QUALITY MEASURES
Point Prevalence Surveys of Antimicrobial
Prescribing in Secondary Care in Wales
2011-2015
Rx rate
Choice
Reason
Route
>7days
CURB-65
>24hrs SP
Number
Review
Authors: Maggie Heginbothom and
Robin Howe
Date: 05/02/2016
Status: Final
Quality Measures 2011-2015 PPS
Page: 1 of 17
Welsh Antibacterial Resistance
Programme: Surveillance Unit
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INTRODUCTION
This report provides compares Quality Measures data from the 2011 to 2015 All-Wales
Point Prevalence Survey (PPS) of antimicrobial usage in secondary care; the data
includes all antibacterial, antiviral, antifungal, topical antibacterial/antiseptic, and TB
agents, which is collectively described as antimicrobials. However, the Quality Measures
concentrate mainly on systemic antibacterial prescribing.
The PPS is carried out annually by pharmacists in acute and community hospitals across
Wales. This report allows for comparison between units and shows trends across time; it
should be noted that patient mix and specialities vary between hospitals and comparisons
should be made with caution.
KEY POINTS
The PPS data for 2015 shows:

A significant DECREASE in antibacterial prescribing across Wales compared
with previous years (28.4% in 2015 compared with 31.1% in 2013)

A DECREASE in prescribing in 7 of the 8 Health Boards

10 of the 16 acute hospitals in Wales REDUCED their antibacterial prescribing

A REDUCTION in intravenous antibacterial usage in the acute hospital in Wales
(53%-51%)

NO SIGNIFICANT change in the number of different antibacterial agents
prescribed

NO SIGNIFICANT change in the proportion of patients prescribed monotherapy

NO CHANGE in the proportion of patients prescribed antibacterials for >7days for
the treatment of infection

A marked DECREASE across Wales in the use of >24hrs surgical prophylaxis
(58%-26%).

A REDUCTION in >24hrs surgical prophylaxis in 4 of the 6 Health Boards

An INCREASE in recording ‘reason for treatment’ in the patient notes (83%-89%)

An INCREASE in recording a stop/review date for antimicrobial prescribing
(48%-52%), but still much room for improvement

Across Wales 91% of prescribing was considered to be an appropriate drug
choice

An INCREASE in recording CURB-65 scores for patients with a diagnosis of
community acquired pneumonia (27%-42%), but still much room for
improvement.
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QUALITY MEASURES
Antibacterial prescribing rates
In 2015, the antibacterial prescribing rate for Wales was 28.4%, showing a significant
decrease in prescribing compared with previous years:




Prescribing decreased in 7 of the 8 Health Boards, including Velindre*.
There was a marked reduction in prescribing in Abertawe Bro Morgannwg
(ABMU) and Aneurin Bevan (ABV).
Prescribing was highest, with similar rates, in Cwm Taf (CWT), Hywel Dda (HDD)
and Betsi Cadwaladr (BCU).
Powys (PWT) remained the lowest prescribing Health Board.
30.0
28.4
28.4
Figure 1: Trend in antibacterial prescribing rates in Wales 2011-2015
Antibacterial prescribing rates for the Health Boards and All-Wales for 2011- 2015 are
shown in Table 1. The table use a colour gradation based on the lowest rate to the highest
rate (20.1% to 36.7%), to highlight trends in prescribing rates across time.
Table 1: Antibacterial prescribing rates for Health Boards and All-Wales 2011-2015
* Velindre hospital is excluded from this table as
the patient numbers were very small.
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In 2015, 11 of the 16 acute hospitals in
Wales reduced their prescribing. There was
greater homogeneity in prescribing and a
marked reduction in the median prescribing
rate from 32.5% in 2013 to 29.9% in 2015.
Figure 2 is a box plot of acute hospital
antibacterial prescribing by year. Each point
on the box plot represents an acute hospital.
Table 2 shows antibacterial prescribing for
the acute hospitals over time. In 2015, rates
varied from 22.9% in Singleton hospital (S) to
35.8% in Royal Glamorgan hospital (C).
Comparing 2014 & 2015 data, there was a
decrease in prescribing in Bronglais (A),
Princess of Wales (B), Royal Gwent (D),
Morriston (E), University Hospital of Wales
(F), Wrexham Maelor (H), Ysbyty Glan Clwyd
(L), Nevill Hall (M), Velindre (data not shown:
38%-37%), Prince Philip (R), & Singleton (S).
Figure 2 & Table 2: Antibacterial prescribing rates for Acute Hospitals 2011-2015
Key:
A – Bronglais
B – Princess of Wales
C – Royal Glamorgan
D – Royal Gwent
E – Morriston
F – University Hospital of Wales
G – Withybush
H – Ysbyty Wrexham Maelor
J – Glangwili
K – Ysbyty Gwynedd
L – Ysbyty Glan Clwyd
M – Nevill Hall
N – Prince Charles
P – University Hospital Llandough
R – Prince Philip
S – Singleton
Note: Velindre hospital is excluded from this
table as the patient numbers were very small.
Neath Port Talbot is excluded as it is no longer
considered an acute hospital.
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Route of administration
In 2015, there was a reduction in
parenteral antibacterial usage in
Wales (53% to 51%), and in the
previously high usage hospitals:
Royal Gwent (D), Morriston (E),
and Velindre (Q)
Figure 3 is a box plot of the rate of
hospital parenteral antibacterial use
by year.
Table 3 shows usage over time by
hospital. In 2015, parenteral usage
varied from 30.8% in Velindre (Q) to
59.8% in Withybush (G). Parenteral
usage increased in Princess of
Wales (B), UHW (F), Withybush
(G), Wrexham (H), Glangwili (J), &
Prince Charles (N).
Figure 3 & Table 3: Parenteral route of administration – hospital level 2011-2015
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Number of different antibacterial agents
There has been no significant
change in the number of different
antibacterial agents recorded on
the day of the PPS across time.
Figure 4 is a box plot of the number of
different systemic antibacterials agents
prescribed on the day of the PPS by
acute hospital by year.
Table 4 shows the number of different
agents prescribed by hospital over
time. In the 2015 PPS, the number of
different antibacterials prescribed at
acute hospital level ranged from 34 in
UHW (F) to 8 in Velindre (Q). For most
hospitals there was no specific trend in
the numbers of agents prescribed,
although for Princess of Wales (B)
there appears to be a general upward
trend in the number of agents (20-30).
Figure 4 & Table 4: Number of different antibacterials - Acute hospital level
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Number of antibacterials per regimen
There has been no significant
change in the proportion of patients
prescribed antibacterial monotherapy
across time.
Figure 5 is a box plot of the proportion
of patients prescribed antibacterial
monotherapy by hospital and year.
Table 5 shows the proportion of
patients prescribed monotherapy by
acute hospital over time. In 2015, the
proportion of monotherapy ranged from
82% in Velindre (Q) to 53% Glangwili
(J). There has been variability in the
monotherapy rates across time for a
number
of
hospitals,
possibility
reflecting changes in guidance and
formulary.
Figure 5 & Table 5: Proportion of patients prescribed systemic antibacterial monotherapy
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Duration of treatment
There has been no change in the proportion of patients
prescribed antibacterials for >7days for the treatment of
infection; with increased heterogeneity across the acute
hospitals (Wales rate 15% in 2014 and 2015).
Figure 6 is a box plot of the proportion of patients prescribed
antibacterials for >7 days for the treatment of infection.
Figure 7 shows the proportion of patients prescribed
antibacterials for > 7 days, by hospital over time. In the 2015
PPS, the proportion ranged from 24% in Morriston (E) and
University Hospital Llandough (P) to 0% in Velindre (Q).
Hospitals showing the greatest improvement appear to the
left of the graph.
There was a notable increase in the proportion of patients
receiving treatment for > 7days in Morriston, University
Hospital of Wales (F), University Hospital Llandough and
Neath Port Talbot (T). Whilst Royal Glamorgan (C), Nevill
Hall (M), Prince Charles (N), Velindre, and the combined
hospitals of Powys Teaching Health Board (X) there was a
decrease in treatment for > 7 days.
Figures 6 & 7: Proportion of patients prescribed antibacterials for > 7 days - Hospital level
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Duration of surgical prophylaxis
There has been a marked decrease in
the use of surgical prophylaxis >24 hr.
The median rate for Wales decreased
from 58% in 2011 to 26% in 2015, with
a reduction in rates in 4 of the 6 Health
Boards. However, there remains room
for improvement.
Figure 8 is a box plot of the proportion
surgical prophylaxis prescribed for >24
hours at Health Board level by year.
Table 6 shows the proportion of surgical
prophylaxis prescribed >24 hours by
Health Board over time.
Prophylaxis >24 hours ranged from 38%
in Hywel Dda University Health Board
(HDD) to 15% in both Aneurin Bevan
Health Board (ABV) and Cardiff and
Vale University Health Board (CVU).
Figure 8 & Table 6: Proportion of surgical prophylaxis given > 24 hours - HB level
Note: Surgical prophylaxis numbers are small and prone to misinterpretation at hospital level;
therefore the data is only presented at Health board level in this report.
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Reason for treatment recorded in notes
There has been an increase in
recording ‘reason for treatment’ in
the patient notes. The median rate
for Wales increased from 83% in
2011 to 89% in 2015.
Figure 9 is a box plot of the proportion
of antimicrobials where the reason for
the prescription was recorded in the
patients notes.
Table 7 shows the reason in notes
over time. In 2015, the rate ranged
from 100% in Neath Port Talbot (T) to
79% in UHW (F), Glangwili (J) and
Ysbyty Glan Clwyd (L). There was a
notable increase in the recording rate
in Withybush (G), Nevill Hall (M), and
UHL (P), and a marked decrease in
Prince Philip (R) and Singleton (S).
Figure 9 & Table 7: Reason recorded in notes - Hospital level
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Stop/review date for treatment recorded in notes
There has been an increase in recording a stop/review date
for antimicrobial prescribing. The rate for Wales increased
from 48% in 2014 to 52% in 2015. However, there remains
much room for improvement.
Figure 10 is a box plot of the proportion of antimicrobials
where a stop/review date is recorded. The data does not
include surgical prophylaxis (as generally single dose or
single day treatment).
Figure 11 shows stop/review dates recorded for 2014 and
2015. In the 2015 PPS, the proportion of antimicrobials that
had a stop/review date recorded ranged from 95% in Neath
Port Talbot (T) to 26% in the combined hospitals of Powys
Teaching Health Board (X).
Hospitals showing the greatest improvement appear to the
left of the graph, with a notable increase in stop/review
recording in Velindre (Q), Nevill Hall (M), and Ysbyty
Gwynedd (K).
Figures 10 & 11: Stop/review date recorded in notes - Hospital level
All-Wales SRD% 2015 = 52%
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Appropriate Drug Choice
The 2015 PPS was the first survey that collected data on Appropriate Drug Choice’;
there are no comparative data for previous years. The data shows that across Wales
91% of prescribing was considered to be the appropriate drug choice.
All-Wales AC% = 91%
Key:
A – Bronglais; B – Princess of Wales; C – Royal Glamorgan; D – Royal Gwent; E – Morriston; F – University Hospital of Wales;
G – Withybush; H – Ysbyty Wrexham Maelor; J – Glangwili; K – Ysbyty Gwynedd; L – Ysbyty Glan Clwyd; M – Nevill Hall
N – Prince Charles; P – University Hospital Llandough; Q – Velindre; R – Prince Philip; S – Singleton; T – Neath Prot Talbot;
X – Combined Community Hospital Powys THB.
Figure 12: Appropriate Drug Choice - Hospital level
Figure 12 shows the rates for of appropriate drug choice for 2015, ranging from 76% in
Velindre (Q) to 100% in Neath Port Talbot (T).
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CURB-65 score recorded
There has been an increase in recording a CURB-65 score.
The median rate for Wales increased from 27% in 2014 to
42% in 2015. However, there remains much room for
improvement.
Figure 13 is a box plot of the proportion of patients with CAP
for whom a CURB-65 score is recorded.
Figure 14 shows CURB-65 score recorded for 2014 and
2015. In the 2015 PPS, the proportion of patients with CAP
for whom a CURB-65 was recorded ranged from 60% in
Bronglais (A) to 21% in Ysbyty Gwynedd (K). Note: the
diagnosis of CAP seemed uncertain in some of the Ysbyty
Gwynedd cases.
There was a notable increase in CURB-65 recording in the
majority of hospitals except for Royal Glamorgan (C), the
University Hospital of Wales (F), and Prince Charles (N).
Figures 13 & 14: CURB-65 score recorded for CAP - Hospital level
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APPENDIX
Rationale for Quality Measures
1. Antibacterial prescribing rates
Rationale for measure
Inappropriate use of antibacterial agents (e.g. use in patients without a bacterial infection
or excessive durations of therapy or prophylaxis) are drivers for the development and
spread of antibiotic resistance and C. difficile infection. It is widely acknowledged that up to
30% of antibiotic use is inappropriate in terms of being used for patients, who do not have
a bacterial infection/need prophylaxis, or incorrect agent chosen, or incorrect dose, or
incorrect duration.
Direction of measure
Given the fact that antibiotics are probably over-used in most areas, a lower proportion of
patients receiving an antibiotic is probably “good”. However, antibiotics are invaluable
agents for the treatment and prophylaxis of infections and therefore use should not be
reduced below the level for effective management of infections.
Factors affecting measure
The number of patients requiring antibiotics will be heavily influenced by patient case mix.
2. Route of administration
Rationale for measure
Parenteral antibacterial therapy is usually indicated for acute severe infections and also
where oral absorption may be a problem. However oral therapy is appropriate for many
infections and reduces the need for intravenous access devices (a potential portal for
Healthcare-Associated Infection) and is usually significantly less expensive. Many Health
Boards have parenteral/oral switch policies that suggest a switch after 48 hours of
treatment and when infection is resolving.
Direction of measure
A higher percentage of oral therapy is probably “good”.
Factors affecting measure
Parenteral therapy is indicated in certain clinical situations. Therefore rates of parenteral
use will be affected by case-mix.
3. Number of different antibacterial agents
Rationale for measure
There are many antibacterials available and some have similar or identical indications.
Local antimicrobial formularies/guidance usually recommends a limited number of agents.
This limit increases familiarity with the agents recommended in terms of dosing and
indications, and thereby reduces the risk of errors.
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Direction of measure
A smaller number of different agents used is probably “good”.
Factors affecting measure
The complexity and variety of infections treated in a hospital may determine the number of
different agents required.
4. Number of antibacterials per regimen
Rationale for measure
Unnecessary polypharmacy with multiple antibacterials potentially exposes patients to
unnecessary adverse effects and may also lead to sub-optimal antibacterial effect due to
interactions.
Direction of measure
Dual therapy is frequently indicated for a number of common infections (e.g. beta-lactam
plus macrolide for severe community-acquired pneumonia, or penicillin plus
aminoglycoside for endocarditis). However a lower proportion of patients receiving 3 or
more antibacterials is probably “good”.
Factors affecting measure
In some cases, equivalent antibacterial effect can be appropriately achieved by dual
therapy or a single agent (e.g. gastrointestinal surgical prophylaxis can be achieved with
co-amoxiclav or a combination of cefuroxime plus metronidazole). Health Boards/Hospitals
may have antibiotic policies that recommend more combination therapies.
5. Duration of treatment
Rationale for measure
Excessive duration of antibiotic therapy has been identified as an element of inappropriate
use. The “Start Smart - Then Focus” guidance from the DH suggests that a planned
duration or stop/review date is included in every antibiotic prescription.
Direction of measure
A high proportion of patients receiving treatment for >7 days at the time of the PPS may
indicate excessive durations of treatment. However, adequate durations of antibiotics are
required to successfully treat infections and thus too small a proportion of patients
receiving antibiotics for >7 days may indicate under-treatment.
Factors affecting measure
The data is shown as duration for all indications (A - community-acquired infections, B hospital-acquired infections, C - surgical prophylaxis, and D - medical prophylaxis), and
duration for treatment of infections alone (i.e. indications A or B). For different infections,
the appropriate duration of therapy varies widely from a single dose (e.g. gonorrhoea) to
many weeks/months. Therefore case mix will affect the results for Hospitals.
The proportion of patients that consumed systemic antibacterials for >7 days for any
indication may be significantly influenced by patient groups requiring long-term medical
prophylaxis (e.g. high proportion for Powys hospitals (X) due to long-term medical
prophylaxis against respiratory and urinary infections in elderly patients).
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6. Duration of surgical prophylaxis
Rationale for measure
Antibiotic prophylaxis for surgical procedures is invaluable in the prevention of postoperative infections. However there has been a tendency in the past to continue
prophylaxis for longer than necessary. Guidance from the Scottish Inter-collegiate
Guidance Network (SIGN 104) recommends “... a single dose of antibiotic with a long
enough half-life to achieve activity throughout the operation...” for most operations,
although there are a few exceptions (e.g. hip arthroplasty) where evidence suggests a full
24 hours of prophylaxis. There is little evidence to support routine prophylaxis for > 24
hours for any surgical procedures.
Direction of measure
A lower proportion of antibacterial prophylaxis for > 24hours is “good”.
Factors affecting measure
Although there is little evidence to support prophylaxis for > 24 hours, there are certain
types of surgery (e.g. arthroplasty, cardiac surgery) for which longer durations may
sometimes be indicated. Therefore case mix may affect the proportions for Health Boards
and Hospitals.
7. Reason for treatment recorded in notes
Rationale for measure
The recording of the reason for an antimicrobial has been identified as good practice that
facilitates review and optimisation of therapy. It is therefore an element of the “Start Smart
- Then Focus” guidance from DH.
Direction of measure
A higher percentage of recording the reason for the antimicrobial in the notes is “good”.
Factors affecting measure
There are few, if any, valid reasons for not recording the reason for an antimicrobial.
8. Stop/review date for treatment recorded in notes
Rationale for measure
Excessive duration of antimicrobial therapy has been identified as an element of
inappropriate use. The “Start Smart - Then Focus” guidance from the DH suggests that a
planned duration or stop/review date is included in every antimicrobial prescription.
Direction of measure
A higher percentage of recording the stop/review date in the notes is “good”.
Factors affecting measure
There are few, if any, valid reasons for not recording the stop/review date for an
antimicrobial.
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9. Appropriate Antimicrobial Choice
Rationale for measure
The “Start Smart - Then Focus” guidance from the DH suggests using local guidance to
initiate prompt effective antibiotic treatment, and avoiding inappropriate use of broad
spectrum antibiotics.
Direction of measure
A higher percentage of appropriate antimicrobial choice is “good”.
Factors affecting measure
The measure of appropriate antimicrobial choice reflects compliance with local guidance or
on microbiology advice, or culture and sensitivity results.
10. CURB-65
Rationale for measure
Guidance from NICE/BTS recommends when a diagnosis of community acquired
pneumonia (CAP) is made in an adult at presentation to hospital a CURB-65 score is used
for rick stratification to determine the appropriate empiric regimen.
Direction of measure
A higher percentage of recording CURB-65 score is “good”.
Factors affecting measure
There are few, if any, valid reasons for not recording the CURB-65 score.
Point Prevalence Survey Reports
Previous point prevalence survey reports available via:
Internet: http://www.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=28906
Intranet: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=457&pid=20791
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