21st European Congress The unintended consequences of of Clinical Microbiology and Infectious Diseases Clostridium difficile reduction programmes London, 31/3/12 - 2/4/12 P 2246

Maggie Heginbothom: Welsh Antimicrobial Resistance Programme Surveillance Unit Public Health , The Temple of Peace & Health, Cathays Park, CF10 3NW

Introduction Results 1 Results 2

In 2008, a National Operating Framework was Secondary care antimicrobial Usage trends: Primary care antimicrobial Usage trends: introduced by the Department of Health in England ● Tetracycline (J01AA) usage increased 121% between 2008 and 2010 to an All-Wales average of 63 DDD ● Tetracycline usage increased 12% between 2008 and laterally by Welsh Government in Wales to per 1000 BD per quarter. and 2010 to 257 DDD/1000 PU per quarter. reduce Clostridium difficile infections. In response, ● Beta-lactam/beta-lactamase inhibitor (J01CR) usage increased 69% to 249 DDD/1000 BD PQ. ● Beta-lactam/beta-lactamase inhibitor usage Health Boards in Wales introduced measures to ● Carbapenem (J01DH) usage increased by 79% to 18 DDD/1000 BD PQ. increased 20% to 92 DDD/1000 PU PQ. reduce C. difficile including implementing restrictive ● Aminoglycoside (J01GB) usage increased 42% to 24 DDD/1000 BD PQ. ● Cephalosporin usage decreased 6% to 47 DDD/ antimicrobial policy guidelines. ● Cephalosporin (J01D) usage decreased 44% to 57 DDD/1000 BD PQ. 1000 PUs PQ. ● Fluoroquinolone (J01MA) usage decreased 24% to 55 DDD/1000 BD PQ - See Figure 1. ● Fluoroquinolone usage remained unchanged at approximately 32 DDD/1000 PU PQ. Aim 8 8 0 0 Conclusions 0 The aim of this study was to examine the impact of 0 2 2

l l i i r r p restrictive antimicrobial guidelines on antimicrobial p A A usage and antimicrobial resistance in Wales. The consequence of the imposed restrictions in cephalosporins and fluoroquinolone use has been an increase in usage of other antibacterial groups. Method In some instances it is too early to detect if the pressure from this increase will impact on Secondary care usage data: Antimicrobial ward resistance rates but in other instances the effect is stock data was extracted from the MEDUSA measurable, with a significant increase in co- database. The data was coded and measured amoxiclav and gentamicin resistance rates in E. coli using the ATC/DDD system. The measure used for bacteraemias. usage was Defined Daily Doses per 1000 Bed Due to successful antimicrobial stewardship Days (DDD/1000 BD). Bed days were calculated initiatives the last three years has witnessed a using electronic in-patient activity data. marked change in antibacterial prescribing practices; continued surveillance is required to Primary care usage data: Dispensed prescription monitor the impact of these changes over time, and data was obtained from the Prescribing Services to detect future changes that may impact on Unit; the data was measured as items/1000 resistance, and our ability to combat it. prescribing units (PU) per annum or DDDs/1000 Figure 1: All-Wales trends in Antibacterial Usage in Secondary Care 2005-2010 Figure 2: All-Wales trends E. coli bacteraemia resistance rates 2005-2010 PU. Prescribing Units are an age adjusted measure Key for Figure 1: The black line shows the introduction of the AOF to reduce C. difficile Key for Figure 2: J01CR02 - co-amoxiclav; J01DC02 – cefuroxime; J01DD - third J01AA - tetracyclines; J01CR - beta-lactam/beta-lactamase inhibitor combinations; generation cephalosporins (cefotaxime, ceftazidime, ceftriaxone & cefpodoxime); of population: Patients ≥ 65 and over are counted J01D - first, second and third generation cephalosporins; J01DH - carbapenems; J01DH - carbapenems; (ertapenem, imipenem & meropenem); J01GB03 - gentamicin; Acknowledgments J01GB - aminoglycosides; J01MA - fluoroquinolones. as 3 prescribing units and patients aged < 65 and J01MA – fluoroquinolones (ciprofloxacin & levofloxacin). temporary residents are counted as 1. The Consultant Microbiologists, Heads of Pharmacy, Antimicrobial E. coli bacteraemia – trends in antimicrobial resistance rates: Pharmacists, and BMS staff: - Bronglais Hospital - Aberystwyth; Glangwili Antimicrobial resistance data: Antimicrobial ● Co-amoxiclav (J01CR02) resistance increased 11% between 2008 & 2010 to an All-Wales average of 41.9%. Hospital - Carmarthen; Llandough Hospital - Llandough; Morriston Hospital - Swansea; Neath Port Talbot Hospital - Port Talbot; Nevill Hall susceptibility testing (AST) data was extracted from ● Carbapenem (J01DH) resistance showed no significant change fluctuating between 3-6%. Hospital - Abergavenny; Prince Charles Hospital - Merthyr; Prince Philip DataStore. Duplicate isolates were removed prior ● Gentamicin (J01GB03) resistance increased 4.2% to an All-Wales average of 9.3% Hospital - Llanelli; Princess of Wales Hospital - Bridgend; to analysis. For community data, organisms from ● Cefuroxime (J01DC02) resistance decreased 0.6% to an All-Wales average of 8.3% Royal Glamorgan Hospital - Pontypridd; Royal Hospital - Newport; Singleton Hospital - Swansea; University Hospital of Wales, - Cardiff; the same patient, with the same ID & susceptibility ● Third generation cephalosporin (J01DD) resistance decreased 0.6% to an All-Wales average of 8.5% Withybush General Hospital - Haverfordwest; Hospital - pattern isolated ≤ 91 days from the date of the ● Fluoroquinolone resistance decreased 1.4% to an All-Wales average of 9.2% - See Figure 2. Wrexham; Ysbyty - Bangor; Ysbyty Glan - Rhyl. Special thanks to:- Robin Burfield, MEDUSA project, NWIS, Cardiff; initial isolate were excluded, and for hospital data Urinary coliforms – trends in antimicrobial resistance rates: Sandra Hennefer, PSUIT, Shared Services Partnership, Cardiff; the cut-off was ≤ 14 days. Co-amoxiclav resistance increased 2.3% between 2008 & 2010 to an All-Wales average of 14.6% (community). Mieko Thomas, Public Health Wales Informatics, Cardiff. Contact: [email protected] +(44) 2920 402473