Antibacterial Usage in Secondary Care in Wales

Transcription

1 A Report from Public Health Wales Antimicrobial Resistance Programme Surveillance Unit: Antibacterial Usage in Secondary Care in Wales Authors: Maggie Heginbothom & Robin Howe Date: 14/4/215 Status: Final Version: 1 Antibacterial Usage in Antimicrobial Resistance Page: 1 of 73 Secondary Care in Wales Programme: Surveillance Unit 1

2 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 Comparisons between hospitals (Overall Antibacterial Use) Comparisons between hospitals (Specific Antibacterial Use) Section 4.2: Individual Hospital Usage Morriston Hospital (Abertawe Bro Morgannwg University Health Board) Neath Port Talbot Hospital (ABMU Health Board) Princess of Wales Hospital (ABMU Health Board) Singleon Hospital (ABMU Health Board) Nevill Hall Hospital (Aneurin Bevan Health Board) Royal Gwent Hospital (Aneurin Bevan Health Board) Wrexham Maelor Hospital (Betsi Cadwaladr University Health Board)... 4 Ysbyty Glan Clwyd (Betsi Cadwaladr University Health Board) Ysbyty Gwynedd (Betsi Cadwaladr University Health Board) Llandough Hospital (Cardiff and Vale University Health Board) University Hospital of Wales (CVU Health Board) Prince Charles Hospital (Cwm Taf Health Board) Royal Glamorgan Hospital (Cwm Taf Health Board) Bronglais Hospital (Hywel Dda Health Board) Glangwili Hospital (Hywel Dda Health Board) Prince Philip Hospital (Hywel Dda Health Board) Withybush Hospital (Hywel Dda Health Board)... 7 Acknowledgments

3 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 2-5% 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 3

4 Section 2: Key points of interest Antimicrobial Usage in Secondary Care Antimicrobial usage varies between hospitals in Wales with significant changes over the last 1 years in response to the problem of C. difficile. Total antibacterial use o In 214, 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 214. o In 214, 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 211, 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 214 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 1%. o Cephalosporins and fluoroquinolones (e.g. ciprofloxacin) which have been implicated as causes of C. difficile infection represented 4.9% and 5.% of total antibiotic use respectively. There was significant inter-hospital variability in gross annual antimicrobial use in 214; the lowest use was recorded at Neath Port Talbot hospital (238 DDDs/1 BD) and highest use at Ysbyty Gwynedd (1511 DDDs/1BD) 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 (325 DDDs/1AD) and the highest use at University Hospital Llandough (7196 DDD/1AD). 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 Ysbyty Glan Clwyd Royal Glamorgan Hospital Broad Spectrum Penicillins (e.g. amoxicillin) Beta-lactam/betalactamase combinations (e.g. co-amoxiclav) Fluoroquinolones 17.2% 12.8% 7.4% 6.1% 3.4% 4.6% 4

5 Section 3: Methods Table 2: Codes for hospital and data Health Board Hospital Hospital Code Princess of Wales B Abertawe Bro Morgannwg UHB Aneurin Bevan HB Betsi Cadwaladr UHB Cardiff and Vale UHB Cwm Taf HB Hywel Dda HB Morriston Singleton Neath Port Talbot Royal Gwent Nevill Hall Wrexham Maelor Ysbyty Gwynedd Ysbyty Glan Clwyd University Hospital of Wales University Hospital Llandough Royal Glamorgan Prince Charles Bronglais Withybush Glangwili Prince Philip All-Wales All-Wales Z Pharmacy data Data sources Antimicrobial ward stock data was extracted from the MEDUSA database. 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 1 Bed Days (DDD/1 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. 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. Note: Due to previous technical difficulties with the Morriston pharmacy system, the data for did not include RETURNS. From 213 onwards RETURNS are included in the data set and any apparent reductions in usage in Morriston in 213 may simply be due to the inclusion of RETURNS interpret data with caution. E S T D M H K L F P C N A G J R 5

6 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 (J1AA) (J1BA) (J1CA) (J1CE) (J1CF) (J1CR) (J1D) (J1D*) (J1DB) (J1DC) (J1DD) (J1DF) (J1DH) (J1E) (J1FA) (J1F) (J1GA) (J1GB) (J1MA) (J1XA) (J1XB) (J1XC) (J1XD) (J1XE) (J1XX) (J4AB) 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. 6

7 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 214 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. 1 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. 7

8 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 1 Bed Days (DDD/1 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. 8

9 Section 4.1: Antibacterial Usage in Secondary care All Wales Antibacterial Usage for Secondary Care in 214 BL inhibitors - J1CR BSP - J1CA Macrolides - J1FA BL resistant penicillins - J1CF Tetracyclines J1AA Imidizole derivatives - J1XD Trimethoprim & Sulphonamides - J1E Fluoroquinolones - J1MA Carbapenems - J1DH Glycopeptides - J1XA BL sensitive penicillins - J1CE Aminoglycosides - J1GB 2 Gen Cephs - J1DC 1 Gen Cephs - J1DB Rifampicin - J4AB Lincosamides & Streptogramins - J1F 3 Gen Cephs - J1DD Nitrofuran derivatives - J1XE Fusidic Acid - J1XC Polymixins - J1XB Linezolid - J1XX DDD/1 Bed Days Figure 1: Comparisons in Antibacterial Usage for All-Wales Figure 1 shows the pattern of antibacterial usage for All-Wales acute hospitals for 211 (blue bars), 212 (green bars), 213 (purple bars) and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including, tetracyclines (J1AA), trimethoprim group (J1E), carbapenems (J1DH), glycopeptides (J1XA), and aminoglycosides (J1DH); and a decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J1CR), 9

10 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Carbapenems - J1DH 3% BL inhibitors - J1CR 27% All Cephalosporins 5% Fluoroquinolones - J1MA 5% Trimethoprim & Sulphonamides - J1E 5% Imidizole derivatives - J1XD 6% BSP - J1CA 1% Tetracyclines J1AA 7% BL resistant penicillins - J1CF 9% Macrolides - J1FA 1% Figure 2: Top 1 Antibacterial Usage for 214 Figure 2 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (27%). Fluoroquinolones (J1MA) accounted for a further 5% of usage, cephalosporins (J1DB, J1DC & J1DD) 5%, and carbapenems (J1DH) 3% J1CR J1D J1MA J1DH Figure 3: Trends in Specific Antibacterial Group Usage (Restricted) 1

11 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 3 shows All-Wales trends in usage from for antibacterials that have restricted usage in some/all hospitals: beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) e.g. piperacillin/tazobactam, shows a marked downward trend in 214. The downward trend cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) levelled off in 211 and remains unchanged. Carbapenem usage (J1DH) 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) J Figure 4: Trends in Total Antibacterial Usage

12 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter J1CR J1CA J1FA J1AA J1MA Figure 5: Trends in Antibacterial Group Usage (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 (J1CR), broad spectrum penicillins (J1CA), fluoroquinolones (J1MA), macrolides (J1FA), and tetracyclines (J1AA): Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) shows a downward trend in 214. Broad spectrum penicillin and macrolide usage (J1CA & J1FA) e.g. amoxicillin and clarithromycin, levelled off, with marked winter peaks. Tetracycline usage (J1AA) e.g. doxycycline, shows an upward trend, with winter peaks suggesting an increased use for respiratory infections. Fluoroquinolones usage (J1MA) e.g. levofloxacin shows a downward trend J1CR J1E J1MA J1DB J1XE Figure 6: Trends in Antibacterial Group Usage (Urinary) 12

13 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 6 shows the trends in usage for antibacterials that can be used to treat urinary tract infections: beta-lactam/beta-lactamase inhibitor combinations (J1CR), first generation cephalosporins (J1DB), fluoroquinolones (J1MA), nitrofurans (J1XE), and trimethoprim and sulphonamide combinations (J1E): Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) shows a downward trend in 214. First generation cephalosporin usage (J1DB) e.g. cefalexin decreased between 28/29 but has levelled off since. Nitrofurantoin usage (J1XE) and trimethoprim and combinations usage (J1E) shows an upward trend. Fluoroquinolones usage (J1MA) e.g. ciprofloxacin shows a downward trend J1CR J1XD J1GB J1DC Figure 7: Trends in Antibacterial Group Usage (Surgery) Figure 7 shows the trends in usage for antibacterials that can be used for surgical prophylaxis and treatment of intra-abdominal infection: aminoglycosides (J1GB), beta-lactam/beta-lactamase inhibitor combinations (J1CR), second generation cephalosporins (J1DC), and imidazoles (J1XD): Aminoglycoside usage (J1GB) e.g. gentamicin shows an upward trend. Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) shows a downward trend in 214. Second generation cephalosporin usage (J1DC) e.g. cefuroxime shows a marked decreased between 28/211 which has levelled off since. Imidazole usage (J1XD) e.g. metronidazole shows a slight downward trend. 13

14 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter J1CF J1XA J1CE J1F Figure 8: Trends in Antibacterial Group Usage (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 (J1CE), beta-lactamase resistant penicillins (J1CF), glycopeptides (J1XA) and lincosamides (J1F): Beta-lactamase resistant penicillin usage (J1CF) e.g. flucloxacillin shows an upward trend, with marked summer peaks in usage. Beta-lactamase sensitive penicillin usage (J1CE) e.g. benzylpenicillin shows a downward trend, with marked spring peaks in usage. Glycopeptide usage (J1XA) 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 (J1F) e.g. clindamycin shows an upward trend. Note: Please note the difference in the y-axis scale which is smaller and finishes at 2 DDD/1 BD per quarter. 14

15 DDD/1 Admissions per Quarter DDD/1 Bed Days per Quarter Comparisons between hospitals (Overall Antibacterial Use) 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 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/1 Bed days The difference in average total antibacterial usage per quarter between the acute hospitals in Wales for 214 is shown in Figures 9 and 1. Figure 9 shows usage in defined daily doses per 1 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/1 BD (Neath Port Talbot), compared to 1511 DDD/1 BD for the hospital at the high end of the scale (Ysbyty Gwynedd). Figure 1 shows usage in defined daily doses per 1 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 P R J K C E H A F L G D M N T B S Figure 1: Total antibacterial usage by hospital DDD/1 Admissions 15

16 83 58 Oral Antimicrobial Usage (%) Number of Differnt Antibacterials 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 214 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) 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 214, 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

17 DDD/1 Bed Days Proportion of Total AB Usage (%) DDD/1 Bed Days Proportion of Total AB Usage Comparisons between hospitals (Specific Antibacterial Use) % C P F L J K N S H R E D G M B A T Figure 13: Tetracycline (J1AA) usage by hospital The difference in average tetracycline (J1AA) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 13. There was >six-fold variation in J1AA usage between hospitals at either end of the scale; the hospital at the low end of the scale used 26 DDD/1 BD of J1AA compared to 167 DDD/1 BD for the hospital at the high end of the scale. J1AA as a proportion of total usage varied between 3% at Bronglais (A) to 12% at University Hospital Llandough (P) % K L M D P H C J E F A N B S G R T Figure 14: Broad spectrum penicillin (J1CA) usage by hospital The difference in average broad spectrum penicillin (J1CA) usage per quarter between the acute hospitals in Wales for 214, and J1CA usage as a proportion of total antibacterial usage is shown in Figure 14. There was >eight-fold variation in J1CA usage between hospitals; the hospital at the low end of the scale used 32 DDD/1 BD compared to 265 DDD/1 BD for the hospital at the high end of the scale. J1CA as a proportion of total usage varied between 5% at Prince Philip (R), to 18% at Ysbyty Gwynedd (K)

18 Co-amoxiclav PipTazo DDD/1 Bed Days Proportion of Total AB Usage % 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 (J1CR) usage The difference in average beta-lactam/beta-lactamase inhibitor combinations (J1CR) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 15. There was >six-fold variation in J1CR usage between hospitals at either end of the scale; the hospital at the low end used 64 DDD/1 BD of J1CR compared to 432 DDD/1 BD for the hospital at the high end of the scale. J1CR as a proportion of total usage varied between 13% at Ysbyty Glan Clwyd (L) to 33% at Glangwili hospital (J). 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % 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 (J1CR) usage by entity (%) The proportion of beta-lactam/beta-lactamase inhibitor combinations (J1CR) usage at entity level is shown in Figure 16. The proportion of total J1CR usage that was co-amoxiclav varied between hospitals, from 52% at Ysbyty Glan Clwyd (L) to 89% at Nevill Hall (M). 18

19 91 3 DDD/1 Bed Days Proportion of Total AB Usage 5 87 DDD/1 Bed Days Proportion of Total AB Usage % A L K S J E G N B R P C F D H M T Figure 17: Cephalosporin (J1D) usage by hospital The difference in average cephalosporin (J1D) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 17. There was a wide variation in J1D usage between hospitals; the hospital at the low end of the scale used 5 DDD/1 BD compared to 87 DDD/1 BD for the hospital at the high end of the scale. J1D as a proportion of total usage varied between 2.1% at Neath Port Talbot (T) to 1.% at Singleton (S) % L K P C F E D J N H A G M R S B T Figure 18: Fluoroquinolone (J1MA) usage by hospital The difference in average fluoroquinolone (J1MA) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 18. There was a wide variation in J1MA usage between hospitals; the hospital at the low end of the scale used 3 DDD/1 BD compared to 91 DDD/1 BD for the hospital at the high end of the scale. J1MA as a proportion of total usage varied between 1.1 % at Neath Port Talbot (T) to 7.4% at Ysbyty Glan Clwyd (L). 19

20 Meropenem Imipenem 63 2 DDD/1 Bed Days Proportion of Total AB Usage % P F E A J R S K D H G L C N B M T Figure 19: Carbapenem (J1DH) usage by hospital The difference in average carbapenem (J1DH) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 19. There was marked variation in J1DH usage between hospitals; the hospital at the low end of the scale used 2 DDD/1 BD of J1DH compared to 63 DDD/1 BD for the hospital at the high end of the scale. J1DH as a proportion of total usage varied between.6% at Nevill Hall hospital (M) to 6.5% at University Hospital Llandough (P). 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % B C G H S N R P K A J F L T E D M Figure 2: Carbapenem (J1DH) usage by entity (%) The proportion of carbapenem (J1DH) usage at entity level is shown in Figure 2. The proportion of total J1DH 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. 2

21 Vancomycin Teicoplanin 75 9 DDD/1 Bed Days Proportion of Total AB Usage % C E N H F L D K P B M R S J A G T Figure 21: Glycopeptide (J1XA) usage by hospital The difference in average glycopeptide (J1XA) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 21. There was a wide variation in J1XA usage between hospitals; the hospital at the low end of the scale used DDD/1 BD of J1XA compared to 75 DDD/1 BD for the hospital at the high end of the scale. J1XA as a proportion of total usage varied between 1.% at Withybush (G) to 6.2% at Wrexham Maelor (H). 1% 9% 8% 7% 6% 5% 4% 3% 2% 1% % T R J A K G F L D P E M S B H C N Figure 22: Glycopeptide (J1XA) usage by entity (%) The proportion of glycopeptide (J1XA) usage at entity level is shown in Figure 22. The proportion of total J1DH usage that was vancomycin varied between hospitals, from 4% at both Princess Charles (N) and Royal Glamorgan (C) to 1% at Neath Port Talbot (T). 21

22 DDD/1 Bed Days Proportion of Total AB Usage 56 4 DDD/1 Bed Days Proportion of Total AB Usage % P M D C F R E J N L K H B G A S T. Figure 23: Aminoglycoside (J1GB) usage by hospital The difference in average aminoglycoside (J1GB) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 23. There was wide variation in J1GB usage between hospitals; the hospital at the low end of the scale used 4 DDD/1 BD of J1GB compared to 56 DDD/1 BD for the hospital at the high end of the scale. J1GB as a proportion of total usage varied between.8% in Singleton hospital (S) to 5.9% at University Hospital Llandough (P) % K J R A C L D G M H S F E P N B T Figure 24: Macrolide (J1FA) usage by hospital The difference in average macrolide (J1FA) usage per quarter between the acute hospitals in Wales for 214, and as a proportion of total antibacterial usage is shown in Figure 24. There was a five-fold variation in J1FA usage between hospitals at either end of the scale; the hospital at the low end of the scale used 35 DDD/1 BD compared to 181 DDD/1 BD for the hospital at the high end of the scale. J1FA as a proportion of total usage varied between 6% at the University Hospital of Wales (F) to 17% at Prince Philip (R). 22

23 Section 4.2: Individual Hospital Usage Morriston Hospital (Abertawe Bro Morgannwg University Health Board) BL inhibitors - J1CR BL resistant penicillins - J1CF BSP - J1CA Macrolides - J1FA Imidizole derivatives - J1XD Tetracyclines J1AA Glycopeptides - J1XA Fluoroquinolones - J1MA Carbapenems - J1DH 2 Gen Cephs - J1DC Trimethoprim & Sulphonamides - J1E BL sensitive penicillins - J1CE Rifampicin - J4AB Aminoglycosides - J1GB Lincosamides & Streptogramins - J1F 1 Gen Cephs - J1DB 3 Gen Cephs - J1DD Fusidic Acid - J1XC Nitrofuran derivatives - J1XE Linezolid - J1XX Polymixins - J1XB DDD/1 Bed Days Figure 25: Morriston Hospital - Antibacterial Usage for 211 to 214 Figure 25 shows the pattern of antibacterial usage for Morriston hospital for 211 (blue bars), 212 (green bars), 213 (purple bars) and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including carbapenems (J1DH) and glycopeptides (J1XA). Note: Due to previous technical difficulties with the Morriston pharmacy system, the data for did not include RETURNS. From 213 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

24 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Carbapenems - J1DH 5% Fluoroquinolones - J1MA 5% BL inhibitors - J1CR 32% Glycopeptides - J1XA 5% Tetracyclines J1AA 5% All Cephalosporins 6% Imidizole derivatives - J1XD 6% Macrolides - J1FA 6% BSP - J1CA 7% BL resistant penicillins - J1CF 11% Figure 26: Top 1 Antibacterial Usage for 214 Figure 26 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials accounting for a nearly a third of total antibacterial usage (32%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 6% of usage, fluoroquinolones (J1MA) - 5%, and carbapenems (J1DH) - 5% J1CR J1D J1MA J1DH Figure 27: Trends in Specific Antibacterial Group Usage

25 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 27 shows Morriston hospital trends in usage from for antibacterials that have restricted usage in some/all hospitals in Wales: betalactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) shows a marked upward trend, with some large winter peaks. The downward trend cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) levelled off in 212. Carbapenem usage (J1DH) 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 213/14 may simply be due to the inclusion of RETURNS in the data (data with RETURNS ) J Figure 28: Trends in Total Antibacterial Usage Morriston Hospital 25

26 Neath Port Talbot Hospital (ABMU Health Board) BL inhibitors - J1CR Macrolides - J1FA BSP - J1CA Trimethoprim & Sulphonamides - J1E Tetracyclines J1AA BL resistant penicillins - J1CF Imidizole derivatives - J1XD Aminoglycosides - J1GB Fluoroquinolones - J1MA 1 Gen Cephs - J1DB 2 Gen Cephs - J1DC Carbapenems - J1DH BL sensitive penicillins - J1CE Nitrofuran derivatives - J1XE Polymixins - J1XB 3 Gen Cephs - J1DD Rifampicin - J4AB Linezolid - J1XX Fusidic Acid - J1XC Glycopeptides - J1XA Lincosamides & Streptogramins - J1F DDD/1 Bed Days Figure 29: Neath Port Talbot Hospital - Antibacterial Usage for 211 to 214 Figure 29 shows the pattern of antibacterial usage for Neath Port Talbot hospital for 211 (blue bars), 212 (green bars), 213 (purple bars) and 214 (grey bars). In 214, there was a marked decrease in prescribing of all antibacterial groups. 26

27 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter All Cephalosporins 2% Imidizole derivatives - J1XD 5% BL resistant penicillins - J1CF 9% Aminoglycosides - J1GB 2% Fluoroquinolones - J1MA 1% BL inhibitors - J1CR 27% Tetracyclines J1AA 11% Macrolides - J1FA 15% Trimethoprim & Sulphonamides - J1E 13% BSP - J1CA 14% Figure 3: Top 1 Antibacterial Usage for 214 Figure 3 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for a more than a quarter of total antibacterial usage (27%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 2% of usage, fluoroquinolones (J1MA) - 1% and carbapenems (J1DH) - 1% J1CR J1D J1DH J1MA Figure 31: Trends in Specific Antibacterial Group Usage

28 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 31 shows trends in specific antibacterial group usage in Neath Port Talbot hospital from 25-14: beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combinations usage (J1CR) shows a marked down ward trend from 212 onwards. Cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) show a downward trend across time. Carbapenem usage (J1DH) decreased in 214. 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 1 DDD/1 BD per quarter J1 Figure 32: Trends in Total Antibacterial Usage

29 Princess of Wales Hospital (ABMU Health Board) BL inhibitors - J1CR BL resistant penicillins - J1CF BSP - J1CA Macrolides - J1FA Imidizole derivatives - J1XD Tetracyclines J1AA 2 Gen Cephs - J1DC BL sensitive penicillins - J1CE Trimethoprim & Sulphonamides - J1E Glycopeptides - J1XA 1 Gen Cephs - J1DB Aminoglycosides - J1GB Carbapenems - J1DH Fluoroquinolones - J1MA Gen Cephs - J1DD Fusidic Acid - J1XC Lincosamides & Streptogramins - J1F Nitrofuran derivatives - J1XE Polymixins - J1XB Linezolid - J1XX Rifampicin - J4AB DDD/1 Bed Days Figure 33: Princess of Wales Hospital - Antibacterial Usage for 211 to 213 Figure 33 shows the pattern of antibacterial usage for Princess of Wales hospital for 211 (blue bars), 212 (green bars), 213 (purple bars) and 214 (grey bars). In 214, there was an increase in prescribing of carbapenems (J1DH), glycopeptides (J1XA) and the imidazole derivatives (J1XD) compared with 213, but generally usage decreased for the other drug groups. 29

30 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Glycopeptides - J1XA 4% Trimethoprim & Sulphonamides - J1E 4% BL sensitive penicillins - J1CE 4% Tetracyclines J1AA 4% BL inhibitors - J1CR 3% Imidizole derivatives - J1XD 8% All Cephalosporins 8% Macrolides - J1FA 8% BSP - J1CA 9% BL resistant penicillins - J1CF 15% Figure 34: Top 1 Antibacterial Usage for 214 Figure 34 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (3%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 8% of usage, carbapenems (J1DH) - 2%, and fluoroquinolones (J1MA) - 1% J1CR J1D J1DH J1MA -5 Figure 35: Trends in Specific Antibacterial Group Usage

31 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 35 shows trends in specific antibacterial group usage in Princess of Wales hospital from 25-14: beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) appears to have levelled off in 214. Cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) show a general downward trend. Carbapenem usage (J1DH) decreased in 212, levelling off in 213/14. Total antibacterial usage shows a general downward trend over time with seasonal peaks (see Figure 36) J1 Figure 36: Trends in Total Antibacterial Usage

32 Singleon Hospital (ABMU Health Board) BL inhibitors - J1CR Macrolides - J1FA Tetracyclines J1AA Imidizole derivatives - J1XD BSP - J1CA 1 Gen Cephs - J1DB Carbapenems - J1DH BL resistant penicillins - J1CF Trimethoprim & Sulphonamides - J1E 2 Gen Cephs - J1DC BL sensitive penicillins - J1CE Fluoroquinolones - J1MA Glycopeptides - J1XA 214 Aminoglycosides - J1GB Nitrofuran derivatives - J1XE 3 Gen Cephs - J1DD Lincosamides & Streptogramins - J1F Fusidic Acid - J1XC Linezolid - J1XX Polymixins - J1XB Rifampicin - J4AB DDD/1 Bed Days Figure 37: Princess of Wales Hospital - Antibacterial Usage for 214 Figure 37 shows the pattern of antibacterial usage for Singleton hospital 214 (grey bars), there is no comparative data for 211, 212, and 213. First generation cephalosporin use (J1DB) is notably high compared with other hospitals e.g. in 214, usage in Morriston hospital was 9 DDD/1 BD compared with 39 DDD/1 BD in Singleton. 32

33 BL sensitive penicillins - J1CE 4% Trimethoprim & Sulphonamides - J1E 4% BL resistant penicillins - J1CF 5% BL inhibitors - J1CR 3% Carbapenems - J1DH 5% BSP - J1CA 8% Imidizole derivatives - J1XD 8% Tetracyclines J1AA 1% Macrolides - J1FA 1% All Cephalosporins 1% Figure 38: Top 1 Antibacterial Usage for 214 Figure 38 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (3%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 1% of usage, carbapenems (J1DH) - 5%, and fluoroquinolones (J1MA) - 3%. 33

34 Nevill Hall Hospital (Aneurin Bevan Health Board) BL inhibitors - J1CR BSP - J1CA BL resistant penicillins - J1CF Macrolides - J1FA Imidizole derivatives - J1XD Trimethoprim & Sulphonamides - J1E Aminoglycosides - J1GB Tetracyclines J1AA BL sensitive penicillins - J1CE Fluoroquinolones - J1MA Glycopeptides - J1XA 1 Gen Cephs - J1DB Carbapenems - J1DH 2 Gen Cephs - J1DC Nitrofuran derivatives - J1XE 3 Gen Cephs - J1DD Lincosamides & Streptogramins - J1F Rifampicin - J4AB Fusidic Acid - J1XC Polymixins - J1XB Linezolid - J1XX DDD/1 Bed Days Figure 39: Nevill Hall Hospital - Antibacterial Usage for 211 to 214 Figure 39 shows the pattern of antibacterial usage for Nevill Hall hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was a marked decrease in prescribing for many antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J1CR), broad spectrum penicillins (J1CA),fluoroquinolones (J1MA), glycopeptides (J1XA), macrolides (J1FA), tetracyclines (J1AA), and the trimethoprim group (J1E).The only increase in prescribing was the aminoglycosides (J1GB). 34

35 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Fluoroquinolones - J1MA 5% BL inhibitors - J1CR 26% BL sensitive penicillins - J1CE 5% Tetracyclines J1AA 5% Aminoglycosides - J1GB 5% BSP - J1CA 11% Trimethoprim & Sulphonamides - J1E 6% Imidizole derivatives - J1XD 6% Macrolides - J1FA 8% BL resistant penicillins - J1CF 1% Figure 4: Top 1 Antibacterial Usage for 214 Figure 4 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (26%). Fluoroquinolones (J1MA) accounted for a further 5% of usage, Cephalosporins (J1DB, J1DC & J1DD) - 3%, and carbapenems (J1DH) - 2% J1CR J1D J1MA J1DH Figure 41: Trends in Specific Antibacterial Group Usage

36 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 41 shows trends in specific antibacterial group usage in Nevill Hall hospital from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) shows a marked downward trend in 213, levelling off in 214. Cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) shows a general downward trend. Carbapenem usage (J1DH) shows a reduction in 213, levelling off in 214. Total antibacterial usage shows a marked downward trend from 213 onwards (see Figure 42) J1 8 7 Figure 42: Trends in Total Antibacterial Usage

37 Royal Gwent Hospital (Aneurin Bevan Health Board) BL inhibitors - J1CR BSP - J1CA Macrolides - J1FA BL resistant penicillins - J1CF Imidizole derivatives - J1XD Tetracyclines J1AA Fluoroquinolones - J1MA Trimethoprim & Sulphonamides - J1E BL sensitive penicillins - J1CE Aminoglycosides - J1GB Carbapenems - J1DH Glycopeptides - J1XA 1 Gen Cephs - J1DB Rifampicin - J4AB Gen Cephs - J1DD Nitrofuran derivatives - J1XE Lincosamides & Streptogramins - J1F Fusidic Acid - J1XC 2 Gen Cephs - J1DC Linezolid - J1XX Polymixins - J1XB DDD/1 Bed Days Figure 43: Royal Gwent Hospital - Antibacterial Usage for 211 to 214 Figure 43 shows the pattern of antibacterial usage for Royal Gwent hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including broad spectrum penicillins (J1CA), tetracyclines (J1AA), third generation cephalosporins (J1DD), nitorfurnas (J1XE) and lincosamides (J1F); and a decrease in macrolides (J1FA), beta lactamae resistant penicillins (J1CF), imidazole derivatives (J1XD) and fluoroquinolones (J1MA). 37

38 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter All Cephalosporins 3% BL sensitive penicillins - J1CE 3% Trimethoprim & Sulphonamides - J1E 4% Fluoroquinolones - J1MA 5% Tetracyclines J1AA 5% Imidizole derivatives - J1XD 7% BL resistant penicillins - J1CF 8% Macrolides - J1FA 12% BL inhibitors - J1CR 28% BSP - J1CA 13% Figure 44: Top 1 Antibacterial Usage for 214 Figure 44 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (28%). Fluoroquinolones (J1MA) accounted for a further 5% of usage, cephalosporins (J1DB, J1DC & J1DD) - 3%, carbapenems (J1DH) - 3% J1CR J1MA J1D J1DH Figure 45: Trends in Specific Antibacterial Group Usage

39 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 45 shows trends in specific antibacterial group usage for the Royal Gwent from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). The upward trend in beta-lactam/beta-lactamase inhibitor combination usage (J1CR) appears to be levelling off. The downward trend in cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) has levelled off. Carbapenem usage (J1DH) shows an upward trend. Total antibacterial usage shows some seasonal variation with no significant change over time from 29 onwards (see Figure 46) J Figure 46: Trends in Total Antibacterial Usage

40 Wrexham Maelor Hospital (Betsi Cadwaladr University Health Board) BL inhibitors - J1CR BSP - J1CA Macrolides - J1FA Tetracyclines J1AA BL resistant penicillins - J1CF Glycopeptides - J1XA Fluoroquinolones - J1MA Imidizole derivatives - J1XD Trimethoprim & Sulphonamides - J1E Carbapenems - J1DH Lincosamides & Streptogramins - J1F Aminoglycosides - J1GB 2 Gen Cephs - J1DC 1 Gen Cephs - J1DB BL sensitive penicillins - J1CE 3 Gen Cephs - J1DD Nitrofuran derivatives - J1XE Rifampicin - J4AB Linezolid - J1XX Fusidic Acid - J1XC Polymixins - J1XB DDD/1 Bed Days Figure 47: Wrexham Maelor Hospital - Antibacterial Usage for 211 to 214 Figure 47 shows the pattern of antibacterial usage for Wrexham Maelor hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including beta-lactam/beta-lactamase inhibitor combinations (J1CR), macrolides (J1FA), bet-lactamase resistant penicillins (J1CF), glycopeptides (J1XA), trimethoprim group (J1E), and carbapenems (J1DH). 4

41 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Trimethoprim & Sulphonamides - J1E 4% All Cephalosporins 4% BL inhibitors - J1CR 26% Imidizole derivatives - J1XD 6% Fluoroquinolones - J1MA 6% Glycopeptides - J1XA 6% BSP - J1CA 12% BL resistant penicillins - J1CF 8% Tetracyclines J1AA 8% Macrolides - J1FA 1% Figure 48: Top 1 Antibacterial Usage for 214 Figure 48 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a quarter of total antibacterial usage (26%). Fluoroquinolones (J1MA) accounted for a further 6% of usage, cephalosporins (J1DB, J1DC & J1DD) - 4%, and carbapenems (J1DH) - 4% J1CR J1MA J1D J1DH Figure 49: Trends in Specific Antibacterial Group Usage

42 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 49 shows trends in specific antibacterial group usage in Wrexham Maelor from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) shows variation in usage over time, with an upward trend from 21 onwards. Cephalosporin usage (J1D) shows variation in usage over time with no obvious trend. Carbapenem usage (J1DH) shows an increasing trend from 213 onwards. Fluoroquinolone usage (J1MA) shows a sharp decrease in 26q3, followed by a slight upward trend from 26q4 onwards. Total antibacterial usage has increased over time, and shows some seasonal variation (see Figure 5) J1 6 5 Figure 5: Trends in Total Antibacterial Usage

43 Ysbyty Glan Clwyd (Betsi Cadwaladr University Health Board) BSP - J1CA BL inhibitors - J1CR Macrolides - J1FA BL resistant penicillins - J1CF Trimethoprim & Sulphonamides - J1E Fluoroquinolones - J1MA Imidizole derivatives - J1XD Tetracyclines J1AA Lincosamides & Streptogramins - J1F 1 Gen Cephs - J1DB Glycopeptides - J1XA 2 Gen Cephs - J1DC Carbapenems - J1DH BL sensitive penicillins - J1CE Rifampicin - J4AB Aminoglycosides - J1GB Nitrofuran derivatives - J1XE 3 Gen Cephs - J1DD Linezolid - J1XX Polymixins - J1XB Fusidic Acid - J1XC DDD/1 Bed Days Figure 51: Ysbyty Glan Clwyd - Antibacterial Usage for 211 to 214 Figure 51 shows the pattern of antibacterial usage for Ysbyty Glan Clwyd for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was a marked increase in prescribing for a number of antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J1CR), macrolides (J1FA), beta-lactamase resistant penicillins (J1CF), fluoroquinolones (J1MA), imidazole derivatives (J1XD), tetracyclines (J1AA), trimethoprim group (J1E), carbapenems (J1DH), second generation cephalosporins (J1DB), lincosamides (J1F), aminoglycosides (J1GB), nitrofurans (J1XE), and third generation cephalosporins (J1DD). 43

44 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Lincosamides & Streptogramins - J1F 4% BSP - J1CA 17% All Cephalosporins 6% Tetracyclines J1AA 7% BL inhibitors - J1CR 13% Imidizole derivatives - J1XD 7% Fluoroquinolones - J1MA 7% Trimethoprim & Sulphonamides - J1E 8% BL resistant penicillins - J1CF 9% Macrolides - J1FA 11% Figure 52: Top 1 Antibacterial Usage for 214 Figure 52 shows the Top 1 antibacterial group usage for 214; broad spectrum penicillins (J1CA) were the most used antibacterials, accounting for a sixth of total antibacterial usage (17%). Fluoroquinolones (J1MA) accounted for a further 7% of usage, cephalosporins (J1DB, J1DC & J1DD) - 6%, and carbapenems (J1DH) - 2% J1CR J1MA J1D J1DH Figure 53: Trends in Specific Antibacterial Group Usage

45 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 53 shows trends in specific antibacterial group usage in Ysbyty Glan Clwyd from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) increased in 214. Cephalosporin usage (J1D) shows a general downward trend. Carbapenem usage (J1DH) shows an upward trend. Fluoroquinolone usage (J1MA) decreased in 212/13 but increased in 214. The general downward trend in total antibacterial usage reversed in 214, and an increase in usage was noted (see Figure 54) J Figure 54: Trends in Total Antibacterial Usage

46 Ysbyty Gwynedd (Betsi Cadwaladr University Health Board) BL inhibitors - J1CR BSP - J1CA Macrolides - J1FA BL resistant penicillins - J1CF Imidizole derivatives - J1XD Fluoroquinolones - J1MA Tetracyclines J1AA Trimethoprim & Sulphonamides - J1E BL sensitive penicillins - J1CE Carbapenems - J1DH 2 Gen Cephs - J1DC 1 Gen Cephs - J1DB Glycopeptides - J1XA Lincosamides & Streptogramins - J1F BSP - J1CA Aminoglycosides - J1GB Nitrofuran derivatives - J1XE 3 Gen Cephs - J1DD Fusidic Acid - J1XC Polymixins - J1XB Linezolid - J1XX DDD/1 Bed Days Figure 55: Ysbyty Glan Clwyd - Antibacterial Usage for 211 to 214 Figure 55 shows the pattern of antibacterial usage for Ysbyty Gwynedd for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was a marked increase in prescribing for a number of antibacterial groups including beta-lactam/beta-lactamase inhibitor combinations (J1CR), macrolides (J1FA), beta-lactamase resistant penicillins (J1CF), fluoroquinolones (J1MA), tetracyclines (J1AA), trimethoprim group (J1E), carbapenems (J1DH), second generation cephalosporins (J1DB), lincosamides (J1F), broad spectrum penicillins (J1CA) an nitrofurans (J1XE). 46

47 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter BL sensitive penicillins - J1CE 2% Trimethoprim & Sulphonamides - J1E 5% BL inhibitors - J1CR 19% All Cephalosporins 5% Tetracyclines J1AA 5% Fluoroquinolones - J1MA 5% BSP - J1CA 18% Imidizole derivatives - J1XD 9% BL resistant penicillins - J1CF 11% Macrolides - J1FA 12% Figure 56: Top 1 Antibacterial Usage for 214 Figure 56 shows the Top 1 antibacterial group usage for 214; broad spectrum penicillins (J1CA) were the most used antibacterials, accounting for nearly a fifth of total antibacterial usage (19%). Fluoroquinolones (J1MA) accounted for a further 5% of usage, cephalosporins (J1DB, J1DC & J1DD) - 5%, and carbapenems (J1DH) - 2% J1CR J1D J1MA J1DH Figure 57: Trends in Specific Antibacterial Group Usage

48 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 57 shows trends in specific antibacterial group usage in Ysbyty Gwynedd from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) increased in 21 and appears to have levelled off. The downward trend in cephalosporin usage (J1D) levelled off in 212/13. Carbapenem usage (J1DH) shows an upward trend. Fluoroquinolone usage (J1MA) appears to have levelled off. Total antibacterial usage shows a marked upward trend over time (see Figure 58) J Figure 58: Trends in Total Antibacterial Usage

49 Llandough Hospital (Cardiff and Vale University Health Board) BL inhibitors - J1CR Tetracyclines J1AA BSP - J1CA BL resistant penicillins - J1CF Fluoroquinolones - J1MA Trimethoprim & Sulphonamides - J1E Carbapenems - J1DH Macrolides - J1FA Aminoglycosides - J1GB Glycopeptides - J1XA Rifampicin - J4AB 2 Gen Cephs - J1DC Polymixins - J1XB 3 Gen Cephs - J1DD Nitrofuran derivatives - J1XE Imidizole derivatives - J1XD Lincosamides & Streptogramins - J1F BL sensitive penicillins - J1CE Linezolid - J1XX Fusidic Acid - J1XC 1 Gen Cephs - J1DB DDD/1 Bed Days Figure 59: University Hospital Llandough Hospital - Antibacterial Usage for 211 to 214 Figure 59 shows the pattern of antibacterial usage for Llandough hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was an increase in prescribing broad spectrum penicillins (J1CA), and glycopeptides, and a marked decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J1CR), beta-lactamase resistance penicillins (J1CF), macrolides (J1FA), second generation cephalosporins (J1DC) and third generation cephalosporins (J1DD); and a marked decrease in beta-lactam/beta-lactamase inhibitor combinations (J1CR). 49

50 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter BL inhibitors - J1CR 18% All Cephalosporins 5% Aminoglycosides - J1GB 6% Tetracyclines J1AA 12% Macrolides - J1FA 6% Carbapenems - J1DH 6% BSP - J1CA 1% Trimethoprim & Sulphonamides - J1E 7% Fluoroquinolones - J1MA 7% BL resistant penicillins - J1CF 9% Figure 6: Top 1 Antibacterial Usage for 214 Figure 6 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations were the most used antibacterials, accounting for over a sixth of total antibacterial usage. Fluoroquinolones (J1MA) accounted for a further 7% of usage, carbapenems (J1DH) - 6%, and cephalosporins (J1DB, J1DC & J1DD) 5% J1CR J1MA J1DH J1D Figure 61: Trends in Specific Antibacterial Group Usage

51 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 61 shows trends in specific antibacterial group usage in Llandough hospital from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) shows a marked downward trend in 214q4. Cephalosporin usage (J1D) decreased between 29/1, and has levelled off. Carbapenem usage (J1DH) shows an upward trend. Fluoroquinolone usage (J1MA) appears to have levelled off. Total antibacterial usage appears to have decreased in 214 (see Figure 62) J Figure 62: Trends in Total Antibacterial Usage

52 University Hospital of Wales (CVU Health Board) BL inhibitors - J1CR Trimethoprim & Sulphonamides - J1E BL resistant penicillins - J1CF Tetracyclines J1AA BSP - J1CA Macrolides - J1FA Fluoroquinolones - J1MA Carbapenems - J1DH Imidizole derivatives - J1XD Glycopeptides - J1XA Aminoglycosides - J1GB BL sensitive penicillins - J1CE Rifampicin - J4AB Lincosamides & Streptogramins - J1F Gen Cephs - J1DC 3 Gen Cephs - J1DD 1 Gen Cephs - J1DB Nitrofuran derivatives - J1XE Fusidic Acid - J1XC Linezolid - J1XX Polymixins - J1XB DDD/1 Bed Days Figure 63: University Hospital of Wales - Antibacterial Usage for 211 to 214 Figure 63 shows the pattern of antibacterial usage for University Hospital of Wales for 211 (blue bars), 212 (green bars), 213 (purple bars) and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including trimethoprim group (J1E), beta-lactamase resistant pencicllins (J1CF), tetracyclines (J1AA), broad spectrum penicillins (J1CA), macrolides (J1FA), fluoroquinolones (J1MA), carbapenems (J1DH), aminoglycosides (J1GB), lincosamides (J1F) and nitrofurans (J1XE); and a decrease in beta-lactam/betalactamase inhibitor combinations (J1CR). 52

53 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter All Cephalosporins 4% Imidizole derivatives - J1XD 4% BL inhibitors - J1CR 3% Carbapenems - J1DH 5% Fluoroquinolones - J1MA 6% Macrolides - J1FA 6% Trimethoprim & Sulphonamides - J1E 9% BSP - J1CA 7% Tetracyclines J1AA 8% BL resistant penicillins - J1CF 8% Figure 64: Top 1 Antibacterial Usage for 214 Figure 64 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (3%). Fluoroquinolones (J1MA) accounted for a further 6% of usage, carbapenems (J1DH) - 5%, and cephalosporins (J1DB, J1DC & J1DD) - 4% J1CR J1MA J1D J1DH Figure 65: Trends in Specific Antibacterial Group Usage

54 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 65 shows trends in specific antibacterial group usage in UHW from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) shows a marked downward trend in 214q4. The downward trend in cephalosporin usage (J1D) levelled off in 21 onwards. Carbapenem usage (J1DH) shows an upward trend. The downward trend in fluoroquinolone usage (J1MA) levelled off in 21, and shows an upward trend from mid-21 onwards. Total antibacterial usage shows some seasonal variation with no significant change over time (see Figure 66) J Figure 66: Trends in Total Antibacterial Usage

55 Prince Charles Hospital (Cwm Taf Health Board) BL inhibitors - J1CR BL resistant penicillins - J1CF Tetracyclines J1AA BSP - J1CA Imidizole derivatives - J1XD Macrolides - J1FA Glycopeptides - J1XA Fluoroquinolones - J1MA Trimethoprim & Sulphonamides - J1E 1 Gen Cephs - J1DB BL sensitive penicillins - J1CE Rifampicin - J4AB Aminoglycosides - J1GB Carbapenems - J1DH Gen Cephs - J1DC Lincosamides & Streptogramins - J1F 3 Gen Cephs - J1DD Nitrofuran derivatives - J1XE Polymixins - J1XB Fusidic Acid - J1XC Linezolid - J1XX DDD/1 Bed Days Figure 67: Prince Charles Hospital - Antibacterial Usage for 211 to 214 Figure 67 shows the pattern of antibacterial usage for Prince Charles hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there were increases in prescribing of tetracyclines (J1AA), imidazoles (J1XD), glycopeptides (J1XA), fluoroquinolones (J1MA), trimethoprim group (J1E), first and second generation cephalosporins (J1DB & J1DC), betalactamase sensitive penicillins (J1CE), rifampicin (J4AB), and aminoglycosides (J1GB); and there was a decrease in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J1CR) and macrolides (J1FA). 55

56 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Trimethoprim & Sulphonamides - J1E 4% Fluoroquinolones - J1MA 5% BL inhibitors - J1CR 31% All Cephalosporins 6% Glycopeptides - J1XA 6% Macrolides - J1FA 7% Imidizole derivatives - J1XD 7% BSP - J1CA 7% Tetracyclines J1AA 8% BL resistant penicillins - J1CF 1% Figure 68: Top 1 Antibacterial Usage for 214 Figure 68 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (31%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 6% of usage, fluoroquinolones (J1MA) - 5%, and carbapenems (J1DH) - 2% J1CR J1D J1MA J1DH Figure 69: Trends in Specific Antibacterial Group Usage

57 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 69 shows trends in specific antibacterial group usage in Prince Charles from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) decreased in 214. Cephalosporin usage (J1D) and fluoroquinolone usage (J1MA) increased in 213 but has levelled off in 214. Carbapenem usage (J1DH) shows an upward trend. Total antibacterial usage shows a general downward trend over time, which appears to have levelled off in 214 (see Figure 7) J Figure 7: Trends in Total Antibacterial Usage

58 Royal Glamorgan Hospital (Cwm Taf Health Board) BL inhibitors - J1CR Tetracyclines J1AA Macrolides - J1FA BL resistant penicillins - J1CF BSP - J1CA Glycopeptides - J1XA Trimethoprim & Sulphonamides - J1E Imidizole derivatives - J1XD Fluoroquinolones - J1MA Aminoglycosides - J1GB BL sensitive penicillins - J1CE Carbapenems - J1DH 1 Gen Cephs - J1DB Nitrofuran derivatives - J1XE Rifampicin - J4AB 2 Gen Cephs - J1DC Lincosamides & Streptogramins - J1F Fusidic Acid - J1XC 3 Gen Cephs - J1DD Linezolid - J1XX Polymixins - J1XB DDD/1 Bed Days Figure 71: Royal Glamorgan Hospital - Antibacterial Usage for 211 to 214 Figure 71 shows the pattern of antibacterial usage for Royal Glamorgan Hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214, there was an increase in prescribing of a number of antibacterial groups, including tetracycline (J1AA), broad spectrum penicillins (J1CA), glycopepetides (J1XA), trimethoprim group (J1E), imidazole deriviatives (J1XD), aminoglycosides (J1GB), and nitrofurans (J1XE). 58

59 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter All Cephalosporins 3% Fluoroquinolones - J1MA 5% BL inhibitors - J1CR 3% Imidizole derivatives - J1XD 5% Trimethoprim & Sulphonamides - J1E 5% Glycopeptides - J1XA 5% BSP - J1CA 6% Tetracyclines J1AA 12% BL resistant penicillins - J1CF 8% Macrolides - J1FA 1% Figure 72: Top 1 Antibacterial Usage for 214 Figure 72 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for nearly a third of total antibacterial usage (3%). Fluoroquinolones (J1MA) accounted for a further 5% of usage, cephalosporins (J1DB, J1DC & J1DD) - 3%, and carbapenems (J1DH) - 2% J1CR J1MA J1D J1DH Figure 73: Trends in Specific Antibacterial Group Usage

60 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter Figure 73 shows trends in specific antibacterial group usage in Royal Glamorgan from : beta-lactam/beta-lactamase inhibitor combinations (J1CR), all cephalosporins (J1D), carbapenems (J1DH) and fluoroquinolones (J1MA). Beta-lactam/beta-lactamase inhibitor combination usage (J1CR) shows marked decrease in 214. Cephalosporin usage (J1D) shows a general downward trend over time. Carbapenem usage (J1DH) shows a general upward trend. Fluoroquinolone usage (J1MA) shows a general downward trend over time, but with a notable increase in 213. Note: Please note the difference in the y-axis scale for Figure 7 which extends to 55 DDD/1 BD per quarter. Total antibacterial usage shows an increase in 214 (see Figure 74) J Figure 74: Trends in Total Antibacterial Usage

61 Bronglais Hospital (Hywel Dda Health Board) BL inhibitors - J1CR Macrolides - J1FA Imidizole derivatives - J1XD BSP - J1CA BL resistant penicillins - J1CF 2 Gen Cephs - J1DC Trimethoprim & Sulphonamides - J1E Carbapenems - J1DH Fluoroquinolones - J1MA BL sensitive penicillins - J1CE Tetracyclines J1AA 1 Gen Cephs - J1DB 3 Gen Cephs - J1DD Glycopeptides - J1XA Fusidic Acid - J1XC Aminoglycosides - J1GB Nitrofuran derivatives - J1XE Rifampicin - J4AB Lincosamides & Streptogramins - J1F Polymixins - J1XB Linezolid - J1XX DDD/1 Bed Days Figure 75: Bronglais Hospital - Antibacterial Usage for 211 to 214 Figure 75 shows the pattern of antibacterial usage for Bronglais hospital for 211 (blue bars), 212 (green bars), 213 (purple bars), and 214 (grey bars). In 214 there was a decrease in prescribing of a number of antibacterial groups, including macrolides (J1FA), imidazole derivatives (J1XD), broad spectrum penicillins (J1CA), trimethoprim group (J1E), second generation cephalosporins (J1DC), trimethoprim group (J1E), fluoroquinolones (J1MA), and glycopeptides (J1XA); and there were increases in prescribing of beta-lactam/beta-lactamase inhibitor combinations (J1CR), beta-lactamase resisatcne penicillins (J1CF), carbapenems (J1DH), and fusidic acid (J1XC). 61

62 25 Q1 26 Q1 27 Q1 28 Q1 29 Q1 21 Q1 211 Q1 212 Q1 213 Q1 214 Q1 DDD/1 BD per Quarter BL sensitive penicillins - J1CE 4% Fluoroquinolones - J1MA 4% BL inhibitors - J1CR 25% Carbapenems - J1DH 5% Trimethoprim & Sulphonamides - J1E 5% BL resistant penicillins - J1CF 7% Macrolides - J1FA 16% BSP - J1CA 8% All Cephalosporins 9% Imidizole derivatives - J1XD 9% Figure 76: Top 1 Antibacterial Usage for 214 Figure 76 shows the Top 1 antibacterial group usage for 214; beta-lactam/betalactamase inhibitor combinations (J1CR) were the most used antibacterials, accounting for a quarter of total antibacterial usage (25%). Cephalosporins (J1DB, J1DC & J1DD) accounted for a further 9% of usage, carbapenems (J1DH) - 5%, and fluoroquinolones (J1MA) - 4% J1CR J1D J1DH J1MA Figure 77: Trends in Specific Antibacterial Group Usage