Antibacterial Primary Care Prescribing Indicators Report

SAPGScottish Antimicrobial Prescribing Group Primary Care Prescribing Indicators

Annual Report 2011-12 Published October 2012 Table of Contents Executive summary 1

Introduction 2

Data source and definitions 3

Data sources 3

Items 3

Defined daily dose 3

Statistical significance 3

Format of indicators 4

Items/1000 patients/day 4

Percentage of total antibacterial use 4

Seasonal variation of fluoroquinolone use 4

Interpretation of data 4

Total use of antibacterials 5

Seasonal variation in use of fluoroquinolones 7

Antibacterials associated with a higher risk of Clostridium difficile infection 9

Co-amoxiclav 12

Fluoroquinolones 14

Cephalosporins 16

Recommended antibacterials 18

Appendix 1 21

i List of Tables

Table 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 6

Table 2: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (DDDs) 2008-09 – 2011-12 8

Table 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, Items/1000/day 2007-08 – 2011-12 10

Table 4: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 11

Table 5: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 13

Table 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 15

Table 7: NHS Scotland use of cephalosporins in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 17

Table 8: NHS Scotland use of recommended agents, total items 2011-12 and change from 2010-11 18

Table 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 19

Table 10: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 20

ii List of Figures

Figure 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 6

Figure 2: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (DDDs) 2008-09 – 2011-12 8

Figure 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, Items/1000/day 2007-08 – 2011-12 10

Figure 4: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 11

Figure 5: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 13

Figure 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 15

Figure 7: NHS Scotland use of cephalosporins in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 17

Figure 8: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 19

Figure 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 20

iii Executive summary

This is the fourth annual report from the Scottish Antimicrobial Prescribing Group (SAPG) published by Information Services Division (ISD)/ Health Protection Scotland (HPS) of NHS National Services Scotland (NSS) containing information on key national primary care antibacterial prescribing indicators. The purpose of this report is to support the work of NHS board Antimicrobial Management Teams (AMTs) and SAPG by enabling identification of areas for detailed local analysis and discussion with prescribers to support improvement in the quality of antimicrobial prescribing.

The SAPG national prescribing indicators are accessible as standard reports within Prescribing Information System for Scotland (PRISMS). PRISMS is the web based application maintained by Information Services Division (ISD) of NHS National Services Scotland (NSS) giving access to prescribing information on all prescriptions dispensed in the community in Scotland in the last five years.

Key findings in 2011-12 include;

• There were 76,000 (15%) fewer prescriptions for broad spectrum antibacterials associated with a higher risk of Clostridium difficile infection (CDI) in primary care in Scotland than in 2010-11. This is the third successive year in which a reduction has been observed. Reductions have been observed in all but one NHS boards.

• An increase of 152,000 (5%) prescriptions for antibacterials recommended for first line empirical treatment of infections commonly encountered in primary care compared to 2010-11. This builds upon the increase observed in each of the previous three years. The increase was observed across all NHS boards and suggests increased compliance with local prescribing policies.

• There were 10 NHS boards below the target for seasonal variation in fluoroquinolone use as part of the prescribing indicators in support of HEAT target for CDI.

• An increase of 2% (p<0.05) in the total number of prescriptions for antibacterials compared to 2010-11. This is equivalent to an increase of 98,000 prescriptions in 2011-12.

The report illustrates the ongoing impact of initiatives to encourage compliance with evidenced based prescribing guidelines that promote use of recommended agents and restrict the use of broad spectrum antibacterials associated with a higher risk of CDI. The increase in total antibacterial use indicates that further priority should be given to working with prescribers in primary care to reduce unnecessary use of antibacterials.

Welcome to the fourth report from the Scottish Antimicrobial Prescribing Group (SAPG) published by Information Services Division (ISD) and Health Protection Scotland (HPS) of NHS National Services Scotland (NSS) containing information on key national primary care antibacterial prescribing indicators. The purpose of the report is to support the work of NHS board Antimicrobial Management Teams (AMTs) and is intended to enable AMTs to identify areas for detailed local analysis and discussion with prescribers to support improvement in prescribing practice. By highlighting patterns of change in the last twelve months the report is intended to support AMTs to monitor the impact of local and national interventions which aim to enhance the quality of antimicrobial prescribing in a primary care setting.

The national prescribing indicators are accessible as standard reports within Prescribing Information System for Scotland (PRISMS). PRISMS is a web based application maintained by Information Services Division (ISD) of NHS National Services Scotland (NSS) giving access to prescribing information on all prescriptions dispensed in the community in Scotland in the last five years. Further information can be found on the PRISMS website: http://www. prismsweb.scot.nhs.uk/. A full list of the national prescribing indicators available in PRISMS is shown in appendix 1.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Data source and definitions Data sources Data on use of systemic antibacterials comes from a database of all NHS prescriptions written by general practitioners, nurses and community pharmacists which are dispensed in the community in Scotland. The information is supplied to ISD by Practitioner Services Division (PSD) of NSS who are responsible for the processing and pricing of all prescriptions dispensed in Scotland.

Items The primary measure of antibacterial use in Scotland presented in this report is the number of items. This refers to the number of times an antibacterial appears on prescription.

Defined daily dose The defined daily dose (DDD) is a technical unit of measurement of medicine use developed by the World Health Organisation. It is internationally recognised and used to standardise the comparative use of medicines over time and between different locations. For further details on DDD see WHO Collaborating Centre for drug statistics methodology website at http://www.whocc.no/atcddd/

Statistical significance Confidence intervals (95%) for proportions were calculated to indicate robustness of the proportions presented. To test for a significant difference between two proportions a ratio of the estimates and a 95% confidence interval based on this were calculated.

The report presents key national prescribing indicators on total use of systemic antibacterials, seasonal variation of fluoroquinolones and patterns of use of groups and certain individual antibacterials.

Items/1000 patients/day This indicator presents use of antibacterials in NHS boards over a given period of time expressed as the number of times an antibacterial has been dispensed. To allow comparison between areas with a different population it is presented as number of items per 1000 patients per day.

Percentage of total antibacterial use This indicator presents use of selected antibacterials in NHS boards as a percentage of all antibacterial use expressed in items.

Seasonal variation of fluoroquinolone use This indicator presents the difference in the use of fluoroquinolones in DDDs in the winter (October to March) compared to the preceding summer (April to September).

Interpretation of data The use of antibacterials should normally reflect prescribing policies, guidelines or formularies for each NHS board. When interpreting the graphs it is important to note that the y axis scales vary between graphs and care is needed in interpretation. On each trend graph a line has been included to show data at Scotland level.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Total use of antibacterials

The development of antimicrobial resistance is a complex evolutionary process. It is accepted that the main driver for the development of resistance is exposure to antimicrobial agents and that resistance is greatest where use is greatest. There is evidence from systematic reviews and randomised controlled trials that antibacterials have limited efficacy in treating a large proportion of respiratory tract infections in adults and children. SAPG has identified reducing unnecessary use of antibacterials as a key aspect of antimicrobial stewardship in Scotland.

In 2011-12 there were 98,000 (2%) more prescriptions for systemic antibacterials in primary care in Scotland than in 2010-11. This increase was statistically significant (p<0.05). There is wide variation in the use of antibacterials (items1000/day) across NHS boards. NHS Orkney had the lowest use at 1.75 items/1000/day and the highest was in NHS Lanarkshire at 2.42 items/1000/day (table 1, figure 1).

The increase in total antibacterial use indicates that further priority should be given to working with prescribers in primary care to reduce unnecessary use of antibacterials.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12 Total antibacterials 2007/08 2008/09 2009/10 2010/11 2011/12 (Items/1000/day) NHS AYRSHIRE & ARRAN 2.05 2.12 2.08 2.09 2.11 NHS BORDERS 1.80 1.85 1.85 1.90 1.93 NHS DUMFRIES & GALLOWAY 1.93 2.00 1.91 1.97 2.00 NHS FIFE 2.06 2.08 2.07 2.05 2.13 NHS FORTH VALLEY 2.02 2.06 2.00 2.01 2.02 NHS GRAMPIAN 1.91 1.90 1.89 1.89 1.93 NHS GREATER GLASGOW & CLYDE 2.15 2.19 2.13 2.10 2.17 NHS HIGHLAND 1.85 1.82 1.84 1.86 1.86 NHS LANARKSHIRE 2.32 2.39 2.38 2.39 2.42 NHS LOTHIAN 1.66 1.71 1.69 1.72 1.80 NHS ORKNEY 1.70 1.69 1.61 1.77 1.75 NHS SHETLAND 1.77 1.89 1.87 1.96 1.94 NHS TAYSIDE 2.01 2.03 1.96 1.97 1.97 NHS WESTERN ISLES 2.15 2.25 2.22 2.23 2.22 SCOTLAND 2.00 2.04 2.00 2.01 2.05

Figure 1: NHS Scotland use of antibacterials in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12

2.5 2.4 2.3 2.2 2.1 2.0 1.9

Items/1000Pts/Day 1.8 1.7 1.6 1.5 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

NHS AYRSHIRE & ARRAN NHS GRAMPIAN NHS ORKNEY NHS BORDERS NHS GREATER GLASGOW & CLYDE NHS SHETLAND NHS DUMFRIES & GALLOWAY NHS HIGHLAND NHS TAYSIDE NHS FIFE NHS LANARKSHIRE NHS WESTERN ISLES NHS FORTH VALLEY NHS LOTHIAN SCOTLAND

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Seasonal variation in use of fluoroquinolones

Use of fluoroquinolones is associated with an increased risk of Clostridium difficile infection (CDI). Fluoroquinolones are not recommended for treatment of most commonly encountered infections in primary care, except for a few specific infections.

The Scottish Government and SAPG agreed antimicrobial prescribing indicators to support achievement of the HEAT target for reduction in CDI. In primary care the indicator is seasonal variation in fluoroquinolone use should be less than 5%. Seasonal variation is defined as the difference in use during the winter (October to March) relative to use in the preceding summer (April to September). In the winter more respiratory tract infections are seen but many are caused by viruses, are self-limiting and do not require treatment with an antibacterial. Excess use of fluoroquinolones in the winter suggests inappropriate use for respiratory infections.

Table 2 and Figure 2 illustrate the percentage seasonal variation of fluoroquinolone use (in DDDs) by NHS board in primary care. In 2011-12 ten NHS boards were below the target. A negative seasonal variation means there was lower use in the winter compared to the preceding summer.

NHS Forth Valley saw a 9.9% seasonal variation in 2011-12. Over the 4 years 2008-09 to 2011-12 there has been a consistent annual reduction in use of fluoroquinolones in NHS Forth Valley. This reduction was more pronounced in summer than in winter 2011-12 with the result that seasonal variation has increased.

NHS Greater Glasgow and Clyde saw a 9.1% seasonal variation in 2011-12. Although the number of fluoroquinolone items/1000/day has not changed the number of DDDs per item increased in 2011-12. This increase can be explained by the implementation of evidence based prescribing guidelines which have resulted in a move towards use of higher doses thereby impacting on seasonal variation expressed in DDD.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 2: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (DDDs) 2008-09 – 2011-12 % Seasonal Variation 2008/09 2009/10 2010/11 2011/12 NHS AYRSHIRE & ARRAN 10.8 13.1 -12.8 -3.7 NHS BORDERS 12.1 6.4 -0.8 -3.8 NHS DUMFRIES & GALLOWAY 5.6 -7.6 1.9 -9.1 NHS FIFE 10.7 -6.1 -4.5 4.1 NHS FORTH VALLEY 18.3 -8.3 -3.9 9.9 NHS GRAMPIAN 5.8 -18.2 -11.1 0.0 NHS GREATER GLASGOW & CLYDE 9.6 3.7 5.5 9.1 NHS HIGHLAND -5.6 1.5 -8.7 -1.9 NHS LANARKSHIRE 7.8 5.8 -1.7 -2.6 NHS LOTHIAN 8.0 4.3 5.6 4.2 NHS ORKNEY -8.9 25.3 -39.9 -13.8 NHS SHETLAND 32.7 3.2 -30.9 21.4 NHS TAYSIDE -0.3 -20.0 0.6 -3.6 NHS WESTERN ISLES 23.1 9.2 -18.4 12.9

Figure 2: NHS Scotland use of antibacterials in primary care by NHS board, % seasonal variation of fluoroquinolones (DDDs) 2008-09 – 2011-12

35 30 25 20 15 10 5 0 -5 -10 -15 -20 -25 % seasonal variation (DDDs) -30 -35 -40 NHS Fife NHS A & NHS D & G NHS Orkney NHS Lothian NHS GG & C NHS Tayside NHS Borders NHS Highland NHS Shetland NHS Grampian NHS Forth Valley NHS Lanarkshire NHS Western Isles

2008/09 2009/10 2010/11 2011/12

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Antibacterials associated with a higher risk of Clostridium difficile infection A key priority for SAPG since its establishment in 2008 has been the reduction in use of broad spectrum antibacterials that increase the risk of CDI. AMTs have developed prescribing policies for first line empirical treatment of infections commonly encountered in primary care based on a national evidence based template. A benefit of this approach is that it restricts the use of high risk antibacterials.

In 2011-12 there were 76,000 (15%) fewer prescriptions for antibacterials associated with a higher risk of CDI in the primary care setting in Scotland than in 2010-11. This builds on the reduction observed in the previous two years.

Table 3 and Figure 3 illustrate the use of antibacterials associated with a higher risk of CDI in primary care by NHS board expressed as items/1000/day. This shows wide variation across NHS boards. NHS Shetland had the lowest use at 0.11 items/1000/day and NHS Western Isles had the highest at 0.26 items/1000/day. In all but one NHS boards there has been a reduction in use of high risk antibacterials.

In 2011-12 antibacterials associated with a higher risk of CDI accounted for 10.2% of total use of antibacterials and continues the downward trend observed in the last two years. In all NHS boards there has been reduction in use of high risk antibacterials as a proportion of overall use (table 4, figure 4).

The continued reduction in 2011-12 in the use of high risk broad spectrum antibacterials is a key finding and shows the ongoing positive impact AMTs and SAPG are having on the quality of antibacterial prescribing in Scotland.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, Items/1000/day 2007-08 – 2011-12 High risk antibacterials 2007/08 2008/09 2009/10 2010/11 2011/12 (Items/1000/day) NHS AYRSHIRE & ARRAN 0.52 0.52 0.46 0.32 0.21 NHS BORDERS 0.36 0.37 0.35 0.26 0.22 NHS DUMFRIES & GALLOWAY 0.48 0.45 0.31 0.24 0.19 NHS FIFE 0.41 0.38 0.32 0.24 0.22 NHS FORTH VALLEY 0.42 0.43 0.35 0.30 0.24 NHS GRAMPIAN 0.45 0.44 0.35 0.18 0.14 NHS GREATER GLASGOW & CLYDE 0.46 0.44 0.33 0.24 0.22 NHS HIGHLAND 0.37 0.35 0.31 0.25 0.19 NHS LANARKSHIRE 0.51 0.49 0.38 0.30 0.24 NHS LOTHIAN 0.30 0.30 0.26 0.25 0.25 NHS ORKNEY 0.40 0.37 0.32 0.24 0.13 NHS SHETLAND 0.36 0.35 0.28 0.14 0.11 NHS TAYSIDE 0.39 0.37 0.26 0.19 0.13 NHS WESTERN ISLES 0.62 0.59 0.51 0.38 0.26 SCOTLAND 0.43 0.41 0.33 0.25 0.21

Figure 3: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, Items/1000/day 2007-08 – 2011-12

0.70

0.60

0.50

0.40

0.30 Items/1000Pts/Day

0.20

0.10 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 4: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 4C Items as % of all agents 2007/08 2008/09 2009/10 2010/11 2011/12 NHS AYRSHIRE & ARRAN 25.5% 24.5% 22.1% 15.3% 9.8% NHS BORDERS 20.2% 19.8% 18.9% 13.6% 11. 5% NHS DUMFRIES & GALLOWAY 25.0% 22.6% 16.2% 12.4% 9.6% NHS FIFE 19.9% 18.2% 15.2% 11.6% 10.3% NHS FORTH VALLEY 20.9% 20.8% 17.4% 14.7% 12.1% NHS GRAMPIAN 23.4% 22.9% 18.4% 9.4% 7.2% NHS GREATER GLASGOW & CLYDE 21.5% 19.9% 15.5% 11.3% 10.0% NHS HIGHLAND 19.9% 18.9% 16.8% 13.4% 10.4% NHS LANARKSHIRE 22.1% 20.5% 16.1% 12.5% 10.0% NHS LOTHIAN 18.2% 17. 5% 15.7% 14.7% 14.2% NHS ORKNEY 23.6% 22.2% 19.7% 13.7% 7.2% NHS SHETLAND 20.3% 18.5% 15.0% 7.3% 5.9% NHS TAYSIDE 19.6% 18.4% 13.1% 9.5% 6.8% NHS WESTERN ISLES 28.8% 26.2% 22.9% 17.2% 11.7% SCOTLAND 21.4% 20.2% 16.5% 12.3% 10.2%

Figure 4: NHS Scotland use of antibacterials associated with a higher risk of Clostridium difficile infection in primary care by NHS board, proportion of total items, 2007-08 – 2011-12

30.0%

26.0%

22.0%

18.0%

14.0% Percentage of total items 10.0%

6.0% 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

In 2011-12 co-amoxiclav accounted for 36% of use of antibacterial items associated with a higher risk of CDI. In 2011-12 there were 27,000 (15%) fewer prescriptions for co-amoxiclav dispensed in primary care in Scotland than in 2010-11. This builds on the reduction observed in previous years.

There was wide variation in the use of co-amoxiclav across NHS boards. NHS Shetland had the lowest use at 0.02 items/1000/day and NHS Lothian the highest at 0.11 items/1000/ day. The trend toward lower use of co-amoxiclav was observed in most NHS boards (table 5, figure 5).

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 5: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 Co-amoxiclav (Items/1000/day) 2007/08 2008/09 2009/10 2010/11 2011/12 NHS AYRSHIRE & ARRAN 0.19 0.20 0.19 0.13 0.08 NHS BORDERS 0.07 0.08 0.09 0.07 0.06 NHS DUMFRIES & GALLOWAY 0.21 0.20 0.13 0.09 0.07 NHS FIFE 0.17 0.16 0.13 0.10 0.09 NHS FORTH VALLEY 0.09 0.09 0.09 0.08 0.08 NHS GRAMPIAN 0.21 0.20 0.15 0.07 0.05 NHS GREATER GLASGOW & CLYDE 0.15 0.14 0.10 0.08 0.07 NHS HIGHLAND 0.14 0.13 0.12 0.10 0.08 NHS LANARKSHIRE 0.17 0.17 0.12 0.10 0.08 NHS LOTHIAN 0.11 0.11 0.11 0.11 0.11 NHS ORKNEY 0.18 0.19 0.13 0.09 0.04 NHS SHETLAND 0.11 0.08 0.08 0.04 0.02 NHS TAYSIDE 0.14 0.13 0.09 0.06 0.05 NHS WESTERN ISLES 0.16 0.16 0.16 0.11 0.07 SCOTLAND 0.15 0.15 0.12 0.09 0.08

Figure 5: NHS Scotland use of co-amoxiclav in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12

0.24

0.2

0.16

0.12

0.08 Items/1000Pts/Day

0.04

0 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

In 2011-12 fluoroquinolones accounted for 33% of use of antibacterial items associated with a higher risk of CDI. Ciprofloxacin, the most commonly prescribed fluoroquinolone accounted for 90% of all fluoroquinolone items in 2011-12.

In 2011-12 there were 13,000 (8%) fewer prescriptions for fluoroquinolones dispensed in primary care in Scotland than in 2010-11. This builds on the reduction observed in previous years.

Table 6 and Figure 6 illustrate the use of fluoroquinolones in primary care by NHS board expressed as items/1000/day. It shows variation between NHS boards. NHS Tayside had the lowest use at 0.04 items/1000/day. NHS Dumfries and Galloway and NHS Fife had the highest at 0.09 items/1000/day.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12 Fluoroquinolone 2007/08 2008/09 2009/10 2010/11 2011/12 (Items/1000/day) NHS AYRSHIRE & ARRAN 0.10 0.11 0.10 0.08 0.06 NHS BORDERS 0.05 0.06 0.06 0.06 0.06 NHS DUMFRIES & GALLOWAY 0.14 0.15 0.13 0.12 0.09 NHS FIFE 0.13 0.13 0.12 0.09 0.09 NHS FORTH VALLEY 0.15 0.17 0.12 0.09 0.08 NHS GRAMPIAN 0.14 0.14 0.11 0.06 0.05 NHS GREATER GLASGOW & CLYDE 0.10 0.10 0.10 0.08 0.08 NHS HIGHLAND 0.10 0.09 0.09 0.07 0.06 NHS LANARKSHIRE 0.11 0.11 0.10 0.09 0.08 NHS LOTHIAN 0.07 0.07 0.07 0.06 0.06 NHS ORKNEY 0.13 0.13 0.13 0.10 0.06 NHS SHETLAND 0.10 0.10 0.09 0.05 0.05 NHS TAYSIDE 0.13 0.12 0.07 0.05 0.04 NHS WESTERN ISLES 0.08 0.09 0.09 0.06 0.05 SCOTLAND 0.11 0.11 0.10 0.08 0.07

Figure 6: NHS Scotland use of fluoroquinolones in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12

0.18

0.16

0.14

0.12

0.10

0.08 Items/1000Pts/Day 0.06

0.04

0.02 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

In 2011-12 cephalosporins accounted for 29% of use of antibacterial items associated with a higher risk of CDI. Cefalexin accounted for 88% of all cephalosporin items in 2011-12.

In 2011-12 there were 36,000 (23%) fewer prescriptions for cephalosporins dispensed in primary care in Scotland than in 2010-11. This builds on the reduction observed in previous years.

Table 7 and Figure 7 illustrate the use of cephalosporins in primary care by NHS board expressed as items/1000/day. This shows wide variation in the use of cephalosporins across NHS boards. NHS Dumfries and Galloway, NHS Grampian and NHS Orkney had the lowest use at 0.03 items/1000/day and NHS Western Isles the highest at 0.13 items/1000/ day. The trend toward lower use of cephalosporins was observed in most NHS boards.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 7: NHS Scotland use of cephalosporins in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12 Cephalosporins 2007/08 2008/09 2009/10 2010/11 2011/12 (Items/1000/day) NHS AYRSHIRE & ARRAN 0.23 0.21 0.16 0.10 0.06 NHS BORDERS 0.24 0.23 0.20 0.12 0.10 NHS DUMFRIES & GALLOWAY 0.13 0.10 0.04 0.03 0.03 NHS FIFE 0.12 0.09 0.07 0.05 0.04 NHS FORTH VALLEY 0.17 0.17 0.14 0.13 0.08 NHS GRAMPIAN 0.10 0.09 0.08 0.05 0.03 NHS GREATER GLASGOW & CLYDE 0.21 0.20 0.13 0.08 0.06 NHS HIGHLAND 0.12 0.11 0.10 0.08 0.06 NHS LANARKSHIRE 0.24 0.21 0.15 0.11 0.08 NHS LOTHIAN 0.13 0.12 0.08 0.08 0.08 NHS ORKNEY 0.09 0.06 0.05 0.05 0.03 NHS SHETLAND 0.14 0.17 0.11 0.06 0.04 NHS TAYSIDE 0.13 0.12 0.09 0.07 0.05 NHS WESTERN ISLES 0.38 0.34 0.25 0.21 0.13 SCOTLAND 0.17 0.15 0.11 0.08 0.06

Figure 7: NHS Scotland use of cephalosporins in primary care by NHS board, Items/1000/ day, 2007-08 – 2011-12

0.40

0.35

0.30

0.25

0.20

0.15 Items/1000Pts/Day 0.10

0.05

0.00 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Recommended antibacterials This indicator presents the use of antibacterials recommended, in the national evidence based guidance template supported by SAPG, as first line empirical treatment in commonly encountered infections in primary care. It includes a group of narrow spectrum antibacterials: amoxicillin; clarithromycin; doxycycline; erythromycin; flucloxacillin; nitrofurantoin; phenoxymethylpenicillin; trimethoprim.

In 2011-12 there were 152,000 (5%) more prescriptions for recommended antibacterials in primary care in Scotland than in 2010-11 and builds upon the increases observed in previous years. In 2011-12 there have been large increases in use of doxycycline and nitrofurantoin (table 8).

Table 8: NHS Scotland use of recommended agents, total items 2011-12 and change from 2010 -11

Number of items 2011/12 % Change from 2010/11 Amoxicillin 1,221,865 0.7% Clarithromycin 274,388 9.9% Doxycycline 206,840 26.2% Erythromycin 230,797 -3.5% Flucloxacillin 458,172 6.5% Nitrofurantoin 198,849 30.6% Phenoxymethylpenicillin 266,887 -4.5% Trimethoprim 464,468 5.0% All Recommended Agents 3,322,266 4.8%

Figure 8 and table 9 illustrate the use of recommended antibacterials in primary care by NHS board expressed as items/1000/day. It shows wide variation in the use of antibacterials across NHS boards. NHS Lothian had the lowest use at 1.38 items/1000/day and the highest was in NHS Lanarkshire at 1.94 items/1000/day. The pattern of increased use is observed in all NHS boards

Figure 9 and table 10 illustrate the number of items of recommended antibacterials as a proportion of total antibacterial use in primary care by NHS board. The use of recommended agents accounted for 80.3% of antibacterial items in 2011/12 which is slightly higher than in 2010-11. The increase in recommended agents as a proportion of overall prescribing of antibacterials was observed in all NHS boards in 2011-12.

The continued increase in the use of first line recommended agents in line with national guidance is a key finding and suggests increased compliance with local prescribing policies.

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12 Recommended agents 2007/08 2008/09 2009/10 2010/11 2011/12 (Items/1000/day) NHS AYRSHIRE & ARRAN 1.37 1.43 1.44 1.59 1.71 NHS BORDERS 1.28 1.32 1.33 1.47 1.53 NHS DUMFRIES & GALLOWAY 1.27 1.36 1.42 1.56 1.62 NHS FIFE 1.48 1.53 1.57 1.63 1.72 NHS FORTH VALLEY 1.43 1.46 1.48 1.55 1.6 NHS GRAMPIAN 1.33 1.32 1.39 1.55 1.61 NHS GREATER GLASGOW & CLYDE 1.5 1.55 1.59 1.65 1.73 NHS HIGHLAND 1.32 1.31 1.37 1.45 1.5 NHS LANARKSHIRE 1.59 1.68 1.77 1.86 1.94 NHS LOTHIAN 1.22 1.26 1.27 1.32 1.38 NHS ORKNEY 1.12 1.14 1.12 1.34 1.44 NHS SHETLAND 1.24 1.36 1.4 1.61 1.62 NHS TAYSIDE 1.46 1.5 1.54 1.62 1.66 NHS WESTERN ISLES 1.36 1.47 1.52 1.65 1.75 SCOTLAND 1.4 1.45 1.49 1.58 1.65

Figure 8: NHS Scotland use of recommended antibacterials in primary care by NHS board, Items/1000/day, 2007-08 – 2011-12

1.8

1.6

1.4 Items/1000Pts/Day

1.2

1 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Table 10: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2007-08 – 2011-12 Recommended agents 2007/08 2008/09 2009/10 2010/11 2011/12 as % of all agents NHS AYRSHIRE & ARRAN 66.9% 67.4% 69.4% 75.8% 81.0% NHS BORDERS 71.1% 71.4% 72.1% 77. 5% 79.1% NHS DUMFRIES & GALLOWAY 65.8% 68.2% 74.5% 78.8% 81.1% NHS FIFE 71.6% 73.2% 75.9% 79.5% 80.8% NHS FORTH VALLEY 71.0% 71.1% 74.1% 77.0% 79.2% NHS GRAMPIAN 69.5% 69.5% 73.6% 81.8% 83.5% NHS GREATER GLASGOW & CLYDE 69.6% 70.7% 74.7% 78.6% 79.8% NHS HIGHLAND 71.1% 71.9% 74.0% 77.7% 80.5% NHS LANARKSHIRE 68.6% 70.1% 74.3% 77.8% 80.0% NHS LOTHIAN 73.2% 73.8% 75.4% 76.5% 76.9% NHS ORKNEY 66.0% 67.4% 69.5% 75.7% 82.1% NHS SHETLAND 70.1% 72.1% 74.8% 81.9% 83.4% NHS TAYSIDE 72.8% 73.9% 78.6% 82.3% 84.2% NHS WESTERN ISLES 63.0% 65.7% 68.5% 73.9% 78.9% SCOTLAND 70.2% 71.1% 74.4% 78.5% 80.3%

Figure 9: NHS Scotland use of recommended antibacterials in primary care by NHS board, proportion of total items, 2007-08 – 2011-12

88.0%

84.0%

80.0%

76.0%

72.0%

68.0% Percentage of totals (items) 64.0%

60.0% 2007/08 2008/09 2009/10 2010/11 2011/12 Financial Year

Scottish Antimicrobial Prescribing Group - Primary Care Prescribing Indicators - Annual Report 2011-12 Appendix 1

List of all measures in PRISMS (available at NHS board, CHP and GP

practice levels) DDD/1000/day Items/1000/day DDD/Item Proportion of (Items) total Proportion of (DDDs) total Seasonal (Items) Variation Seasonal (DDDs) Variation Seasonal variation of fluoroquinolone use x x Total antibacterial use x x x x x x x Recommended antibacterials – total use x x x x Antibacterials associated with a higher risk of Clostridium x x x x difficile infection – total use Total penicillin use x x x Amoxicillin use x x x Flucloxacillin use x x x Phenoxymethylpenicillin use x x x Co-amoxiclav use x x x Total tetracycline use x x x Doxycycline use x x x Total macrolide use x x x Trimethoprim use x x x Co-trimoxazole use x x x Total fluoroquinolone use x x x Ciprofloxacin use x x x Nitrofurantoin use x x x Clindamycin use x x x