The document discusses antibiotic consumption data in UK hospitals. It notes that hospital inpatient antibiotic use increased 11.9% from 2010-2013 while other settings remained stable. There is significant regional variation in antibiotic use both within general practices and between hospitals. The document also examines different methods of dispensing antibiotics in hospitals and issues with using patient days vs. admissions as denominators when calculating antibiotic use rates. It concludes by discussing opportunities to improve hospital antibiotic use data through electronic prescribing and validating data against other sources.

1. Understanding the issues with
Hospital antimicrobial
consumption data, UK-EN
Susan Hopkins
Healthcare Epidemiologist, Public Health England
Chair of the English Surveillance Programme on Antimicrobial
Utilisation and Resistance
Consultant in Infectious Diseases & Microbiology, Royal Free London

2. Public Health England & ESPAUR
• English Surveillance Programme for Antimicrobial Utilisation and
Resistance (ESPAUR) was established by Public Health England (PHE) in
2013 in response to the strategy.
• Key aims:
• To develop surveillance systems to measure both antimicrobial utilisation and
resistance
• To measure the impact of antimicrobial utilisation on resistance and
patient/public safety
• To develop quality measures for optimal prescribing and markers for the
consequences of these quality measures within primary and secondary care
• To develop initiatives with key partners for both public and professional behaviour
change, including education, around antimicrobial prescribing and consumption.
2 ESPAUR - antibiotics in England

3. Antibiotic consumption, England 2010-2013
Total prescriptions 6%
GP 4.1%
Hospital inpatients 11.9%
Hospital outpatients stable
other community (e.g. dentists) 32%
Total antibiotic consumption by prescriber, England, 2010-2013 Total antibiotic consumption by AB group, England, 2010-2013
ESPAUR - antibiotics in England3

4. GP consumption by ATs,
England, 2013
Hospital consumption, by ATs,
England, 2013
Total consumption, by ATs,
England, 2013
Significant regional variation
General Practice
Durham, Darlington and Tees over 40% higher than London
26.5 compared to 18.9 DID
Hospital
London twice Leicestershire and Lincolnshire
6.0 DID compared to 2.9 DID
Total
Merseyside, highest (similar to Southern Europe) over 30% higher Thames Valley
30.4 DID compared to 22.8 DID
11/2/2015ESPAUR - antibiotics in England4

5. Antibacterial consumption, England
5 ESPAUR - antibiotics in England
0.0
5.0
10.0
15.0
20.0
25.0
30.0
2010 2011 2012 2013
DDD/1000inhabitants/d
Year
General Practice Other (Dentist, HP10 etc) Hospital ambulatory Hospital inpatient

6. DDD in Hospitals
96% DDD from secondary or tertiary hospitals – large
• Average admissions 98,760 per year (10,000-240,000)
• Mean day cases 40% (6-90%)
• 25% DDD parenteral
4% DDD from other hospitals
• Average admissions 4,500 per year (7-27,000)
• Mean day cases 11% (0-99%)
• 10% DDD parenteral parenteral
6 ESPAUR - antibiotics in England
Hospital type number admissions
% total
admissions
Acute secondary/tertiary 159 14452279 95.5%
Community acute/chronic 129 295932 2.0%
Treatment centre – acute/private 169 380395 2.5%

7. Type of dispensed antibiotics
1. Bulk - ward or clinical area, A&E, day cases, satellite pharmacies, dialysis
• includes OPAT delivered to patient in an ambulatory setting including A&E,
dialysis, day treatment units etc
2. Individual patient
 Inpatient (IP)
 One-stop - to be used as inpatient or outpatient
 Take away – at point of discharge to finish outside hospital; 2 weeks routine
 Includes oral and parenteral (for OPAT, administered by community/ patient
 Outpatient (OP) - usually from outpatient clinics, also community sites
 Includes oral and parenteral (for OPAT, administered by community/ patient
Type of dispensing Inpatient Outpatient
Bulk X
Inpatient X
One-stop X
Outpatient X
Take away X

8. Quantities dispensed by method
Bulk IP One stop OP
Take
away
Total
Penicillins 9712 3950 2246 13128 10888 39924
Macrolides 1423 490 561 2879 705 6058
Quinolones 593 655 668 2144 1062 5122
Metronidazole 2011 611 198 793 1389 5002
Tetracyclines 150 213 728 1363 604 3059
Carbapenems 374 1015 7 188 32 1616
Cephalosporins 461 344 15 605 77 1502
Glycopeptides 500 486 143 144 121 1350
Aminoglycosides 130 225 37 19 411
8 ESPAUR - antibiotics in England
Example of quantity dispensed for one month from a
teaching hospital, with an OPAT service

9. How does OPAT contribute?
Bulk IP
One
Stop
OP
Take
Away
Total
OPAT
% Total
Hospital
Carbapenems 22 7 188 32 249 15%
Cephalosporins 143 62 14 186 37 442 51%
Glycopeptides 1 144 93 245 20%
Aminoglycosides 37 19 56 14%
9 ESPAUR - antibiotics in England
20% as day attendances (majority through A&E)
80% in the community:
60% community nurses 40% self-admin

10. Denominators?
10 ESPAUR - antibiotics in England
y = 2.5497x + 4363.1
R² = 0.9194
-
100,000
200,000
300,000
400,000
500,000
600,000
700,000
800,000
- 50,000 100,000 150,000 200,000 250,000
patient-days
admissions
Scatterplot of acute hospitals admissions and patient
days, England, 2013/14
Numerator more clearly defined by admissions rather than
patient days, as ~ 1/3 of medications dispensed for
inpatients are used outside the hospital
Excellent correlation for patient-days and admissions

11. Scatterplot relationships for DDD/
various denominators
11 ESPAUR - antibiotics in England
y = 19.232x + 91.684
R² = 0.1253
100
120
140
160
180
200
220
1.00 1.50 2.00 2.50 3.00 3.50
DDD/1000inhanitants/day
DDD/100 bed-days
Relationship between DDD /1000
inhabitants/day and DDD/100/bed-days
across England Area Teams, 2013
y = 2.1628x + 1.7571
R² = 0.7148
100
150
200
250
300
350
400
450
500
100 120 140 160 180 200 220
DDD/100admissions
DDD/100 bed-days
Relationship between DDD per
100/admissions and 100/bed-days across
England Area Teams, 2013

12. How to improve data?
E-prescribing Percentage
Trust has electronic-prescribing for inpatients 22.4
e-prescribing for >90% inpatients in:
Adult ICU 7.9
Paediatric/neonatal ICU 3.9
Neonatal/paediatrics 7.9
Adult medicine 15.8
Adult surgery 14.5
Geriatrics 15.8
All Areas 7.9
Other 5.3
12 ESPAUR - antibiotics in England
Individual level dispensing….
When will that happen in England?

13. Final points
ENGLAND
1. Validation of hospital level compared to IMS Health datasets
2. Deepen understanding of hospital level data
3. Use admissions rather than bed-days or population as denomiantors
ECDC
1. Understand the differences in hospital prescribing across countries
2. Understand inpatient and outpatient differences
3. Clarify best denominators to use moving forward
13 ESPAUR - antibiotics in England