough hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a marked downward trend in 2014q4. Cephalosporin usage (J01D) decreased between 2009/10, and has levelled off. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) appears to have levelled off. Total antibacterial usage appears to have decreased in 2014 (see Figure 62). 1600 1500


1400 1300 1200 1100 J01

1000 900

800 700


600


51

University Hospital of Wales (CVU Health Board) BL inhibitors - J01CR

Trimethoprim & Sulphonamides - J01E BL resistant penicillins - J01CF Tetracyclines J01AA BSP - J01CA Macrolides - J01FA

Fluoroquinolones - J01MA Carbapenems - J01DH Imidizole derivatives - J01XD Glycopeptides - J01XA Aminoglycosides - J01GB

2011


2012

Rifampicin - J04AB

2013 2014

Lincosamides & Streptogramins - J01F 2 Gen Cephs - J01DC

3 Gen Cephs - J01DD 1 Gen Cephs - J01DB Nitrofuran derivatives - J01XE Fusidic Acid - J01XC Linezolid - J01XX


50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 63: University Hospital of Wales - Antibacterial Usage for 2011 to 2014

Figure 63 shows the pattern of antibacterial usage for University Hospital of Wales for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including trimethoprim group (J01E), beta-lactamase resistant pencicllins (J01CF), tetracyclines (J01AA), broad spectrum penicillins (J01CA), macrolides (J01FA), fluoroquinolones (J01MA), carbapenems (J01DH), aminoglycosides (J01GB), lincosamides (J01F) and nitrofurans (J01XE); and a decrease in beta-lactam/betalactamase inhibitor combinations (J01CR).

52

All Cephalosporins 4% BL inhibitors - J01CR 30%

Imidizole derivatives J01XD 4% Carbapenems - J01DH 5%


Macrolides - J01FA 6% BSP - J01CA 7%




Figure 64 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (30%). Fluoroquinolones (J01MA) accounted for a further 6% of usage, carbapenems (J01DH) - 5%, and cephalosporins (J01DB, J01DC & J01DD) - 4%.

450


400 350 300 250 J01CR

200 150 100

J01MA J01D

50

J01DH 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0


53

Figure 65 shows trends in specific antibacterial group usage in UHW from 20052013: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a marked downward trend in 2014q4. The downward trend in cephalosporin usage (J01D) levelled off in 2010 onwards. Carbapenem usage (J01DH) shows an upward trend. The downward trend in fluoroquinolone usage (J01MA) levelled off in 2010, and shows an upward trend from mid-2010 onwards. Total antibacterial usage shows some seasonal variation with no significant change over time (see Figure 66). 1600 1500


1400 1300 J01

1200 1100 1000 900 800 700


600


54

Prince Charles Hospital (Cwm Taf Health Board) BL inhibitors - J01CR BL resistant penicillins - J01CF Tetracyclines J01AA BSP - J01CA Imidizole derivatives - J01XD Macrolides - J01FA

Glycopeptides - J01XA Fluoroquinolones - J01MA Trimethoprim & Sulphonamides - J01E 1 Gen Cephs - J01DB BL sensitive penicillins - J01CE

2011

Rifampicin - J04AB

2012


2013 2014

Carbapenems - J01DH 2 Gen Cephs - J01DC Lincosamides & Streptogramins - J01F 3 Gen Cephs - J01DD

Nitrofuran derivatives - J01XE Polymixins - J01XB Fusidic Acid - J01XC Linezolid - J01XX 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 67: Prince Charles Hospital - Antibacterial Usage for 2011 to 2014

Figure 67 shows the pattern of antibacterial usage for Prince Charles hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there were increases in prescribing of tetracyclines (J01AA), imidazoles (J01XD), glycopeptides (J01XA), fluoroquinolones (J01MA), trimethoprim group (J01E), first and second generation cephalosporins (J01DB & J01DC), betalactamase sensitive penicillins (J01CE), rifampicin (J04AB), and aminoglycosides (J01GB); and there was a decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J01CR) and macrolides (J01FA).

55

Trimethoprim & Sulphonamides - J01E 4% Fluoroquinolones J01MA 5%







BSP - J01CA 7%



Figure 68 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (31%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 6% of usage, fluoroquinolones (J01MA) - 5%, and carbapenems (J01DH) - 2%.

400


350 300 250 J01CR

200 150 100

J01D

50

J01MA J01DH 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0


56

Figure 69 shows trends in specific antibacterial group usage in Prince Charles from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).    

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) decreased in 2014. Cephalosporin usage (J01D) and fluoroquinolone usage (J01MA) increased in 2013 but has levelled off in 2014. Carbapenem usage (J01DH) shows an upward trend. Total antibacterial usage shows a general downward trend over time, which appears to have levelled off in 2014 (see Figure 70). 1600 1500


1400

1300 1200 1100 1000 J01

900 800 700


600


57

Royal Glamorgan Hospital (Cwm Taf Health Board) BL inhibitors - J01CR

Tetracyclines J01AA Macrolides - J01FA BL resistant penicillins - J01CF BSP - J01CA Glycopeptides - J01XA

Trimethoprim & Sulphonamides - J01E Imidizole derivatives - J01XD Fluoroquinolones - J01MA Aminoglycosides - J01GB BL sensitive penicillins - J01CE

2011

Carbapenems - J01DH

2012

1 Gen Cephs - J01DB

2013 2014

Nitrofuran derivatives - J01XE Rifampicin - J04AB

2 Gen Cephs - J01DC Lincosamides & Streptogramins - J01F Fusidic Acid - J01XC 3 Gen Cephs - J01DD Linezolid - J01XX


50

100 150 200 250 300 350 400 450 500 DDD/1000 Bed Days

Figure 71: Royal Glamorgan Hospital - Antibacterial Usage for 2011 to 2014

Figure 71 shows the pattern of antibacterial usage for Royal Glamorgan Hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was an increase in prescribing of a number of antibacterial groups, including tetracycline (J01AA), broad spectrum penicillins (J01CA), glycopepetides (J01XA), trimethoprim group (J01E), imidazole deriviatives (J01XD), aminoglycosides (J01GB), and nitrofurans (J01XE).

58

All Cephalosporins 3% Fluoroquinolones J01MA 5%


Imidizole derivatives J01XD 5% Trimethoprim & Sulphonamides - J01E 5% Glycopeptides - J01XA 5%


BSP - J01CA 6% BL resistant penicillins - J01CF 8%



Figure 72 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (30%). Fluoroquinolones (J01MA) accounted for a further 5% of usage, cephalosporins (J01DB, J01DC & J01DD) - 3%, and carbapenems (J01DH) - 2%.

550 500


450 400 350 300

J01CR

250 200 150 100 J01MA

50

J01D 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0

J01DH


59

Figure 73 shows trends in specific antibacterial group usage in Royal Glamorgan from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).      

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows marked decrease in 2014. Cephalosporin usage (J01D) shows a general downward trend over time. Carbapenem usage (J01DH) shows a general upward trend. Fluoroquinolone usage (J01MA) shows a general downward trend over time, but with a notable increase in 2013. Note: Please note the difference in the y-axis scale for Figure 70 which extends to 550 DDD/1000 BD per quarter. Total antibacterial usage shows an increase in 2014 (see Figure 74). 1600 1500


1400

J01

1300 1200 1100 1000 900 800 700


600


60

Bronglais Hospital (Hywel Dda Health Board) BL inhibitors - J01CR Macrolides - J01FA Imidizole derivatives - J01XD BSP - J01CA BL resistant penicillins - J01CF

2 Gen Cephs - J01DC Trimethoprim & Sulphonamides - J01E Carbapenems - J01DH Fluoroquinolones - J01MA BL sensitive penicillins - J01CE Tetracyclines J01AA

2011

1 Gen Cephs - J01DB

2012

3 Gen Cephs - J01DD

2013 2014

Glycopeptides - J01XA Fusidic Acid - J01XC Aminoglycosides - J01GB Nitrofuran derivatives - J01XE

Rifampicin - J04AB Lincosamides & Streptogramins - J01F Polymixins - J01XB Linezolid - J01XX 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days Figure 75: Bronglais Hospital - Antibacterial Usage for 2011 to 2014

Figure 75 shows the pattern of antibacterial usage for Bronglais hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014 there was a decrease in prescribing of a number of antibacterial groups, including macrolides (J01FA), imidazole derivatives (J01XD), broad spectrum penicillins (J01CA), trimethoprim group (J01E), second generation cephalosporins (J01DC), trimethoprim group (J01E), fluoroquinolones (J01MA), and glycopeptides (J01XA); and there were increases in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J01CR), beta-lactamase resisatcne penicillins (J01CF), carbapenems (J01DH), and fusidic acid (J01XC).

61

BL sensitive penicillins - J01CE 4% Fluoroquinolones J01MA 4%





BSP - J01CA 8% All Cephalosporins 9%



Figure 76 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for a quarter of total antibacterial usage (25%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 9% of usage, carbapenems (J01DH) - 5%, and fluoroquinolones (J01MA) - 4%. 400


350 J01CR

300 250 200 150 100

J01D 50

J01DH J01MA


0


62

Figure 77 shows trends in specific antibacterial group usage in Bronglais hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a general upward trend. Cephalosporin usage (J01D) shows a downward trend. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) shows a downward trend, and a decrease in the seasonal winter peaks over time. Total antimicrobial usage shows a downward trend between 2012 and 2014 (see Figure 78). 1600 1500


1400 1300 1200 1100 1000 J01

900

800 700


600


Note: The data set for Bronglais hospital is incomplete, and does not include data for the clinical decisions unit (CDU). CDU issues are dispensed to the A&E issue point and cannot be identified and separated from A&E issues. Therefore, the data presented in this report is an UNDERESTIMATE of usage at Bronglais hospital. The data for all other clinical decisions units are included in the relevant hospital data sets.

63

Glangwili Hospital (Hywel Dda Health Board) BL inhibitors - J01CR Macrolides - J01FA Imidizole derivatives - J01XD BL resistant penicillins - J01CF Tetracyclines J01AA BSP - J01CA BL sensitive penicillins - J01CE Trimethoprim & Sulphonamides - J01E Fluoroquinolones - J01MA Carbapenems - J01DH 2 Gen Cephs - J01DC

2011

1 Gen Cephs - J01DB

2012


2013


2014

Nitrofuran derivatives - J01XE Lincosamides & Streptogramins - J01F Rifampicin - J04AB Fusidic Acid - J01XC 3 Gen Cephs - J01DD Linezolid - J01XX Polymixins - J01XB 0

50

100

150

200

250

300

350

400

450

DDD/1000 Bed Days

Figure 79: Glangwili Hospital - Antibacterial Usage for 2011 to 2014

Figure 79 shows the pattern of antibacterial usage for Glangwili hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars) and 2014 (grey bars). In 2014, there was decrease in prescribing of a number of antibacterial groups, betalactam/beta-lactamase inhibitor combinations (J01CR), macrolides (J01FA), imidazole derivatives (J01XD), broad spectum penicillin (J01CA), trimethorpim gruop (J01E), aminoglycosides (J01GB), and rifampicin (J04AB); and there were increases in prescribing of beta-lactamase resistant penicillins (J01CF), tetracyclines (J01AA), and beta-lactamase sensitive penicillins (J01CE).

64



BL sensitive penicillins - J01CE 4% All Cephalosporins 5%

BSP - J01CA 6%

Tetracyclines J01AA 6% BL resistant penicillins - J01CF 8%

Macrolides - J01FA 13% Imidizole derivatives J01XD 8%


Figure 80 shows the Top 10 antibacterial group usage for 2013; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for a third of total antibacterial usage (33%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 5% of usage, fluoroquinolones (J01MA) 4%, and carbapenems (J01DH) - 3%.

500 450

J01CR


400 350 300 250 200 150 100

J01D J01MA

0

J01DH


50


65

Figure 81 shows trends in specific antibacterial group usage in Glangwili hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).      

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a marked upward trend which appears to be levelling off in 2014. Cephalosporin usage (J01D) shows a downward trend, levelling off from 2012 onwards. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) shows no significant change from 2012 onwards. Note: Please note the difference in the y-axis scale for Figure 78 which extends to 500 DDD/1000 BD per quarter. Total antibacterial usage shows a general upward trend, with marked seasonal variation (see Figure 82). 1600 1500

J01


1400 1300 1200 1100 1000 900 800 700 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

600


66

Prince Philip Hospital (Hywel Dda Health Board) BL inhibitors - J01CR

Macrolides - J01FA BL resistant penicillins - J01CF Tetracyclines J01AA BSP - J01CA Trimethoprim & Sulphonamides - J01E

Carbapenems - J01DH Imidizole derivatives - J01XD 2 Gen Cephs - J01DC BL sensitive penicillins - J01CE Fluoroquinolones - J01MA

2011


2012


2013 2014

Rifampicin - J04AB 3 Gen Cephs - J01DD

Nitrofuran derivatives - J01XE Lincosamides & Streptogramins - J01F Fusidic Acid - J01XC 1 Gen Cephs - J01DB Polymixins - J01XB

Linezolid - J01XX 0

50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 83: Prince Philip Hospital - Antibacterial Usage for 2011 to 2014

Figure 83 shows the pattern of antibacterial usage for Prince Philip hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (grey bars). In 2014, there was an increase in prescribing of beta-lactam resistant penicillins (J01CF), tetracyclines (J01AA), beta-lactam sensitive penicillins (J01CE), and rifampicin (J04AB); and a decrease in prescribing of macrolides (J01FA), broad spectrum penicillins (J01CA) adn second genration cephalosporins (J01DC).

67

BL sensitive penicillins - J01CE 3% BL inhibitors - J01CR 30%


Carbapenems - J01DH 5% Trimethoprim & Sulphonamides - J01E 5% All Cephalosporins 5%

BSP - J01CA 5%






400


350 300 J01CR 250 200 150 100 J01DH

50

J01D J01MA 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

0


68

Figure 85 shows trends in specific antibacterial group usage in Prince Philip hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows a marked upward trend. Cephalosporin usage (J01D) shows a general downward trend. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) shows variation in usage across time with no clear trend. Total antibacterial usage shows an upward trend levelling off in 2014, with very little difference in prescribing between quarters in 2014 (see Figure 86). 1600 1500


1400 1300 1200 1100 1000 J01

900 800 700


600


69

Withybush Hospital (Hywel Dda Health Board) BL inhibitors - J01CR

Macrolides - J01FA Imidizole derivatives - J01XD BL resistant penicillins - J01CF BSP - J01CA Tetracyclines J01AA

Fluoroquinolones - J01MA Trimethoprim & Sulphonamides - J01E 2 Gen Cephs - J01DC Carbapenems - J01DH 1 Gen Cephs - J01DB

2011


2012

Lincosamides & Streptogramins - J01F

2013 2014

Aminoglycosides - J01GB Glycopeptides - J01XA

3 Gen Cephs - J01DD Nitrofuran derivatives - J01XE Fusidic Acid - J01XC Rifampicin - J04AB Linezolid - J01XX


50

100

150

200

250

300

350

400

DDD/1000 Bed Days

Figure 87: Withybush Hospital - Antibacterial Usage for 2011 to 2014

Figure 87 shows the pattern of antibacterial usage for Withybush hospital for 2011 (blue bars), 2012 (green bars), 2013 (purple bars), and 2014 (Grey bars). In 2014, there was a decrease in prescribing of a number of antibacterial groups, including beta-lactam/beta-lactamase inhibitor combinations (J01CR), macrolides (J01FA), beta-lactamse resistant penicillins (J01CF), broad spectrum penicillins (J01CA), tetracyclines (J01AA), first and second generation cephalosporins (J01DB & J01DC), carbapenems (J01DH), lincosamides (J01F), aminoglycosides (J01GB), fusidic acid (J01XC) and rifampicin (J04AB).

70





BSP - J01CA 6%

All Cephalosporins 7% Macrolides - J01FA 14%




Figure 88 shows the Top 10 antibacterial group usage for 2014; beta-lactam/betalactamase inhibitor combinations (J01CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (31%). Cephalosporins (J01DB, J01DC & J01DD) accounted for a further 7% of usage, fluoroquinolones (J01MA) - 4%, and carbapenems (J01DH) - 3%.

400


350 300 J01CR 250 200 150 100 J01D

50

J01MA 0 2005 Q1 Q2 Q3 Q4 2006 Q1 Q2 Q3 Q4 2007 Q1 Q2 Q3 Q4 2008 Q1 Q2 Q3 Q4 2009 Q1 Q2 Q3 Q4 2010 Q1 Q2 Q3 Q4 2011 Q1 Q2 Q3 Q4 2012 Q1 Q2 Q3 Q4 2013 Q1 Q2 Q3 Q4 2014 Q1 Q2 Q3 Q4

J01DH


71

Figure 89 shows trends in specific antibacterial group usage in Withybush hospital from 2005-2014: beta-lactam/beta-lactamase inhibitor combinations (J01CR), all cephalosporins (J01D), carbapenems (J01DH) and fluoroquinolones (J01MA).     

Beta-lactam/beta-lactamase inhibitor combination usage (J01CR) shows an upward trend which appears to be levelling off in 2014. Cephalosporin usage (J01D) shows a downward trend over time, but with an increase in usage in 2013/14. Carbapenem usage (J01DH) shows an upward trend. Fluoroquinolone usage (J01MA) decreased between 2007 and 2008, and has levelled off since, but shows some seasonal variation. Total antibacterial usage shows a general decrease in 2014 (see Figure 90). 1600 1500


1400 1300 1200 1100 1000 900 J01

800 700


600


72

Acknowledgments We would like to acknowledge our colleagues in Wales for their encouragement, support and help in the production of this report. In particular our thanks go to: The Heads of Pharmacy and pharmacy staff at:                 

Bronglais Hospital, Aberystwyth Glangwili Hospital, Carmarthen Llandough Hospital, Cardiff Morriston Hospital, Swansea Neath Port Talbot Hospital, Port Talbot Nevill Hall Hospital, Abergavenny Prince Charles Hospital, Merthyr Prince Philip Hospital, Llanelli Princess of Wales Hospital, Bridgend Royal Glamorgan Hospital, Llantrisant Royal Gwent Hospital, Newport Singleton Hospital, Swansea University Hospital of Wales, Cardiff Withybush General Hospital, Haverfordwest Wrexham Maelor Hospital, Wrexham Ysbyty Gwynedd Bangor Ysbyty Glan Clwyd Rhyl

Special thanks to:  

Robin Burfield, MEDUSA project, NWIS Andrew Olden, Public Health Wales Informatics, Cardiff

73

Antibacterial Usage in Secondary Care in Wales ... - Health in Wales

Antibacterial Usage in Secondary Care in Wales ... - Health in Wales

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