Geographic Variability of Antibacterials Dispensed within the Province of Alberta, Canada B Dalton PharmD1, D Sabuda BSP1, L Bresee BScPharm, PhD1, OE Larios MD2,3, B Missaghi MD2,3, L Svenson4,5,6, K Simmonds MSc4,6 and J Conly MD2,3

1Pharmacy, Alberta Health Services, Calgary Zone, Calgary, AB, Canada, 2Snyder Institute, University of Calgary, Calgary, AB, Canada, 3Alberta Health Services, Calgary Zone, Calgary, AB, Canada, 4Alberta Health, Edmonton, AB, Canada, 5School of Public Health, University of Alberta, Edmonton, AB, Canada, 6Community Health Sciences, University of Calgary, Calgary, AB, Canada

Table 3:North Zone (pop. 447,740) Fig 3. Zonal Antibiotic Use - ages 0-17, All ABx Penicillins Quinolones PrID, % Background: DID PrID DID PrID DID PrID Fig. 1 0-17 20.0 1.6 13.9 0.86 0.1 0.01 100% Fig 3. Pediatric Antibiotic Use. The majority of • Alberta (AB) is a province of ~4 million people in western Canada. Canada prescriptions per inhabitant day in pediatric age Public health care services administered by 5 zones with provincial oversight. 18-64 16.3 1.4 5.0 0.41 1.8 0.23 80% • 65+ 22.2 2.0 4.6 0.37 4.3 0.54 group are for J01C – Penicillins. J01D – Total • 2 urban zones; Calgary and Edmonton (~2.6 million, or 68% of the population) and 3 rural 60% prescriptions and cephalosporins specifically Legend; Figures 3-5 zones; rural populations and small urban centres. 40% were prescribed at a higher rate in South and Table 4:Edmonton Zone (pop. 1,196,121) 1 Central zones versus others. Tetracyclines Socioeconomic indicators: 20% All ABx Penicillins Quinolones Penicillins • Median family income (AB: $76, 642 vs CAN: $66,452). DID PrID DID PrID DID PrID 0% Cephalosporins • University program completion (AB 26.6% vs CAN 27.9% ) . 0-17 23.7 1.58 15.7 0.82 0.11 0.02 Sulfonamides • Within AB: Median income; Calgary>Edmonton>North>Central>South. University completion; 18-64 19.8 1.66 4.9 0.39 2.2 0.29 Fig 4. Zonal Antibiotic Use, ages 18-64, Total PrID 1.64 1.50 1.79 1.56 1.58 Calgary>Edmonton>South>Central>North. 65+ 25.6 2.33 4.6 0.36 6.0 0.73 DID, % Macrolides & Clindamycin Health Indicators:1 Fig 4 . Adult Antibiotic Use. Higher rates of Aminoglycosides Table 5:Central Zone (pop. 453,469) 100% • Age standardized, all cause death rates and non-birth & non-pregnancy related hospitalization systemic antibacterials prescriptions were 90% Fluoroquinolones All ABx Penicillins Quinolones 80% rates: North>Central>South>Edmonton>Calgary zones (2007-2009) observed in the adult population in 70% DID PrID DID PrID DID PrID 60% Misc. Systemic antibacterials • Most common causes of death; circulatory disorders, cancer and respiratory disorders Edmonton, South and North zones versus 50% 0-17 21.5 1.79 14.1 0.87 0.1 0.02 Calgary and North zones. Explanation for 40% References: • HATi score (Healthy Alberta Trends index, a composite of health risks), highest (poorest health) in 18-64 18.1 1.64 4.8 0.41 2.0 0.26 30% 1. How Healthy Are We? Alberta; Population, Socioeconomics and this observation is not yet determined. 20% Health Summary. Alberta Health. Feb 2011. the Central>North,>South=Edmonton>Calgary 65+ 22.5 2.08 3.5 0.29 5.1 0.61 10% 0% http://www.albertahealthservices.ca/poph/hi-poph-surv-hsa-report- • Licensed physicians per capita; Edmonton>Calgary>South>Central>North 2011-alberta.pdf Methods: 2. Canadian Antimicrobial Resistance Alliance. http://www.can-r.com/ Table 6:Calgary Zone (pop. 1,409,606) Accessed Apr 30, 2013. ® Fig 5. Zonal Antibiotic Use, ages 65+, We obtained data from the IMS Brogan Xponent database to estimate the use of systemic All ABx Penicillins Quinolones Total DID 19.5 17.2 18.1 19.8 16.3 3. Hicks LA, Taylor TH & Hunkler RJ. US Outpatient Antibiotic Prescribing , DID, % 2010. NEJM 2013. 368(15):1461-1462 antibacterials (Abx) for 8 quarters for period of Jul 2010 - Jun 2012. Population data were DID PrID DID PrID DID PrID 100% 4. Adrianssens N, Coenen S, Versporten A et al. European Surveillance of obtained from the Alberta Health Care Insurance Plan (AHCIP) for each year and end of quarter Fig 5. Some zones prescribed more Antimicrobial Consumption (ESAC): outpatient antibiotic use in Europe 0-17 23.8 1.49 16.8 0.77 0.1 0.01 80% populations were estimated using a linear model. fluoroquinolones and macrolides in the (1997-2009). J Antimicrob Chemo 2011; 66 suppl 6:vi3-vi12 18-64 17.1 1.41 4.5 0.36 1.6 0.21 60% 5. Adrianssens N, Coenen S, Versporten A et al. European Surveillance of elderly as percentage of total. Those Number of prescriptions per 1000 inhabitant-days (PrID) and defined daily doses per 1000 65+ 22.5 2.11 4.6 0.37 4.4 0.58 40% Antimicrobial Consumption (ESAC): quality appraisal of antibiotic use zones also had higher rates of in Europe. J Antimicrob Chemo 2011; 66 suppl 6:vi71-vi77 inhabitant-days (DID) were calculated for the zones, stratified by ages 0-17 (pediatrics), 18-64 20% consumption of all systemic antibacterials 6. Antimicrobial consumption rates by country. European surveillance of 0% (adults) and ≥65 years (seniors). in this age group. antimicrobial consumption (ESAC-Net) interactive database. European Statistical comparisons of DID and PrID were conducted using tests for person-time data. Table 7:South Zone (pop. 299,661) centre for disease prevention and control. All ABx Penicillins Quinolones http://ecdc.europa.eu/en/activities/surveillance/ESAC- Data were benchmarked against Canadian National data,2 US national IMS Xponent®3 and European Net/database/Pages/consumption-rates-by-country.aspx DID PrID DID PrID DID PrID Total DID 24.9 22.5 22.5 25.6 22.2 3,4,5 Accessed Aug 26, 2013 Surveillance of Antimicrobial Consumption (ESAC) data. We further characterized our results by 0-17 21.0 1.64 14.2 0.79 0.1 0.02 4 benchmarking against the quality indicators used by ESAC. 18-64 19.5 1.73 4.8 0.40 2.4 0.30 Results: 65+ 24.9 2.37 3.9 0.31 5.9 0.72 • The average DID/PrID were 19.8/1.6 (Table 1; range: 16.0/1.37 [Q2 2012] to 22.7/1.85 [Q1 2011]) • All inter-zone comparisons were statistically significant Edmonton>South>Central>Calgary>North by DID [Table 1]. Table1: DID & PrID averages by zone and comparison to Table 2: Alberta Antimicrobial Consumption Quality Indicators Benchmarked against 33 nation ESAC survey 2009 • Close to the median nation (Iceland, 16th of 33) in the European survey.4 other jurisdictions 25th% percentile 25th-50th percentile 50th-75th percentile 75th to 100th percentile • Seasonal variation was observed in use of all systemic Abx (14-19%) which was less than that of the median Zone DID PrID (Very low) (Low) (Above average) (High) European nation (25.7% [Table 2]). However seasonal variation of fluroquinolones in Alberta (6-14%) was similar to Alberta 19.8 1.6 J01_DID J01C_DID J01D_DID J01F_DID J01M_DID % J01CE %J01CR %J01DD&DE %J01MA J01B/N J01_SV J01M_SV the median European country (7.6%).5 South 20.6 1.8 South 20.6 7.0 2.2 4.5 2.3 1.6 3.7 0.71 11.3 4.3 17.4 13.9 • Seniors highest in prescriptions and DDD consumption; 2.2 PrID and 23.7 DID, respectively, followed by pediatrics Calgary 19.2 1.5 Calgary 19.2 7.2 1.6 4.0 1.6 1.2 3.0 0.57 8.2 3.8 19.1 11.1 (1.57/22.8) and adults [(1.54/18.4), Tables 3-7] Central 19.5 1.7 Central 19.5 6.8 2.2 4.3 2.0 1.3 4.7 0.90 10.2 4.2 16.2 8.2 Edmonton 21.3 1.7 Edmonton 21.3 7.2 1.9 4.5 2.2 1.5 3.9 1.3 10.3 3.6 14.1 9.4 Discussion: Abx consumption is difficult to measure. We calculated appropriate measures for various populations and found Abx consumption differences, in some ways consistent with differences in health and socioeconomic indicators. North 17.7 1.5 North 17.73 7.2 1.6 3.8 1.6 1.3 7.4 1.4 9.0 5.3 15.1 5.8 Compared to data available for Canada, consumption of Abx drugs is similar (Table 1). The ESAC survey in 2009 of 33 2 All AB 19.8 7.1 1.83 4.2 1.9 1.4 4.0 0.95 9.5 3.9 16.5 9.8 Canada (2011) 17.6 NA developed countries provide valuable benchmarks and quality indicators for comparison purposes. This has led to the United States (2010)3 NA 2.28 J01DID: Systemic antibacterials defined daily doses per inhabitant %J01CE: Percentage of beta-lactamase sensitive penicillins (of total J01_SV: seasonal variation of J01 drugs - identification of macrolides in almost all zones and fluoroquinolones in some zones as priority areas for antimicrobial day (DID) J01) percent 6 Europe (ESAC, 2010) 20.1 NA J01C_DID: Penicillins per DID %J01CR: Percentage of beta-lactam/beta-lactamase inhibitor combo J01M_SV: seasonal variation of stewardship initiatives. We recognize the limitation that figures from Europe in 2009 may not be perfectly suited to J01D_DID: Cephalosporins DID %J01DD+DE: Percentage of 3rd and 4th gen cephalosporins fluroquinolones comparison to our provincial data from 2010-2012 . J01F_DID: Macrolides DID %J01MA: Percentage of fluroquinolones J01M_DID: Fluorouinolones DID J01B/N: ratio of broad to narrow