Antimicrobial Dispensing in Primary Care in Wales (2006 – 2008)

National Public Health Service for Wales Antimicrobial Dispensing in Primary Care in Wales

Antimicrobial Dispensing In Primary Care in Wales (2006 – 2008)

Authors: Maggie Heginbothom Date: Status: Final Robin Howe 18/11/09 Report entitled ‘Antimicrobial Dispensing Welsh Antimicrobial Resistance Programme: in Primary Care in Wales’ Surveillance Unit Executive Summary

This is the first report from the Welsh Antimicrobial Resistance Programme Surveillance Unit regarding antimicrobial usage in primary care, and is aimed at providing an overview of antimicrobial prescriptions prescribed by general practices and dispensed in primary care in Wales

Key points of note are:

 Antimicrobial usage in primary care in Wales is common In 2008, there were 2,417,104 antimicrobial prescription items dispensed. This equates to almost 1 antibiotic for every member of the population.

 Antimicrobial use has increased from 2006 Between 2006 and 2007 antimicrobial dispensing increased from 538.9 to 570.2 prescriptions/1000 PUs* (5.8% increase). However, from 2007 to 2008 there was little change in the All-Wales dispensing rate.

 Antimicrobial use, in terms of amount, varies between Local Health Boards (LHBs) In 2008, dispensing varied from 487.9 prescriptions/1000 PUs per annum to 659.5 prescriptions/1000 PUs per annum.

 Antimicrobial use, in terms of agents selected, varies between Local Health Boards (LHBs) For example, the percentage use by LHBs of different oral tetracyclines was: oxytetracycline 20-49%, doxycycline 15-48%, lymecycline 5-33%, and minocycline 7-16%.

 The proportion of total dispensing of antimicrobials that are included in the “Top 9” (amoxicillin, clarithromycin, doxycycline, erythromycin, flucloxacillin, nitrofurantoin, oxytetracycline, penicillin V and trimethoprim) ranged from 70-79%.

 The commonest antimicrobial used is amoxicillin, presumably for the treatment of respiratory tract infections. In 2008, dispensing varied from142.9 prescriptions/1000 PUs per annum to 240.5 prescriptions/1000 PUs per annum.

 The length of antimicrobial prescription courses does not always correlate with National recommendations. This is likely to be partly due to configuration of computer systems in primary care. HPA recommendations for the treatment of uncomplicated UTI in women suggest a 3-day course of trimethoprim; in 2008 26.1% of prescriptions for trimethoprim 200mg capsules were for 3 days.

* PU (Prescribing Unit) – an age-adjusted measure of population

i Table of Contents

Section 1: Introduction ...... 1 Background ...... 1 Collation and Presentation of Antimicrobial Dispensing Data...... 1 Data Interpretation...... 3 Section 2: Antimicrobial Dispensing Data...... 4 All-Wales dispensing by antimicrobial group 2006-2008 ...... 4 Local Health Board dispensing rates by antimicrobial group 2006-2008 ...... 6 All-Wales Dispensing of Top 9 Antimicrobials ...... 28 LHB by Area - Dispensing of Top 9 Antimicrobials...... 30 Section 3: Detailed Description of Antimicrobial Use...... 33 Penicillin Group ...... 33 Amoxicillin Dispensing by Dosage and Duration ...... 37 Cephalosporin Group...... 40 Macrolide/ Lincosamide/ Streptogrammin Group ...... 42 Tetracycline Group ...... 44 Fluoroquinolone Group ...... 46 Trimethoprim/Sulfonamide Group ...... 48 Trimethoprim Dispensing by Dosage and Duration ...... 49

ii Section 1: Introduction

Background

Welsh Antimicrobial Resistance Programme Surveillance Unit This is the first report from the Welsh Antimicrobial Resistance Programme Surveillance Unit regarding antimicrobial usage in primary care, and is aimed at providing an overview of antimicrobial prescriptions prescribed by general practices and dispensed in primary care in Wales. Collation and Presentation of Antimicrobial Dispensing Data

Data sources Antimicrobial prescribing data was provided by the Prescribing Services Unit (PSU). PSU is part of Health Solutions Wales (HSW), a division of Velindre NHS Trust. PSU is responsible for calculating the remuneration due to community pharmacies, dispensing doctors, appliance contractors and GPs who personally administer drugs for issuing prescribed items against NHS prescriptions. The data collected during this process is also used to drive a range of information products that are provided to stakeholders across the NHS and, where applicable, made publicly available.

Data is collected from prescriptions that are submitted to PSU by dispensing contractors at the end of each month. Data is collected only from prescriptions that have actually been dispensed.

Data is allocated to Local Health Boards on the basis of where the item is prescribed. References to “dispensed” items should therefore be read as items dispensed by community dispensing contractors against prescriptions written in the referenced Local Health Board.

Data presentation In general, data in the report is expressed as scripts/1000PU or DDDs/1000PU collated at the level of the former 22 Local Health Boards listed in Table 1.

Prescriptions or “scripts” refers to an antimicrobial item that has been dispensed; please note that a prescription may contain more than one antimicrobial item.

“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. http://www.whocc.no/atcddd/.

“PU” is an abbreviation for Prescribing Unit. PUs are an age adjusted measure of population. They are used to take account of the greater need of elderly patients for medication. Rather than compare the number of items prescribed by patient, comparison by PU weights the result according to the number of elderly patients in population. Patients aged 65 and over are counted as 3 prescribing units and patients under 65 and temporary residents are counted as 1.

1 Table 1: LHB codes Former LHBs Code Area Bridgend LHB BGD Mid & West Wales Blaenau Gwent LHB BLG South East Wales Caerphilly LHB CAE South East Wales Carmarthen LHB CAM Mid & West Wales Cardiff LHB CAR South East Wales Ceredigion LHB CER Mid & West Wales Conwy LHB CON North Wales Denbighshire LHB DEN North Wales Flintshire LHB FLI North Wales Gwynedd LHB GWY North Wales Merthyr Tydfil LHB MER South East Wales Monmouth LHB MON South East Wales Newport LHB NEW South East Wales Neath/ Port Talbot LHB NPT Mid & West Wales Pembrokeshire LHB PEM Mid & West Wales Powys LHB POW Mid & West Wales Rhondda Cynon Taff LHB RCT South East Wales Swansea LHB SWA Mid & West Wales Torfaen LHB TOR South East Wales The Vale of Glamorgan LHB VOG South East Wales Wrexham LHB WRX North Wales Ynys Mon LHB YNY North Wales

For ease of interpretation and presentation, antimicrobial data has been collated into Groups as shown in Table 2.

Table 2: Antimicrobial Group codes Code Antimicrobial Group Example from data set BLIC Beta Lactamase Inhibitor Combinations Co-amoxiclav BLRP Beta Lactamase Resistant Penicillins Flucloxacillin BLSP Beta Lactamase Sensitive Penicillins Penicillin V BSP Broad Spectrum Penicillins Amoxicillin CEF Cephalosporins Cefalexin MLS Macrolides, Lincosamides & Streptogrammins Erythromycin QUIN Quinolones Ciprofloxacin TET Tetracyclines Oxytetracycline TRI Trimethoprim & Sulfonamides Trimethoprim Other Other antimicrobials Metronidazole

2 Data Interpretation A number of factors should be considered when examining the data presented in this report:  The data presented is for antimicrobial items that have been dispensed and therefore DO NOT necessarily correlate with antimicrobial prescriptions (e.g. delayed prescriptions that were not dispensed would not be included in the data set) or antimicrobial use (ie dispensed antimicrobial courses may not be completed by the patient).  Differences in antimicrobial use between Local Health Boards may be due to many differences that have been shown to influence use including population health, population deprivation, or availability of dispensing practices.  Only data for oral and parenteral antimicrobial usage are included in this report; it DOES NOT include topical, inhaled, rectal or genital preparation usage.  It should be noted that PSU uses a drug database supplied and maintained by the NHS Business Services Authority, Prescription Pricing Division (PPD). This database does not have full coverage of Defined Daily Dose (DDD) allocations for all of the products contained therein. For the products with ATC codes used in this dataset the coverage is approximately 96%. This should be noted when considering data using DDD as a measure.

3 Section 2: Antimicrobial Dispensing Data

All-Wales dispensing by antimicrobial group 2006-2008

All-Wales antimicrobial prescribing & dispensed rates: Prescriptions/1000 PUs per annum 2006-2008

600 550 500

a 450 p

s 400 U P

350 0

0 300 0 1 /

s 250 t p i

r 200 c

S 150 100 50 0 2006 2007 2008 (n = 538.9) (n = 570.2) (n = 569.4) QUIN 17.6 18.6 18.1 Other 21.0 22.1 23.5 BLIC 32.7 33.1 32.7 BLSP 39.7 41.3 39.0 TET 40.6 43.0 44.6 CEF 45.8 47.9 48.4 TRI 49.5 51.5 52.6 BLRP 53.3 54.8 55.9 MLS 63.1 67.8 67.7 BSP 175.5 190.1 186.8 Antibacterial group/Year

Figure 1: All-Wales overall dispensing by antimicrobial group 2006-2008

The changes in total antimicrobial dispensing (prescribing & dispensed) by antimicrobial group during the period 2006-2008 in Wales are shown in Figure 1. Between 2006 & 2007 dispensing increased from 538.9 to 570.2 prescriptions/1000 PUs (5.8% increase). However, from 2007 to 2008 there was little change in the All- Wales dispensing rate. Broad spectrum penicillins (BSP) were the most commonly dispensed items, comprising approximately one third of all antimicrobial dispensing each year. BSP dispensing was largely amoxicillin (99.6% in 2008).

4 Prescribing & dispensed rates by antimicrobial groups at LHB level & All-Wales for 2008

POW CON MER MON CAR NEW CAE CER PEM DEN RCT B

H SWA L Wales WRX VOG FLI CAM BGD GWY TOR YNY NPT BLG

0 50 100 150 200 250 300 350 400 450 500 550 600 650 700 Prescriptions/1000 PUs pa

BSP MLS BLRP TRI CEF TET BLSP BLIC Other QUIN

Figure 2: LHB dispensing by antimicrobial group 2008

Figure 2 shows the difference in antimicrobial dispensing rates (prescribing and dispensed) between the LHBs in Wales by antimicrobial group for 2008. Blaenau Gwent LHB had the highest dispensing rate of 659.5 prescriptions/1000 PUs per annum; Powys LHB had the lowest rate with 487.9 prescriptions/1000 PUs per annum. The dispensing rates for individual LHBs during 2006-2008 are presented on pages 8 to 30.

5 Local Health Board dispensing rates by antimicrobial group 2006-2008

Blaenau Gwent LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 565.9) (n = 626.5) (n = 659.5) QUIN 18.3 22.3 21.9 Other 18.4 22.4 22.0 BLIC 25.8 30.4 28.8 BLSP 28.7 30.7 33.5 TET 35.4 40.0 42.0 TRI 47.0 51.2 54.4 BLRP 53.1 57.7 61.9 CEF 70.1 73.1 77.4 MLS 65.1 73.9 77.7 BSP 200.4 224.9 240.5 Antibacterial group/Year

Figure 3: Blaenau Gwent LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Blaenau Gwent increased yearly between 2006 and 2008; as shown in Figure 3. Dispensing increased from 565.9 to 659.5 prescriptions/1000 PUs; an increase of 17% in total. In 2008, Blaenau Gwent had the highest dispensing rate across in Wales. BSPs were the most commonly dispensed items, comprising just over one third of dispensing (37%) each year. Macrolides (erythromycin & clarithromycin), cephalosporins (cefalexin) & BLRP (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

6 Bridgend LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 569.6) (n = 622.1) (n = 619.5) QUIN 13.6 17.5 17.9 Other 13.7 17.7 18.0 BLIC 32.7 36.3 34.8 BLSP 45.7 50.8 44.4 TET 39.0 41.6 44.8 TRI 49.4 51.2 51.7 BLRP 61.4 63.2 62.2 CEF 58.5 62.4 64.6 MLS 64.2 70.3 69.2 BSP 183.7 207.1 208.5 Antibacterial group/Year

Figure 4: Bridgend LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing rates for GP practices in Bridgend LHB were similar to those seen for All-Wales with a 9% increase in dispensing between 2006 & 2007 and little change between 2007 & 2008; as shown in Figure 4. BSPs were the most commonly dispensed antimicrobial items, comprising approximately one third of all dispensing each year. Macrolides (erythromycin & clarithromycin), cephalosporins (cefalexin) and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

7 Caerphilly LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 529.4) (n = 538.6) (n = 538.9) QUIN 14.9 15.1 13.6 Other 15.0 15.2 13.7 BLIC 35.3 33.9 29.7 BLSP 33.3 32.3 35.9 CEF 44.4 44.8 43.6 TET 41.4 45.3 47.4 TRI 52.0 52.5 52.7 BLRP 53.2 53.5 58.4 MLS 59.9 61.6 60.9 BSP 179.9 184.3 181.0 Antibacterial group/Year

Figure 5: Caerphilly LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing rates for GP practices in Caerphilly LHB increased marginally between 2006 & 2007 (<2% increase) and did not change between 2007 & 2008; as shown in Figure 5. BSPs were the most commonly dispensed antimicrobial items, comprising approximately one third of all dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up nearly another third of dispensing.

8 Cardiff LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 512.3) (n = 537.4) (n = 546.0) QUIN 15.3 16.1 16.4 Other 15.3 16.2 16.4 BLIC 27.9 29.3 31.2 CEF 28.7 30.5 32.7 BLSP 43.3 45.0 42.5 TET 43.4 44.9 46.2 TRI 53.1 54.0 55.3 BLRP 56.8 57.0 57.7 MLS 57.6 62.0 63.7 BSP 163.2 175.6 174.7 Antibacterial group/Year

Figure 6: Cardiff LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Cardiff LHB increased by 5% between 2006 and 2007, and increased by 2% between 2007 and 2008; as shown in Figure 6. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of all dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

9 Carmarthen LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 547.1) (n = 577.2) (n = 590.9) QUIN 19.3 19.7 19.2 Other 19.4 20.0 19.6 CEF 34.8 33.7 33.7 BLSP 41.1 43.7 38.9 TET 41.1 44.3 48.6 BLIC 58.6 51.8 48.6 BLRP 45.8 47.2 50.2 TRI 48.4 50.4 52.0 MLS 63.2 68.3 72.1 BSP 172.8 194.5 201.0 Antibacterial group/Year

Figure 7: Carmarthen LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Carmarthen LHB increased by 6% between 2006 & 2007, and increased by 2% between 2007 and 2008; as shown in Figure 7. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of all dispensing each year. Macrolides (erythromycin & clarithromycin), trimethoprim and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up nearly another third of dispensing. Co-amoxiclav (BLIC) was more commonly dispensed (approx. 8% of all items) than in other LHBs.

10 Ceredigion LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 531.2) (n = 559.6) (n = 550.7) QUIN 19.0 19.3 17.7 Other 19.2 19.4 18.0 BLSP 35.2 37.4 33.9 TET 37.0 39.0 37.5 BLIC 49.1 49.4 41.6 TRI 41.9 43.7 44.7 BLRP 43.8 45.2 45.1 CEF 64.4 61.4 58.6 MLS 65.7 67.4 69.4 BSP 152.0 173.4 175.8 Antibacterial group/Year

Figure 8: Ceredigion LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Ceredigion LHB increased by 5% between 2006 & 2007, and decreased by 2% between 2007 and 2008; as shown in Figure 8. Broad spectrum penicillins were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), cephalosporins (cefalexin & cefaclor) and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

11 Conwy LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0 0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 508.2) (n = 536.5) (n = 530.9) BLIC 21.6 20.3 19.2 QUIN 20.5 19.3 20.7 Other 20.6 19.4 20.8 BLSP 35.5 35.3 36.2 TET 39.5 41.8 42.0 TRI 41.0 45.8 47.6 BLRP 55.5 55.8 57.6 CEF 62.3 62.1 60.5 MLS 58.8 63.2 60.8 BSP 155.0 173.1 165.5 Antibacterial group/Year

Figure 9: Conwy LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Conwy LHB increased by 6% between 2006 & 2007, and decreased by 1% between 2007 and 2008; as shown in Figure 9. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Macrolides (erythromycin and clarithromycin), cephalosporins (cefalexin) and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

12 Denbighshire LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 561.3) (n = 577.2) (n = 548.7) BLIC 29.1 25.7 19.7 QUIN 22.3 23.1 22.7 Other 22.3 23.1 22.7 BLSP 36.5 38.3 33.4 CEF 38.8 40.0 36.7 TET 47.5 49.4 49.3 TRI 49.3 51.4 51.8 BLRP 58.7 59.2 59.3 MLS 72.7 72.6 71.8 BSP 185.6 195.0 180.7 Antibacterial group/Year

Figure 10: Denbighshire LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Denbighshire LHB increased by 3% between 2006 & 2007, and decreased by 5% between 2007 and 2008; as shown in Figure 10. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin and clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

13 Flintshire LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 /

s 300 t p i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 527.6) (n = 555.9) (n = 569.1) QUIN 20.5 21.1 18.8 Other 20.5 21.2 18.9 BLIC 37.2 33.6 32.3 BLSP 37.9 41.9 38.9 CEF 39.0 43.1 43.6 TET 44.5 47.4 52.2 TRI 52.1 54.3 57.2 BLRP 57.2 57.7 59.4 MLS 59.2 61.9 62.3 BSP 157.7 172.2 177.8 Antibacterial group/Year

Figure 11: Flintshire LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Flintshire LHB increased by 5% between 2006 & 2007, and increased by 2% between 2007 and 2008; as shown in Figure 11. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin and clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

14 Gwynedd LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 587.2) (n = 626.0) (n = 623.6) QUIN 22.4 24.0 22.9 Other 22.4 24.0 22.9 BLIC 21.5 23.1 23.3 TET 35.1 37.4 37.8 BLSP 48.5 48.3 44.5 TRI 49.3 51.8 51.9 BLRP 54.1 56.8 57.7 MLS 62.0 65.0 66.6 CEF 72.6 79.7 83.6 BSP 204.4 221.6 215.1 Antibacterial group/Year

Figure 12: Gwynedd LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Gwynedd LHB increased by 7% between 2006 & 2007, and marginally decreased (<1%) between 2007 and 2008; as shown in Figure 12. BSPs were the most commonly dispensed antimicrobial items, comprising approximately one third of dispensing each year. Cephalosporins (cefalexin), macrolides (erythromycin and clarithromycin), and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

15 Merthyr Tydfil LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 521.8) (n = 538.7) (n = 536.5) QUIN 12.0 13.7 12.2 Other 12.0 13.7 12.2 CEF 25.1 24.2 22.5 BLSP 34.3 37.6 32.0 BLRP 43.1 43.0 42.2 BLIC 46.2 49.5 47.3 TRI 53.4 49.4 52.7 TET 47.6 54.0 54.5 MLS 58.6 63.0 63.6 BSP 181.9 181.2 186.7 Antibacterial group/Year

Figure 13: Merthyr Tydfil LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Merthyr Tydfil LHB increased by 7% between 2006 & 2007, and marginally decreased (<1%) between 2007 and 2008; as shown in Figure 13. BSPs were the most commonly dispensed antimicrobial items, comprising approximately one third of dispensing each year. Macrolides (erythromycin & clarithromycin), tetracyclines (doxycycline & oxytetracycline) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

16 Monmouth LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 487.2) (n = 532.6) (n = 530.0) QUIN 17.7 19.4 19.7 Other 17.7 19.4 19.8 BLIC 31.0 33.7 34.4 BLSP 36.3 37.6 37.0 TET 40.3 42.0 42.1 TRI 42.9 44.7 45.5 BLRP 53.4 53.2 54.0 MLS 49.3 56.7 54.1 CEF 60.9 68.7 71.8 BSP 138.5 158.8 154.1 Antibacterial group/Year

Figure 14: Monmouth LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Monmouth LHB increased by 9% between 2006 & 2007, and marginally decreased (<1%) between 2007 and 2008; as shown in Figure 14. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Cephalosporins (cefalexin), macrolides (erythromycin & clarithromycin), and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

17 Neath/Port Talbot LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 599.3) (n = 644.5) (n = 652.7) QUIN 20.3 22.7 24.0 Other 20.3 22.8 24.1 BLIC 24.8 27.3 26.8 TET 35.4 38.1 39.0 BLSP 44.3 49.9 47.1 TRI 51.1 54.1 55.1 BLRP 62.1 62.2 64.3 CEF 58.0 64.9 68.2 MLS 69.2 75.5 77.2 BSP 208.2 222.8 221.9 Antibacterial group/Year

Figure 15: Neath/ Port Talbot LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Neath/Port Talbot LHB increased by 8% between 2006 and 2007, and increased by 1% between 2007 and 2008; as shown in Figure 15. Broad spectrum penicillins were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), cephalosporins (cefalexin & cefaclor) and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

18 Newport LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 512.2) (n = 556.7) (n = 530.5) QUIN 13.7 13.8 12.6 Other 13.7 13.9 12.7 BLIC 20.8 22.9 23.3 TET 36.0 37.0 37.7 BLSP 39.2 42.6 40.7 CEF 42.5 45.3 45.2 TRI 43.8 48.6 47.6 BLRP 52.8 57.9 57.2 MLS 65.5 75.0 68.8 BSP 183.6 197.1 180.2 Antibacterial group/Year

Figure 16: Newport LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Newport LHB increased by 9% between 2006 & 2007, and decreased by 5% between 2007 and 2008; as shown in Figure 16. Broad spectrum penicillins were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

19 Pembrokeshire LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 523.2) (n = 547.5) (n = 550.3) QUIN 14.5 16.2 14.1 Other 14.5 16.3 14.3 BLIC 34.2 32.1 27.8 TET 36.0 37.4 38.8 BLSP 38.6 37.1 36.0 CEF 35.6 40.0 41.8 TRI 46.1 47.8 46.4 BLRP 55.7 56.0 57.4 MLS 70.0 74.8 77.1 BSP 171.8 183.2 186.9 Antibacterial group/Year

Figure 17: Pembrokeshire LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Pembrokeshire LHB increased by 5% between 2006 and 2007, and marginally increased (<1%) between 2007 and 2008; as shown in Figure 17. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

20 Powys LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c 200 S 150 100 50 0 2006 2007 2008 (n = 460.9) (n = 491.2) (n = 487.9) QUIN 17.0 17.5 16.8 Other 17.0 17.5 16.8 BLSP 36.8 37.1 34.8 BLIC 35.2 35.3 35.8 CEF 38.2 39.3 36.1 TET 35.1 37.1 39.5 BLRP 38.7 41.6 41.8 TRI 46.9 48.5 52.4 MLS 58.2 62.9 63.4 BSP 134.3 150.4 142.9 Antibacterial group/Year

Figure 18: Powys LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Powys LHB increased by 7% between 2006 & 2007, and marginally decreased (<1%) between 2007 and 2008; as shown in Figure 18. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Macrolides (erythromycin & clarithromycin), trimethoprim and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

21 Rhondda Cynon Taff LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 538.2) (n = 560.5) (n = 551.5) QUIN 12.7 13.7 13.8 Other 12.8 13.8 13.9 BLSP 29.1 31.5 28.3 CEF 31.6 31.0 33.3 BLIC 42.0 44.0 47.3 BLRP 46.2 49.5 51.3 TET 50.8 53.6 55.0 TRI 54.0 54.9 54.0 MLS 61.0 64.2 61.2 BSP 193.0 198.5 187.8 Antibacterial group/Year

Figure 19: Rhondda Cynon Taff LHB dispensing by antimicrobial group 2006- 2008

Antimicrobial dispensing for GP practices in RCT LHB increased by 4% between 2006 & 2007, and decreased by 2% between 2007 and 2008; as shown in Figure 19. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), trimethoprim and tetracyclines (oxytetracycline & doxycycline) were the next most commonly dispensed items making up nearly another third of dispensing.

22 Swansea LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 542.6) (n = 571.3) (n = 577.9) QUIN 20.1 21.9 23.2 Other 20.3 22.0 23.4 BLIC 29.9 32.0 33.3 TET 33.3 36.0 37.8 CEF 42.5 43.7 42.9 BLSP 48.3 49.6 46.9 TRI 47.4 48.2 50.9 BLRP 52.8 54.4 56.2 MLS 67.5 71.4 71.9 BSP 171.5 183.7 183.3 Antibacterial group/Year

Figure 20: Swansea LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Swansea LHB increased by 5% between 2006 and 2007, and increased by 1% between 2007 and 2008; as shown in Figure 20. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

23 Torfaen LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 586.0) (n = 640.1) (n = 632.1) QUIN 16.7 18.3 17.8 Other 16.9 18.3 17.8 BLIC 26.0 29.4 33.1 TET 36.4 39.9 41.5 BLSP 44.1 44.9 42.2 CEF 47.2 51.5 57.1 BLRP 58.6 63.5 60.8 TRI 56.6 60.3 62.7 MLS 85.2 94.8 92.8 BSP 199.0 219.3 205.2 Antibacterial group/Year

Figure 21: Torfaen LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Torfaen LHB increased by 9% between 2006 & 2007, and decreased by 1% between 2007 and 2008; as shown in Figure 21. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (erythromycin & clarithromycin), trimethoprim and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up another third of dispensing.

24 Vale of Glamoragan LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 541.1) (n = 570.5) (n = 575.0) QUIN 20.8 19.4 18.4 Other 20.9 19.5 18.5 BLIC 26.6 28.0 30.4 CEF 36.5 37.5 38.3 BLSP 41.1 40.7 40.5 TET 47.5 48.3 49.8 TRI 54.5 57.6 58.8 BLRP 63.6 63.8 65.2 MLS 65.4 70.9 69.8 BSP 162.7 181.9 178.9 Antibacterial group/Year

Figure 22: Vale of Glamorgan LHB dispensing by antimicrobial group 2006- 2008

Antimicrobial dispensing for GP practices in the Vale of Glamorgan LHB increased by 5% between 2006 and 2007, and increased marginally (<1%) between 2007 and 2008; as shown in Figure 22. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Macrolides (erythromycin & clarithromycin), beta lactamase resistant penicillins (flucloxacillin) and trimethoprim were the next most commonly dispensed items making up another third of dispensing.

25 Wrexham LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 566.8) (n = 603.0) (n = 580.0) QUIN 18.1 16.0 14.8 Other 18.2 16.1 14.9 BLIC 34.6 33.6 33.2 BLSP 38.1 38.1 34.2 CEF 50.5 52.1 47.0 BLRP 48.1 50.1 48.1 TET 44.6 47.3 49.0 TRI 51.3 54.3 55.3 MLS 59.5 67.0 65.1 BSP 197.7 218.1 206.2 Antibacterial group/Year

Figure 23: Wrexham LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Wrexham LHB increased by 6% between 2006 & 2007, and decreased by 4% between 2007 and 2008; as shown in Figure 23. BSPs were the most commonly dispensed antimicrobial items, comprising around one third of dispensing each year. Macrolides (predominantly erythromycin), trimethoprim and tetracyclines (oxytetracycline, lymecycline & doxycycline) were the next most commonly dispensed items making up nearly another third of dispensing.

26 Ynys Mon LHB prescriptions/1000 PUs PA

700 650 600 550

a 500 p

s 450 U P

400 0

0 350 0 1 / 300 s t p

i 250 r c

S 200 150 100 50 0 2006 2007 2008 (n = 613.7) (n = 641.7) (n = 640.7) BLIC 22.9 23.8 23.8 QUIN 28.4 29.8 25.6 Other 28.5 29.9 25.7 TET 41.0 40.8 43.0 BLSP 48.6 47.9 50.0 TRI 50.2 51.4 52.5 BLRP 59.1 58.0 58.8 MLS 60.3 66.3 66.7 CEF 102.9 105.3 107.2 BSP 181.2 195.9 190.7 Antibacterial group/Year

Figure 24: Ynys Mon LHB dispensing by antimicrobial group 2006-2008

Antimicrobial dispensing for GP practices in Ynys Mon LHB increased by 5% between 2006 & 2007, and marginally decreased (<1%) between 2007 and 2008; as shown in Figure 24. BSPs were the most commonly dispensed antimicrobial items, comprising nearly one third of dispensing each year. Cephalosporins (cefalexin & cefaclor), macrolides (erythromycin & clarithromycin), and beta lactamase resistant penicillins (flucloxacillin) were the next most commonly dispensed items making up over a third of dispensing. Cephalosporins alone accounted for 16.7% of dispensing in 2008, a higher rate than in any other LHB.

27 All-Wales Dispensing of Top 9 Antimicrobials

Antibacterial comparators are produced by HSW and include the Top 6 antimicrobials as a comparative measure of prescribing. The data presented below includes the Top 9 antimicrobials comprising approximately 75% of antimicrobial dispensing across Wales. http://howis.wales.nhs.uk/sites3/home.cfm?orgid=428&redirect=yes&CFID=522854& CFTOKEN=92783870

Top 9 antimicrobials - Scripts/1000 PUs per annum All-Wales 2006-2008

200

a 180 p

s 160 U P

140 0

0 120 0 1 /

s 100 n o

i 80 t p i

r 60 c s

e 40 r

P 20 0 AMO FLU TRI ERY PEN CLA OXY DOX NIT 2006 173.2 53.3 48.7 48.3 39.7 12.5 15.0 12.3 7.1 2007 188.0 54.8 50.6 51.0 41.3 14.0 15.3 13.4 7.8 2008 185.0 55.9 51.7 48.8 39.0 15.6 15.0 13.9 8.9 Antimicrobial

Figure 25: Top 9 antimicrobials – prescriptions/1000 PUs pa

Figures 25 shows the All-Wales dispensing rates for the ‘Top 9’ antimicrobials between 2006 and 2008, and Figure 26 shows the proportion of total dispensing for each of the ‘Top 9’.

 Amoxicillin dispensing rates (prescription/1000 PUs per annum) increased by 8.5% between 2006 & 2007, and decreased by 1.6% between 2007 & 2008; as shown in Figure 25. Amoxicillin dispensing as a proportion of total prescription items dispensed increased 0.9% between 2006 & 2007 and decreased by 0.5% between 2007 & 2008; as shown in Figure 26.  Flucloxacillin dispensing rates increased by 2.8% between 2006 & 2007, and increased by 2% between 2007 & 2008 (Figure 25). Flucloxacillin dispensing as a proportion of total prescription items dispensed decreased by 0.3% between 2006 & 2007 and increased by 0.2% between 2007 & 2008 (Figure 26).  Trimethoprim dispensing rates increased by 3.9% between 2006 & 2007, and increased by 2.2% between 2007 & 2008 (Figure 25). Trimethoprim dispensing as a proportion of total prescription items dispensed decreased by 0.1% between 2006 & 2007 and increased by 0.2% between 2007 & 2008 (Figure 26).

28 Top 9 antimicrobials as a proportion of total prescription items dispensed: All-Wales 2006-2008

30 g n

i 25 s n e

p 20 s i D

l 15 a t o T

10 % 5

0 AMO FLU TRI ERY PEN CLA OXY DOX NIT 2006 32.1 9.9 9.0 9.0 7.4 2.3 2.8 2.3 1.3 2007 33.0 9.6 8.9 8.9 7.2 2.5 2.7 2.4 1.4 2008 32.5 9.8 9.1 8.6 6.8 2.7 2.6 2.4 1.6 Antimicrobial

Figure 26: Top 9 antimicrobials as a proportion of total dispensing

 Erythromycin dispensing rates increased by 5.6% between 2006 & 2007, and decreased by 4.3% between 2007 & 2008 (Figure 25). Erythromycin dispensing as a proportion of prescription items dispensed decreased by 0.1% between 2006 & 2007 and decreased by 0.3% between 2007 & 2008 (Figure 26).  Penicillin V dispensing rates increased by 4.0% between 2006 & 2007, and decreased by 5.6% between 2007 & 2008 (Figure 25). Penicillin V dispensing as a proportion of prescription items dispensed decreased by 0.2% between 2006 & 2007 and decreased by 0.4% between 2007 & 2008 (Figure 26).  Clarithromycin dispensing rates increased by 12% between 2006 & 2007, and increased by 11.4% between 2007 & 2008 (Figure 25). Clarithromycin dispensing as a proportion of prescription items dispensed increased by 0.2% between 2006 & 2007 and increased by 0.2% between 2007 & 2008 (Figure 26).  Oxytetracycline dispensing rates increased by 2% between 2006 & 2007, and decreased by 2% between 2007 & 2008 (Figure 25). Oxytetracycline dispensing as a proportion of prescription items dispensed decreased by 0.1% between 2006 & 2007 and decreased by 0.1% between 2007 & 2008 (Figure 26).  Doxycycline dispensing rates increased by 8.9% between 2006 & 2007, and increased by 3.7% between 2007 & 2008 (Figure 25). Doxycycline dispensing as a proportion of prescription items dispensed increased by 0.1% between 2006 & 2007 and marginally increased by <0.1% between 2007 & 2008 (Figure 26).  Nitrofurantoin dispensing rates increased by 9.9% between 2006 & 2007, and by 14.1% between 2007 & 2008 (Figure 25). Nitrofurantoin dispensing as a proportion of prescription items dispensed increased by 0.1% between 2006 & 2007 and increased by 0.2% between 2007 & 2008 (Figure 26).

29 LHB by Area - Dispensing of Top 9 Antimicrobials

Proportion of Top 9 and 'Non-Top 9' antimicrobials by LHBs in Mid & West Wales in 2008

100% 700

90% 675

80% 650 g 70% a

n 625 p i

s s n U

e 60% 600 P p

s 0 i 0

D 50%

575 0

l 1 / a t s t o 40% 550 p T i

r c %

30% 525 S

20% 500

10% 475

0% 450 All- BGD CAM CER NPT PEM POW SWA Wales

'Non Top 9' 153.8 133.7 153.6 162.2 116.8 121.7 142.1 135.7 NIT 8.3 11.3 11.1 7.3 9.2 9.8 12.3 8.9 DOX 10.7 21.7 16.8 10.5 10.3 19.0 10.9 13.9 OXY 17.2 15.7 11.4 10.6 19.1 10.8 8.4 15.0 CLA 13.5 14.9 15.4 18.3 21.3 19.0 13.6 15.6 PEN 44.4 38.9 33.8 47.1 36.0 34.8 46.9 39.0 ERY 53.1 53.5 48.3 56.5 48.8 42.2 55.5 48.8 TRI 50.8 51.0 43.3 54.7 45.5 51.3 50.1 51.7 FLU 62.2 50.2 45.1 64.3 57.4 41.8 56.2 55.9 AMO 205.5 200.0 172.0 221.2 185.8 137.3 182.1 185.0 Total 619.5 590.9 550.7 652.7 550.3 487.9 577.9 569.4

LBH & Scripts/1000 PUs per annum Figure 27: Top 9 antimicrobials by LHBs in South East Wales Figure 27 shows the dispensing rates and the proportion of total dispensing for the ‘Top 9’ and ‘non-Top 9’ antimicrobials for the LHBs in South East Wales in 2008. The ‘Top 9’ dispensing rates (amoxicillin, flucloxacillin, trimethoprim, erythromycin, penicillin V, clarithromycin, oxytetracycline, doxycycline & nitrofurantoin) ranged from 70% of total dispensing in Monmouth LHB to 79% in the Vale of Glamorgan LHB. Blaenau Gwent LHB had the highest overall dispensing rate in the South East Wales area, and Newport LHB had the lowest dispensing rate.

30 Proportion of Top 9 and 'Non-Top 9' antimicrobials by LHBs in Mid & West Wales in 2008

100% 700

90% 675

80% 650 g 70% 625 a n p i

s s n U

e 60% 600 P p

s 0 i 0

D 50% 575 0

l 1 / a t s t o 40% 550 p T i

r c %

30% 525 S

20% 500

10% 475

0% 450 All- BGD CAM CER NPT PEM POW SWA Wales

LBH & Scripts/1000 PUs per annum

Figure 28: Top 9 antimicrobials by LHBs in Mid & West Wales

Figure 28 shows the dispensing rates and the proportion of total dispensing for the ‘Top 9’ and ‘non-Top 9’ antimicrobials for the LHBs in Mid and West Wales in 2008. The ‘Top 9’ dispensing rates ranged from 72% of total dispensing in Ceredigion LHB to 79% in Pembroke LHB. The All-Wales rate of Top 9 dispensing in 2008 was 76.2%. Neath Port Talbot LHB had the highest overall dispensing rate in the Mid & West Wales area, and Powys LHB had the lowest dispensing rate.

31 Proportion of Top 9 and 'Non-Top 9' antimicrobials by LHBs in North Wales in 2008

100% 700

90% 675

80% 650

g 70% 625 a n p i

s s n

60% 600 U e P p

s 0 i 0

D 50%

575 0

l 1 / a t s t o

40% 550 p T i

r c % 30% 525 S

20% 500

10% 475

0% 450 CON DEN FLI GWY WRX YNY All-Wales

'Non Top 9' 131.1 113.0 139.4 162.9 139.1 190.9 135.7 NIT 6.5 8.3 11.3 3.9 10.2 4.4 8.9 DOX 15.6 11.7 15.5 15.7 20.8 19.5 13.9 OXY 13.5 21.7 13.0 9.3 9.7 10.9 15.0 CLA 18.2 16.4 12.3 14.6 9.8 20.9 15.6 PEN 36.2 33.4 38.9 44.5 34.2 49.9 39.0 ERY 41.1 53.8 47.5 49.0 51.3 43.7 48.8 TRI 46.9 51.3 56.5 51.4 53.8 51.7 51.7 FLU 57.6 59.3 59.4 57.7 48.1 58.8 55.9 AMO 164.2 179.9 175.2 214.6 202.9 190.0 185.0 Total 530.9 548.7 569.1 623.6 580.0 640.7 569.4

LBH & Scripts/1000 PUs per annum

Figure 29: Top 9 antimicrobials by LHBs North Wales

Figure 29 shows the dispensing rates and the proportion of total dispensing for the ‘Top 9’ and ‘non-Top 9’ antimicrobials for the LHBs in North Wales in 2008. The ‘Top 9’ dispensing rates ranged from 70% of total dispensing in Ynys Mon LHB to 79% in Denbighshire LHB. The All-Wales rate of Top 9 dispensing in 2008 was 76.2%. Ynys Mon LHB had the highest overall dispensing rate in the North Wales area, and Conwy LHB had the lowest dispensing rate.

32 Section 3: Detailed Description of Antimicrobial Use

A detailed description of antimicrobial use is presented below for the most commonly dispensed antimicrobials. The data is presented in more detail, and explores potential factors that may impact on temporal and regional variation in antimicrobial dispensing. Penicillin Group

All-Wales penicillin group dispensing 2006-2008 Prescriptions/1000 PUs per annum

350

325 a p

300 s 275 U P

250 0

0 225 0

1 200 /

s 175 n

o 150 i p

t 125 i r 100 c

s 75 e r 50 P 25 0 2006 2007 2008 Co-amoxiclav 32.7 33.1 32.7 Penicillin V 39.7 41.3 39.0 Flucloxacillin 53.3 54.8 55.9 Amoxicillin 173.2 188.0 185.0 Total Pencillins 301.2 319.4 314.4 Presciptions/1000 PUs per annum by Year

Figure 30: All-Wales penicillin group dispensing Figure 30 shows the dispensing for individual antimicrobials belonging to the ‘penicillin group’ (amoxicillin, co-amoxiclav, flucloxacillin & penicillin V) and the ‘penicillin group’ in total:Ampicillin, amoxicillin, benzyl penicillin, benzathine benzyl penicillin, co-amoxiclav, flucloxacillin, penicillin V, piperacillin & tazobactam, and pivmecillinam. The individual antimicrobials reported made up around 99% of the total ‘penicillin group’ dispensing for each LHB each year. Amoxicillin dispensing accounted for around 58% of total ‘penicillin group’ dispensing each year.

The change in dispensing rates for amoxicillin, flucloxacillin and penicillin V have been previously described (pages 28 & 29). Co-amoxiclav dispensing rates increased by 1% between 2006 & 2007, and decreased by 1% between 2007 & 2008. Dispensing rates for the ‘penicillin group’ increased by 6% between 2006 & 2007, and decreased by 2% between 2007 & 2008.

33 Amoxicillin is the most commonly prescribed antimicrobial across Wales; the data presented below suggests that variability in usage between LHBs over time may relate to changes in dosage and duration of therapy as well as in the number of prescriptions.

Amoxicillin Dispensing (DDDs per prescription) by LHBs in South East Wales 2006-2008

240 8.4 220 8.2

200 8.0 a p

180 7.8 s t U 160 7.6 p P i

140 7.4 r 0 c 0 S

0 7.2

120 / 1 / 7.0 D

s 100 D t D p

i 80 6.8 r

c 60 6.6 S 40 6.4 20 6.2 0 6.0 BLG CAE CAR MER MON NEW RCT TOR VOG

06 scripts 195.2 177.9 160.5 177.7 137.0 181.9 189.5 196.8 161.2 07 scripts 220.8 182.8 173.1 177.9 157.2 196.0 196.2 217.5 180.4 08 scripts 236.8 179.6 172.7 182.5 153.0 179.1 186.5 203.8 177.7 06 DDD/scripts 6.6 6.5 6.6 6.5 6.4 6.3 6.2 6.2 6.5 07 DDD/scripts 6.8 6.8 6.8 6.6 6.5 6.5 6.5 6.4 6.5 08 DDD/scripts 6.8 6.9 6.9 6.7 7.0 6.7 6.5 6.6 6.6 LHB

Figure 31: Amoxicillin dispensing (DDD/Script) by LHBs in South East Wales

Figure 31 shows amoxicillin dispensing in prescriptions/1000 PUs pa for the LHBs in South East Wales during 2006-2008 compared to the number of defined daily doses per prescription (DDDs/Script) for the same time period. In all nine LHBs, the number of prescriptions increased between 2006 and 2007 and in 2008 the number decreased in seven of the nine LHBs; however the number of DDDs/script increased between 2006 and 2007, and continued to increase between 2007 and 2008 in all nine LHBs.

In 2006, the number of DDDs/Script ranged from 6.2 DDDs/Script to 6.6 DDDs/Script for all LHBs in South East Wales. In 2007, the number of DDDs/Script increased in eight of the nine LHBs, ranging from 6.4 to 6.8 DDDs/script. In 2008 there was a further increase in DDDs/Script for all LHBs; ranging between 6.5 and 7.0 DDDs/script.

The largest increase in DDDs/Script was in Monmouth LHB where the DDDs/Script increased from 6.4 in 2006 to 7.0 in 2008. The number of prescriptions/1000 PUs per annum for Monmouth increased between 2006 and 2007 but then decreased between 2007 and 2008. The data shows a change in dispensing during 2007/2008 and suggests a probable increase in the dosage or in the duration of length of the course of amoxicillin prescribed/dispensed for a proportion of amoxicillin prescriptions in the LHBs in SE Wales.

34 Amoxicillin Dispensing (DDDs per prescription) by LHBs in Mid & West Wales 2006-2008

240 8.4 220 8.2

200 8.0 a

p 7.8

180 s t U 160 7.6 p P i

140 7.4 r 0 c 0 S

0 120 7.2 / 1 / 7.0 D

s 100 D t D p

i 80 6.8 r

c 60 6.6 S 40 6.4 20 6.2 0 6.0 BGD CAM CER NPT PEM POW SWA Wales

06 scripts 180.3 171.2 148.6 207.2 170.5 128.1 170.2 173.2 07 scripts 203.8 193.3 169.0 222.1 182.1 144.7 182.3 188.0 08 scripts 205.5 200.0 172.0 221.2 185.8 137.3 182.1 185.0 06 DDD/scripts 6.9 6.5 6.4 6.8 7.1 6.4 6.4 6.6 07 DDD/scripts 7.1 6.7 6.3 7.1 7.3 6.4 6.5 6.8 08 DDD/scripts 7.2 6.8 6.4 7.2 7.6 6.6 6.8 6.9 LHB

Figure 32: Amoxicillin dispensing (DDD/Script) by LHBs in Mid & West Wales

Figure 32 shows amoxicillin dispensing in prescriptions/1000 PUs pa for the LHBs in Mid & West Wales during 2006-2008 compared to the number of defined daily doses per prescription (DDDs/Script) for the same time period. In all seven LHBs the number of prescriptions increased between 2006 and 2007 and in 2008 the number of scripts increased further in four of the seven LHBs.The number of DDDs/script increased in five of the LHB between 2006 and 2007, and in all of the LHBs and in All-Wales between 2007 and 2008.

In 2006, the number of DDDs/Script ranged from 6.4 DDDs/Script to 7.1 DDDs/Script for the LHBs in Mid and West Wales. In 2007, the number of DDDs/Script ranged from 6.3 to 7.3 DDDs/script, and in 2008 the number of DDDs/Script ranged from 6.4 to 7.6 DDD/Scripts. The largest increase in DDDs/Script was in Pembroke LHB where the DDDs/Script increased from 7.1 in 2006 to 7.6 in 2008. The All-Wales average also increased from 6.6 DDDs/Script in 2006 to 6.9 DDDs/Script in 2008.

35 Amoxicillin Dispensing (DDDs per prescription) by LHBs in North Wales 2006-2008

240 8.4 220 8.2

200 8.0 a

p 7.8

180 s t U 160 7.6 p P i

140 7.4 r 0 c 0 S

0 7.2

120 / 1 / D

s 100 7.0 D t D p

i 80 6.8 r c 60 6.6 S 40 6.4 20 6.2 0 6.0 CON DEN FLI GWY WRX YNY Wales

06 scripts 153.1 184.7 155.5 203.6 195.0 180.4 173.2 07 scripts 171.7 194.2 170.0 220.9 215.2 194.9 188.0 08 scripts 164.2 179.9 175.2 214.6 202.9 190.0 185.0 06 DDD/scripts 7.1 7.5 6.4 6.9 6.5 7.8 6.6 07 DDD/scripts 7.1 7.7 6.7 7.0 6.6 7.9 6.8 08 DDD/scripts 7.4 7.6 6.9 7.2 6.9 8.1 6.9

LHB

Figure 33: Amoxicillin dispensing (DDD/Script) by LHBs in North Wales

Figure 33 shows amoxicillin dispensing in prescriptions/1000 PUs pa for the LHBs in North Wales during 2006-2008 compared to the number of defined daily doses per prescription (DDDs/Script) for the same time period. In all six LHBs the number of prescriptions increased between 2006 and 2007 and in 2008 the number of scripts decreased further in five of the six LHBs. The number of DDDs/script increased in all of the LHBs between 2006 and 2007, and in five of the LHBs between 2007 and 2008.

In 2006, the number of DDDs/Script ranged from 6.4 DDDs/Script to 7.8 DDDs/Script for the LHBs in North Wales. In 2007, the number of DDDs/Script ranged from 6.6 to 7.9 DDDs/script, and in 2008 they ranged from 6.9 to 8.1 DDD/Scripts. The DDDs/Script for amoxicillin in Ynys Mon LHB was notably higher (7.8-8.1) than for any LHB in Wales.

36 Amoxicillin Dispensing by Dosage and Duration

AmoxicillinAmoxicillin dispensing by dosage/preparation All-Wales 2006-2008

350,000

300,000 s s 250,000 m m e e t t i i

f f 200,000 o o

r r e e 150,000 b b m m u u 100,000

N 100,000 N

50,000

0 125mg/5ml 250mg/5ml 125mg/1.25ml 500mg CAP 250mg CAP 3g SACH SUSP SUSP SUSP 2006 data 255,327 281,132 135,394 47,846 4,138 1,785 2007 data 303,720303720 291,696291696 143,083143083 48,51848518 4,0804080 2,0292029 2008 data 326,480 273,662 133,274 46,655 3,594 1,638 Preparation

800,000800,000.00 750,000750,000.00 700,000700,000.00 650,000.00 650,000 600,000.00 600,000 s

s 550,000.00

m 550,000 m e t e i 500,000.00

t i f 500,000

f o

o 450,000.00 r 450,000 r e

e b 400,000.00 b

m 400,000 u m 350,000.00 u N 350,000 N 300,000.00 300,000 250,000.00 250,000 200,000.00 200,000 150,000.00 303,720 326,480 150,000 255,327 303720 326,480 100,000.00 255,327 100,000 50,000.00 50,000 0.00 0 2006 2007 2008 2006 2007 2008

500mg CAP 250mg CAP 125mg/5ml SUSP 250mg/5ml SUSP 125mg/1.25ml SUSP 3g SACH 500mg CAP 250mg CAP 125mg/5ml SUSP 250mg/5ml SUSP 125mg/1.25ml SUSP 3g SACH

Figure 34: Amoxicillin dispensing by dosage/preparation

Figure 34 shows amoxicillin dispensing by dosage and preparation for All-Wales during 2006-2008. The amoxicillin preparations comprised 250mg & 500mg capsules (CAP); 125mg/5ml, 250mg/5ml & 125mg/1.25ml oral suspensions (SUSP), and 3 gram sachets of powder (SACH).

37 Parenteral preparations have been excluded from this data set as the numbers were very small (<0.1% of the amoxicillin items dispensed). The data shows that between 2006 & 2007 dispensing of oral amoxicillin preparations increased overall and between 2007 & 2008 there was a slight overall decrease.

 In 2006, 250mg capsules were the most commonly dispensed amoxicillin item in Wales (39%); 500mg capsules were the second most commonly dispensed (35%).  In 2007, 500mg capsules became the most commonly dispensed amoxicillin item (38%); 250mg capsules were the second most common item (37%).  In 2008, dispensing of 500mg capsules increased to 42% of all amoxicillin items dispensed; 250mg capsules were the second most common item (35%).

Amoxicllin dispensing 250mg capsules by quantity per script for All-Wales 2008 )

s 220000 e l 200000 u 74.5% of 250mg scripts s 21 capsules – 7 days p 180000 a c

160000 g 140000 m 0

5 120000 2 ( 100000 y t i t 80000 n a

u 60000 Q

40000 l a t 20000 o T 0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 Quantity per script

Figure 35:Amoxicillin 250mg capsules quantity per script

Figure 35 shows the quantity of amoxicillin 250mg capsules dispensed per prescription for All-Wales in 2008. The most common number of 250mg capsules dispensed was 21 per prescription (75% of total amoxicillin 250mg scripts); 21% of amoxicillin 250mg prescriptions were dispensed with 15 capsules and there were small proportions of the quantities - 18, 28, 30 and 42. The quantities shown in the figure above (10-42 capsules) accounted for 99% of all 250mg amoxicillin capsules prescriptions dispensed in 2008.

38 Amoxicllin dispensing 500mg capsules by quantity per script for All-Wales 2008 )

s 280000.0 e

l 260000.0

u 81.1% of 500mg scripts

s 240000.0

p 21 capsules – 7 days

a 220000.0 c 200000.0 g 180000.0 m

0 160000.0 0 5

( 140000.0

t 120000.0 i t 100000.0 n

a 80000.0 u

Q 60000.0

a 40000.0 t

o 20000.0 T 0.0 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 3 3 3 3 3 3 3 3 4 4 4 Quantity per script

Figure 36: Amoxicillin 500mg capsules quantity per script

Figure 36 shows the quantity of amoxicillin 500mg capsules dispensed per prescription for All-Wales in 2008. The most common number of 500mg capsules dispensed was 21 per prescription (81% of total amoxicillin 500mg scripts); 14% of amoxicillin 500mg prescriptions were dispensed with 15 capsules and there were small proportions of the quantities - 28, 30 and 42. The quantities shown in the figure above (10-42 capsules) accounted for 99% of all 500mg amoxicillin capsules prescriptions dispensed in 2008.

It is of note that HPA guidance for the management of acute exacerbation of COPD and acute bronchitis suggests duration of therapy of 5 days. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947340160

39 Cephalosporin Group

All-Wales Cephalosporin dispensing Prescriptions/1000 PUs per annum

70 65

a 60 p

s 55

U 50 P

0 45 0

0 40 1 /

s 35 n 30 o i t 25 p i

r 20 c

s 15 e r

P 10 5 0 2006 2007 2008

Cefaclor 11.2 7.6 6.6 Cephalexin 45.4 37.3 38.9 Total Cephs 61.1 47.9 48.4 Prescriptions/1000 PUs per annum by Year

Figure 37: All-Wales cephalosporin group dispensing

Figure 37 shows the difference in dispensing rates for cefaclor and cefalexin between 2006 & 2008, and the ‘Cephalosporin group comprising: Cefaclor, cefadroxil, cefalexin, cefixime, cefotaxime, cefpodoxime cefradine, ceftazidime, ceftriaxone and cefuroxime. Cefalexin and cefaclor made up around 93% of the total ‘Cephalosporin group’ dispensing overall each year. Cefalexin dispensing alone accounted for 74% to 80% of total ‘Cephalosporin group’ dispensing on average across Wales each year.

Proportion of Cephalosporin Group Dispensing by LHBs in Sout East Wales for 2008

100% 120 90% 110

80% 100 a p

n 70% 90 u o P i

t 60% 80 0 r 0

o 70

50% 0 p 1 /

o 40% 60 s r t p

P 30% 50 i r 20% 40 c S 10% 30 0% 20 BLG CAE CAR MER MON NEW RCT TOR VOG

Cefalexin Cefaclor Other Cephs Total Cephs scripts/1000 PUs pa

Figure 38: Cephalosporin dispensing by LHBs in South East Wales

40 Proportion of Cephalosporin Group Dispensing by LHBs in Mid & West Wales for 2008

100% 120 90% 110

80% 100 a p

n 70% 90 U o i P

t 60% 80 0 r 0 o 50% 70 0 p 1 /

o 40% 60 s r t p P 30% 50 i r c

20% 40 S 10% 30 0% 20 BGD CAM CER NPT PEM POW SWA Wales

Cefalexin Cefaclor Other Cephs Total Cephs scripts/1000 PUs pa

Figure 39: Cephalosporin dispensing by LHBs in Mid & West Wales

Proportion of Cephalosporin Group Dispensing by LHBs in North Wales for 2008

100% 120 90% 110 a p

80% 100 s n

70% 90 U o i P

t 60% 80 0 r 0 o 50% 70 0 p 1 /

o 40% 60 s r t p

P 30% 50 i r

20% 40 c 10% 30 S 0% 20 CON DEN FLI GWY WRX YNY Wales

Cefalexin Cefaclor Other Cephs Total Cephs scripts/1000 PUs pa

Figure 40: Cephalosporin dispensing by LHBs in North Wales Figures 38-40 show the difference of antimicrobial dispensing within the Cephalosporin group, broken down by LHB/Area:

 Cefalexin dispensing as a proportion of total cephalosporin dispensing ranged from 42% in Ceredigion LHB to 96% in Gwynedd LHB.  Cefaclor dispensing ranged from 1% in Monmouth to 42% in Ceredigion LHB.  ‘Other cephalosporin’ dispensing ranged from 1% in Gwynedd LHB to 20% in Carmarthen LHB. Carmarthen LHB dispensing of ‘other cephalosporins’ comprised predominantly cefradine, cefuroxime, and cefixime.  There was a notable difference in cephalosporin choice in LHBs in Mid & West Wales compared to those in the rest of Wales.  Ynys Mon LHB had the highest rate of cephalosporin dispensing in 2008.

41 Macrolide/ Lincosamide/ Streptogrammin Group

All-Wales MLS dispensing Prescriptions/1000 PUs per annum

65 a

p 60

s 55 U

P 50

0 45 0

0 40 1 /

s 35 n

o 30 i t

p 25 i r 20 c

s 15 e r 10 P 5 0 2006 2007 2008

Clarithromycin 12.5 14.0 15.6 Erythromycin 48.3 51.0 48.8 Total MLS 63.1 67.8 67.7 Prescriptions/1000 PUs per annum by Year

Figure 41: All-Wales MLS group dispensing Figure 41 shows the difference in dispensing rates for clarithromycin and erythromycin between 2006 & 2008, and for the ‘MLS group’ comprising: Azithromycin, clarithromycin, clindamycin erythromycin and telithromycin. The individual antimicrobials reported made up around 95% of the total ‘MLS group’ dispensing overall each year. Erythromycin dispensing accounted for 72% to 77% of total ‘MLS group’ dispensing each year across Wales. The change in dispensing rates for erythromycin & clarithromycin at an All-Wales level have been previously described (pages 28 & 29).

Proportion of MLS group Dispensing by LHBs in South East Wales for 2008

100% 120 90% 115

80% 110 a p

70% 105 s U n P o

i 60% 100 t 0 r 0

o 50% 95 0 p 1 o /

r 40% 90 s t P p

30% 85 i r c

20% 80 S 10% 75 0% 70 BLG CAE CAR MER MON NEW RCT TOR VOG

Erythromycin Clarithromycin Other MLS Total MLS scripts/1000 PUs pa

Figure 42: MLS dispensing by LHBs in South East Wales

42 Proportion of MLS group Dispensing by LHBs in Mid & West Wales for 2008

100% 120 90% 115

80% 110 a p

70% 105 s n U o P

i 60% 100 t 0 r 0

o 50% 95 0 p 1 /

o 40% 90 s r t P p

30% 85 i r

20% 80 c S 10% 75 0% 70 BGD CAM CER NPT PEM POW SWA Wales

Erythromycin Clarithromycin Other MLS Total MLS scripts/1000 PUs pa

Figure 43: MLS dispensing by LHBs in Mid & West Wales

Proportion of MLS group Dispensing by LHBs in North Wales for 2008

100% 120 90% 115 80% 110 70% 105 n o

i 60% 100 t r

o 50% 95 p

o 40% 90 r

P 30% 85 20% 80 10% 75 0% 70 CON DEN FLI GWY WRX YNY Wales

Erythromycin Clarithromycin Other MLS Total MLS scripts/1000 PUs pa

Figure 44: MLS dispensing by LHBs in North Wales

Figures 42-44 show the difference of antimicrobial dispensing within the MLS group, broken down by LHB/Area:

 Erythromycin dispensing as a proportion of MLS group dispensing ranged between 66% in Pembroke LHB to 85% in Wrexham LHB.  Clarithromycin dispensing ranged from 15% in Wrexham to 31% in Ynys Mon.  ‘Other MLS’ dispensing ranged from 2% in Denbighshire LHB to 9% in Pembroke LHB. Pembroke LHB dispensing of ‘other MLS’ comprised: azithromycin (83%) and clindamycin (17%).  Newport LHB had the highest rate of MLS dispensing in 2008.

43 Tetracycline Group

All-Wales Tetracycline dispensing Prescriptions/1000 PUs per annum

50 a p

45 s 40 U P 35 0

0 30 0 1 / 25 s

n 20 o i

t 15 p i

r 10 c

s 5 e r

P 0 1 2 3 Minocycline 6.2 5.3 4.9 Lymecycline 5.5 7.3 9.1 Doxycycline 12.3 13.4 13.9 Oxytetracycline 15.0 15.3 15.0 Total Tets 40.6 43.0 44.6 Prescription/1000 Pus per annum by Year

Figure 45: All-Wales tetracycline group dispensing

Figure 45 shows the difference in the dispensing rates for doxycycline, lymecycline, minocycline and oxytetracycline between 2006 & 2008, and for the ‘Tetracycline group’ comprising: Doxycycline, lymecycline, minocycline oxytetracycline and tetracycline. The four individual antimicrobials reported made up around 96% of the total ‘Tetracycline group’ dispensing overall each year. The change in dispensing rates for doxycycline and oxytetracycline at an All-Wales level have been previously described (pages 28 & 29).

Proportion of Tetracycline group Dispensing by LHBs in South East Wales for 2008

100% 60

80% 55 a p

s n U o P i

t 60% 0 r 0 o 0 p 1 /

o 45 40% s r t p P i r c

20% 40 S

0% 35 BLG CAE CAR MER MON NEW RCT TOR VOG

Oxytetracycline Doxycycline Lymecycline Minocycline Other Tets Total Tets scripts/1000 PUs pa

Figure 46: Tetracycline dispensing by LHBs in South East Wales

44 Proportion of Tetracycline group Dispensing by LHBs in Mid & West Wales for 2008

100% 60 90% a

80% p 55 s

70% U n P

o 0

i 60% 50 0 t r 0 1 o 50% / p s t o

40% 45 p r i r P 30% c S 20% 40 10% 0% 35 BGD CAM CER NPT PEM POW SWA Wales

Oxytetracycline Doxycycline Lymecycline Minocycline Other Tets Total Tets scripts/1000 PUs pa

Figure 47: Tetracycline dispensing by LHBs in Mid & West Wales

Proportion of Tetracycline group Dispensing by LHBs in North Wales for 2008

100% 60 90%

80% 55 a p

70% s n U o P

i 60% 50 t 0 r 0

o 50% 0 p 1 / o

40% 45 s r t P p 30% i r c

20% 40 S 10% 0% 35 CON DEN FLI GWY WRX YNY Wales

Oxytetracycline Doxycycline Lymecycline Minocycline Other Tets Total Tets scripts/1000 PUs pa

Figure 48: Tetracycline dispensing by LHBs in North Wales

Figures 46-48 show the wide variation of antimicrobial dispensing within the tetracycline group, broken down by LHB/Area:

 Oxytetracycline dispensing as a proportion of tetracycline group dispensing ranged between 20% in Wrexham LHB to 49% in Pembroke LHB.  Doxycycline dispensing ranged from 15% in Newport LHB to 48% in Powys LHB.  Lymecycline dispensing ranged from 5% in Pembroke LHB to 33% in NPT LHB.  Minocycline dispensing ranged from 7% in Monmouth LHB to 16% in Ynys Mon.  ‘Other Tetracycline’ dispensing ranged from 2% in Monmouth LHB to 10% in Merthyr Tydfil LHB. Merthyr Tydfil dispensing of ‘other tetracyclines’ comprised solely of tetracycline.  Rhondda Cynon Taff and Merthyr Tydfil LHB had the highest rate of tetracycline dispensing in 2008.

45 Fluoroquinolone Group

All-Wales Fluoroquinolone dispensing Prescriptions/1000 PUs per annum

26 24

p 22

s 20 U

P 18

0 16 0 0

1 14 /

s 12 n

o 10 i t

p 8 i r

c 6 s

e 4 r

P 2 0 2006 2007 2008 Levofloxacin 1.5 0.9 0.7 Ciprofloxacin 20.5 16.5 16.4 Total FQ 23.5 18.6 18.1 Prescription/1000 PUs per annum by Year

Figure 49: All-Wales fluoroquinolone group dispensing Figure 49 shows the difference in dispensing rates for ciprofloxacin and levofloxacin between 2006 & 2008, and for the ‘Fluoroquinolone group’ comprising: Ciprofloxacin, levofloxacin, moxifloxacin, norfloxacin and ofloxacin. Ciprofloxacin accounted for 87% to 91% the total ‘Fluoroquinolone group’ dispensing each year. The change in dispensing rates for fluoroquinolones at LHB level have been previously described (pages 6 to 27).

Proportion of Fluoroquinolone Group Dispensing by LHBs in Sout East Wales for 2008

100% 30 90% 28

80% 26 a p

70% 24 s n U o P

i 60% 22 t 0 r 0 o 50% 20 0 p 1 / o

r 40% 18 s t P p i

30% 16 r c

20% 14 S 10% 12 0% 10 BLG CAE CAR MER MON NEW RCT TOR VOG

Ciprofloxacin Levofloxacin Other FQs Total FQ scripts/1000 PUs pa

Figure 50: Fluoroquinolone dispensing by LHBs in South East Wales

46 Proportion of Fluoroquinolone Group Dispensing by LHBs in Mid & West Wales for 2008

100% 30 90% 28 80% 26 a p 70% 24 s n U o

i 60% 22 P

t 0 r 0

o 50% 20 0 1 p / s o 40% 18 t r p i P 30% 16 r c 20% 14 S 10% 12 0% 10 BGD CAM CER NPT PEM POW SWA Wales

Ciprofloxacin Levofloxacin Other FQs Total FQ scripts/1000 PUs pa

Figure 51: Fluoroquinolone dispensing by LHBs in Mid & West Wales

Proportion of Fluoroquinolone Group Dispensing by LHBs in NorthWales for 2008

100% 30 90% 28

80% 26 a p

70% 24 s n U o P i 60% 22 t 0 r 0

o 50% 20 0 p 1 / o

r 40% 18 s t P p i

30% 16 r c

20% 14 S 10% 12 0% 10 CON DEN FLI GWY WRX YNY Wales

Ciprofloxacin Levofloxacin Other FQs Total FQ scripts/1000 PUs pa

Figure 52: Fluoroquinolone dispensing by LHBs in North Wales

Figures 50-52 show the wide variation of antimicrobial dispensing within fluoroquinolone group, broken down by LHB/Area:

 Ciprofloxacin dispensing as a proportion of fluoroquinolone group dispensing ranged between 61% in Wrexham LHB to 98% in Bridgend LHB.  Levofloxacin dispensing ranged from <1% in Bridgend to 33% in Wrexham LHB.  ‘Other Fluoroquinolone’ dispensing ranged from 1% in Caerphilly LHB to 24% in Ynys Mon LHB. Ynys Mon dispensing of ‘other fluoroquinolones’ comprised norfloxacin (87%), ofloxacin (8%) and moxifloxacin (5%).  Ynys Mon LHB & Neath Port Talbot LHB had the highest rate of fluoroquinolone dispensing in 2008.

47 Trimethoprim/Sulfonamide Group

All-Wales Trimethoprim & Sulfonamide dispensing Prescriptions/1000 PUs per annum

70 65

a 60 p

s 55

U 50 P 45 0

0 40 0 1

/ 35 s

n 30 o

i 25 t p

i 20 r

c 15 s

e 10 r

P 5 0 2006 2007 2008 Co-trimoxazole 1.1 0.9 0.9 Trimethoprim 65.0 50.6 51.7 Total Trim/Sulfa 66.1 51.5 52.6 Prescription/1000 PUs per annum by Year

Figure 53: All-Wales trimethoprim/sulfonamide group dispensing Figure 53 shows the difference in the All-Wales dispensing rates for co-trimoxazole and trimethoprim between 2006 and 2008, and for the Trim/Sulfa group comprising: Co-trimoxazole, sulfadiazine, sulfamethoxypyridazine, sulfapyridine & trimethoprim. Trimethoprim accounted for approximately 98% of the total ‘Trim/Sulfa group’ dispensing each year. The change in dispensing rates for trimethoprim at an All- Wales level has been previously described (pages 28 & 29).

Figure 54 shows trimethoprim dispensing by dosage & preparation for All-Wales during 2006-2008. The trimethoprim preparations comprised 100mg & 200mg tablets (TAB), and 50mg/5ml oral suspensions (SUSP).

 200mg tablets were the most common item prescribed & dispensed, comprising approximately 80% of all trimethoprim items dispensed across Wales during 2006-2008.  The total number of prescriptions increased from 206,085 in 2006, 215,293 in 2007 to 221,369 in 2008 – Note: There are no age or population adjustments to the figures shown in Figure 54.  The number of 200mg tablets dispensed increased between 2006 & 2008 from 164,336 scripts to 175,098 scripts (7% increase)  The number of 100mg tablets dispensed increased between 2006 & 2008 from 21,659 scripts to 27,622 scripts (28%)

48 Trimethoprim Dispensing by Dosage and Duration

Amoxicillin dispensing by dosage/preparation Trimethoprim dispensing by dosage/preparation Trimethoprim dispensingAll-Wales by 2006-2008 dosage/preparation All-WalesAll-Wales 2006-2008 2006-2008

200,000350,000 200,000 180,000 180,000300,000 160,000 160,000 s s 140,000250,000 m m s e e 140,000 t t m i 120,000 i

f t f 200,000 i o 120,000

f 100,000

r r o e

b 100,000 r 150,00080,000 b e m b m u 60,00080,000 u N m 100,000 N u 40,00060,000 N 20,00040,00050,000 20,0000 0 100mg TAB 200mg TAB 50mg/5ml SUSP 0 125mg/5ml 250mg/5ml 125mg/1.25ml 500mg CAP 250mg CAP 3g SACH 2006 data 100mg21,659 TAB SUSP200mg164,336 TABSUSP SUSP50mg/5ml18,084 SUSP 20062007 data 21,65924,203 164,336171,103 18,08417,980 2006 data 255,327 281,132 135,394 47,846 4,138 1,785 20072008 data 24,20327,622 171,103175,098 17,98016,641 2007 data 303720 291696 143083 48518 4080 2029 2008 data 27,622 Preparation175,098 16,641 2008 data 326,480 273,662 133,274 46,655 3,594 1,638 Preparation Preparation

250,000 800,000 250,000 750,000225,000 700,000225,000 650,000200,000 200,000 600,000 175,000 s s 550,000s 175,000 m m e m e t t e i 500,000i

t 150,000 f f i

o 150,000 o f

450,000 r r o e

e r b 400,000125,000 b

e 125,000 m b m u 350,000 u N m 100,000 N 300,000u 100,000

N 175,098 164,336 171,103171,103 175,098 250,00075,000 164,336 75,000 200,000 150,00050,000 303720 326,480 255,327 100,000 25,000 50,000

0 00 200620062006 200720072007 20082008 Preparation 500mg CAP 250mg CAP 125mg/5ml SUSP 250mg/5ml SUSP 125mg/1.25ml SUSP 3g SACH 200mg200mg TAB TAB 100mg100mg TAB TAB 50mg/5ml50mg/5ml SUSP SUSP

Figure 54: Trimethoprim dispensing by dosage/preparation

49 Trimethoprim dispensing 100mg tablets by quantity per script for All-Wales 2008

22500 s t e

l 20000 71.1% of 100mg scripts

b 28 tablets a

t 17500

m 15000 0 0

1 12500

y t i

t 10000 n a 7500 u Q

l 5000 a t

o 2500 T 0 6 7 8 9 0 1 2 3 4 5 6 7 8 0 1 3 4 5 8 0 4 5 8 9 0 2 8 9 0 4 5 6 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 3 3 3 3 3 4 4 4 4 5 5 5 5 Quantity per script

Figure 55: Trimethoprim 100mg capsules quantity per script

Figure 55 shows the quantity of trimethoprim 100mg tablets dispensed per prescription for All-Wales in 2008. The most common number of 100mg tablets dispensed was 28 per prescription (71% of total trimethoprim 100mg scripts); 12% of trimethoprim 100mg prescriptions were dispensed with 7 tablets and 7% were dispensed with 56 tablets there were small proportions of the quantities – 6, 10, 14, 28 and 30. The quantities shown in the figure above (6-56 tablets) accounted for 97% of all 100mg trimethoprim tablets prescriptions dispensed in 2008.

Trimethoprim dispensing 200mg tablets by quantity per script for All-Wales 2008

70000 s

t 38.5% of 200mg scripts e l 14 tablets b 60000 a t

g 50000 m 0 0

2 40000

y t i t 30000 n a u

Q 20000

l a t

o 10000 T 0 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 4 6 7 8 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 Quantity per script

Figure 56: Trimethoprim 200mg capsules quantity per script

Figure 56 shows the quantity of trimethoprim 200mg tablets dispensed per prescription for All-Wales in 2008. The most common number of 200mg tablets dispensed was 14 per prescription (39% of total trimethoprim 200mg scripts); 26% of

50 trimethoprim 200mg prescriptions were dispensed with 10 tablets and another 26% were dispensed with 6 tablets there were small proportions of the quantities – 7, 12 and 20. The quantities shown in the figure above (6-28 tablets) accounted for 98% of all 200mg trimethoprim tablets prescriptions dispensed in 2008.

Trimethoprim dispensing 200mg tablets by quantities per script for All-Wales 2006-2008

45 )

% 40 (

s t 35 p i r

c 30 s

o 25

n o

i 20 t r

o 15 p o r 10 P 5 0 6 10 14 28 2006 21.6 28.4 40.2 4.9 2007 25.0 26.6 39.0 5.0 2008 26.1 26.2 38.5 5.0 Quantities (Number of tablets)

Figure 57: Trimethoprim 200mg capsules quantity per script 2006-2008

Figure 57 shows the change in quantities of trimethoprim 200mg tablets dispensed per prescription for All-Wales between 2006 and 2008:

 For all 3 years the most common quantity of 200mg tablets dispensed was 14 tablets per prescription, however, the proportion decreased from 40.2% of all 200mg tablets scripts in 2006 to 38.5% in 2008.  The proportion of scripts dispensed for 10 tablets decreased from 28.4% in 2006 to 26.2% in 2008.  The proportion of scripts dispensed for 6 tablets increased from 21.6% in 2006 to 26.1% in 2008, probably reflecting increased compliance to guidance for treatment of uncomplicated UTI in women of 200mg trimethoprim BD for 3 days. http://www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947340160