antimicrobial usage in secondary care in wales 200...antimicrobial-associated adverse events,...

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National Public Health Service for Wales Antimicrobial Usage in Secondary Care in Wales

Antimicrobial Usagein Secondary Care in Wales

(2005 – 2008q1)

Authors: Maggie HeginbothomRobin Howe

Date:06/10/2008

Status: Final

Version: 1First report entitled ‘Antimicrobial Usage inSecondary Care in Wales’

Page: 1 of 75 Welsh AntimicrobialResistance Programme:Surveillance Unit

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Table of Contents

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

Background...........................................................................................................................3Collation and Presentation of Antimicrobial Usage Data.................................................5Antimicrobial Groups...........................................................................................................6Data Interpretation................................................................................................................8Report structure....................................................................................................................8

Section 2: Antimicrobial Usage Data ..................................................................... 9Individual hospital antimicrobial usage data.....................................................................9Hospital A: Bronglais District Hospital, Aberystwyth.....................................................14Hospital B: Princess of Wales Hospital, Bridgend..........................................................18Hospital C: Royal Glamorgan Hospital, Pontypridd .......................................................22Hospital D: Royal Gwent Hospital, Newport ....................................................................26Hospital F: University Hospital of Wales, Cardiff............................................................30Hospital G: Withybush General Hospital .........................................................................34Hospital H: Wrexham Maelor Hospital, Wrexham ...........................................................38Hospital J: West Wales General Hospital, Carmarthen ..................................................42Hospital K: Ysbyty Gwynedd, Bangor ..............................................................................46Hospital L: Ysbyty Glan Clwyd, Rhyl................................................................................50Hospital M: Nevill Hall Hospital, Abergavenny................................................................54Hospital N: Prince Charles Hospital, Merthyr..................................................................59Hospital P: Llandough Hospital, Llandough....................................................................63Hospital Q: Velindre Hospital, Cardiff ..............................................................................67Hospital R: Prince Philip Hospital, Llanelli ......................................................................71Section 3: Acknowledgments............................................................................................75

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Section 1: Introduction

Background

Welsh Antimicrobial Resistance Programme Surveillance Unit

This is the first report from the Welsh Antimicrobial Resistance ProgrammeSurveillance Unit regarding antimicrobial usage in secondary care, and is aimed atproviding an overview of hospital antimicrobial usage in Wales. The report has had tobe selective in what is presented, and concentrates on the major acute hospitals anddistrict general hospitals in Wales. However, we would welcome feedback and weare happy to discuss and consider bespoke reports for specific hospitals/specialties,or antimicrobials that might be helpful.

Surveillance of Antimicrobial Usage in Secondary Care

While the use of antimicrobials has revolutionised our ability to treat infections it isassociated inevitably with the risk of development and spread of antimicrobialresistance leading to infections that are increasingly difficult to treat, andantimicrobial-associated adverse events, importantly Clostridium difficile-associateddisease (CDAD).

It has been estimated that 20-50% of antimicrobial use, both in the Community and inHospitals, is “inappropriate”. This means that patients and society may be exposed toa significant unnecessary risk of resistant infections and CDAD. In addition there is afinancial cost, not only in terms of unnecessary antimicrobial use, but also theadditional cost of treating resistant infections and CDAD. The 1000 lives campaignsuggests possible components of inappropriate antimicrobial use and methods thatmight improve matters:

Table 1: 1000 Lives campaign recommendations

Inappropriate use Main Risk Improvement methodPrescribingantimicrobials forpatients who do nothave an infection orrequire prophylaxis

Spread of resistance Adverse events CDAD

EducationDiagnostic algorithmsProphylaxis guidelines

Incorrectantimicrobial choice

Ineffective therapy Spread of resistance Adverse events CDAD

EducationTreatment guidelinesRisk stratification guidelinesRestrictive antimicrobialformulary

Incorrect dose Ineffective therapy Spread of resistance (increased at low

dose)

EducationTreatment guidelinesRisk stratification guidelines

Incorrect duration Ineffective therapy Spread of resistance (increased with short

duration) Adverse events (increased with long

duration) CDAD (increased with long duration)

EducationTreatment guidelinesAutomatic review dates

Incorrect route Ineffective therapy IV-line-associated infection Cost (IV formulations cost ~10x oral

formulations)

EducationTreatment guidelinesIV/oral switch policy

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A key step in improvement of antimicrobial use is the surveillance and assessment ofcurrent antimicrobial usage. This can be achieved using a number of complementarymethods:

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

Point Prevalence Survey (PPS): In this type of survey, the prescription chartof every patient in a ward or hospital on a set day is checked to see if anantibiotic has been prescribed, and the reasons for the prescription arerecorded. This local information about which antibiotics are used and why canbe used to target interventions. The Welsh Antimicrobial ResistanceProgramme is engaged with ESAC (European Surveillance of AntimicrobialConsumption), an EU-funded collaboration that, among other projects,supports hospitals in performing comparative PPSs across Europe. In May2008, two hospitals, Ysbyty Glan Clwyd (Rhyl) and University Hospital Wales(Cardiff) took part in the ESAC PPS. The table shows broad comparative datafrom this exercise with approximately 34% of patients in each hospitalreceiving an antibiotic on the study day.

Table 2: Preliminary results of Point Prevalence Surveys

YGC UHW% of patients receiving an antibiotic 34.1 33.4

% for treatment ofinfection

79.5 78.6

% surgicalprophylaxis

16.3 12.2Of patientsreceiving anantibiotic

% medicalprophylaxis

4.2 9.2

Skin & soft tissueinfection

21.1 20.1

Pneumonia 20.1 17.1

Of patientsreceiving anantibiotic to treat aninfection Urinary tract infection 9.6 17.1

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 forimprovement. Simple audit tools designed for this purpose are available in the1000 lives “Getting Started Kit”.

Until now, access to standardised and validated antimicrobial usage data has beendifficult. Collaborative developments between Hospital pharmacists, Health SolutionsWales (HSW), and the NPHS IT team have enabled the collation of data acrossWales as described below. 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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Collation and Presentation of Antimicrobial Usage Data

Data sourcesAntimicrobial ward stock data was extracted from the MEDUSA database. MEDUSAis the name of an on-going project that is headed by Robin Burfield at HSW. The aimof the project is to extract the data on the issue of drugs from hospital pharmacies tocreate an All-Wales database.http://www.wales.nhs.uk/sites3/home.cfm?orgid=428&redirect=yes

The ward stock data held on Pharmacy computer systems is not primarily intendedfor analysis of comparative usage and thus there is significant data processingrequired to standardize the data. Thus the data presented in this report has beencoded and measured using the ATC/DDD system as described below. Thedenominator for antimicrobial usage is Defined Daily Doses per 1000 Bed Days(DDD/1000 BD). Bed days have been calculated using in-patient activity (averagedaily occupied beds) downloaded from Health Solutions Wales Information andStatistics website: e-Quest.http://eproducts.wales.nhs.uk/equest/

Note: Only data for oral and parenteral antimicrobial usage are included in thisreport; it DOES NOT include topical, inhaled, rectal or genital preparation usage.Data for Morriston and Singleton Hospitals are not included in this report as their datawas not available from MEDUSA at the time of data extraction. It is hoped that thesedata will be included in future reports. The hospitals with their code included in thisreport comprise:

Table 3: Hospital codes

Hospital Code

Bronglais General Hospital, Aberystwyth A

Princess of Wales Hospital, Bridgend BRoyal Glamorgan Hospital, Pontypridd C

Royal Gwent Hospital, Newport D

University Hospital of Wales, Cardiff F

Withybush General Hospital, Haverfordwest GWrexham Maelor Hospital, Wrexham H

West Wales General Hospital, Carmarthen J

Ysbyty Gwynedd, Bangor KYsbyty Glan Clwyd, Rhyl L

Nevill Hall Hospital, Abergavenny M

Prince Charles, Merthyr N

Llandough Hospital, Llandough PVelindre Hospital, Cardiff Q

Prince Philip Hospital, Llanelli R

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The ATC/DDD system

In 1969 the Drug Utilization Research Group in Oslo was established and tasked withthe development of internationally applicable methods for drug utilization research.By modifying and extending the European Pharmaceutical Market ResearchAssociation (EPhMRA) classification system, Norwegian researchers developed asystem known as the Anatomical Therapeutic Chemical (ATC) classification and atechnical unit of measurement called the Defined Daily Dose (DDD).

In 1981, the WHO Regional Office for Europe recommended the ATC/DDD systemfor international drug utilization studies. In connection with this, and to make themethodology more widely used, there was a need for a central body responsible forcoordinating the use of the methodology. The WHO Collaborating Centre for DrugStatistics Methodology was accordingly established in Oslo in 1982. The Centre isnow located at the Norwegian Institute of Public Health and is linked directly to WHOHeadquarters in Geneva. http://www.whocc.no/atcddd/

Antimicrobial GroupsData is presented for the following antimicrobials/antimicrobial groups (ATC code):

Tetracyclines e.g. oxytetracycline (J01AA) Amphenicols e.g. chloramphenicol (J01BA) Broad spectrum penicillins e.g. amoxicillin (J01CA) Beta-lactamase sensitive penicillins e.g. penicillin V (J01CE) Beta-lactamase resistant penicillins e.g. flucloxacillin (J01CF) Beta-lactam/beta-lactamase inhibitor combinations (J01CR) First generation cephalosporins e.g. cefalexin (J01DB) Second generation cephalosporins e.g. cefuroxime (J01DC) Third generation cephalosporins e.g. cefotaxime (J01DD) Monobactams e.g. aztreonam (J01DF) Carbapenems e.g. imipenem (J01DH) Trimethoprim & sulphonamides (J01E) Macrolides e.g. erythromycin (J01FA) Lincosamides & streptogrammins e.g. clindamycin (J01F) Streptomycin (J01GA) Aminoglycosides e.g. gentamicin (J01GB) Fluoroquinolones e.g. ciprofloxacin (J01MA) Glycopeptides e.g. vancomycin (J01XA) Polymixins e.g. colisitin (J01XB) Fusidic Acid (J01XC) Imidazole derivatives e.g. metronidazole (J01XD) Nitrofuran derivatives e.g. nitrofurantoin (J01XE) Linezolid (J01XX) Rifampicin (J04AB)

Explanation of ATC coding system e.g. amoxicillin (J01CA04)

J denotes that the item is an anti-infective J01 an anti-infective for systemic use J01C a beta-lactam antibacterial, pencillin J01CA a penicillin with extended spectrum J01CA04 is the specific code for amoxicillin

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Data Processing

The data was processed using on-line analytical processing (OLAP) using AnalysisServer 2005 software (Microsoft, UK). Pharmacy data was imported into the OLAPdata warehouse. Data Transformation Services (DTS) within OLAP transforms thedata; the data in the Medusa database is stored in a free text format and has to beconverted to numerical data for analysis. During this process:

A custom DTS transformation translates the free text in the Medusa databaseto ATC codes and the numeric measures for each individual issue.

The numbers of DDDs for each dispensed item are calculated

The process 'learns' how to translate similar text items and can automaticallyprocess almost any items from the Medusa database.

The data was exported to Microsoft excel for analysis, tabulation and graphics. Mostof the graphs in this report have been fitted with an Order 6 polynomial trend line; thecloser the R-squared value is to 1 the better the line trend line fits the data.http://office.microsoft.com/en-us/help/HP100074611033.aspx

Data presented

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

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

The main objective of this report is to describe antimicrobial usage within thehospital. Thus the dataset does not include the issue types A&E scripts, Clinics, Daycases, Day hospital, OP scripts and Sales usage. As we are unable to resolvereturns against their original issue type, and as only IP scripts, POMs, returns, TTAsand ward requisitions are included in the analysis, there is a possibility that the usagedata is higher than the figures shown in this report.

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Data Interpretation

In interpreting the data presented in this report it is important to appreciate the waysin which the data is collated (see above) and the factors that may drive variability inantimicrobial usage between units or hospitals. Important issues that should beconsidered include:

Data applicability. As noted above, the data is drawn from Pharmacycomputer systems that are designed primarily for stock control, and which areconfigured slightly differently in different units. These differences may meanthat some antimicrobials that are used out-of-hospital are included in the datafor some hospitals.

The usage of antimicrobials is standardised against a denominator of patientactivity (i.e. 1000 bed days) but may also be influenced by patient case-mix indifferent hospitals. Thus a hospital which treats significant numbers ofimmunocompromised patients might be expected to use comparatively largeramounts of broad-spectrum antimicrobials. An example of this would beVelindre Hospital which uses large amounts of piperacillin/tazobactam (seegraph 9, page 14).

The usage of antimicrobials should normally reflect the antimicrobial policiesof each unit. For example the usage of piperacillin/tazobactam rather than analternative broad spectrum agent is a reflection of the hospital policy for thetreatment of patients presenting with neutropenic sepsis.

The data presented can be used to identify changes in usage and monitor theeffect of interventions. For example, Wrexham Maelor Hospital decided toreduce fluoroquinolone use in response to concerns about levels of C. difficileinfection. The success of this campaign can be seen from Figure 62, page 41.

When interpreting graphs it is important to note that the y-axis scales varybetween graphs and care should be used in interpretation.

Report structure

The first section gives comparative information between hospitals of overall usage,oral usage and data on the most heavily used agents. Following this are reports foreach individual hospital which show time-trends for overall usage and the four or fivemost commonly used agents.

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Section 2: Antimicrobial Usage Data

Individual hospital antimicrobial usage data

Total Antimicrobial usage by Hospital 2007

(DDD/1000 BD)

0

200

400

600

800

1000

1200

1400

1600

Hospital Code

DD

D/1

000

BD

DDD 1468 1451 1364 1255 1254 1181 1147 1144 1133 1080 1010 869 817 768

Returns % 4 6 3 5 11 6 15 5 5 4 6 6 6 3

C L M D Q A K N J F B P H G

Figure 1: Total antimicrobial usage by hospital

The difference in total antimicrobial usage between hospitals in Wales for 2007 isshown in Figure 1. There is a two-fold variation in usage between hospitals rangingfrom 768 DDD/1000 BD to 1468 DDD/1000 BD. There may be many valid reasonsfor these differences e.g. case-mix, amounts dispensed as TTA and POMs. Figure 1also shows the percentage returns to pharmacy for each hospital; varying from 3% -15%.

The number of different antimicrobials dispensed

by each hospital in 2007

30

35

40

45

50

55

Hospital Code

No

.an

tim

icro

bia

ls

No. AM 53 48 48 48 47 46 46 46 45 40 40 39 39 31

F B K L P J D C H A N G M Q

Figure 2: Number of different antimicrobials dispensed by each hospital

Figure 2 shows the number of different antimicrobials dispensed varied betweenhospitals from 31 to 53. The largest number was used by the University Hospital ofWales (F), the smallest number by Velindre Hospital (Q).

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Proportion of total oral antimicrobial usage by hospital 2007

60

62

64

66

68

70

72

74

76

78

80

Hospital Code

Pro

po

rtio

n(%

)

Oral % 68.1 68.3 70.1 70.4 70.5 71.6 72.5 72.9 73.5 73.6 75.7 77.6 78.7 79.5

P F J G A Q B D K H L C M N

Figure 3: Proportion of total oral antimicrobial usage by hospital

Figure 3 shows the proportion of total oral antimicrobial usage in 2007, which variedbetween 68.1% - 79.5%. The hospital with the lowest proportion of oral antimicrobialusage was Llandough Hospital (P) and the one with the highest was Prince CharlesHospital (N).

Broad spectrum penicillin (J01CA) usage by Hospital 2007

(DDD/1000 BD)

0

25

50

75

100

125

150

175

200

225

250

Hospital Code

DD

D/1

000

BD

J01CA 242 223 184 173 159 158 144 142 102 90 89 88 77 63 29

K M D L H J R G C N B B P F Q

Figure 4: Broad spectrum penicillin (J01CA) usage by hospital

The difference in broad spectrum penicillin (e.g. amoxicillin) usage between hospitalsin Wales for 2007 is shown in Figure 4. There is an eight-fold variation in usagebetween hospitals from 29 DDD/1000 BD 242 DDD/1000 BD.

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Beta-lactam/beta-lactamase inhibitor combinations (J01CR)

Usage by Hospital 2007 (DDD/1000 BD)

0

50

100

150

200

250

300

350

400

450

500

Hospital Code

DD

D/1

000

BD

J01CR 472 406 311 286 256 252 217 207 184 166 154 132 131 111 91

Q C N L B F B M D H P K J G R

Figure 5: Beta-lactam/beta-lactamase inhibitor combinations (J01CR) usage

The difference in beta-lactam/beta-lactamase inhibitor combinations (e.g. co-amoxiclav) usage in Wales for 2007 is shown in Figure 5. There is a five-foldvariation in usage between hospitals from 91 DDD/1000 BD to 472 DDD/1000 BD.

Macrolide (J01FA) usage by Hospital 2007

(DDD/1000 BD)

0

25

50

75

100

125

150

175

200

225

250

Hospital Code

DD

D/1

000

BD

J01FA 242 240 221 220 206 190 167 155 152 121 112 109 103 98 80

R C M D Q L K J N B P F G B H

Figure 6: Macrolide (J01FA) usage by hospital

The difference in macrolide (e.g. clarithromycin) usage in Wales for 2007 is shown inFigure 6. There is a three-fold variation in usage between hospitals from 80DDD/1000 BD to 242 DDD/1000 BD.

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Fluoroquinolone (J01MA) usage by Hospital 2007

(DDD/1000 BD)

0

20

40

60

80

100

120

140

160

180

200

Hospital Code

DD

D/1

00

0B

D

J01M A 178 128 127 117 113 109 98 94 92 82 76 59 46 37 27

Q F C D K L B M N P B J R H G

Figure 7: Fluoroquinolone (J01MA) usage by hospital

The difference in fluoroquinolone (e.g. ciprofloxacin) usage in Wales for 2007 isshown in Figure 7. There is a six-fold variation in J01MA usage from 27 DDD/1000BD to 178 DDD/1000 BD.

Carbapenem (J01DH) usage by Hospital 2007

(DDD/1000 BD)

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Hospital Code

DD

D/1

00

0B

D

J01DH 27 25 25 24 21 21 15 13 13 13 13 11 8.7 7.8 2.9

F J K R P H M B C D G L N B Q

Figure 8: Carbapenem (J01DH) usage by hospital

The difference in carbapenem (e.g. meropenem) usage in Wales for 2007 is shownin Figure 8. There is nearly a ten-fold variation in usage from 2.9 DDD/1000 BD to 27DDD/1000 BD.

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Piperacillin/tazobactam (J01CR05), meropenem (J01DH02) &

imipenem (J01DH51) usage in 2007 by hospital (DDD/1000BD)

0

510

15202530

35

404550

556065

Hospital code

DD

D/1

000

BD

J01CR05 57 18 16 13 6.2 4.9 9.8 0.8 8.0 5.3 5.0 3.8 7.1 2.8 0.5

J01DH02 0.5 14 6.0 8.5 1.3 19 2.4 0.4 4.5 13 2.8 12 7.8 7.2 2.0

J01DH51 2.4 12 17 16 23 5.1 13 21 8.4 0.0 10 0.6 0.0 1.5 8.0

Q F R J K P M H D G A C B N L

Figure 9: Piperacillin/tazobactam (J01CR05), meropenem (J01DH02) andimipenem (J01DH51) usage by hospital

The difference in piperacillin/tazobactam, meropenem and imipenem usage betweenhospitals in Wales for 2007 is shown in Figure 9.

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Hospital A: Bronglais District Hospital, Aberystwyth

Antimicrobial usage DDD/1000 Bed Days

Hospital A: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180

200

220

240

Antimicrobial groups

DD

D/1

00

0B

D.

2005 40 80 47 96 178 37 77 61 17 113 87 4.8 12 129 19 2.8 8.5 121 4.2 0.1 2.4

2006 63 114 37 96 172 56 86 61 28 100 98 3.9 14 112 24 1.6 10 137 6.3 0.7 2.0

2007 56 89 39 80 217 56 87 61 13 117 98 5.8 9.2 98 11 3.4 4.9 124 5.8 0.7 4.8

2008 35 75 42 75 206 46 73 82 15 100 100 4.3 4.7 103 13 6.8 5.7 103 3.4 0.2 0.3

J01AA J01CA J01CE J01CF J01CR J01DB J01DC J01DD J01DH J01E J01FA J01F J01GB J01M A J01XA J01XB J01XC J01XD J01XE J01XX J04AB

Figure 10: Antimicrobial usage DDD/1000 bed days

Figure 10 shows antimicrobial usage in DDD/1000 BD for hospital A from January2005 to March 2008. Beta-lactam/beta-lactamase inhibitor combinations (J01CR)were the most prescribed antimicrobials accounting for 14-19% of total usageannually. Total antimicrobial usage varied annually: 1136.7 DDD/1000 BD (2005),1222.5 DDD/1000 BD (2006), and 1180.9 DDD/1000 BD (2007).

Antimicrobial groups - proportion of total antimicrobial usage


0

2

4

6

8

10

12

14

16

18

20


Pro

po

rtio

n%

.

2005 3.6 7.0 4.1 8.4 15.6 3.3 6.7 5.3 1.6 9.9 7.7 0.4 1.0 11.3 1.7 0.2 0.7 10.7 0.4 0.0 0.2

2006 5.3 9.3 3.0 7.8 14.1 4.6 7.0 4.9 2.3 8.2 8.0 0.3 1.1 9.2 1.9 0.1 0.8 11.2 0.5 0.1 0.2

2007 5.1 7.4 3.3 6.8 18.4 4.7 7.3 5.1 1.1 9.8 8.3 0.5 0.8 8.3 0.9 0.3 0.4 10.5 0.5 0.1 0.4

2008 3.5 6.9 3.8 7.0 18.8 4.2 6.5 7.4 1.4 9.1 9.0 0.4 0.4 9.5 1.1 0.6 0.5 9.4 0.3 0.0 0.0


Figure 11: Proportion of total antimicrobial usage

Figure 11 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage during 2005-2008 q1 (

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Proportion of oral antimicrobial usage


0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 92.9 52.9 66.0 76.7 99 17.9 32.8 0.0 98.0 84.4 51.4 0.0 82.7 0.0 0.0 96.6 47.8 100 100 91

2006 100 76.5 49.1 60.4 80.3 100 14.0 27.2 0.0 99.2 81.7 50.7 0.0 87.6 0.0 0.0 96.8 48.1 100 87 28.2

2007 100 83.9 57.1 61.8 80.2 100 10.9 37.6 0.0 99.6 82.3 76.8 0.0 87.1 0.0 0.0 89.9 50.6 100 100 100

2008 100 100 50.8 58.4 82.5 100 11.0 31.6 0.0 100 77.1 85.9 0.0 87.6 0.0 0.0 94.4 41 100 100 100.0

J01AA J01CA J01CE J01CF J01CR J01DB J01DC J01DD J01DH J01E J01FA J01F J01GB J01MA J01XA J01XB J01XC J01XD J01XE J01XX J04AB

Figure 12: Proportion of oral antimicrobial usage

Figure 12 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital A. Most of the changes were smaller than 5% although oral usageof broad spectrum penicillins (J01CA) fluctuated from 76.5% to 100%, and oral usageof clindamycin (J01F) from 50.7% to 85.9%.

Beta-lactam/beta-lactamase inhibitor combinations DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2

= 0.6504

0

25

50

75

100

125

150

175

200

225

250

Quarter

DD

D/1

00

0B

D

J01CR 184 187 175 165 187 181 147 174 223 203 208 233 206

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 13 shows the variation in usage of J01CR (predominantly co-amoxiclav) inhospital A; with evidence of seasonal prescribing and an increase in prescribing in2007.

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Antifolates (J01E) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.7095

0

20

40

60

80

100

120

140

Quarter

DD

D/1

000

BD

J01E 107 117 123 106 89 90 106 117 106 104 128 129 100

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 14: Antifolate (J01E) usage

Figure 14 shows the variation in J01E usage in hospital A, with no apparent trend inprescribing (predominantly trimethoprim usage).

Macrolides (J01FA) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2

= 0.3354

0

20

40

60

80

100

120

140

Quarter

DD

D/1

00

0B

D

J01FA 94 84 81 88 117 94 72 108 133 94 79 87 100

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 15: Macrolide (J01FA) usage

Figure 15 shows evidence of seasonal usage of J01FA in hospital A, with the highestuse in each year occurring in the winter quarters (Jan-Mar & Oct-Dec).

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Fluoroquinolones (J01MA) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2

= 0.4783

0

20

40

60

80

100

120

140

160

180

Quarter

DD

D/1

00

0B

D

J01MA 103 130 161 123 97 106 101 145 81 107 99 108 103

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 16: Fluoroquinolone (J01MA) usage

Figure 16 shows the variation in J01MA usage in hospital A, with a reduction inusage in 2007 q1 and little variation thereafter.

Total Antimicrobial Usage (J01) DDD/1000 Bed DaysQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.3753

0

100200

300

400

500600

700

800900

1000

1100

12001300

1400

Quarter

DD

D/1

00

0B

D

J01 1095 1024 1229 1199 1167 1257 1143 1323 1145 1221 1113 1245 1094

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 17: Total antimicrobial usage (oral and parenteral)

Figure 17 shows the variation in total antimicrobial usage in hospital A, from 2005 to2008 q1, fluctuating between 1024 -1323 DDD/1000 BD.

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Hospital B: Princess of Wales Hospital, Bridgend


Hospital B: 2005 - 2008q1

0

25

50

75

100

125

150

175

200

225

250

275

300


DD

D/1

00

0B

D.

2005 16 82 40 75 220 21 49 15 6.3 37 99 1.5 8.1 81 18 0.6 6.0 59 3.0 0.6 9.5

2006 14 81 54 86 250 26 46 17 6.7 47 123 4.4 7.9 89 18 0.8 8.7 71 2.7 0.2 11

2007 21 88 56 91 256 25 44 18 7.8 59 121 1.2 10 76 19 0.8 12 87 2.9 0.5 15

2008 14 112 40 75 278 24 37 18 6.5 64 145 0.4 10 64 11 0.5 2.6 83 3.0 0.4 16



Figure 18 shows antimicrobial usage in DDD/1000 BD for hospital B from January2005 to March 2008. Beta-lactam/beta-lactamase inhibitor combinations (J01CR)were the most prescribed antimicrobials accounting for 25 -28% of total usageannually. There has been a small increase in total antimicrobial usage each year:846.5 DDD/1000 BD (2005), 964.5 DDD/1000 BD (2006), and 1010.5 DDD/1000 BD(2007).


Hospital B: 2005 - 2008q1

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Pro

po

rtio

n%

.

2005 1.8 9.7 4.8 8.8 26.0 2.5 5.8 1.8 0.7 4.4 11.8 0.2 1.0 9.5 2.1 0.1 0.7 6.9 0.4 0.1 1.1

2006 1.5 8.4 5.6 8.9 25.9 2.7 4.8 1.7 0.7 4.8 12.8 0.5 0.8 9.3 1.9 0.1 0.9 7.3 0.3 0.0 1.2

2007 2.1 8.7 5.5 9.0 25.3 2.4 4.4 1.7 0.8 5.8 11.9 0.1 1.0 7.5 1.9 0.1 1.2 8.6 0.3 0.0 1.5

2008 1.4 11.1 4.0 7.5 27.6 2.4 3.7 1.8 0.6 6.4 14.4 0.0 1.0 6.4 1.1 0.0 0.3 8.3 0.3 0.0 1.6



Figure 19 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage during 2005-2008 q1 (

19


Hospital B 2005 - 2008q1

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 91.9 50.2 56.3 84.3 100 0.7 12.6 0.0 99.8 86.3 64.8 0.0 85.8 0.0 0.0 99.5 40.2 100 66 96

2006 99.7 89.2 54.8 58.7 86.4 100 3.5 6.6 0.0 99.4 89.1 38.5 0.0 86.7 0.0 0.0 98.9 47.5 100 10.9 91.9

2007 100 86.7 54.0 54.7 84.9 100 3.4 2.7 0.0 99.7 93.1 75.2 0.0 88.6 0.0 0.0 98.9 50.5 100 48 93

2008 100 82.7 56.6 60.9 84.1 100 3.0 6.6 0.0 99 96.1 51.8 0.0 93.5 0.0 0.0 100 56.1 100 100 97.1



Figure 20 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital A. Most of the changes were smaller than 5% although oral usageof clindamycin (J01F) fluctuated from 38.5% to 75.2%, and oral usage of linezolid(J01XX) from 10.9% to 100%.

Beta-lactam/beta-lactamase inhibitor combinations (J01CR)Quarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.7217

0

25

50

75

100

125

150

175

200

225

250

275

300

Quarter

DD

D/1

00

0B

D

J01CR 236 212 204 228 233 258 234 276 291 267 213 253 278

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 21 shows seasonal usage of J01CR (predominantly co-amoxiclav) in hospitalB, with the highest use generally in the winter quarters (Jan-Mar & Oct-Dec).

20


R2 = 0.5429

0

20

40

60

80

100

120

140

160

Quarter

DD

D/1

00

0B

D

J01FA 106 100 88 103 137 129 108 118 148 108 100 127 145

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 22 shows the variation in J01FA usage in hospital B; with some evidence ofseasonal prescribing and an increase in prescribing in 2006/2007.

Broad Spectrum Pencillins (J01CA) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.5808

0

10

20

30

40

50

60

70

80

90

100

110

120

Quarter

DD

D/1

000

BD

J01CA 82 75 75 96 107 73 64 80 92 67 87 107 112

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 23: Broad spectrum penicillin (J01CA) usage

Figure 23 shows seasonal usage of J01CA in hospital B, with the highest use in thewinter quarters (Jan-Mar & Oct-Dec).

21


R2

= 0.691

0

10

20

30

40

50

60

70

80

90

100

Quarter

DD

D/1

00

0B

D

J01MA 80 77 83 83 97 78 89 93 81 76 76 72 64

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 24 shows the variation in J01MA usage in hospital B; which peaked in quarter5 (Jan-Mar 2006) and decreased through 2007 to 2008 q1.


R2

= 0.8334

0

100

200

300

400

500

600

700

800

900

1000

1100

Quarter

DD

D/1

00

0B

D

J01 813 826 855 892 962 978 919 999 1047 983 954 1058 1005

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 25 shows a gradual increase in total antimicrobial usage in hospital B duringthe period 2005 to 2007.

22

Hospital C: Royal Glamorgan Hospital, Pontypridd


Hospital C: 2005 - 2008q1

0

50

100

150

200

250

300

350

400

450

500


DD

D/1

00

0B

D.

2005 72 95 33 99 405 34 42 21 7 47 253 1.1 14 130 12 2.4 10 85 3.6 1.0 6.2

2006 87 88 40 95 433 37 44 30 11 42 244 5.7 16 139 15 0.6 19 96 5.3 1.1 5.9

2007 95 102 48 111 406 34 46 32 13 46 240 6.3 18 127 17 0.1 19 92 4.6 1.3 8.9

2008 138 94 46 107 394 30 45 23 12 52 220 5.4 20 111 14 0.5 13 88 3.8 0.5 3.7



Figure 26 shows antimicrobial usage in DDD/1000 BD for hospital C from January2005 to March 2008. Beta-lactam/beta-lactamase inhibitor combinations (J01CR)were the most prescribed antimicrobials accounting for 28-30% of total usageannually. There has been a small increase in total antimicrobial usage each year:1373.2 DDD/1000 BD (2005), 1455.3 DDD/1000 BD (2006), to 1468.1 DDD/1000 BD(2007).



02468

1012141618202224262830


Pro

po

rtio

n%

.

2005 5.2 6.9 2.4 7.2 29.5 2.4 3.1 1.5 0.5 3.4 18.4 0.1 1.0 9.5 0.9 0.2 0.7 6.2 0.3 0 0.5

2006 6.0 6.1 2.7 6.5 29.8 2.5 3.0 2.1 0.8 2.9 16.8 0.4 1.1 9.5 1.0 0.0 1.3 6.6 0.4 0 0.4

2007 6.5 7.0 3.3 7.6 27.7 2.3 3.1 2.1 0.9 3.1 16.4 0.4 1.2 8.7 1.1 0.0 1.3 6.3 0.3 0 0.6

2008 9.7 6.6 3.2 7.5 27.7 2.1 3.2 1.7 0.9 3.7 15.5 0.4 1.4 7.8 1.0 0.0 0.9 6.2 0.3 0 0.3



Figure 27 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage between 2005-2008 q1 (

23



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 93.2 53.0 74.6 86.4 100 0.9 2.5 0.0 99.5 95.8 92.3 0.0 86.4 0.0 0.0 95.7 49 100 86.7 100

2006 100 85.6 58.9 67.3 86.5 100 0.7 0.9 0.0 97.9 96.5 83.2 0.0 88.5 0.0 0.0 97.5 52 100.0 65.6 99.2

2007 100 87.2 54.7 66.1 85.8 100 1.0 0.4 0.0 97.1 96.6 83.3 0.0 87.7 0.0 0.0 97.0 50 100 60.0 93.6

2008 100 91.2 56.1 71.5 85.3 100 0.0 0.0 0.0 99 96.2 75.6 0.0 89.8 0.0 0 98.7 54 100.0 43.8 87.1



Figure 28 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital C. Most of the changes were smaller than 5%, the only notableexceptions were clindamycin (J01F) that have changed from 92.3% oral use to75.6% and linezolid (J01XX) that changed from 86.7 % oral use to 43.8 %.


R2 = 0.8702

0

50

100

150

200

250

300

350

400

450

500

Quarter

DD

D/1

00

0B

D

J01CR 453 375 366 427 435 445 418 435 462 412 387 364 394

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 29 shows seasonal usage of J01CR (predominantly co-amoxiclav) in hospitalC, with the highest use generally in the winter quarters (Jan-Mar & Oct-Dec).

24


R2

= 0.7651

0

50

100

150

200

250

300

350

Quarter

DD

D/1

00

0B

D

J01FA 338 226 188 260 268 253 207 248 266 245 217 233 220

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 30 shows the variation in J01FA usage in hospital C; there is some evidenceof seasonal usage with the highest use in each year occurring in the winter quarter(Jan-Mar).


R2

= 0.9557

0

20

40

60

80

100

120

140

160

Quarter

DD

D/1

00

0B

D

J01MA 149 128 119 124 131 139 145 141 142 126 118 123 111

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 31 shows the variation in J01MA usage in hospital C; with no apparent trendin usage.

25


R2 = 0.8262

0100200300400500600700800900

1000110012001300140015001600

Quarter

DD

D/1

00

0B

D

J01 1539 1251 1260 1442 1408 1469 1403 1541 1552 1484 1414 1423 1423

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 32 shows the variation in total antimicrobial usage in hospital C, with moreobvious seasonal prescribing in 2005 (winter peaks) and a smoother but slightlyhigher trend line through 2006 and 2007.

26

Hospital D: Royal Gwent Hospital, Newport


Hospital D: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180

200

220

240


DD

D/1

00

0B

D.

2005 22 173 53 86 172 61 64 17 8.3 55 208 9.4 13 104 18 0.8 5.9 90 2.8 1.0 15

2006 18 184 56 94 200 67 71 20 11 57 211 6.7 13 108 17 0.7 4.7 100 1.1 1.5 17

2007 18 184 48 87 184 65 79 20 13 51 220 3.6 17 117 20 0.7 3.0 109 2.1 0.9 12

2008 15 175 45 80 193 64 74 19 14 38 196 3.5 17 104 29 0.5 5.8 114 3.7 0.9 14



Figure 33 shows antimicrobial usage in DDD/1000 BD for hospital D from January2005 to March 2008. Macrolides (J01FA) were the most prescribed antimicrobialsaccounting for 16-18% of total usage annually, though usage of broad spectrumpenicillins (J01CA) and beta-lactam/beta-lactamase inhibitor combinations (J01CR)were only slightly less than macrolides. Total annual antimicrobial usage hasremained relatively stable: 1178.4 DDD/1000 BD (2005), 1259.6 DDD/1000 BD(2006), to 1255.5 DDD/1000 BD (2007).



0

2

4

6

8

10

12

14

16

18


Pro

po

rtio

n%

.

2005 1.9 14.7 4.5 7.3 14.6 5.2 5.4 1.4 0.7 4.6 17.7 0.8 1.1 8.8 1.5 0.1 0.5 7.7 0.2 0 1.3

2006 1.4 14.6 4.5 7.5 15.9 5.3 5.7 1.6 0.9 4.5 16.7 0.5 1.0 8.6 1.4 0.1 0.4 7.9 0.1 0 1.3

2007 1.4 14.6 3.8 7.0 14.6 5.2 6.3 1.6 1.0 4.0 17.6 0.3 1.4 9.4 1.6 0.1 0.2 8.7 0.2 0 1.0

2008 1.3 14.5 3.7 6.6 16.0 5.3 6.2 1.5 1.1 3.2 16.2 0.3 1.4 8.6 2.4 0.0 0.5 9.5 0.3 0 1.1



Figure 34 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage between 2005-2008 q1 (

27



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 86.8 55.5 59.9 84.1 99 0.4 0.0 0.0 99.7 94.8 86.4 0.0 91.3 0.0 0.0 99.0 50 100 62.3 99.2017

2006 100 86.4 51.5 55.6 84.9 99 0.1 0.0 0.0 99.6 94.7 76.7 0.0 92.0 0.0 0.0 93.8 52 100.0 49.0 93.2

2007 100 84.6 53.9 58.4 84.2 100 0.1 0.0 0.0 97.9 95.5 61.6 0.0 95.4 0.0 0.0 99.5 50 100 52.0 91.8

2008 100 87.1 46.9 55.7 83.0 100 0.0 0.0 0.0 99 93.7 86.6 0.0 95.7 0.0 0 98.9 55 100.0 47.2 92.3



Figure 35 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital D. Most of the changes were smaller than 5%, the only notableexception was clindamycin (J01F) that fluctuated between 61.6% to 86.6% oral use.


R2

= 0.0668

0

40

80

120

160

200

240

280

Quarter

DD

D/1

00

0B

D

J01FA 211 211 203 209 229 214 170 231 269 202 179 231 196

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 36 shows some evidence of seasonal usage of J01FA in hospital D, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec).

28


R2 = 0.3734

0

20

40

60

80

100

120

140

160

180

200

220

Quarter

DD

D/1

000

BD

J01CA 191 171 142 187 177 190 164 204 217 170 169 179 175

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 37 shows seasonal usage of J01CA in hospital D, with the highest use eachyear in the winter quarters (Jan-Mar & Oct-Dec).

Beta-lactam/beta-lactamase Inhibitor combinations (J01CR)Quarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2

= 0.6642

0

25

50

75

100

125

150

175

200

225

Quarter

DD

D/1

00

0B

D

J01CR 161 161 184 183 184 190 210 216 200 157 176 203 193

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 38: Beta-lactam/beta-lactam inhibitor combinations (J01CR) usage

Figure 38 shows some evidence of seasonal usage of J01CR (predominantly co-amoxiclav) in hospital D, with the highest use generally in the winter quarters (Jan-Mar & Oct-Dec).

29


R2

= 0.958

0

20

40

60

80

100

120

140

Quarter

DD

D/1

00

0B

D

J01MA 93 113 106 104 104 104 109 115 110 114 120 126 104

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 39 shows the variation in J01MA usage in hospital D; with a small increase inusage during 2007.


R2

= 0.6448

0

200

400

600

800

1000

1200

1400

Quarter

DD

D/1

00

0B

D

J01 1110 1186 1185 1233 1224 1249 1222 1343 1297 1194 1221 1309 1205

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 40 shows the total antimicrobial usage in hospital D; with more obviousseasonal prescribing in 2007 (winter peaks) and a smoother and slightly lower trendline through 2005 and 2006.

30

Hospital F: University Hospital of Wales, Cardiff


Hospital F: 2005 - 2008q1

0

25

50

75

100

125

150

175

200

225

250

275

300


DD

D/1

00

0B

D.

2005 13 52 44 87 279 25 49 20 20 77 123 6.7 29 137 39 3.7 12 71 6.0 3.0 13

2006 14 59 44 87 230 26 49 18 22 64 112 6.9 28 132 38 3.5 11 67 10 3.8 17

2007 19 63 38 90 252 27 49 17 27 62 109 6.0 26 128 43 3.8 13 77 6.3 3.7 21

2008 13 61 28 70 258 23 48 17 28 56 100 3.6 24 97 56 2.1 4.2 66 7.3 2.4 15



Figure 41 shows antimicrobial usage in DDD/1000 BD for hospital F from January2005 - March 2008. Beta-lactam/beta-lactamase inhibitor combinations (J01CR)were the most prescribed antimicrobials accounting for 22-26% of total usageannually. There has been little change in annual total antimicrobial usage rates 2005-2007: 1108.5 DDD/1000 BD (2005), 1042.0DDD/1000 BD (2006), and 1080.0DDD/1000 BD (2007).



0.02.04.06.08.0

10.012.014.016.018.020.022.024.026.028.0


Pro

po

rtio

n%

.

2005 1.2 4.7 4.0 7.8 25.1 2.3 4.4 1.8 1.8 6.9 11.1 0.6 2.7 12.3 3.5 0.3 1.1 6.4 0.5 0 1.1

2006 1.3 5.7 4.2 8.3 22.0 2.5 4.7 1.7 2.2 6.1 10.8 0.7 2.7 12.6 3.6 0.3 1.1 6.4 1.0 0 1.6

2007 1.8 5.8 3.5 8.3 23.3 2.5 4.5 1.6 2.5 5.7 10.1 0.6 2.4 11.8 4.0 0.3 1.2 7.1 0.6 0 1.9

2008 1.4 6.2 2.8 7.2 26.3 2.3 4.9 1.8 2.8 5.7 10.2 0.4 2.5 9.9 5.7 0.2 0.4 6.8 0.7 0 1.5



Figure 42 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage between 2005-2008q1 (

31



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 86.8 55.5 59.9 84.1 99 0.4 0.0 0.0 99.7 94.8 86.4 0.0 91.3 0.0 0.0 99.0 50 100 62.3 99.2017

2006 100 86.4 51.5 55.6 84.9 99 0.1 0.0 0.0 99.6 94.7 76.7 0.0 92.0 0.0 0.0 93.8 52 100.0 49.0 93.2

2007 100 84.6 53.9 58.4 84.2 100 0.1 0.0 0.0 97.9 95.5 61.6 0.0 95.4 0.0 0.0 99.5 50 100 52.0 91.8

2008 100 87.1 46.9 55.7 83.0 100 0.0 0.0 0.0 99 93.7 86.6 0.0 95.7 0.0 0 98.9 55 100.0 47.2 92.3



Figure 43 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital F; most of the changes were smaller than 5%.


R2

= 0.7971

0

40

80

120

160

200

240

280

320

Quarter

DD

D/1

00

0B

D

J01CR 315 265 268 266 255 235 210 220 262 225 250 270 258

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 44 shows some evidence of seasonal usage of J01CR in hospital F, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec). In 2007, J01CRusage comprised 92.5% co-amoxiclav, 7.3% piperacillin/tazobactam, and 0.2%ticarcillin/clavulanate.

32


R2

= 0.785

0

20

40

60

80

100

120

140

160

180

Quarter

DD

D/1

00

0B

D

J01MA 118 129 139 160 133 129 142 122 130 128 132 121 97

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 39 shows the variation in J01MA usage in hospital F, which peaked in quarter4 (Oct-Dec 2005).


R2

= 0.7982

0

25

50

75

100

125

150

175

Quarter

DD

D/1

00

0B

D

J01FA 171 111 99 111 133 118 96 101 122 96 101 119 100

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 40 shows seasonal usage of J01FA in hospital F, with the highest use in thewinter quarters (Jan-Mar & Oct-Dec).

33

Beta-lactamase resistant pencillins (J01CF) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.6561

0

10

20

30

40

50

60

70

80

90

100

110

Quarter

DD

D/1

000

BD

J01CF 71 88 97 92 86 96 92 72 66 100 90 103 70

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 47: Beta-lactamase resistant penicillins (J01CF) usage

Figure 47 shows some evidence of seasonal usage of J01CF (predominantlyflucloxacillin) in hospital F, with the highest use generally in the summer quarters(Apr-Jun & Jul-Sep).


R2

= 0.8325

0

100

200

300

400

500

600

700

800

900

1000

1100

1200

Quarter

DD

D/1

00

0B

D

J01 1125 1103 1096 1111 1097 1051 1026 994 1058 1040 1067 1154 980

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 48 shows the variation in total antimicrobial usage in hospital F, from 2005 to2008 q1, fluctuating between 980 -1154 DDD/1000 BD.

34

Hospital G: Withybush General Hospital


Hospital G: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180


DD

D/1

00

0B

D.

2005 27 119 26 54 71 30 44 20 10 35 88 30 6.3 50 3.0 0.3 5.3 69 1.8 3.0 15

2006 10 118 26 53 90 35 37 17 11 28 75 27 5.7 47 3.0 1.7 8.1 68 3.4 3.5 17

2007 16 142 30 54 111 43 44 17 13 35 103 38 7.5 27 2.3 0.8 6.5 75 5.3 1.6 14

2008 46 155 21 40 106 40 44 23 18 47 135 34 6.9 18 2.4 0.2 4.6 64 6.4 1.4 7.9



Figure 49 shows antimicrobial usage in DDD/1000 BD for hospital G from January2005 to March 2008. Broad spectrum penicillins (J01CA) were the most prescribedantimicrobials accounting for 17-19% of total usage annually. There was a notableincrease in total antimicrobial usage in 2007 and in the first quarter of 2008: 707.8DDD/1000 BD (2005); 687.1 DDD/1000 BD (2006); to 785.7 DDD/1000 BD (2007)and 819.9 DDD/1000 BD (2008q1).



0

2

4

6

8

10

12

14

16

18

20


Pro

po

rtio

n%

.

2005 3.9 16.8 3.6 7.6 10.0 4.3 6.3 2.9 1.5 4.9 12.4 4.3 0.9 7.1 0.4 0.0 0.8 9.7 0.2 0 2.1

2006 1.5 17.2 3.9 7.7 13.2 5.1 5.4 2.5 1.6 4.1 10.9 3.9 0.8 6.8 0.4 0.2 1.2 9.9 0.5 1 2.5

2007 2.1 18.1 3.8 6.8 14.1 5.5 5.6 2.2 1.7 4.5 13.1 4.8 1.0 3.5 0.3 0.1 0.8 9.5 0.7 0 1.8

2008 5.6 18.9 2.6 4.9 13.0 4.8 5.4 2.8 2.1 5.7 16.4 4.2 0.8 2.1 0.3 0.0 0.6 7.9 0.8 0 1.0



Figure 50 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with only minor changes in usage between 2005 – 2008 q1 (

35



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 99.0 69.1 51.8 68.7 83.9 100 17.9 0.0 0.0 98.5 95.0 93.4 0.0 77.1 0.0 0.0 99.2 52.0 100 82.2 99.0

2006 100 75.1 55.8 67.7 83.5 100 10.4 1.0 0.0 99.2 92.2 93.7 0.0 72.7 0.0 0.0 98.2 54.3 100.0 74.0 95.2

2007 99.4 69.3 56.1 68.5 79.3 100 8.7 0.4 0.0 98.8 94.4 89.3 0.0 70.5 0.0 0.0 99.2 52.7 100 75.6 95.7

2008 100 63.5 76.1 70.1 70.5 100 9.8 2.8 0.0 98.3 92.6 86.0 0.0 64.3 0.0 0 100 44.7 100 93.3 84.5



Figure 51 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital G. Most of the changes were smaller than 8%; the only notableexceptions were the beta-lactamase sensitive penicillins (J01CE) that changed from51.8% oral use to 76.1% and linezolid (J01XX) that changed from 74.0 % oral use to93.3 %.


R2 = 0.4295

0

20

40

60

80

100

120

140

160

Quarter

DD

D/1

000

BD

J01CA 122 119 104 130 151 142 93 87 149 142 121 157 155

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 52 shows some evidence of seasonal usage of J01CA in hospital G, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec).

36


R2 = 0.6867

0

20

40

60

80

100

120

140

Quarter

DD

D/1

000

BD

J01FA 106 87 75 84 86 73 63 78 120 96 79 116 135

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 53 shows seasonal usage of J01FA in hospital G, with the highest use in thewinter quarters (Jan-Mar & Oct-Dec), and an increase in usage during 2007-2008q1.


R2

= 0.7505

0

20

40

60

80

100

120

140

160

180

Quarter

DD

D/1

00

0B

D

J01CR 70 64 68 81 89 75 83 114 85 89 100 168 106

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 54 shows some evidence of seasonal usage of J01CR in hospital G, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec); with a notable peakin quarter 12 (Oct-Dec 2007). In 2007, J01CR usage comprised 91.2% co-amoxiclavand 9.8% piperacillin/tazobactam.

37


R2

= 0.9102

0

10

20

30

40

50

60

Quarter

DD

D/1

00

0B

D

J01MA 56 54 41 51 55 45 46 41 46 31 16 16 18

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 55 shows the variation in J01MA usage in hospital G; with a notable reductionin usage beginning in quarter 10 (Apr-Jun 2007) and continuing through to quarter 13(Jan-Mar 2008).


R2 = 0.7902

0

100

200

300

400

500

600

700

800

900

1000

Quarter

DD

D/1

000

BD

J01 706 714 688 724 703 685 685 675 738 760 731 914 820

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 56 shows very little difference in total antimicrobial usage in hospital G duringthe period 2005 to 2006, but a marked increase in usage in the winter quarters 12(Oct-Dec 2007) and 13 (Jan-Mar 2008).

38

Hospital H: Wrexham Maelor Hospital, Wrexham


Hospital H: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180


DD

D/1

00

0B

D.

2005 24 137 25 39 118 14 7.2 12 14 39 83 6.0 12 140 14 0.2 1.6 68 5.9 0.8 8.7

2006 31 152 25 43 148 19 7.1 14 20 43 85 9.1 12 67 12 0.4 1.7 77 10 1.8 7.1

2007 36 159 23 47 166 26 9.7 18 21 54 80 11 15 37 14 0.4 2.0 77 8.0 1.8 8.6

2008 49 147 24 38 152 22 8.8 22 17 45 79 8.8 12 44 9.2 2.8 0.7 71 7.7 3.4 7.9



Figure 57 shows antimicrobial usage in DDD/1000 BD for hospital H from January2005 to March 2008. The fluoroquinolones (J01MA) were the most prescribedantimicrobials in 2005; however in 2006 and 2007 the highest usage was amongstthe broad spectrum penicillins (J01CA) & beta-lactam/beta lactamase inhibitorcombinations (J01CR). There has been a small increase in total antimicrobial usageannually 2005-2007: 769.2 DDD/1000 BD (2005), 785.2 DDD/1000 BD (2006), and816.5 DDD/1000 BD (2007).


Hospital H: 2005 - 2007

0

24

6

810

1214

16

1820

22


Pro

po

rtio

n%

.

2005 3.1 17.8 3.3 5.1 15.3 1.8 0.9 1.6 1.8 5.1 10.8 0.8 1.5 18.2 1.8 0.0 0.2 8.9 0.8 0 1.1

2006 3.9 19.3 3.2 5.5 18.9 2.4 0.9 1.8 2.6 5.5 10.9 1.2 1.5 8.6 1.5 0.1 0.2 9.8 1.3 0 0.9

2007 4.3 19.1 2.8 5.7 20.0 3.1 1.2 2.2 2.6 6.5 9.6 1.4 1.9 4.5 3.6 0.0 0.2 9.3 1.0 0 1.0

2008 6.3 19.1 3.1 5.0 19.7 2.8 1.1 2.8 2.2 5.8 10.3 1.1 1.5 5.7 1.2 0.4 0.1 9.3 1.0 0 1.0



Figure 58 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with notable changes in usage of fluoroquinolones and beta lactamscombined with a beta lactamase inhibitor between 2005 & 2006.

39


Hospital H: 2005 - 2008q1

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 90.9 54.8 93.6 78.8 100 9.1 0.0 0.0 98.7 90.1 74.9 0.0 87.7 0.0 0.0 98.2 52 100 86.7 87.5518

2006 100 92.7 48.1 93.3 75.1 100 9.6 0.0 0.0 99.5 90.3 90.8 0.0 88.7 0.0 0.0 95.2 48 100.0 86.5 74.8

2007 99 90.1 63.5 91.0 74.3 100 4.2 0.4 0.0 98.6 92.0 86.9 0.0 86.3 0.0 0.0 98.2 49 100 99.1 90.1

2008 99 91.1 54.7 90.4 79.1 100 -0.2 0.1 0.0 99 88.2 91.1 0.0 87.7 0.0 0 100.0 45 100.0 96.9 85.8



Figure 59 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital H; most of the changes were smaller than 5%.


R2

= 0.9466

0

20

40

60

80

100

120

140

160

180

200

Quarter

DD

D/1

00

0B

D

J01CR 141 127 94 110 128 140 151 173 166 160 174 165 152

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 60 shows the variation in usage of J01CR (predominantly co-amoxiclav) inhospital H, and a gradual increase in prescribing throughout 2006, stabilizing in 2007.

40


R2 = 0.5531

0

25

50

75

100

125

150

175

200

Quarter

DD

D/1

000

BD

J01CA 151 138 109 151 148 148 145 167 189 153 144 151 147

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 61: Broad Spectrum Penicillin (J01CA) usage

Figure 61 shows seasonal usage J01CA in hospital H, with the highest use each yearin the winter quarters (Jan-Mar & Oct-Dec).


R2

= 0.9467

0

20

40

60

80

100

120

140

160

Quarter

DD

D/1

00

0B

D

J01MA 143 147 131 138 113 99 21 36 39 37 37 36 44

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 62 shows the variation in J01MA usage in hospital H; prescribing decreasedmarkedly in quarter 7 (Jul-Sep 2006) and has remained low throughout the followingquarters.

41

Third Generation Cephalosporins (J01DD) DDD/1000 BDQuarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.8217

0

5

10

15

20

25

30

Quarter

DD

D/1

000

BD

J01DD 12 12 12 14 11 15 14 14 16 14 15 28 22

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 63: Third Generation Cephalosporin (J01DD) usage

Figure 63 shows the variation in usage of J01DD in hospital H; showing a markedincrease in prescribing in Oct-Dec 2007.


R2

= 0.4141

0

100

200

300

400

500

600

700

800

900

Quarter

DD

D/1

00

0B

D

J01 812 749 725 791 780 804 719 837 809 837 777 843 771

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 64 shows evidence of seasonal antimicrobial usage, with the third quarter ofeach year (Jul-Sep) being the lowest.

42

Hospital J: West Wales General Hospital, Carmarthen


Hospital J: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180

200


DD

D/1

00

0B

D.

2005 51 140 53 72 115 61 58 23 11 50 165 1.1 13 89 9.4 0.2 14 93 2.5 6.5 6.8

2006 55 158 60 91 130 52 75 20 18 54 168 2.0 17 64 9.9 0.2 17 109 2.5 3.4 3.6

2007 72 158 58 84 131 52 81 20 25 55 155 1.0 21 59 14 0.0 17 118 3.0 2.9 5.2

2008 74 140 47 83 152 61 66 23 22 45 175 4.2 18 63 15 0.8 17 112 5.5 1.5 5.6



Figure 65 shows antimicrobial usage in DDD/1000 BD for hospital J from January2005 to March 2008. Macrolides (J01FA) were the most prescribed antimicrobialsaccounting for 14-16% of total usage annually, though usage of the broad spectrumpenicillins (J01CA) and beta-lactam/beta-lactamase inhibitor combinations (J01CR)was only slightly less than macrolides. Total annual antimicrobial usage increasedthrough 2006-2007: 1034.8 DDD/1000 BD (2005) to 1109.4 DDD/1000 BD (2006);1132.8 DDD/1000 BD (2007).



0

2

4

6

8

10

12

14

16

18


Pro

po

rtio

n%

.

2005 4.9 13.5 5.1 7.0 11.1 5.9 5.6 2.2 1.1 4.9 16.0 0.1 1.2 8.6 0.9 0.0 1.4 9.0 0.2 1 0.7

2006 5.0 14.3 5.4 8.2 11.8 4.6 6.8 1.8 1.6 4.8 15.1 0.2 1.5 5.7 0.9 0.0 1.5 9.8 0.2 0 0.3

2007 6.4 14.0 5.1 7.4 11.5 4.6 7.2 1.7 2.2 4.9 13.7 0.1 1.8 5.2 1.2 0.0 1.5 10.4 0.3 0 0.5

2008 6.5 12.3 4.1 7.3 13.4 5.4 5.8 2.1 2.0 4.0 15.4 0.4 1.6 5.6 1.3 0.1 1.5 9.9 0.5 0 0.5




43



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 85.2 57.5 60.3 81.0 100 5.5 11.5 0.0 99.7 94.6 70.3 0.0 86.5 0.0 0.0 97.9 45 100 91.2 95.124519

2006 100 87.1 53.3 57.2 82.0 100 14.9 4.3 0.0 98.5 94.5 46.2 0.0 89.4 0.0 0.0 97.1 43 100.0 79.8 87.1

2007 100 81.2 55.6 63.9 78.8 100 19.2 8.6 0.0 97.8 96.1 62.2 0.0 88.2 0.0 0.0 99.5 44 100 88.1 93.9

2008 100 83.8 57.7 66.1 78.0 100 16.0 7.5 0.0 100 96.4 84.5 0.0 87.3 0.0 0 99.2 50 100.0 80.0 95.8



Figure 67 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital J. Most of the changes were smaller than 10% although oral usageof clindamycin (J01F) fluctuated from 46.2% to 84.5%.


R2

= 0.2887

0

20

40

60

80

100

120

140

160

180

200

220

Quarter

DD

D/1

00

0B

D

J01FA 190 192 136 144 200 156 139 177 192 120 138 170 175

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 68 shows evidence of seasonal usage of J01FA in hospital J, with the highestuse generally in the winter quarters (Jan-Mar & Oct-Dec).

44


R2 = 0.3339

0

25

50

75

100

125

150

175

200

Quarter

DD

D/1

000

BD

J01CA 150 136 115 159 182 139 150 163 184 150 139 160 140

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 69 shows seasonal usage of J01CA in hospital J, with the highest use in thewinter quarters (Jan-Mar & Oct-Dec).


R2

= 0.7556

0

20

40

60

80

100

120

140

160

180

200

Quarter

DD

D/1

00

0B

D

J01CR 117 114 129 98 123 122 129 147 104 109 136 174 152

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 70: Beta lactams combined with beta lactamase inhibitor (J01CR) usage

Figure 70 shows some evidence of seasonal usage of J01CR in hospital J, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec). In 2007, J01CRusage comprised 93.7% co-amoxiclav, and 6.3% piperacillin/tazobactam.

45


R2

= 0.8693

0

10

20

30

40

50

60

70

80

90

100

Quarter

DD

D/1

00

0B

D

J01MA 76 92 96 92 64 71 68 50 48 59 66 64 63

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 71 shows the variation in J01MA usage in hospital J; with a notable reductionin usage 2006 and a slight increase in 2007.


R2

= 0.7179

0

100

200300

400

500

600700

800

900

10001100

1200

1300

Quarter

DD

D/1

00

0B

D

J01 1043 1099 989 1009 1077 1052 1124 1185 1181 1040 1086 1224 1133

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 72: Total antimicrobial (oral and parenteral)

Figure 72 shows the variation in total antimicrobial usage in hospital J; with slightlyhigher and more obvious seasonal usage in 2007 (winter peaks).

46

Hospital K: Ysbyty Gwynedd, Bangor


Hospital K: 2005 - 2008q1

0

25

50

75

100

125

150

175

200

225

250

275


DD

D/1

00

0B

D.

2005 20 226 51 74 91 55 25 59 14 35 127 3.7 16 102 13 1.3 6.4 88 2.1 0.5 11

2006 25 226 50 85 116 53 28 57 20 36 142 4.3 13 108 14 1.1 11 92 3.3 0.1 14

2007 20 242 36 86 132 65 33 56 25 35 167 4.2 13 113 18 0.8 0 100 2.7 0.5 11

2008 13 254 24 87 146 61 37 54 22 45 158 14 13 126 20 1.6 13 97 0.0 1.4 15



Figure 73 shows antimicrobial usage in DDD/1000 BD for hospital K from January2005 to March 2008. Broad spectrum penicillins (J01CA) were the most prescribedantimicrobials accounting for 21-22% of total usage annually. There has been a smallincrease in total antimicrobial usage 2005-2007: 1020.1 DDD/1000 BD (2005);1109.4 DDD/1000 BD (2006); to 1147.0 DDD/1000 BD (2007).



02468

1012141618202224


Pro

po

rtio

n%

.

2005 2.0 22.1 5.0 7.2 8.9 5.4 2.4 5.7 1.3 3.4 12.4 0.4 1.6 10.0 1.3 0.1 0.6 8.6 0.2 0 1.1

2006 2.3 20.5 4.6 7.7 10.6 4.8 2.5 5.2 1.9 3.3 12.9 0.4 1.2 9.8 1.3 0.1 1.0 8.4 0.3 0 1.2

2007 1.7 21.1 3.1 7.5 11.5 5.7 2.9 4.9 2.1 3.0 14.6 0.4 1.1 9.9 1.6 0.1 -1.1 8.7 0.2 0 1.0

2008 1.1 21.1 2.0 7.2 12.1 5.0 3.1 4.5 1.8 3.7 13.1 1.1 1.1 10.5 1.7 0.1 1.1 8.1 0.0 0 1.2




47



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 87.7 55.0 60.7 81.1 100 3.9 0.0 0.0 96.3 94.4 64.3 0.0 93.1 0.0 0.0 96.5 42.2 100 100 85.0

2006 100 87.7 57.7 64.8 83.2 100 4.3 0.0 0.0 99.3 92.8 52.7 0.0 94.5 0.0 0.0 95.1 44.7 100.0 100.0 88.7

2007 100 88.7 80.1 65.3 84.1 100 3.1 0.0 0.0 96.2 93.8 56.2 0.0 94.0 0.0 0.0 101.8 48.0 100 97.3 85.0

2008 100 91.1 96.1 64.5 82.9 100 0.0 0.0 0.0 95.2 92.0 64.3 0.0 97.9 0.0 0 98.2 48.9 100.0 63.9 87.8



Figure 75 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital K. Most of the changes were smaller than 8%, the only notableexceptions were the beta-lactamase sensitive penicillins (J01CE) that changed from55.0% oral use to 96.1% and linezolid (J01XX) that changed from 100 % oral use to63.9 %.


R2 = 0.5788

0

25

50

75

100

125

150

175

200

225

250

275

300

Quarter

DD

D/1

000

BD

J01CA 264 200 202 236 256 227 196 223 238 221 211 299 254

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 76 shows seasonal usage of J01CA in hospital K, with the highest use in thewinter quarters (Jan-Mar & Oct-Dec).

48


R2 = 0.5702

0

20

40

60

80

100

120

140

160

180

200

Quarter

DD

D/1

00

0B

D

J01FA 137 119 106 145 154 136 119 157 192 163 145 169 158

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 77: Macrolide usage DDD/1000 bed days

Figure 77 shows evidence of seasonal usage of J01FA in hospital K, with the highestuse generally in the winter quarters (Jan-Mar & Oct-Dec).

Beta-lactam/beta-lactamase Inhibitor combinations (J01CR)Quarter 1 (Jan-Mar 2005) - Quarter 13 (Jan-Mar 2008)

R2 = 0.88

0

20

40

60

80

100

120

140

160

Quarter

DD

D/1

00

0B

D

J01CR 78 89 99 96 112 96 130 126 135 126 143 122 146

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 78: Beta lactams combined with beta lactamase inhibitor (J01CR) usage

Figure 78 shows a marked increase in J01CR usage (predominantly co-amoxiclav)through 2005-2007 in hospital K.

49


R2

= 0.7313

0

20

40

60

80

100

120

140

Quarter

DD

D/1

00

0B

D

J01MA 110 92 104 103 97 105 118 112 104 113 108 127 126

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 79 shows the variation in J01MA usage in hospital K; with a small increase inusage over time.


R2

= 0.7807

500

600

700

800

900

1000

1100

1200

1300

Quarter

DD

D/1

00

0B

D

J01 1042 943 1000 1095 1135 1028 1099 1132 1134 1103 1111 1240 1201

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 80 shows the variation in total antimicrobial usage in hospital K; with a notableincrease in quarters 12 (Oct-Dec 2007) and 13 (Jan-Mar 2008).

50

Hospital L: Ysbyty Glan Clwyd, Rhyl


Hospital L: 2005 - 2008q1

0255075

100125150175200225250275300325350


DD

D/1

00

0B

D.

2005 44 113 46 105 334 42 57 52 4.4 80 175 4.1 10 113 16 0.5 11 127 5.1 1.7 11

2006 39 104 49 91 332 48 54 67 5.5 71 163 3.4 11 118 16 2.4 10 125 6.1 2.1 8.0

2007 51 173 52 108 286 55 58 62 11 91 190 4.8 11 109 18 1.6 12 138 7.1 1.0 11

2008 60 269 60 102 144 60 75 50 15 95 212 8.0 12 133 24 1.5 7.5 143 9.5 0.9 3.0



Figure 81 shows antimicrobial usage in DDD/1000 BD for hospital L from January2005 to March 2008. Beta-lactam/beta-lactamase inhibitor combinations (J01CR)were the most prescribed antimicrobials in 2005/06, however in the winter of 2007and into 2008q1 usage changed to the broad spectrum penicillins (J01CA). Therehas been a small increase in annual total antimicrobial usage 2005-2007: 1353.4DDD/1000 BD (2005), 1326.9 DDD/1000 BD (2006), and 1451.2 DDD/1000 BD(2007).


Hospital L: 2005 - 2007

02468

101214161820222426


Pro

po

rtio

n%

.

2005 3.2 8.3 3.4 7.7 24.7 3.1 4.2 3.9 0.3 5.9 13.0 0.3 0.8 8.3 1.2 0.0 0.8 9.4 0.4 0 0.8

2006 3.0 7.9 3.7 6.8 25.0 3.6 4.1 5.0 0.4 5.4 12.3 0.3 0.8 8.9 1.2 0.2 0.8 9.4 0.5 0 0.6

2007 3.5 11.9 3.6 7.4 19.7 3.8 4.0 4.3 0.7 6.3 13.1 0.3 0.7 7.5 1.2 0.1 0.8 9.5 0.5 0 0.8

2008 4.1 18.1 4.1 6.8 9.7 4.0 5.1 3.3 1.0 6.4 14.3 0.5 0.8 8.9 1.6 0.1 0.5 9.6 0.6 0 0.2



Figure 82 shows individual antimicrobial usage as a proportion of total antimicrobialprescribing, with notable changes in usage of broad spectrum penicillins (J01CA) andbeta-lactam/beta lactamase inhibitor combinations (J01CR) during 2007-2008q1.

51


Hospital L: 2005 - 2008q1

0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 91.7 57.9 69.8 90.8 100 1.4 0.0 0.0 99.8 94.1 77.7 0.0 95.1 0.0 0.0 99.0 43.6 100 97.3 98.9

2006 100 84.7 56.0 71.6 91.8 100 2.8 0.0 0.0 99.0 92.9 69.3 0.0 96.2 0.0 0.0 99.4 47.1 100 92.3 98.5

2007 100 86.9 56.8 69.3 92.6 100 0.8 0.0 0.0 98.9 95.0 71.1 0.0 95.7 0.0 0.0 95.9 47.3 100 74.2 94.4

2008 100 88.2 52.1 74.9 93.1 100 0.2 0.0 0.0 100 93.5 60.1 0.0 94.7 0.0 0 93.2 46.6 100 33.9 58.1



Figure 83 shows changes in the proportion of oral dispensing for each antimicrobialgroup in hospital L. Most of the changes were smaller than 5%, the only notableexceptions were clindamycin (J01F) that fluctuated between 60.1% oral use to 77.7%and linezolid (J01XX) that changed from 97.3 % oral use to 33.9 %.


R2

= 0.9276

0

50

100

150

200

250

300

350

400

450

Quarter

DD

D/1

00

0B

D

J01CR 406 336 293 301 345 329 318 334 386 300 251 208 144

1 2 3 4 5 6 7 8 9 10 11 12 13

Figure 84: Beta-lactam/beta lactamase inhibitor combinations (J01CR) usage

Figure 84 shows a marked decrease in J01CR usage (predominantly co-amoxiclav)through 2007-2008q1 in hospital L.

52


R2

= 0.5231

0

20

40

60

80

100

120

140

160

180

200

220

240

Quarter

DD

D/1

00

0B

D

J01FA 234 167 153 148 166 171 144 172 234 168 141 216 212

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 85 shows some evidence of seasonal usage of J01FA in hospital L, with thehighest use generally in the winter quarters (Jan-Mar & Oct-Dec).


R2 = 0.9615

0

25

50

75

100

125

150

175

200

225

250

275

300

Quarter

DD

D/1

000

BD

J01CA 125 108 102 116 97 103 104 113 129 131 165 267 269

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 86 shows seasonal usage of J01CA in hospital L, with a notable increase inquarters 12 (Oct-Dec 2007) & 13 (Jan-Mar 2008).

53


R2

= 0.7226

0

20

40

60

80

100

120

140

Quarter

DD

D/1

00

0B

D

J01MA 127 103 109 112 119 109 130 114 109 108 100 121 133

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 87 shows the variation in J01MA usage in hospital L, with no obvious trend inusage.


R2

= 0.6395

500

600

700

800

900

1000

1100

1200

1300

1400

1500

1600

Quarter

DD

D/1

00

0B

D

J01 1500 1312 1325 1276 1277 1286 1392 1353 1497 1401 1315 1592 1485

1 2 3 4 5 6 7 8 9 10 11 12 13


Figure 88 shows the variation in total antimicrobial usage in hospital L, with a notableincrease in quarter 12 (Oct-Dec 2007).

54

Hospital M: Nevill Hall Hospital, Abergavenny


Hospital M: 2005 - 2008q1

0

20

40

60

80

100

120

140

160

180

200

220

240


DD

D/1

00

0B

D.

2005 25 192 56 108 147 64 75 17 0.8 8.1 67 190 0.2 12 70 13 0.9 2.1 81 1.8 0.2 3.4

2006 16 188 61 113 183 60 77 18 1.1 13 72 181 0.6 12 83 11 1.5 2.0 93 2.1 0.5 4.0

2007 28 223 65 129 207 71 83 17 0.7 15 74 221 1.7 9.4 94 11 0.5 4.2 98 2.1 0.4 8.8

2008 33 224 62 110 217 70 83 19 0.9 17 66 228 3.7 13 73 13 0.4 5.0 95 0.0 0.0 9.6

J01AA J01CA J01CE J01CF J01CR J01DB J01DC J01DD J01DF J01DH J01E J01FA J01F J01GB J01MA J01XA J01XB J01XC J01XD J01XE J01XX J04AB


Figure 89 shows antimicrobial usage in DDD/1000 BD for hospital M from January2005 to March 2008. There is no predominant antimicrobial, with equally high usageamongst broad spectrum penicillins (J01CA), beta-lactam/beta-lactamase inhibitorcombinations (J01CR) and macrolides (J01FA). There has been an increase inannual total antimicrobial usage 2005-2007: 1136.3 DDD/1000 BD (2005), 1194.8DDD/1000 BD (2006), and 1364.1 DDD/1000 BD (2007).



0.0

2.0

4.0

6.0

8.0

10.0

12.0

14.0

16.0

18.0


Pro

po

rtio

n%

.

2005 2.2 16.9 4.9 9.5 13.0 5.7 6.6 1.5 0.1 0.7 5.9 16.7 0.0 1.1 6.1 1.2 0.1 0.2

2006 1.4 15.8 5.1 9.5 15.3 5.0 6.4 1.5 0.1 1.1 6.0 15.2 0.0 1.0 6.9 0.9 0.1 0.2

2007 2.0 16.3 4.8 9.4 15.1 5.2 6.1 1.3 0.1 1.1 5.4 16.2 0.1 0.7 6.9 0.8 0.0 0.3

2008 2.5 16.7 4.6 8.2 16.2 5.2 6.2 1.4 0.1 1.3 4.9 17.0 0.3 1.0 5.5 1.0 0.0 0.4

J01AA J01CA J01CE J01CF J01CR J01DB J01DC J01DD J01DF J01DH J01E J01FA J01F J01GB J01M A J01XA J01XB J01XC



55



0

10

20

30

40

50

60

70

80

90

100


Pro

po

rtio

n%

.

2005 100 92.0 57.0 68.

antimicrobial usage in secondary care in wales 200...antimicrobial-associated adverse events,...

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