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Antibiotics
Medicines Management Team October 2008
Antibiotics – Good news
Trafford 4th lowest frequency prescriber of antibiotics in the NW SHA
Antibiotics – Bad news
Trafford is expensive - 3rd highest costs for antibiotics in the NWSHA
TSC – Main Culprits
Azithromycin Quinolones Minocycline Clindamycin Cefalexin
Azithromycin - NWSHAFigure 8a. North West SHA: Weighted macrolide prescribing frequency
October 2007 - March 2008
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0
Blackpool
Western Cheshire
Central Lancashire
Wirral
Bolton
North Lancashire
Liverpool
Manchester
Trafford
England
Oldham
Central & Eastern Cheshire
North of England
North West
Knowsley
Stockport
Ashton, Leigh & Wigan
Blackburn With Darwen
Cumbria
Warrington
Sefton
Heywood, Middleton & Rochdale
East Lancashire
Bury
Halton & St.Helens
Tameside & Glossop
Salford
items/1000 Star-PU
Erythromycin
Erythromycin Ethylsuccinate
Clarithromycin
Erythromycin Stearate
Azithromycin
Telithromycin
Erythromycin Estolate
Roxithromycin
Spiramycin
Azithromycin - TSCTSC Azithromycin prescribing Sep 07 - Aug 08
0
2
4
6
8
10
12
14
16
18
ST
.JO
HN
S M
.C. (D
AV
IES
)
TH
E V
ILLA
GE
SU
RG
ER
Y
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
DR
DJ M
AR
SH
ST
.JO
HN
S M
.C. (A
LLR
ED
)
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
ST
.JO
HN
S M
.C. (S
AN
GH
A)
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
BR
IDG
EW
AT
ER
SU
RG
ER
Y
TG
EA
RN
SH
AW
PA
RK
ME
DIC
AL P
RA
CT
ICE
ST
.JO
HN
S M
.C. (L
OR
D)
BO
DM
IN R
OA
D H
.C.
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
TH
E F
AM
ILY
SU
RG
ER
Y
Practice
Ite
ms
/ST
AR
pu
Azithromycin
On Trafford guidelines as treatment for Chlamydia only
Although, recommended by SMUHT respiratory physicians for some patients with Bronchiectasis
Need to ensure appropriate indications
Quinolones - NWSHAFigure 10a. North East SHA: Weighted quinolone prescribing frequency
October 2007 - March 2008
0.0 5.0 10.0 15.0 20.0 25.0
Blackburn With Darwen
Central Lancashire
North of England
Halton & St.Helens
Knowsley
East Lancashire
Western Cheshire
England
Central & Eastern Cheshire
Manchester
Liverpool
Bury
Salford
Cumbria
North West
Warrington
Sefton
Blackpool
Heywood, Middleton & Rochdale
Stockport
North Lancashire
Bolton
Wirral
Ashton, Leigh & Wigan
Oldham
Trafford
Tameside & Glossop
items/1000 Star-PU
Ciprofloxacin
Levofloxacin
Ofloxacin
Norfloxacin
Moxifloxacin
Nalidixic Acid
Quinolones - TSCTSC Quinolone prescribing Sep 07 - Aug 08
0
10
20
30
40
50
60
70
80
90
100
ST
.JO
HN
S M
.C. (S
AN
GH
A)
ST
.JO
HN
S M
.C. (A
LLR
ED
)
ST
.JO
HN
S M
.C. (D
AV
IES
)
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
ST
.JO
HN
S M
.C. (L
OR
D)
BO
DM
IN R
OA
D H
.C.
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
PA
RK
ME
DIC
AL P
RA
CT
ICE
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
TH
E V
ILLA
GE
SU
RG
ER
Y
TH
E F
AM
ILY
SU
RG
ER
Y
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
DR
DJ M
AR
SH
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
TG
EA
RN
SH
AW
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
BR
IDG
EW
AT
ER
SU
RG
ER
Y
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
Practice
Ite
ms
/ST
AR
pu
Quinolones On Trafford guidelines for;
1st line – Acute prostatitis 2nd line with Metronidazole – Acute or
chronic rhinosinusitis Only if patient allergic to penicillin –
Acute pyelonephritis Only if patient allergic to penicillin
with Metronidazole – Pelvic Inflammatory Disease
Quinolones
Trafford are the No 1 prescribers in NWSHA!
Associated with the virulent 027 strain of C Difficile
Need to ensure used for appropriate indications only
Minocycline - NWSHAFigure 7a. North West SHA: Weighted tetracycline prescribing frequency
October 2007 - March 2008
0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 40.0 45.0 50.0
Manchester
Oldham
Heywood, Middleton & Rochdale
Tameside & Glossop
Warrington
Blackburn With Darwen
Salford
Liverpool
Bolton
Bury
Knowsley
Trafford
East Lancashire
Stockport
England
North West
Central & Eastern Cheshire
Sefton
Wirral
North of England
Halton & St.Helens
Central Lancashire
Western Cheshire
Ashton, Leigh & Wigan
North Lancashire
Cumbria
Blackpool
items/1000 Star-PU
Doxycycline Hyclate
Oxytetracycline
Lymecycline
MinocyclineHydrochloride
Tetracycline
DemeclocyclineHydrochloride
Tetracycline CombinedPreparations
Tigecycline
Minocycline - TSCTSC Minocycline prescribing Sep 07 - Aug 08
0
5
10
15
20
25
30
35
PA
RK
ME
DIC
AL P
RA
CT
ICE
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
BO
DM
IN R
OA
D H
.C.
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
DR
DJ M
AR
SH
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
ST
.JO
HN
S M
.C. (L
OR
D)
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
BR
IDG
EW
AT
ER
SU
RG
ER
Y
ST
.JO
HN
S M
.C. (A
LLR
ED
)
TH
E V
ILLA
GE
SU
RG
ER
Y
TH
E F
AM
ILY
SU
RG
ER
Y
ST
.JO
HN
S M
.C. (S
AN
GH
A)
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
ST
.JO
HN
S M
.C. (D
AV
IES
)
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
TG
EA
RN
SH
AW
Practice
Ite
ms
/ST
AR
pu
Minocycline No longer recommended in Trafford
guidelines Minocycline can cause hepatotoxicity and
pigmentation (sometimes irreversible) when used long term. If it is to be used for more than six months then three-monthly monitoring for hepatotoxicity, pigmentation and systemic lupus erythematosus is recommended.
Minocycline A meta-analysis of tetracycline efficacy in the
treatment of acne showed no difference in efficacy between first generation tetracyclines, Doxycycline, Minocycline and Lymecycline. Using a tetracycline with a low acquisition cost first line would therefore appear to be a reasonable strategy for treatment of acne – Lymecycline now considered tetracycline of choice for acne
Review any person currently taking Minocycline and change to a more appropriate therapy
Clindamycin - NWSHAFigure 9: Greater Manchester PCTs: Weighted Clindamycin Prescribing Frequency
April 2005 to March 2008
0
1
2
3
4
5
6
0506Q1 0506Q2 0506Q3 0506Q4 0607Q1 0607Q2 0607Q3 0607Q4 0708Q1 0708Q2 0708Q3 0708Q4
Ite
ms
/10
00 S
TA
RP
U
Ashton, Leigh & Wigan
Bolton
Bury
Heywood, Middleton &Rochdale
Manchester
Oldham
Salford
Stockport
Tameside & Glossop
Trafford
North West
North of England
England
Clindamycin - TSCTSC Clindamycin prescribing Sep 07 - Aug 08
0
2
4
6
8
10
12
14
16
18
20
ST
.JO
HN
S M
.C. (L
OR
D)
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
BO
DM
IN R
OA
D H
.C.
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
TG
EA
RN
SH
AW
ST
.JO
HN
S M
.C. (D
AV
IES
)
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
DR
DJ M
AR
SH
BR
IDG
EW
AT
ER
SU
RG
ER
Y
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
TH
E V
ILLA
GE
SU
RG
ER
Y
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
PA
RK
ME
DIC
AL P
RA
CT
ICE
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
ST
.JO
HN
S M
.C. (A
LLR
ED
)
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
ST
.JO
HN
S M
.C. (S
AN
GH
A)
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
TH
E F
AM
ILY
SU
RG
ER
Y
Practice
Ite
ms
/ST
AR
pu
Clindamycin Only recommended as a second line
therapy or if patient has spreading cellulitis
If Clindamycin is prescribed please ensure that patient is counselled that if they experience any abdominal pain or diarrhoea that they should stop treatment and seek advice immediately
Seek microbiology advice if needed
Clindamycin However, clindamycin is strongly
associated with antibiotic‑associated colitis (C. difficile) infections and therefore high prescribing rates of clindamycin may be associated with C. difficile rates. Information on local (hospital) MRSA and C. difficile rates can be found on the Health Protection Agency website. (www.hpa.org.uk)
Cefalexin - NWSHAFigure 6a. North West SHA: Weighted cephalosporin prescribing frequency
October 2007 - March 2008
0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0
Warrington
Manchester
Blackburn With Darwen
England
Tameside & Glossop
Bolton
Central & Eastern Cheshire
Western Cheshire
Blackpool
Salford
Bury
Ashton, Leigh & Wigan
Cumbria
Oldham
North of England
North West
Stockport
Trafford
Halton & St.Helens
Liverpool
Heywood, Middleton & Rochdale
Knowsley
Central Lancashire
East Lancashire
Wirral
North Lancashire
Sefton
items/1000 Star-PU
Cefalexin
Cefaclor
Cefradine
Cefadroxil
Cefuroxime Axetil
Cefixime
Cefpodoxime
Ceftriaxone Sodium
Ceftazidime Pentahydrate
Cefotaxime Sodium
Ertapenem Sodium
Meropenem
Cefuroxime Sodium
Imipenem With Cilastatin
Aztreonam
Cefalexin - TSCTSC Cefalexin prescribing
0
20
40
60
80
100
120
140
160
PA
RK
ME
DIC
AL P
RA
CT
ICE
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
TG
EA
RN
SH
AW
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
TH
E V
ILLA
GE
SU
RG
ER
Y
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
ST
.JO
HN
S M
.C. (A
LLR
ED
)
ST
.JO
HN
S M
.C. (S
AN
GH
A)
ST
.JO
HN
S M
.C. (D
AV
IES
)
ST
.JO
HN
S M
.C. (L
OR
D)
DR
DJ M
AR
SH
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
BO
DM
IN R
OA
D H
.C.
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
BR
IDG
EW
AT
ER
SU
RG
ER
Y
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
TH
E F
AM
ILY
SU
RG
ER
Y
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
Practice
Ite
ms
/ST
AR
pu
Cephalosporins - TSCTSC Cephalosporin prescribing Sep 07 - Aug 08
0
20
40
60
80
100
120
140
160
180
PA
RK
ME
DIC
AL P
RA
CT
ICE
TH
E S
UR
GE
RY
(DE
RB
YS
HIR
E R
D S
OU
TH
)
TG
EA
RN
SH
AW
TH
E N
OR
RIS
RO
AD
SU
RG
ER
Y
TH
E V
ILLA
GE
SU
RG
ER
Y
SH
AY
LA
NE
ME
D' C
TR
(KE
LM
AN
)
ALT
RIN
CH
AM
ME
DIC
AL P
RA
CT
ICE
ST
.JO
HN
S M
.C. (D
AV
IES
)
CO
NW
AY
RO
AD
H.C
. (MA
RC
HI)
ST
.JO
HN
S M
.C. (A
LLR
ED
)
ST
.JO
HN
S M
.C. (S
AN
GH
A)
ST
.JO
HN
S M
.C. (L
OR
D)
DR
DJ M
AR
SH
BO
DM
IN R
OA
D H
.C.
WA
SH
WA
Y R
OA
D M
ED
ICA
L C
EN
TR
E
TIM
PE
RLE
Y H
.C. (C
AP
LA
N)
ME
AD
WA
Y H
.C. (D
RA
BB
LE
)
ME
AD
WA
Y H
.C. (J
AC
KS
ON
)
BO
UN
DA
RY
HO
US
E M
ED
ICA
L C
EN
TR
E
BR
IDG
EW
AT
ER
SU
RG
ER
Y
ME
AD
WA
Y H
.C. (L
UK
EM
AN
)
WE
ST
TIM
PE
RLE
Y M
ED
ICA
L C
EN
TR
E
RID
DIN
GS
FA
MIL
Y H
EA
LT
H C
EN
TR
E
CO
NW
AY
RO
AD
H.C
. (MC
GA
RR
Y)
BA
RR
ING
TO
N M
ED
ICA
L C
EN
TR
E
GR
OV
E M
ED
ICA
L P
RA
CT
ICE
TIM
PE
RLE
Y H
.C. (W
ES
TW
OO
D)
TH
E F
AM
ILY
SU
RG
ER
Y
Practice
Ite
ms
/ST
AR
pu
Cephalosporins - TSC On Trafford guidelines only for;
2nd line – Uncomplicated UTI, depending on susceptibility 2nd line – UTI in pregnancy or men After Trimethoprim or Nitrofurantion in UTIs in children
The HPA has recommended that broad spectrum antibiotics, including co-amoxiclav, quinolones and cephalosporins, are best avoided when narrow spectrum antibiotics remain effective, because they increase the risk of C. difficile, MRSA and resistant urinary tract infections.
Hospital lab no longer reporting on Cefalexin
