Report on Point Prevalence Survey of Antibacterial Prescribing at Ysbyty Gwynedd Hospital November 2008

Transcription

1 Report on Point Prevalence Survey of Antibacterial Prescribing at Ysbyty Gwynedd Hospital November 2008 Authors: Maggie Heginbothom Robin Howe Version: 1 Antibacterial PPS Ysbyty Gwynedd Date: 29/05/2009 Page: 1 of 19 Status: Draft Welsh Antibacterial Resistance Programme: Surveillance Unit

2 Introduction This report provides a simple analysis of data collected as part of the Wales Point Prevalence Survey (PPS) of antibacterial usage in secondary care; the PPS was supported and carried out by pharmacists in nineteen hospitals across the principality during November/December 2008 to mark the first European antibacterial awareness day (18 th November 2008). Summary of Antimicrobial use at Ysbyty Gwynedd 385 patients were surveyed 34.5% of patients surveyed were receiving an antibacterial o 16.1% for a community-acquired infection o 10.1% for a hospital-acquired infection o 3.9% for surgical prophylaxis o 1.0% for medical prophylaxis o 3.5% for mixed or unknown indications 28 different antibacterials were used o The commonest agents were metronidazole, cefotaxime, amoxicillin, ciprofloxacin & cefalexin o 36.8% of patients receiving an antibacterial received more than one agent Community-acquired infection (CAI) was the indication for 49.6% of patients receiving an antibacterial o 23 different antibacterials were used o Respiratory infections (CA-RTI) were the commonest indication for antibacterials 40.9% of patients prescribed for a CAI 45% of antibacterials prescribed for CAI o Amoxicillin monotherapy was the most commonly prescribed regimen for CA-RTI Hospital-acquired infection (HAI) was the indication for 33.8% of patients receiving an antibacterial o 23 different antibacterials were used o The commonest sites of infection was skin soft tissue bone and joint 33% Surgical prophylaxis was the indication for 12% of patients receiving an antibacterial o 36.8% of patients received prophylaxis for more than 1 day Medical prophylaxis was the indication for 3.0% of patients receiving an antibacterial 2

3 Hospital: Ysbyty Gwynedd The PPS at Ysbyty Gwynedd was carried out on the 18 th of November 2008 Patient Information 385 patients were surveyed 194 of the patients were general medicine patients (50.4%) 182 of the patients were surgical patients (47.3%) 9 of the patients were intensive care patients (2.3%) Of the 385 patients surveyed 133 were prescribed systemic antimicrobial/s (34.5%). o 128 were prescribed systemic antibacterials o 1 was prescribed antibacterials including anti-tb drugs o 3 were prescribed antibacterials and a systemic antifungal o 1 was prescribed antibacterials and a systemic antiviral For the purposes of the report only systemic antibacterial data is included in the analysis. Age group & gender of patients receiving antimicrobials inlcuded in the Ysbyty Gwynedd PPS F M Figure 1: Age group & gender of patients prescribed antibacterials. The age and gender of the 133 patients prescribed antimicrobials is shown in Figure 1. Over 70% of the patients that were prescribed an antimicrobial/s were 60+ in age (72.2%); in this PPS study group 57.9% of the patients were male and 42.1% were female. 3

4 Clinical indication The PPS included four main indications for antibacterial usage: A Community acquired infection B Hospital acquired infection C Surgical prophylaxis D Medical prophylaxis Of the 385 patients surveyed antibacterial agents were prescribed for the following clinical indications (See Figure 2): 62 patients were prescribed an antibacterial/s for a community acquired infection (16.1%) 39 patients were prescribed an antibacterial/s for a hospital acquired infection (10.1%) 15 patients were prescribed an antibacterial/s for surgical prophylaxis (3.9%) 4 patients were prescribed an antibacterial/s for medical prophylaxis (1.0%) 5 patients were prescribed an antibacterial/s for a community acquired infection and a hospital acquired infection (1.3%) 1 patient was prescribed an antibacterial/s for a community acquired infection and for surgical prophylaxis (0.3%) 1 patient was prescribed an antibacterial/s for a community acquired infection and for an unknown indication (0.3%) 1 patient was prescribed an antibacterial/s for a hospital acquired infection and for medical prophylaxis (0.3%) 1 patient was prescribed an antibacterial/s for a hospital acquired infection and for an unknown indication (0.3%) 4 patients were prescribed antibacterial/s unknown indications (1.0%) 252 patients were not prescribed an antibacterial/s (65.5% - NoABx) NoABx, 252, 66% U, 4, 1% A, 62, 17% B&U, 1, 0% B, 39, 10% C, 15, 4% D, 4, 1% A&B, 5, 1% A&C, 1, 0% A&U, 1, 0% B&D, 1, 0% A B C D A&B A&C A&U B&D B&U U NoABx Figure 2: Clinical indication for antibacterial prescribing in patients (n = 385) 4

5 Ward Information Patients from 17 wards/units were included in the Ysbyty Gwynedd PPS. The ward specialty, the number of patients surveyed on the ward, and the number of patients prescribed antimicrobials at or before 8:00 am on the day of the PPS are shown in Table 1. Table 1: Ward information Ward Specialty Patients on ward No. prescribed antibacterials Alaw General Medicine Glaslyn General Medicine Glyder/CCU General Medicine Gogarth General Medicine Hebog General Medicine Moelwyn General Medicine Prysor General Medicine Tryfan General Medicine Aran Surgery Beuno Surgery Conwy Surgery Dulas Surgery Enlli Surgery Ffrancon Surgery Ogwen Surgery Tegid Surgery ITU ITU/HDU % prescribed antibacterials Speciality Information 55 general medicine patients were prescribed antibacterial/s (29.9%) 71 surgical patients were prescribed antibacterial/s (38.8%) 7 intensive care patients were prescribed antibacterial/s (38.9%) Indication for antibacterial The indications recorded for antibacterial usage in the 133 patients included in the PPS are shown in Figure antibacterials were prescribed for community acquired infections (50%) 67 antibacterials were prescribed for hospital acquired infections (33.8%) 19 antibacterials were prescribed for surgical prophylaxis (9.6%) 7 antibacterials were prescribed for medical prophylaxis (3.5%) For 6 antibacterials the indication was unknown (3%) 5

6 U, 6, 3% D, 7, 4% C, 19, 10% B, 67, 34% A, 99, 49% A B C D U Figure 3: Antibacterial usage by indication The indication for each of the antibacterial prescribed for the patients on each ward is shown in Figure 4. The ward with the highest number of antibacterials prescribed on the day of the PPS was Dulas (30 prescribed). The indications for the antibacterials prescribed were: 15 for community acquired infections, 11 for hospital acquired infections, 1 for surgical prophylaxis & 2 for unknown indications. Indications for antibacterial usage by ward/unit Ysbyty Gwynedd PPS - November 2008 Tryfan Tegid Prysor Ogwen Moelwyn ITU Hebog Gogarth Glyder/CCU Glaslyn Ffrancon Enlli Dulas Conwy Beuno Aran Alaw A B C D U Figure 4: Indication for antibacterial usage by ward 6

7 The proportion of instances where the reason for an antibacterial prescription was recorded in the patient notes is shown in Table 2. Table 2: Reason for prescription recorded in the notes Indication No Yes Unknown Total % Yes A B C D Unknown All indications % Overall, the reason for a prescription was recorded in 65.2% of cases. 7

8 Antibacterial Information Twenty eight different antibacterials were prescribed as treatment/prophylaxis in this patient group (see Table 3); comprising 194 issues to 133 patients: Table 3: Antibacterials included in PPS group Antibacterial ATC code Number of Issues Metronidazole J01XD01 32 Cefotaxime J01DD01 19 Amoxicillin J01CA04 18 Ciprofloxacin J01MA02 15 Cefalexin J01DB01 14 Cefuroxime J01DC02 12 Flucloxacillin J01CF05 11 Clarithromycin J01FA09 10 Vancomycin J01XA01 9 Co-amoxiclav J01CR02 8 Erythromycin J01FA01 5 Gentamicin J01GB03 5 Trimethoprim J01EA01 5 Ceftazidime J01DD02 4 Penicillin V J01CE02 4 Piperacillin/Tazobactam J01CR05 4 Benzylpenicillin J01CE01 3 Clindamycin J01FF01 2 Colistin J01XB01 2 Doxycycline J01AA02 2 Fusidic Acid J01XC01 2 Meropenem J01DH02 2 Amikacin J01GB06 1 Ethambutol J04AK02 1 Imipenem J01DH51 1 Nitrofurantoin J01XE01 1 Norfloxacin J01MA06 1 Rifampicin J04AB02 1 All-antibacterials J There were 35 different combinations of antibacterial prescribed in this group; the most common were: Cefotaxime plus clarithromycin (prescribed for 4 patients) Cefotaxime plus metronidazole (prescribed for 4 patients) Cefuroxime plus metronidazole (prescribed for 4 patients) 8

9 Figure 5 shows the proportion of antibacterials prescribed by indication (A-D); monotherapy was prescribed in 60.6% of patients with community acquired infections (A), compared to 55.8% with hospital acquired infections (B) and 81.3% for surgical prophylaxis (C). The numbers of antibacterials prescribed for medical prophylaxis were too small to make any meaningful conclusions for this type of prescribing. Proportion A B C D U Monotherapy Antibacterials Antibacterials Proportion of antibacterials/indication Figure 5: Prescriptions for antibacterial usage by indication Diagnosis groups The PPS included ten diagnosis groups based on anatomical site: Central nervous system (CNS) Eye Ear, nose, throat, mouth or larynx (ENT) Respiratory tract (RESP) Cardiovascular system (CVS) Gastrointestinal tract including liver and biliary tree (GI) Skin, soft tissue, bone and joint (SSTBJ) Urinary tract (UTI) Genitourinary tract (GUOB) No clear anatomical site (Not Defined) 9

10 Community Acquired Infections (A) The antibacterials prescribed for community acquired infections (A) and the proportion of issues administered parenterally is show in Table patients of the 385 patients surveyed were prescribed antimicrobial/s for community acquired infections (17.1%) Of the 133 patients in the survey that were prescribed antibacterials, 66 (49.6%) were indicated for community acquired infections (A). 23 different antibacterials were prescribed within this group. Table 4: Antibacterials prescribed for community acquired infections (A) Antibacterial ATC code Number of Issues % IV administration Cefotaxime J01DD Amoxicillin J01CA Metronidazole J01XD Clarithromycin J01FA Cefalexin J01DB Ciprofloxacin J01MA Flucloxacillin J01CF Co-amoxiclav J01CR Vancomycin J01XA Erythromycin J01FA Gentamicin J01GB ** Piperacillin/Tazobactam J01CR Benzylpenicillin J01CE Penicillin V J01CE Trimethoprim J01EA Amikacin J01GB Ceftazidime J01DD Cefuroxime J01DC Clindamycin J01FF Colisitin J01XB01 1 0** Doxycycline J01AA Ethambutol J04AK Nitrofurantoin J01XE Rifampicin J04Ab All-antibacterials J % ** One prescription for gentamicin and for colistin was for inhaled use. The antibacterials most commonly prescribed for community acquired infections were: Cefotaxime (14.3% of all issues for indication A) Amoxicillin (13.3% of all issues for indication A Metronidazole (11.2% of all issues for indication A) Clarithromycin (9.2% of all issues for indication A) 10

11 Figure 6 shows that 45% of the antibacterials prescribed for community acquired infections were for respiratory tract infections. UTI, 13, 13% CNS, 4, 4% CVS, 2, 2% ENT, 1, 1% GI, 9, 9% MIX, 1, 1% SSTBJ, 18, 18% RESP, 43, 45% Not Defined, 7, 7% CNS CVS ENT GI MIX Not Defined RESP SSTBJ UTI Figure 6: Antibacterial prescribed for indication A by diagnosis group The number of antibacterials prescribed and the diagnosis groups excluding respiratory (RESP) for community acquired infections is shown in Table 5. Table 5: Antibacterials prescribed by diagnosis group Indication A Antibacterial Not Defined SSTBJ UTI Name CNS CVS ENT GI MIX Amoxicillin 1 Benzylpenicillin 1 1 Cefalexin Cefotaxime Cefuroxime 1 Ciprofloxacin 1 3 Clarithromycin 1 1 Clindamycin 1 Co-amoxiclav 1 1 Erythromycin 1 Flucloxacillin 5 Gentamicin 1 Metronidazole Nitrofurantoin 1 Penicillin V 2 Pip/Tazobactam 1 1 Trimethoprim 1 1 Vancomycin All-antibacterials

12 SSTBJ and UTI were the most common diagnosis in the remaining group (56.4%); the most commonly prescribed antibacterial for the treatment of SSTBJ infections was flucloxacillin (27.8%), & for UTI was both cefalexin and cefotaxime (61.5%). 28 patients were prescribed antimicrobials for community acquired respiratory tract infections (RESP). The PPS allowed the diagnosis group RESP to be split into sub-groups: Community acquired bronchitis (Bron) Community acquired pneumonia (Pneu) Note: The diagnosis group for one patient in this group was recorded as ProphRes, if the antibacterial was prescribed as prophylaxis then the main indication is a misclassification and should have been recorded as medical prophylaxis (D) and not community acquired infection (A); therefore the patient is excluded from the table below. The number of patients and the antibacterials prescribed for their community acquired bronchitis or pneumonia (CAP) are shown in Table 6. Table 6: Antibacterials prescribed for RTI Indication A No. of Patients Antibacterial/s Pneu Total Amikacin/Clarithromycin/Ethambutol/Rifampicin* 1 1 Amoxicillin 7 7 Amoxicillin/Ciprofloxacin 1 1 Amoxicillin/Clarithromycin 1 1 Amoxicillin/Metronidazole 1 1 Cefalexin/Erythromycin 1 1 Cefotaxime Cefotaxime/Clarithromycin Cefotaxime/Clarithromycin/Metronidazole 1 1 Cefotaxime/Metronidazole 1 1 Ceftazidime/Colistin**/Gentamicin** 1 1 Ciprofloxacin 1 1 Clarithromycin 2 2 Co-amoxiclav 2 2 Doxycycline 1 1 Erythromycin 1 1 Gentamicin/Piperacillin 1 1 All-antibacterials *The regimen for one patient clearly showed the prescribing was for the treatment of a mycobacterial infection (amikacin, clarithromycin, ethambutol & rifampicin). **One patient was prescribed a regimen of parenteral ceftazidime with inhaled colistin & gentamicin suggesting the patient was a cystic fibrosis (CF) patient. 12

13 For the remaining 25 patients, the BTS guidelines for treatment of a community acquired RTI is amoxicillin or co-amoxiclav +/- clarithromycin: 12 of the 25 patients in this group were prescribed antibacterials that are included in the BTS guidelines (48%) o 7 amoxicillin monotherapy o 1 amoxicillin plus clarithromycin o 2 clarithromycin monotherapy o 2 co-amoxiclav monotherapy In this survey 7 different antimicrobial combinations were prescribed for patients with a diagnosis of community acquired RTI, other than for CF and mycobacterial infection. 13

14 Hospital Acquired Infections (B) The antibacterials prescribed for hospital acquired infections (B) and the proportion of issues administered parenterally is show in Table patients of the 385 patients surveyed were prescribed antimicrobial/s for hospital acquired infections (11.2%) Of the 133 patients in the survey that were prescribed antibacterials, 43 (33.8%) were indicated for hospital acquired infections (B). 23 different antibacterials were prescribed within this group. Table 8: Antibacterials prescribed for hospital acquired infections (B) Antibacterial ATC code Number of Issues % IV administration Metronidazole J01XD Flucloxacillin J01CF Cefalexin J01DB Ciprofloxacin J01MA Amoxicillin J01CA Vancomycin J01XA Cefotaxime J01DD Ceftazidime J01DD Co-amoxiclav J01CR Erythromycin J01FA Fusidic Acid J01XC Meropenem J01DH Penicillin V J01CE Trimethoprim J01EA Benzylpenicillin J01CE Clarithromycin J01FA Clindamycin J01FF Colisitin J01XB01 1 0** Doxycycline J01AA Gentamicin J01GB Imipenem J01DH Norfloxacin J01MA Piperacillin/Tazobactam J01CR All-antibacterials J % ** The prescription for colistin was for inhaled use. The antibacterials most commonly prescribed for hospital acquired infections were: Metronidazole (21.5% of all issues for indication B) Flucloxacillin (9.2% of all issues for indication B) Cefalexin (7.7% of all issues for indication B) Ciprofloxacin (7.7% of all issues for indication B) 14

15 UTI, 12, 18% ENT, 2, 3% GI, 12, 18% GUOB, 3, 5% Not Defined, 2, 3% ENT GI GUOB Not Defined RESP SSTBJ UTI SSTBJ, 21, 33% RESP, 13, 20% Figure 7: Antibacterial prescribed for indication B by diagnosis group Figure 7 shows that 33% of the antibacterials prescribed for hospital acquired infections were for skin soft tissue infections. The PPS included five sub-indications within hospital acquired infection (B): B1 Post-operative infection B2 Other intervention related infections B3 C. difficle associated diarrhoea B4 Other hospital acquired infection B5 Infection present on admission from another hospital The diagnosis groups & sub-indications within the hospital acquired infection group are shown in Table 9. Table 9: Diagnosis group by sub-indication Diagnosis Group B1 B2 B3 B4 ENT 2 GI GUOB 3 Not Defined 2 RESP SSTBJ UTI 1 11 All diagnosis B3 there were 6 prescriptions for C. difficle associated diarrhoea B4 other hospital infections were the most common sub-indication recorded accounting for 39 of the 65 prescriptions in this group (60%) 15

16 The antibacterials prescribed for the sub-indications B1, B2 and B4 are shown in Table 10 (excluding B3). Table 10: Antibacterials prescribed by diagnosis group & sub -indications Antibacterial Name ENT GI GUOB Not Defined RESP SSTBJ UTI Amoxicillin 2 2 Benzylpenicillin 1 Cefalexin Cefotaxime 1 2 Ceftazidime Ciprofloxacin 1 4 Clarithromycin 1 Clindamycin 1 Co-amoxiclav 2 Colistin 1 Doxycycline 1 Erythromycin 1 1 Flucloxacillin 6 Fusidic Acid 2 Gentamicin 1 Imipenem 1 Meropenem 1 1 Metronidazole Norfloxacin 1 Penicillin V 2 Piperacillin/Tazobactam 1 Trimethoprim 2 Vancomycin Grand Total Flucloxacillin was the most commonly prescribed antibacterial for SSTBJ infections (27%) Ciprofloxacin was the most commonly prescribed antibacterial for UTIs (33%) The other groups were too small in numbers to draw any conclusions For C. difficle associated diarrhoea (sib-indication B3), metronidazole was prescribed in all cases (100%) 16

17 Surgical Prophylaxis (Indication C) The antibacterials prescribed for surgical prophylaxis (C) and the proportion of issues administered parenterally is shown in Table of the 385 patients surveyed were prescribed antimicrobial/s for surgical prophylaxis (4.2%) Of the 133 patients in the survey that were prescribed antibacterials, 16 (12%) were indicated for surgical prophylaxis (C). 7 different antibacterials were prescribed within this group. Table 11: Antibacterials prescribed for hospital acquired infections (C) Antibacterial ATC code Number of Issues % IV administration Cefuroxime J01DC Metronidazole J01XD Cefotaxime J01DD Co-amoxiclav J01CR Gentamicin J01GB Trimethoprim J01EA Vancomycin J01XA All-antibacterials J % Cefuroxime, metronidazole and cefotaxime were the most commonly prescribed antibacterials for surgical prophylaxis (78.9% of all issues) 17of the 19 antibacterials prescribed for surgical prophylaxis were for IV administration only (89.5%) Table 12 shows the antibacterials prescribed by diagnosis group; the most common diagnoses was prophylaxis prior to skin, soft tissue, bone and joint procedures (52.6%) Table 12: Antibacterials prescribed by diagnosis group Indication C Antibacterial Proph CVS Proph ENT Proph GI Proph SBJ Proph UT Cefuroxime 2 Metronidazole 1 9 Cefotaxime 1 Co-amoxiclav 1 Gentamicin 2 1 Trimethoprim 1 Vancomycin 1 All antibacterials

18 Figure 8 shows that 23 of the 38 antibacterials prescribed (53%) for surgical prophylaxis was for skin, soft tissue bone & joint (Proph SBJ). Proph UT, 2, 11% Proph CVS, 1, 5% Proph ENT, 1, 5% Proph GI, 5, 26% Proph CVS Proph ENT Proph GI Proph SBJ Proph UT Proph SBJ, 10, 53% Figure 8: Antibacterial prescribed for indication C by diagnosis group The PPS included three categories within surgical prophylaxis (C) based on the number of doses of antibacterial prescribed: C1 Single dose C2 One day C3 > 1 day The number of antibacterials prescribed for surgical prophylaxis and the proportion for more than one day duration (C3) is shown in Table % of antibacterials were prescribed for more than one day in duration. Table 12: Antibacterials prescribed by sub indication C1, C2 & C3 Antibacterial Proportion C3 > I day Name Indication C1 Indication C2 Indication C3 Cefuroxime Metronidazole Cefotaxime Co-amoxiclav Gentamicin 1 0 Trimethoprim 1 0 Vancomycin 1 0 All antibacterials % Table 13 shows the diagnosis subgroups and the proportion of antibacterials that were prescribed for more than one day duration (C3); however, the numbers in the some groups are really too small to draw any firm conclusions. 18

19 Table 13: Diagnosis subgroup by sub indication C1, C2 & C3 Diagnosis subgroup Indication C1 Indication C2 Indication C3 Proportion C3 > I day Proph CVS 1 0 Proph ENT Proph GI Proph SBJ Proph UT All diagnosis % Medical Prophylaxis (Indication D) The antibacterials prescribed for medical prophylaxis (D) and the proportion of issues administered parenterally is shown in Table of the 385 patients surveyed were prescribed an antimicrobial/s for medical prophylaxis (1.0%) Of the 133 patients in the survey that were prescribed antibacterials, 4 (3.0%) were indicated for medical prophylaxis (D). 3 different antibacterials were prescribed within this group. 4 antibacterials (66.7%) were prescribed as medical prophylaxis for GI 3 of the 6 antibacterial were prescribed for IV administration (50%) All ciprofloxacin was prescribed for oral administration Table 14: Antibacterials prescribed for medical prophylaxis Antibacterial ATC code Number of Issues Diagnosis GI Diagnosis Not defined Ciprofloxacin J01MA Metronidazole J01XD Cefuroxime J01DC All antibacterials J