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1
A Report from Public Health WalesAntimicrobial Resistance Programme Surveillance Unit:
Antibacterial ResistanceIn Wales 2005-2013
Authors: Maggie Heginbothom andRobin Howe
Date: 18/11/2014 Status: Final
Version: 1 Antibacterial Resistance in Wales2005 - 2013
Page: 1 of 58Antimicrobial ResistanceProgramme: Surveillance Unit
2
Table of Contents
Table of Contents.................................................................................................... 2Section 1: Introduction ........................................................................................... 3Section 2: Key points of interest............................................................................ 4Section 3: Methods ................................................................................................. 5
Resistance data ....................................................................................................................5Section 4: Monitoring Trends in Resistance ......................................................... 9UK 5 Year Antimicrobial Resistance Strategy....................................................... 9
Background...........................................................................................................................9ARHAI Primary Data Set ................................................................................................... 10
Section 5.1: Antimicrobial resistance rates for the most common organismscausing bacteraemia............................................................................................. 11
Background........................................................................................................................ 11Escherichia coli ................................................................................................................. 12Enterobacter spp., Serratia spp., Proteus spp., and Ps. Aeruginosa .......................... 22Enterobacter spp ............................................................................................................... 23Serratia spp ........................................................................................................................ 24Proteus spp ........................................................................................................................ 25Pseudomonas aeruginosa................................................................................................ 26Staphylococcus aureus .................................................................................................... 27Meticillin Sensitive Staphylococcus aureus................................................................... 30Meticillin Resistant Staphylococcus aureus .................................................................. 32Enterococcus spp.............................................................................................................. 34Streptococcus pneumoniae ............................................................................................. 36
Section 5.2: Antimicrobial resistance rates for urinary coliforms ..................... 38Community Urinary Coliforms ......................................................................................... 42Out-patient Urinary Coliforms .......................................................................................... 43In-patient Urinary Coliforms ............................................................................................. 44
Section 5.3: Antimicrobial resistance rates for Staphylococcus aureus .......... 45MSSA .................................................................................................................................. 47MRSA .................................................................................................................................. 49
Section 5.4: Antimicrobial resistance rates for other pathogens. ..................... 50Haemophilus influenzae ................................................................................................... 52Streptococcus pneumoniae ............................................................................................ 54Streptococcus pyogenes.................................................................................................. 55Campylobacter species .................................................................................................... 56Neisseria gonorrhoeae...................................................................................................... 57
3
Section 1: Introduction
Antimicrobial resistance is an increasing problem that can result in difficulty intreating infections, leading to failed therapy and potential complications. Treatmentfor most infections is started empirically before antimicrobial susceptibilities areknown. A particular problem with the spread of antimicrobial resistance is that itbecomes more difficult to select empirical therapy that will have reliable activity.
The aim of this report from the Welsh Antimicrobial Resistance ProgrammeSurveillance Unit is to provide data that can be used to design empirical therapyguidance, and to track antimicrobial resistance trends in Wales from 2005 to 2013.The report has had to be selective in what is presented, and concentrates on themajor acute hospitals and district general hospitals in Wales, and the localcommunity health boards.
4
Section 2: Key points of interest
UK 5 Year Antimicrobial Resistance StrategyThe Wales resistance trends for drug-bug combinations reported by ARHAI as part ofthe UK 5 year Antimicrobial Resistance Strategy are comparable to the aggregatedrates and trends for the UK (page 10). However, in some cases there is considerablevariability in resistance rates between different areas and hospitals.
E. coli (the commonest cause of blood stream infections in Wales) Resistance to co-amoxiclav, fluoroquinolones and 3rd generation
cephalosporins remains high, but stable. Resistance to gentamicin and piperacillin-tazobactam appears to be
increasing, with particularly high rates emerging in some hospitals. Carbapenem resistance has emerged in Wales
Staphylococcus aureus Flucloxacillin resistance rates for Staphylococcus aureus bacteraemias were
variable between hospitals and ranged from 3.3% in the University HospitalLlandough to 38.8% in Ysbyty Glan Clwyd (page 28).
Tetracycline resistanceThere has been an increase in usage of tetracyclines across Wales in the last fewyears. This may be responsible for increasing resistance rate emerging in variousorganisms.
Resistance in MRSA (meticillin resistant S. aureus from blood cultures andwound swabs has increased to 15-20% with rates of >50% in some areas.
Resistance in Streptococcus pneumoniae has risen to 8.2%
Urinary tract infections
“Coliforms” (the commonest cause of urinary tract infections in Wales) Resistance to most antimicrobials has increased over the last 9 years (page
39):o Trimethoprim (first-line empirical therapy for uncomplicated UTI in the
community) resistance has increased to 34.8%. This high rate ofresistance reflects an element of selective testing. The true rate ofresistance in patients presenting with uncomplicated UTI in thecommunity is likely to be considerably lower, and trimethoprimremains the suggested first-line empirical therapy for these patients.
o Co-amoxiclav resistance decreased from 17.2% in 2011 to 10.5% in2013.
o Ciprofloxacin resistance remained unchanged at 10%.o Nitrofurantoin resistance remained stable at approximately 12%.
5
Section 3: Methods
Resistance data
Data presentedAntimicrobial resistance data is provided for the following selected areas and specificpathogens:
Top ten bacteraemia pathogens Urinary coliforms (community & hospital) Wound swab isolates (community & hospital)
o Staphylococcus aureus including MRSA from wound swabs All specimens (community & hospital)
o Streptococcus pneumoniaeo Streptococcus pyogeneso Haemophilus influenzaeo Campylobacter spp.o Neisseria gonorrhoeae
“Community” data is from samples referred from a general practice and hospital datais from samples submitted from hospital in-patients or out-patients as described.
Data sourcesAntimicrobial susceptibility testing data was extracted from the regional DataStoresystems. Data from Nevill Hall Hospital for 2005 & 2006 is not included in this reportas it was not available for this period. Community data is presented by DataStore sitee.g. data for specimens processed by the laboratories at Prince Philip and WestWales General hospitals will both be reported together as Carmarthen communitydata (J). The DataStore sites, and the codes and abbreviations for community andhospital data included in this report are shown in Table 1.
Data interpretation
As with all surveillance schemes, appropriate interpretation of the data, with anappreciation of the potential biases, is key. The main potential biases which shouldbe considered in the data presented herein are:
Sampling biaso This occurs if the submission of samples to the microbiology
laboratory does not represent all patients presenting with thatinfection, but is selective in some way. If this is the case, the publishedresistance rate may be skewed, and not representative of the true ratein patients presenting with uncomplicated infection. This effect is likelyto be more of an issue with certain sample types. For examplebacteraemia data is felt to be fairly representative, since most patientspresenting with sepsis will have a blood culture sent. However ifgeneral practitioners only submit urine samples from patients whohave failed initial therapy, the published rates of resistance will befalsely high.
6
Selective testingo This occurs if a laboratory only tests susceptibility to a certain agent
against selected organisms. For example, a laboratory might only testsome agents when an organism is resistant to first-line drugs. Thiswould result in falsely high published rates of resistance. In order toreduce the effect of selective testing on the published rates, data isonly included if >80% of a given isolate from a given specimen istested against the agent.
Methodological variabilityo There are many methods available for antimicrobial susceptibility
testing which may give inconsistent results. In order to reduce thiseffect on the published rates the Welsh Antimicrobial ChemotherapyGroup is working to standardize testing across Wales. All but onelaboratory use a combination of the BSAC (British Society forAntimicrobial Chemotherapy) standardized disc sensitivity method,and the BD Phoenix automated AST/ID system.
Duplicate testingo This occurs if a patient has multiple specimens tested from a single
infection episode. Potentially this can skew the resistance data. Inorder reduce the effect of this; duplicate isolates are removed fromanalysis by a sub-routine in DataStore. Isolates are deemed to beduplicates if the same organism with the same antibiogram is grownfrom the same sample type within 14 days (for hospital in-patients) or91 days (for community patients).
All Wales data
The All-Wales resistance rates for each antimicrobial comprise an aggregate of datafrom a number of different laboratories. All-Wales resistance rates are only presentedfor organisms where no testing bias occurred at individual hospital level – see below.
Individual Hospital/Laboratory data
Individual hospital or laboratory resistance rates are only presented for organismswhere ≥80% of such isolates from the given sample type was tested and where the number of isolates tested exceeds 9.
Duplicates
Data from duplicate isolates was removed prior to analysis. For community data,organisms from the same patient, with the same identification and susceptibilitypattern isolated ≤ 91 days from the date of the initial isolate were excluded, and for hospital data the cut-off was ≤ 14 days.
Antimicrobial Groups
Although there has been a move towards standardization of antimicrobials used forAST, some variation between laboratories remains (e.g. differences in choice andnumber of third generation cephalosporins tested). In such cases data is aggregatedand resistance rates are expressed at group level.
7
Generally, most laboratories only test a single agent from antimicrobial groups suchas fluoroquinolones and carbapenems where appropriate, but the choice of agentoften varies between laboratories. The antimicrobial groups included in this reportcomprise of the following aggregated susceptibility data:
Fluoroquinolones – ciprofloxacin &/or levofloxacin, norfloxacin Third generation cephalosporins (3GC) – ceftazidime &/or cefotaxime,
ceftriaxone, cefpodoxime. Carbapenems – imipenem &/or meropenem, ertapenem.
Susceptibility results
Throughout data is presented in tables and on graphs as resistance rates with 95%confidence intervals (95% CI). 1 For the purpose of this report susceptibility resultsrecorded as ‘intermediate’ are included in the category ‘resistant’, and in the case ofpenicillin susceptibility results for S. pneumoniae results recorded as intermediate,low- level or high-level resistance are included in the category ‘resistant’.
1. Newcombe, Robert G. "Two-Sided Confidence Intervals for the SingleProportion: Comparison of Seven Methods," Statistics in Medicine, 17, 857-872 (1998).
Other surveillance schemes
This report focuses on comparisons of data collected for Wales in the calendar years2005 and 2013. To provide some external context to the data presented, it has beenalso been compared to surveillance data from other sources – see websites:
Public Health England (PHE):http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AntimicrobialResistance/
British Society for Antimicorbial Chemotherapy (BSAC):http://www.bsac.org.uk/
European Centre for Disease Prevention and Control (EARS-Net):http://www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/database.aspx
All of the above surveillance schemes are also susceptible to potential biases,particularly selective coverage and selective reporting. Thus comparisons with thepresented data should be treated with caution.
NB. Throughout this document all resistance rates quoted from PHE publicationsrelate to England, Wales and Northern Ireland (unless otherwise stated), and dataquoted from EARS-Net website database relate to the United Kingdom (UK).
8
Table 1: Codes for hospital and community data
Hospital Hospital Code DataStore Site
Princess of Wales B
SwanseaNeath Port Talbot T
Singleton S
Morriston E
Nevill Hall MNewport
Royal Gwent D
Wrexham Maelor H Wrexham
Ysbyty Gwynedd K Bangor
Ysbyty Glan Clwyd L Rhyl
University Hospital of Wales FCardiff
University Hospital Llandough P
Prince Charles N Merthyr
Royal Glamorgan C Pontypridd
Glangwili JCarmarthen
Prince Philip R
Bronglais A Aberystwyth
Withybush G Haverfordwest
All-Wales Z
9
Section 4: Monitoring Trends in ResistanceUK 5 Year Antimicrobial Resistance Strategy
Background
In 2014, a sub-group of ARHAI was established to recommend surveillance outputsto support the UK Five Year Antimicrobial Resistance Strategy. Appendix C“Monitoring Trends in Resistance” of the Strategy document states: “Changes in thelevel of resistance to antibiotics like the carbapenems, which are often the last optionfor hard to treat infections, will be monitored”.
The agreed “drug-bug” combinations for monitoring resistance are listed in Table 2;the combinations were ratified by the Department of Health (DoH) High-LevelSteering Group. Public Health Wales provided the Wales data to ARHAI for thissurveillance project.
Blood specimens (except N. gonorrhoeae data) 14 day episode de-duplication Non-susceptible (NS) is resistant and intermediate isolate totals combined Where two antimicrobials from the same class are listed an ‘or’ relationship is
applied, the more resistant result takes priority
Table 2: ARHAI Drug-Bug Combinations
Specimen Organism Data Set Antimicrobial
Blood Culture
Escherichia coliPrimary
cefotaxime or ceftazidime
imipenem or meropenem
ciprofloxacin
gentamicin
Secondary piperacillin/tazobactam
Klebsiella pneumoniaePrimary
cefotaxime or ceftazidime
imipenem or meropenem
ciprofloxacin
gentamicin
Secondary piperacillin/tazobactam
Klebsiella oxytoca Primary
cefotaxime or ceftazidime
imipenem or meropenem
ciprofloxacin
gentamicin
piperacillin/tazobactam
Pseudomonas spp. Primaryceftazidime
imipenem or meropenem
Acinetobacter spp. Secondary colistin
Enterococcus spp. Secondary vancomycin
Staphylococcus aureus Secondary meticillin
Streptococcus pneumoniae Primary penicillin
All specimensNeisseria gonorrhoeae Primary
ceftriaxone
azithromycin
10
ARHAI Primary Data Set
Table 3 shows the resistance rates for Wales compared with the UK aggregate ratesfor the primary data set drug-bug combinations. There are small differences in someof the resistance rates, but generally the trends in resistance are comparable.
Table 3: ARHAI Primary Data Set
ARHAI Primary data set
Escherichia coli 2009 2010 2011 2012 2013
Cefotaxime &/or ceftazidimeWales 14 14 13 16 13
*UK 11 10 11 11 10
CiprofloxacinWales 22 22 21 23 20
*UK 20 19 19 19 18
GentamicinWales 6 9 9 10 11
*UK 8 9 9 10 10
Imipenem &/or meropenemWales 0.0 0.0 0.0 0.0 0.1
*UK 0.1 0.0 0.1 0.1 0.1
Klebsiella pneumoniae 2009 2010 2011 2012 2013
Cefotaxime &/or ceftazidimeWales 14 10 8 9 10
*UK 11 11 10 11 11
CiprofloxacinWales 12 10 8 9 10
*UK 10 10 9 10 11
GentamicinWales 7 7 4 3 3
*UK 7 7 7 7 8
Imipenem &/or meropenemWales 0.0 0.4 0.7 0.3 0.6
*UK 0.3 0.6 0.8 0.7 0.8
Pseudomonas spp. 2009 2010 2011 2012 2013
CeftazidimeWales 8 12 8 6 6
*UK 8 8 8 7 7
Imipenem &/or meropenemWales 10 13 10 11 4
*UK 12 10 11 10 9
Streptococcus pneumoniae 2009 2010 2011 2012 2013
PenicillinWales 2 2 3 2 5
*UK 2 3 3 3 3
*UK rates include data for England, Scotland, Wales and Northern Ireland provided by ARHAIsub-group.
The secondary data set has not been published by ARHAI as yet, and cannot bepresented in this report.
11
Section 5.1: Antimicrobial resistance rates for themost common organisms causing bacteraemia
Background
The 2013 top ten bacteraemia report for Wales comprises the commonest organismsisolated from blood cultures in Wales, see Table 4 below.Internet: http://www.wales.nhs.uk/sites3/page.cfm?orgId=379&pid=13066#zIntranet: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=379&pid=18707#topt
Table 4: Top Ten Bacteraemias
Rank Organism Rate per 100,000 bed days
1 Escherichia coli (E. coli) 742 Staphylococcus aureus (MSSA) 253 Enterococcus species 164 Klebsiella species 165 Streptococcus pneumoniae 96 Coagulase-negative Staphylococcus 87 Pseudomonas aeruginosa 68 Proteus species 69 Staphylococcus aureus (MRSA) 5
10 Enterobacter species 5
The datasets include infections originating from community and hospital sources (in-patient and out-patient), and so may be affected by local clonal strains which canresult in marked variability in resistance rates between hospitals/regions; resultsshould be interpreted with caution.
Since coagulase negative staphylococci are frequently contaminants when isolatedfrom blood cultures, data on susceptibility are not presented here. However, althoughSerratia species have dropped out of the ‘top 10’, resistance data for the genus willbe presented as it has appeared in previous reports.
The data in this report is not presented in rank order, but rather an order to alloweasy comparison of resistances for related bacteria.
12
Escherichia coli (n=2135 in 2013)
E. coli is the commonest organism grown from blood cultures in Wales and the UK.The All-Wales patterns of resistance for 2005 to 2013 are shown in Figure 1, and theindividual hospital resistance rates for ARHAI primary drug set are shown in Table5.The data for 2013 shows a statistically significant decrease in resistance to co-amoxiclav compared with the 2012 rates. Imipenem and meropenem resistance ratesremain below 1% in the UK.
Figure 1: All-Wales resistance rates for E. coli bacteraemia (2005 to 2013).
20
05
20
12
20
13
0
5
10
15
20
25
30
35
40
45
50
3GC COA CARB CXM FQ GEN PTZ
Re
sist
ance
(%)
13
Table 5: Escherichia coli
Note: The range of resistance is outlined with boxes e.g. the range for co-amoxiclav(COA) was 16.7% to 49.6%; individual hospital resistance rates statistically higherthan the All-Wales rate are highlighted in blue. Resistance rates are not recordedwhen <80% of the isolates were tested (All-Wales rate shown in red). The resistancerates for E. coli bacteraemia in Wrexham Maelor (H) and Ysbyty Gwynedd (K) werenotably high to a number of agents suggesting a higher incidence of multi-resistantstrains locally. Imipenem and/or meropenem resistant E. coli were reported in UHWand Withybush.
Escherichia coli from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)
A (n=54) 37.3 (25.3, 51.0) 6.3 (2.1, 16.8) 8.3 (3.3, 19.6) 0.0 (0.0, 7.4)B (n=126) 19.8 (13.8, 27.7) 6.4 (3.3, 12.1) 7.9 (4.4, 14.0) 2.4 (0.8, 6.8)
C (n=125) 50.0 (41.4, 58.6) 5.7 (2.8, 11.4) 10.3 (6.1, 16.9) 0.8 (0.1, 4.5)
D (n=208) 36.5 (30.3, 43.3) 9.8 (6.4, 14.6) 10.6 (7.1, 15.5) 2.4 (1.0, 5.6)
E (n=84) 34.5 (25.2, 45.2) 10.7 (5.7, 19.1) 8.3 (4.1, 16.2) 2.4 (0.7, 8.3)
F (n=258) 45.3 (39.3, 51.6) 8.1 (5.3, 12.2) 9.3 (6.3, 13.6) 2.0 (0.9, 4.7)G (n=90) 22.2 (14.9, 31.8) 7.0 (3.2, 14.4) 5.6 (2.4, 12.4) 1.2 (0.2, 6.3)
H (n=191) 20.7 (15.6, 27.1) 27.5 (21.6, 34.3) 15.5 (11.0, 21.4)
J (n=148) 23.8 (17.5, 31.4) 2.2 (0.7, 6.2) 2.8 (1.1, 7.1) 0.0 (0.0, 2.7)
K (n=126) 38.4 (30.3, 47.2) 14.3 (9.2, 21.5) 20.0 (13.9, 27.9) 8.8 (5.0, 15.1)
L (n=156) 45.8 (38.2, 53.7) 4.5 (2.2, 9.0) 14.7 (10.0, 21.2) 1.9 (0.7, 5.5)
M (n=121) 36.1 (28.1, 45.1) 5.9 (2.9, 11.6)N (n=104) 44.8 (35.6, 54.3) 8.0 (4.1, 15.0)
P (n=63) 39.7 (28.5, 52.0) 12.7 (6.6, 23.1) 4.8 (1.6, 13.1) 1.6 (0.3, 8.5)
Q (n=12) 18.2 (5.1, 47.7) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)
R (n=53) 32.1 (21.1, 45.5) 8.0 (3.2, 18.8) 5.7 (1.9, 15.4) 0.0 (0.0, 7.1)
S (n=195) 30.9 (24.8, 37.7) 3.6 (1.8, 7.3) 6.7 (3.9, 11.1) 0.5 (0.1, 2.9)
T (n=15) 40.0 (19.8, 64.3) 13.3 (3.7, 37.9) 13.3 (3.7, 37.9) 13.3 (3.7, 37.9)
All-Wales: Resistance rates 36.5 (34.3, 38.6) 8.5 (7.4, 9.8) 10.7 (9.5, 12.1) 3.4 (2.7, 4.2)
All-Wales: Number of isolates 1925 2025 2101 2018
Location Code (Number) AMO (95% CI) 3GC (95% CI) AMI (95% CI) FQ (95% CI)
A (n=54) 18.0 (9.8, 30.8) 2.2 (0.4, 11.3) 27.1 (16.6, 41.0)
B (n=126) 61.1 (52.4, 69.2) 13.5 (8.6, 20.5) 17.7 (12.0, 25.4)C (n=125) 66.1 (57.3, 73.9) 20.0 (13.9, 27.9) 3.4 (1.3, 8.4) 20.6 (14.5, 28.5)
D (n=208) 61.0 (54.2, 67.4) 12.0 (8.3, 17.1) 1.5 (0.5, 4.2) 18.8 (14.0, 24.6)
E (n=84) 65.5 (54.8, 74.8) 14.3 (8.4, 23.3) 19.0 (12.1, 28.7)
F (n=258) 63.2 (57.0, 68.9) 10.9 (7.6, 15.4) 1.2 (0.4, 3.5) 20.7 (16.1, 26.2)
G (n=90) 61.8 (51.4, 71.2) 5.6 (2.4, 12.4) 1.2 (0.2, 6.4) 15.6 (9.5, 24.4)
H (n=191) 68.9 (62.0, 75.1) 41.6 (34.8, 48.7)
J (n=148) 12.2 (7.8, 18.4) 9.9 (6.0, 16.0)
K (n=126) 64.3 (55.6, 72.1) 24.8 (18.1, 33.0) 1.6 (0.4, 5.6) 24.0 (17.4, 32.2)
L (n=156) 54.2 (46.3, 61.8) 17.3 (12.2, 24.0) 0.0 (0.0, 2.4) 25.0 (18.9, 32.3)
M (n=121) 57.5 (48.6, 66.0) 11.7 (7.1, 18.6) 1.7 (0.5, 6.0) 15.0 (9.7, 22.5)
N (n=104) 56.4 (46.7, 65.7) 11.4 (6.7, 18.9) 13.3 (8.1, 21.1)
P (n=63) 58.7 (46.4, 70.0) 12.7 (6.6, 23.1) 4.8 (1.6, 13.1) 20.6 (12.5, 32.2)
Q (n=12) 54.5 (28.0, 78.7) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 27.8)
R (n=53) 66.7 (52.5, 78.3) 3.8 (1.0, 12.8) 0.0 (0.0, 7.4) 11.3 (5.3, 22.6)S (n=195) 62.1 (55.1, 68.6) 11.3 (7.6, 16.5) 15.0 (10.7, 20.7)
T (n=15) 60.0 (35.7, 80.2) 6.7 (1.2, 29.8) 13.3 (3.7, 37.9)
All-Wales: Resistance rates 62.1 (59.9, 64.2) 13.3 (11.9, 14.9) 1.6 (1.1, 2.3) 20.4 (18.7, 22.2)All-Wales: Number of isolates 2038 1943 1635 2103
Location Code (Number) ERT (95% CI) IMI (95% CI) MER (95% CI) IMI or MER (95% CI)
A (n=54) 0.0 (0.0, 7.9) 0.0 (0.0, 7.4) 0.0 (0.0, 7.4)B (n=126) 0.0 (0.0, 3.0) 0.0 (0.0, 3.0)
C (n=125) 0.0 (0.0, 3.2) 0.0 (0.0, 3.2) 0.0 (0.0, 3.0) 0.0 (0.0, 3.0)
D (n=208) 0.0 (0.0, 1.8) 0.0 (0.0, 1.9) 0.0 (0.0, 1.8) 0.0 (0.0, 1.8)
E (n=84) 0.0 (0.0, 5.3) 0.0 (0.0, 4.4) 0.0 (0.0, 4.4) 0.0 (0.0, 4.4)
F (n=258) 0.4 (0.1, 2.3) 0.0 (0.0, 1.5) 0.4 (0.1, 2.3)
G (n=90) 0.0 (0.0, 4.3) 1.2 (0.2, 6.3)
H (n=191)
J (n=148) 0.0 (0.0, 2.7) 0.0 (0.0, 2.7)K (n=126) 0.0 (0.0, 3.3) 0.0 (0.0, 3.0)
L (n=156) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4)
M (n=121) 0.9 (0.2, 4.7) 0.0 (0.0, 3.4) 0.0 (0.0, 3.1) 0.0 (0.0, 3.1)
N (n=104) 0.0 (0.0, 4.0) 0.0 (0.0, 3.6)
P (n=63) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7)
Q (n=12) 0.0 (0.0, 29.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)R (n=53) 0.0 (0.0, 7.4) 0.0 (0.0, 6.8) 0.0 (0.0, 6.8)
S (n=195) 0.0 (0.0, 2.4) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9)
T (n=15) 0.0 (0.0, 20.4) 0.0 (0.0, 20.4) 0.0 (0.0, 20.4)
All-Wales: Resistance rates 0.2 (0.1, 0.7) 0.1 (0.0, 0.4) 0.0 (0.0, 0.2) 0.1 (0.0, 0.4)
All-Wales: Number of isolates 1224 1632 1778 1976Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,
3GC = resistance to ceftazidime &/or cefotaxime, cefpodoxime, ceftriaxone, AMI = amikacin, FQ = resistance to ciprofloxacin &/or levofloxacin,
ERT = ertapenem, IMI = imipenem, MER = meropenem, IMI or MER = resistance to either or both agents
14
ARHAI Primary data Set
Interpretation Tables 6-10: The tables show trends in resistance to drug/bugcombinations in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time. The first column in thetables show the hospital code and the median number of isolates tested across thetime period e.g. in Table 6, hospital code A (43) denotes Bronglais hospital with amedian number of 43 isolates tested per year across the five year period. Note:Individual hospital or laboratory resistance rates are only presented for organismswhere ≥80% of such isolates from the given sample type was tested and where the number of isolates tested exceeds 9. It is important to remember when interpretingthis data set that hospital level data often represents small numbers of organisms,and single isolate resistance within these numbers can produce misleadingly largechanges in resistance.
Table 6: Trends in third generation cephalosporin resistance for E. coli by hospital(2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
Q = Velindre
R = Prince Philip
S = Singleton
T = Neath Port Talbot
15
Table 7: Trends in fluoroquinolone resistance for E. coli by hospital (2009-2013)
Table 8: Trends in gentamicin resistance for E. coli by hospital (2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
Q = Velindre
R = Prince Philip
S = Singleton
T = Neath Port Talbot
16
Table 9: Trends in piperacillin/tazobactam resistance for E. coli (2009-2013)
Table 10: Trends in imipenem/meropenem resistance for E. coli (2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
Q = Velindre
R = Prince Philip
S = Singleton
T = Neath Port Talbot
17
Klebsiella spp. (n=474 in 2013)
The All-Wales patterns of antimicrobial resistance in Klebsiella spp. are shown inFigure 2 and Table 11; with no significant difference in resistance rates between2012 and 2013. Imipenem and meropenem resistance rates remain below 1% in theUK.
Figure 2: All-Wales antimicrobial resistance rates for Klebsiella species; isolatedfrom blood culture (2005 to 2013)
20
05
20
06
20
13
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
32
34
3GC COA CARB CXM FQ GEN PTZ
Re
sist
ance
(%)
18
Table 11: Klebsiella spp.
Note: The resistance rates for Klebsiella spp. bacteraemia at hospital level were notstatistically different to the All-Wales rates except for co-amoxiclav resistance inBronglais and gentamicin resistance in Princess of Wales (B). Imipenem and/ormeropenem resistant Klebsiella spp. were reported in Bronglais (A), UHW (F) andSingleton (S). Resistance rates are not recorded if the organisms are intrinsicallyresistant to an antibacterial agent e.g. for amoxicillin, or when <80% of the isolateswere tested (All-Wales rate shown in red).
Klebsiella spp. from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)
A (n=11) 54.5 (28.0, 78.7) 18.2 (5.1, 47.7) 9.1 (1.6, 37.7) 9.1 (1.6, 37.7)
B (n=29) 20.7 (9.8, 38.4) 10.7 (3.7, 27.2) 17.2 (7.6, 34.5) 10.7 (3.7, 27.2)
C (n=22) 9.1 (2.5, 27.8) 4.5 (0.8, 21.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)
D (n=43) 11.6 (5.1, 24.5) 4.8 (1.3, 15.8) 2.3 (0.4, 12.1) 0.0 (0.0, 8.4)
E (n=34) 14.7 (6.4, 30.1) 11.8 (4.7, 26.6) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2)
F (n=67) 16.4 (9.4, 27.1) 9.0 (4.2, 18.2) 4.5 (1.5, 12.4) 4.5 (1.5, 12.4)
G (n=17) 5.9 (1.0, 27.0) 6.3 (1.1, 28.3) 11.8 (3.3, 34.3) 0.0 (0.0, 19.4)
H (n=32) 21.9 (11.0, 38.8) 0.0 (0.0, 10.7) 0.0 (0.0, 10.7)
J (n=29) 3.4 (0.6, 17.2) 0.0 (0.0, 12.1) 0.0 (0.0, 11.7) 0.0 (0.0, 12.1)
K (n=32) 28.1 (15.6, 45.4) 15.6 (6.9, 31.8) 6.3 (1.7, 20.1) 3.1 (0.6, 15.7)
L (n=42) 23.8 (13.5, 38.5) 2.4 (0.4, 12.3) 7.1 (2.5, 19.0) 0.0 (0.0, 8.4)
M (n=23) 26.1 (12.5, 46.5) 5.3 (0.9, 24.6) 4.5 (0.8, 21.8) 0.0 (0.0, 16.8)
N (n=23) 8.7 (2.4, 26.8) 0.0 (0.0, 15.5) 0.0 (0.0, 22.8)
P (n=13) 7.7 (1.4, 33.3) 7.7 (1.4, 33.3) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)
R (n=12) 8.3 (1.5, 35.4) 0.0 (0.0, 24.3) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)
S (n=35) 20.6 (10.3, 36.8) 15.2 (6.7, 30.9) 5.7 (1.6, 18.6) 3.0 (0.5, 15.3)
All-Wales: Resistance rates 16.7 (13.5, 20.4) 8.6 (6.4, 11.6) 4.3 (2.8, 6.5) 2 (1.1, 3.8)
All-Wales: Number of isolates 438 452 466 449
Location Code (Number) AMO (95% CI) 3GC (95% CI) AMI (95% CI) FQ (95% CI)
A (n=11) _ 18.2 (5.1, 47.7) 0.0 (0.0, 25.9) 9.1 (1.6, 37.7)
B (n=29) _ 17.2 (7.6, 34.5) 21.4 (10.2, 39.5)
C (n=22) _ 4.5 (0.8, 21.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)
D (n=43) _ 4.7 (1.3, 15.5) 0.0 (0.0, 8.2) 0.0 (0.0, 8.2)
E (n=34) _ 8.8 (3.0, 23.0) 0.0 (0.0, 14.3) 0.0 (0.0, 10.2)
F (n=67) _ 10.4 (5.2, 20.0) 0.0 (0.0, 5.4) 9.0 (4.2, 18.2)
G (n=17) _ 5.9 (1.0, 27.0) 0.0 (0.0, 19.4) 0.0 (0.0, 18.4)
H (n=32) _ 12.5 (5.0, 28.1)
J (n=29) _ 0.0 (0.0, 11.7) 0.0 (0.0, 13.3) 0.0 (0.0, 11.7)
K (n=32) _ 18.8 (8.9, 35.3) 0.0 (0.0, 10.7) 15.6 (6.9, 31.8)
L (n=42) _ 11.9 (5.2, 25.0) 0.0 (0.0, 8.6) 16.7 (8.3, 30.6)
M (n=23) _ 0.0 (0.0, 14.3) 0.0 (0.0, 15.5) 0.0 (0.0, 14.3)
N (n=23) _ 4.3 (0.8, 21.0) 8.7 (2.4, 26.8)
P (n=13) _ 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)
R (n=12) _ 0.0 (0.0, 24.3) 0.0 (0.0, 25.9)
S (n=35) _ 5.7 (1.6, 18.6) 14.7 (6.4, 30.1)
All-Wales: Resistance rates 62.0 (59.9, 64.1) 8.2 (6.0, 11.1) 0.3 (0.0, 1.5) 7.7 (5.6, 10.5)
All-Wales: Number of isolates 2048 439 363 467
Location Code (Number) ERT (95% CI) IMI (95% CI) MER (95% CI) IMI or MER (95% CI)
A (n=11) 9.1 (1.6, 37.7) 0.0 (0.0, 25.9) 9.1 (1.6, 37.7)
B (n=29) 0.0 (0.0, 12.1) 0.0 (0.0, 12.1)
C (n=22) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)
D (n=43) 0.0 (0.0, 8.4) 0.0 (0.0, 8.4) 0.0 (0.0, 8.2) 0.0 (0.0, 8.2)
E (n=34) 0.0 (0.0, 11.7) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2)
F (n=67) 0.0 (0.0, 5.4) 1.5 (0.3, 8.0) 1.5 (0.3, 8.0)
G (n=17) 0.0 (0.0, 19.4) 0.0 (0.0, 19.4)
H (n=32)
J (n=29) 0.0 (0.0, 13.3) 0.0 (0.0, 12.1) 0.0 (0.0, 11.7)
K (n=32) 0.0 (0.0, 11.4) 0.0 (0.0, 10.7)
L (n=42) 2.4 (0.4, 12.3) 0.0 (0.0, 8.4) 0.0 (0.0, 8.4)
M (n=23) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)
N (n=23) 0.0 (0.0, 16.8) 0.0 (0.0, 17.6) 0.0 (0.0, 14.9)
P (n=13) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)
R (n=12) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)
S (n=35) 2.9 (0.5, 14.9) 2.9 (0.5, 14.9) 2.9 (0.5, 14.9)
All-Wales: Resistance rates 0.7 (0.2, 2.7) 0.5 (0.1, 1.9) 0.5 (0.1, 1.9) 0.7 (0.2, 2.0)
All-Wales: Number of isolates 270 373 388 440Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,
3GC = resistance to ceftazidime &/or cefotaxime, cefpodoxime, ceftriaxone, AMI = amikacin, FQ = resistance to ciprofloxacin &/or levofloxacin,
ERT = ertapenem, IMI = imipenem, MER = meropenem, IMI or MER = resistance to either or both agents
19
ARHAI Primary data Set
Interpretation Tables 12-16: The tables show trends in resistance to drug/bugcombinations in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time. Note 1: The data isdifferent to that shown in Table 3 (page 11); Table 3 shows the rates for Klebsiellapneumoniae as per ARHAI instructions, but the following tables show the data for allKlebsiella species to allow comparisons with previous reports. Note 2: Individualhospital or laboratory resistance rates are only presented for organisms where ≥80% of such isolates from the given sample type was tested and where the number ofisolates tested exceeds 9. It is important to remember when interpreting this data setthat hospital level data often represents small numbers of organisms, and singleisolate resistance within these numbers can produce misleadingly large changes inresistance.
Table 12: Trends in third generation cephalosporin resistance for Klebsiella spp.(2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
R = Prince Philip
S = Singleton
20
Table 13: Trends in fluoroquinolone resistance for Klebsiella spp. (2009-2013)
Table 14: Trends in gentamicin resistance for Klebsiella spp. (2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
R = Prince Philip
S = Singleton
21
Table 15: Trends in piperacillin/tazobactam resistance for Klebsiella spp.
(2009-2013)
Table 16: Trends in imipenem/meropenem resistance for Klebsiella spp.
(2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
R = Prince Philip
S = Singleton
22
Enterobacter spp., Serratia spp., Proteus spp., and Ps. Aeruginosa
Table 17: Enterobacter spp., Serratia spp., Proteus spp., and Ps. aeruginosa
Note: The numbers shown in red denote that <80% of total isolates were testedagainst the particular antibacterial agent. Resistance rates are not recorded if theorganisms are intrinsically resistant to an antibacterial agent e.g. for amoxicillin.When <80% of all isolates were tested, the All-Wales rate is shown in red.
Enterobacter spp., Serratia spp., Proteus spp., and Pseudomonas aeruginosa from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Oragnism COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)
Enterobacter spp. _ 13.9 (9.2, 20.5) 8.1 (4.7, 13.5) 2.1 (0.7, 5.9)
All-Wales: Number of isolates 144 149 144
Serratia spp. _ 9.8 (5.2, 17.6) 0.0 (0.0, 3.9) 0.0 (0.0, 4.0)
All-Wales: Number of isolates 92 94 92
Proteus spp. 17.6 (12.4, 24.5) 1.3 (0.4, 4.5) 15.3 (10.6, 21.7) 0.6 (0.1, 3.5)
All-Wales: Number of isolates 153.0 157 163 157
* Pseudomonas aeruginosa _ 4.9 (2.5, 9.4) 3.0 (1.3, 6.9) 1.3 (0.3, 4.5)
All-Wales: Number of isolates 163 169 159
Location Code (Number) AMO (95% CI) 3GC (95% CI) AMI (95% CI) FQ (95% CI)
Enterobacter spp. _ 28.0 (21.3, 35.8) 0.0 (0.0, 3.1) 3.4 (1.5, 7.7)
All-Wales: Number of isolates 143 121 147
Serratia spp. _ 29.3 21.0, 39.3) 1.4 (0.2, 7.4) 21.1 (14.1, 30.3)
All-Wales: Number of isolates 92 73 95
Proteus spp. _ 3.9 (1.8, 8.3) 2.5 (0.9, 7.1) 10.6 (6.7, 16.4)
All-Wales: Number of isolates 153 120 160
* Pseudomonas aeruginosa _ 5.6 (3.0, 10.3) 2.7 (0.9, 7.6) 5.3 (2.8, 9.8)
All-Wales: Number of isolates 160 111 169
Location Code (Number) ERT (95% CI) IMI (95% CI) MER (95% CI) IMI or MER (95% CI)
Enterobacter spp. 7.1 (3.5, 14.0) 1.6 (0.4, 5.7) 0.8 (0.1, 4.2) 1.4 (0.4, 5.0)
All-Wales: Number of isolates 98 124 132 141
Serratia spp. 2.0 (0.4, 10.5) 0.0 (0.0, 4.9) 0.0 (0.0, 4.4) 0.0 (0.0, 4.0)
All-Wales: Number of isolates 50 73 84 92
Proteus spp. 1.2 (0.2, 6.7) 6.8 (3.5, 12.8) 0.0 (0.0, 7.4) 5.2 (2.7, 10.0)
All-Wales: Number of isolates 81 118 135 153
* Pseudomonas aeruginosa _ 3.0 (1.2, 7.4) 1.3 (0.4, 4.7) 2.4 (0.9, 6.0)
All-Wales: Number of isolates 134 151 168
Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,
3GC = resistance to ceftazidime &/or cefotaxime, cefpodoxime, ceftriaxone, AMI = amikacin, FQ = resistance to ciprofloxacin &/or levofloxacin,
ERT = ertapenem, IMI = imipenem, MER = meropenem, IMI or MER = resistance to either or both agents
23
Enterobacter spp. (n=154 in 2013)
The All-Wales patterns of antimicrobial resistance for Enterobacter spp. are shown inFigure 3 & Table 17. There has been a significant decrease in fluoroquinoloneresistance across time, and in piperacillin/tazobactam resistance between 2010 and2013.
Figure 3: All-Wales antimicrobial resistance rates for Enterobacter species;isolated from blood culture (2005 to 2013)
The resistance rates for piperacillin/tazobactam resistance are generally lower in theWales data than the PHE data e.g. in 2012 the Wales rate was 9% compared with aUK rate of 20%. Although the rates of carbapenem resistance in Wales are higherthan those reported by the PHE, the Wales figure includes ertapenem resistancedata, and not only imipenem and meropenem data.
Table 18: PHE data for Enterobacter species bacteraemia 2005-2012
Enterobacter spp. 2005 2006 2007 2008 2009 2010 2011 2012
Total reports: 2,522 2,613 2,675 2,414 2,208 2,037 2,052 1,917
Piperacillin/Tazobactam
% NS 23% 24% 21% 18% 17% 18% 16% 20%
No. reports 1,368 1,594 1,884 1,774 1,554 1,484 1,582 1,499
Imipenem/Meropenem
% NS 1% 1.2% 1.1% 0.7% 0.4% <1% <1% <1%
No. reports 1,506 1,732 1,984 1,909 1,662 1,524 1,561 1,486
Cefotaxime% NS 40% 42% 37% 38% 35% 33% 29% 26%
No. reports 1,040 1,213 1,271 1,195 1,081 993 1,012 999
Ceftazidime% NS 42% 41% 36% 36% 32% 32% 30% 29%
No. reports 1,334 1,519 1,769 1,612 1,376 1,370 1,391 1,317
Ciprofloxacin% NS 15% 14% 10% 8% 6% 5% 5% 5%
No. reports 1,860 2,092 2,237 1,987 1,693 1,638 1,683 1,6585
Gentamicin% NS 12% 11% 9% 7% 7% 5% 6% 6%
No. reports 1,988 2,108 2,337 2,139 1,844 1,723 1,803 1,708
Key: % NS = percentage of non-susceptible isolates
20
05
20
13
0
5
10
15
20
25
30
35
40
45
50
55
60
65
3GC CARB FQ GEN PTZ
Re
sist
ance
(%)
24
Serratia spp. (n=97 in 2013)
The All-Wales patterns of antimicrobial resistance for Serratia spp. are shown inFigure 4 and Table 17. There has been a statistically significant decrease inresistance rates third generation cephalosporins (3GC), fluoroquinolones (FQ) andpiperacillin/tazobactam (PTZ) between 2005 and 2013.
Figure 4: All-Wales antimicrobial resistance rates for Serratia species; isolatedfrom blood culture (2005 to 2013)
The significant decrease in resistance between 2008 and 2012 reported by PHE isreflected in the Welsh data. Although the rates of carbapenem resistance in Walesare generally higher than those reported by the PHE, the Wales figure includesertapenem resistance data, and not only imipenem and meropenem data.
Table 19: PHE data for Serratia species bacteraemia 2005-2012
Serratia spp. 2005 2006 2007 2008 2009 2010 2011 2012
Total reports: 1,158 1,270 1,208 1,071 992 943 887 827
Piperacillin/Tazobactam
% NS 20% 20% 16% 16% 12% 15% 10% 8%
No. reports 604 774 828 764 712 712 707 657
Imipenem/Meropenem
% NS 0% 1% 0.3% 0.6% 0.1% 0.5% 0.4% <1%
No. reports 642 807 888 821 780 735 701 675
Cefotaxime% NS 27% 29% 28% 28% 30% 29% 21% 19%
No. reports 426 548 582 537 541 497 458 454
Ceftazidime% NS 18% 16% 14% 22% 20% 21% 16% 14%
No. reports 549 681 742 678 647 681 643 620
Ciprofloxacin% NS 26% 25% 20% 16% 12% 12% 11% 9%
No. reports 854 996 1,007 864 800 794 756 709
Gentamicin% NS 2% 2% 1% 3% 3% 2% 1% 1%
No. reports 1,002 1,002 1.046 917 855 838 824 762
Key: % NS = percentage of non-susceptible isolates
20
05
20
13
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
75
3GC CARB FQ GEN PTZ
Re
sist
ance
(%)
25
Proteus spp. (n=166 in 2013)
The All-Wales patterns of antimicrobial resistance in Proteus spp. are shown inFigure 5 & Table 17, with a statistically significant decrease in carbapenem andgentamicin resistance between 2012 and 2013 Note: Due to known issues withsusceptibility testing of carbapenems with automated systems the reliability of thehigh carbapenem resistance is uncertain.
Figure 5: All-Wales antimicrobial resistance rates for Proteus species; isolatedfrom blood culture (2005 to 2013)
The PHE data for Proteus spp., Morganella morganii & Providencia spp. bacteraemiashows that 89% of bacteraemias from this group were Proteus mirabilis and 4% wereProteus vulgaris. The PHE resistance rates for Proteus mirabilis 2006-2012 areshown for comparison with the Welsh data (see Figure 5 and Table 20).
Table 20: PHE data for Proteus mirabilis bacteraemia 2006-2012
Proteus mirabilis 2006 2007 2008 2009 2010 2011 2012
Total reports: 1,671 1,842 2,083 2,133 2,091 2,091 2,238
Amoxicillin% NS 35% 30% 31% 32% 33% 34% 34%
No. reports 1,289 1,459 1,719 1,660 1,690 1,793 1,909
Cefuroxime% NS 5% 2% 2% 1% 2% 2% 1%
No. reports 1,234 1,369 1,476 1,323 1,311 1,458 1,477
Cefotaxime% NS 5% 1% 1% 0% 1% 2% 2%
No. reports 743 858 983 1,044 1,005 1,0734 1,160
Ceftazidime% NS 2% 1% 1% 1% 1% 2% 2%
No. reports 916 1,190 1,355 1,380 1,383 1,517 1,512
Ciprofloxacin% NS 7% 7% 6% 6% 6% 7% 9%
No. reports 1,293 1,460 1,648 1,622 1,677 1,775 1,857
Gentamicin% NS 4% 4% 3% 6% 7% 7% 10%
No. reports 1,296 1,527 1,816 1,779 1,795 1,897 2,000
Imipenem% NS 1% 2% 4% 6% 8% 9% 5%
No. reports 389 529 591 524 407 339 247
Key: % NS = percentage of non-susceptible isolates
20
05
20
13
0
5
10
15
20
25
30
35
40
45
50
55
3GC AMO COA CARB CXM FQ GEN PTZ
Re
sist
ance
(%)
26
Pseudomonas aeruginosa (n=173 in 2013)
The All-Wales patterns of antimicrobial resistance in Pseudomonas aeruginosa areshown in Figure 6 & Table 17. The data is different to that shown in Table 3 (page11); Table 3 shows the rates for Pseudomonas spp as per ARHAI instructions, butthe following tables show the data for Ps. aeruginosa to allow comparisons withprevious reports.
Figure 6: All-Wales antimicrobial resistance rates for Pseudomonas aeruginosa;isolated from blood culture (2005 to 2013)
There was a statistically significant decrease in ciprofloxacin resistance between2011 and 2013. The PHE rates are shown below for comparison with the Welsh data(see Figure 6 and Table 21).http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Bacteraemia/
Table 21: PHE data for Pseudomonas aeruginosa bacteraemia 2005-2012
Pseudomonas aeruginosa 2006 2007 2008 2009 2010 2011 2012
Total reports: 2,866 3,090 3,987 3,927 3,833 3,694 3,743
Piperacillin/Tazobactam
% NS 4% 5% 6% 8% 7% 7% 9%
No. reports 1,985 2,324 2,490 2,509 2,570 2,544 2,654
Imipenem % NS 11% 12% 9% 13% 12% 14% 13%
No. reports 965 1,147 1,110 1,172 1,038 926 926
Meropenem% NS 10% 9% 10% 11% 9% 9% 9%
No. reports 1,087 1,396 1,713 1,785 2,017 2,210 2,3
Ceftazidime% NS 7% 8% 7% 8% 8% 8% 6%
No. reports 2,213 2,514 2,484 2,461 2,530 2,526 2,595
Ciprofloxacin% NS 12% 12% 11% 11% 10% 11% 9%
No. reports 2,393 2,646 2,657 2,709 2,696 2,703 2,728
Gentamicin% NS 5% 5% 4% 4% 5% 6% 4%
No. reports 2,415 2,754 2,785 2,778 2,812 2,810 2,864
Key: % NS = percentage of non-susceptible isolates
20
05
20
13
0
5
10
15
20
25
30
35
CARB CAZ CIP GEN PTZ
Re
sist
ance
(%)
27
Staphylococcus aureus
The All-Wales resistance rates for Staphylococcus aureus at hospital level are shownin Table 22, the data includes all Staphylococcus aureus both MSSA and MRSA. In2013, flucloxacillin resistance rates for S. aureus bacteraemias in Ysbyty Glan Clwydand Ysbyty Gwynedd were notably high; 38.8% and 32.7% respectively.Flucloxacillin resistance reflects the proportion of S. aureus bacteraemias that wereMRSA; the proportions of MRSA bacteraemias were notably higher in these localitiesthan other acute hospitals in Wales.
Surveillance data was obtained from the Welsh Healthcare Associated Programme(WHAIP). Figure 7 shows the numbers of Staphylococcus aureus bacteraemias from2005 to 2013. Across time both the number of Staphylococcus aureus (SAUR) andMeticillin Resistant Staphylococcus aureus (MRSA) bacteraemias has decreased,whilst the numbers of Meticillin Sensitive Staphylococcus aureus (MSSA)bacteraemias increased significantly between 2011 and 2013.
Figure 7: All-Wales Staphylococcus aureus bacteraemia numbers (2005 to 2013)
407
164
632
759
1039
923
0
200
400
600
800
1000
1200
2005 2006 2007 2008 2009 2010 2011 2012 2013
MRSA 407 341 363 344 286 229 203 180 164
MSSA 632 682 658 638 681 664 661 701 759
SAUR 1039 1023 1021 982 967 893 864 881 923
Nu
mb
er
of
bac
tera
em
ias
28
Table 22: Staphylococcus aureus (MSSA & MRSA)
Staphylococcus aureus from blood cultures (MSSA & MRSA)Resistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code CLI (95% CI) ERY (95% CI) FLU (95% CI)
A (n=13) 18.2 (5.1, 47.7) 18.2 (5.1, 47.7) 23.1 (8.2, 50.3)
B (n=51) 2.0 (0.3, 10.3) 7.8 (3.1, 18.5) 11.8 (5.5, 23.4)
C (n=56) 6.5 (2.2, 17.5) 12.5 (6.2, 23.6) 12.5 (6.2, 23.6)
D (n=85) 14.3 (8.4, 23.3) 6.0 (2.6, 13.2) 21.2 (13.8, 31.0)
E (n=65) 10.8 (5.3, 20.6) 12.3 (6.4, 22.5)
F (n=162) 16.4 (11.2, 23.4) 15.6 (10.8, 22.0) 16.0 (11.2, 22.5)
G (n=46) 8.7 (3.4, 20.3) 14.3 (6.7, 27.8) 10.9 (4.7, 23.0)
H (n=56) 17.9 (10.0, 29.8) 7.7 (3.0, 18.2) 25.0 (15.5, 37.7)
J (n=50) 28.0 (17.5, 41.7) 12.5 (5.9, 24.7) 26.0 (15.9, 39.6)
K (n=49) 3.7 (0.7, 18.3) 32.7 (21.2, 46.6)
L (n=49) 38.8 (26.4, 52.8)
M (n=35) 12.1 (4.8, 27.3) 11.8 (4.7, 26.6) 5.7 (1.6, 18.6)
N (n=40) 12.8 (5.6, 26.7) 10.0 (4.0, 23.1)
P (n=30) 10.7 (3.7, 27.2) 17.2 (7.6, 34.5) 3.3 (0.6, 16.7)
R (n=21) 19.0 (7.7, 40.0) 4.8 (0.8, 22.7) 14.3 (5.0, 34.6)
S (n=71) 8.6 (4.0, 17.5) 14.1 (7.8, 24.0)
All-Wales: Resistance rates 12.8 (10.6, 15.5) 11.5 (9.5, 13.8) 17.7 (15.3, 20.4)
All-Wales: Number of isolates 710 838 701
Location Code FUS (95% CI) GEN (95% CI) LZD (95% CI)
A (n=13)
B (n=51) 29.4 (18.7, 43.0) 0.0 (0.0, 7.4)
C (n=56) 23.6 (14.4, 36.3) 3.7 (1.0, 12.5) 0.0 (0.0, 6.9)
D (n=85) 27.2 (18.7, 37.7) 6.1 (2.6, 13.5) 0.0 (0.0, 4.5)
E (n=65) 27.7 (18.3, 39.6) 1.5 (0.3, 8.2) 1.6 (0.3, 8.5)
F (n=162) 27.0 (20.7, 34.4) 6.9 (3.9, 12.0) 2.5 (1.0, 6.3)
G (n=46) 14.0 (6.6, 27.3) 2.4 (0.4, 12.6)
H (n=56) 0.0 (0.0, 6.4)
J (n=50) 28.6 (17.2, 43.6) 0.0 (0.0, 8.4) 2.4 (0.4, 12.3)
K (n=49) 21.2 (10.7, 37.8) 6.1 (2.1, 16.5)
L (n=49) 44.9 (31.9, 58.7) 6.1 (2.1, 16.5)
M (n=35) 15.2 (6.7, 30.9) 8.8 (3.0, 23.0) 0.0 (0.0, 10.7)
N (n=40) 17.6 (8.3, 33.5) 10.8 (4.3, 24.7) 0.0 (0.0, 10.7)
P (n=30) 17.2 (7.6, 34.5) 6.9 (1.9, 22.0) 3.4 (0.6, 17.2)
R (n=21) 26.3 (11.8, 48.8) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8)
S (n=71) 32.9 (23.0, 44.5) 2.8 (0.8, 9.7) 3.1 (0.8, 10.5)
All-Wales: Resistance rates 25.8 (23.0, 28.9) 5.5 (4.1, 7.3) 1.2 (0.6, 2.3)
All-Wales: Number of isolates 824 786 753
Location Code MUP (95% CI) RIF (95% CI) TET (95% CI)
A (n=13)
B (n=51) 0.0 (0.0, 7.0) 0.0 (0.0, 7.0) 0.0 (0.0, 7.4)
C (n=56) 0.0 (0.0, 6.9) 0.0 (0.0, 6.8) 3.6 (1.0, 12.3)
D (n=85) 5.0 (2.0, 12.2) 6.3 (2.7, 14.0)
E (n=65) 1.6 (0.3, 8.5) 0.0 (0.0, 5.7) 3.2 (0.9, 10.9)
F (n=162) 0.6 (0.1, 3.5) 1.3 (0.3, 4.5) 7.5 (4.4, 12.7)
G (n=46) 0.0 (0.0, 7.7) 0.0 (0.0, 8.2) 4.3 (1.2, 14.5)
H (n=56)
J (n=50) 0.0 (0.0, 8.4) 6.1 (1.7, 19.6)
K (n=49) 2.1 (0.4, 11.1) 12.2 (5.7, 24.2)
L (n=49) 2.0 (0.4, 10.7) 0.0 (0.0, 7.3) 8.2 (3.2, 19.2)
M (n=35) 3.1 (0.6, 15.7)
N (n=40) 0.0 (0.0, 9.6) 2.6 (0.5, 13.5)
P (n=30) 6.9 (1.9, 22.0) 0.0 (0.0, 11.7) 6.9 (1.9, 22.0)
R (n=21) 0.0 (0.0, 16.8)
S (n=71) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7) 2.8 (0.8, 9.7)
All-Wales: Resistance rates 1.7 (0.9, 2.9) 0.4 (0.1, 1.2) 5.9 (4.5, 7.8)
All-Wales: Number of isolates 725 724 797Key:CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, GEN = gentamicin, LZD = linezolid,
MUP = mupirocin, PEN = pencillin, RIF = rifampicin, TET = tetracycline.
29
ARHAI Primary data Set
Interpretation Table 23: The table show trends in resistance to a drug/bugcombination in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time.
Table 23: Trends in meticillin resistance for Staphylococcus aureus (2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
R = Prince Philip
S = Singleton
30
Meticillin Sensitive Staphylococcus aureus (n=734 in 2013)
The All-Wales pattern of antimicrobial resistance in MSSA is shown in Figure 8 andTable 24; with no statistically significant changes between 2005 and 2013.
Figure 8: All-Wales antimicrobial resistance rates for Meticillin SensitiveStaphylococcus aureus (MSSA) isolated from blood culture (2005 to 2013)
The All-Wales antimicrobial resistance rates for MSSA are largely comparable tothose published by BSAC for the UK except for clindamycin resistance whichappears higher in Wales. In 2013, the All-Wales clindamycin resistance rate was6.7% compared with the UK rate of 1.1%. The All-Wales rate is skewed by high localrates in some areas including Glangwili (16.2%), Bronglais (11.1%) and Nevill Hallhospitals (9.7%). This presumably reflects the varying presence of epidemic strains.
In 2013, the All-Wales resistance rate for penicillin was 84.6%, and resistance tolinezolid and vancomycin remained undetected.
20
05
20
05
20
13
20
13
0
2
4
6
8
10
12
14
16
18
20
ERY FUS GEN MUP RIF TET
Re
sist
ance
(%)
31
Table 24: Meticillin Sensitive Staphylococcus aureusMeticillin Sensitive Staphylococcus aureus from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code CLI (95% CI) ERY (95% CI) FUS (95% CI)
A (n=10) 11.1 (2.0, 43.5) 20.0 (5.7, 51.0)
B (n=45) 0.0 (0.0, 7.9) 8.9 (3.5, 20.7) 20.0 (10.9, 33.8)
C (n=48) 4.5 (1.3, 15.1) 14.3 (7.1, 26.7) 14.6 (7.2, 27.2)
D (n=67) 3.0 (0.8, 10.4) 7.6 (3.3, 16.5) 7.9 (3.4, 17.3)
E (n=57) 9.8 (3.9, 22.5) 12.3 (6.1, 23.2) 17.5 (9.8, 29.4)
F (n=136) 8.3 (4.6, 14.7) 18.7 (13.0, 26.1) 16.5 (11.2, 23.8)
G (n=41) 7.3 (2.5, 19.4) 14.6 (6.9, 28.4) 7.5 (2.6, 19.9)
H (n=42) 7.1 (2.5, 19.0) 10.5 (4.2, 24.1) 12.5 (5.5, 26.1)
J (n=37) 16.2 (7.7, 31.1) 16.2 (7.7, 31.1) 6.7 (1.8, 21.3)
K (n=33) 9.1 (3.1, 23.6) 21.2 (10.7, 37.8)
L (n=30) 16.7 (7.3, 33.6) 10.0 (3.5, 25.6)
M (n=33) 9.7 (3.3, 24.9) 12.5 (5.0, 28.1) 9.7 (3.3, 24.9)
N (n=36) 13.9 (6.1, 28.7) 10.0 (3.5, 25.6)
P (n=29) 7.4 (2.1, 23.4) 17.9 (7.9, 35.6) 17.9 (7.9, 35.6)
R (n=18) 5.6 (1.0, 25.8) 5.6 (1.0, 25.8) 12.5 (3.5, 36.0)
S (n=61) 9.8 (4.6, 19.8) 23.0 (14.2, 34.9)
All-Wales: Resistance rates 6.7 (4.9, 9.0) 13.2 (11.0, 15.9) 14.6 (12.1, 17.4)
All-Wales: Number of isolates 599 725 701
Location Code GEN (95% CI) LZD (95% CI) MUP (95% CI)
A (n=10)
B (n=45) 0.0 (0.0, 7.9) 0.0 (0.0, 7.9)
C (n=48) 4.3 (1.2, 14.2) 0.0 (0.0, 7.9) 0.0 (0.0, 7.9)
D (n=67) 6.3 (2.5, 15.0) 0.0 (0.0, 5.7) 1.6 (0.3, 8.6)
E (n=57) 1.8 (0.3, 9.3) 0.0 (0.0, 6.5) 0.0 (0.0, 6.5)
F (n=136) 2.3 (0.8, 6.4) 0.0 (0.0, 2.8) 0.8 (0.1, 4.1)
G (n=41) 0.0 (0.0, 9.4) 0.0 (0.0, 8.6)
H (n=42) 0.0 (0.0, 8.4)
J (n=37) 0.0 (0.0, 11.4) 0.0 (0.0, 11.4)
K (n=33) 3.0 (0.5, 15.3)
L (n=30) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)
M (n=33) 9.4 (3.2, 24.2) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)
N (n=36) 9.1 (3.1, 23.6) 0.0 (0.0, 11.7)
P (n=29) 3.6 (0.6, 17.7) 0.0 (0.0, 12.1) 7.1 (2.0, 22.6)
R (n=18) 0.0 (0.0, 19.4) 0.0 (0.0, 19.4)
S (n=61) 0.0 (0.0, 5.9) 0.0 (0.0, 6.5) 0.0 (0.0, 6.6)
All-Wales: Resistance rates 3 (1.9, 4.7) 0 (0.0, 0.6) 1.4 (0.7, 2.6)
All-Wales: Number of isolates 631 603 592
Location Code PEN (95% CI) RIF (95% CI) TET (95% CI)
A (n=10) 88.9 (56.5, 98.0)
B (n=45) 77.8 (63.7, 87.5) 0.0 (0.0, 7.9) 0.0 (0.0, 8.4)
C (n=48) 91.3 (79.7, 96.6) 0.0 (0.0, 7.7) 4.2 (1.2, 14.0)
D (n=67) 86.7 (75.8, 93.1) 6.5 (2.5, 15.4)
E (n=57) 83.9 (72.2, 91.3) 0.0 (0.0, 6.5) 1.8 (0.3, 9.4)
F (n=136) 0.0 (0.0, 2.8) 4.5 (2.1, 9.5)
G (n=41) 75.6 (60.7, 86.2) 0.0 (0.0, 9.0) 0.0 (0.0, 8.6)
H (n=42)
J (n=37) 0.0 (0.0, 11.4)
K (n=33) 81.8 (65.6, 91.4) 3.2 (0.6, 16.2) 9.1 (3.1, 23.6)
L (n=30) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)
M (n=33) 81.3 (64.7, 91.1)
N (n=36) 80.0 (64.1, 90.0) 0.0 (0.0, 10.7) 2.9 (0.5, 14.9)
P (n=29) 100.0 (86.2, 100) 0.0 (0.0, 12.1) 3.6 (0.6, 17.7)
R (n=18) 0.0 (0.0, 19.4)
S (n=61) 88.3 (77.8, 94.2) 0.0 (0.0, 6.5) 3.3 (0.9, 11.2)
All-Wales: Resistance rates 87.6 (84.7, 90.0) 0.2 (0.0, 0.9) 3.7 (2.5, 5.4)
All-Wales: Number of isolates 597 605 649Key:CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, GEN = gentamicin, LZD = linezolid,
MUP = mupirocin, PEN = pencillin, RIF = rifampicin, TET = tetracycline.
32
Meticillin Resistant Staphylococcus aureus (n=158 in 2013)
The All-Wales pattern of antimicrobial resistance in MRSA is shown in Figure 9 &Table 25; with a statistically increase in tetracycline resistance between 2005 and2013.
Figure 9: All-Wales antimicrobial resistance rates for Meticillin ResistantStaphylococcus aureus (MRSA) isolated from blood culture (2005 to 2013)
The All-Wales antimicrobial resistance rates for MRSA for 2005 to 2012 are largelycomparable to those published by BSAC for the UK. BSAC have not as yet publishedantimicrobial resistance rates for MRSA for 2013, however the clindamycinresistance rates for Wales in 2013 were notably high at 45.9% compared with theBSAC rate of 13.1% in 2012.
Resistance to vancomycin and linezolid has remained undetected.
20
05
2007
20
13
0
10
20
30
40
50
60
70
80
90
100
ERY FUS GEN MUP RIF TET
Re
sist
ance
(%)
33
Table 25: Meticillin Resistant Staphylococcus aureus
The number of MRSA bacteraemias has reduced markedly over the past few yearsand so the number of individual hospitals with 10 isolates or more has reduced, andso the table is small. When <80% of all isolates were tested, the All-Wales rate isshown in red.
Meticillin Resistant Staphylococcus aureus from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code CLI (95% CI) ERY (95% CI) FQ (95% CI)
D (n=18) 55.6 (33.7, 75.4) 55.6 (33.7, 75.4) 94.4 (74.2, 99.0)
F (n=27) 65.0 (43.3, 81.9) 73.1 (53.9, 86.3) 80.8 (62.1, 91.5)
H (n=14) 50.0 (26.8, 73.2) 50.0 (26.8, 73.2)
J (n=13) 61.5 (35.5, 82.3) 61.5 (35.5, 82.3) 83.3 (55.2, 95.3)
K (n=16) 87.5 (64.0, 96.5)
L (n=19) 89.5 (68.6, 97.1) 100 (83.2, 100)
S (n=10) 70.0 (39.7, 89.2) 100 (70.1, 100)
All-Wales: Resistance rates 45.9 (37.0, 55.2) 70.1 (62.5, 76.7) 90.2 (83.7, 94.3)
All-Wales: Number of isolates 111 157 123
Location Code FUS (95% CI) GEN (95% CI) LZD (95% CI)
D (n=18) 5.6 (1.0, 25.8) 0.0 (0.0, 17.6) 0.0 (0.0, 17.6)
F (n=27) 30.8 (16.5, 50.0) 3.8 (0.7, 18.9) 0.0 (0.0, 12.9)
H (n=14) 21.4 (7.6, 47.6) 0.0 (0.0, 21.5) 0.0 (0.0, 21.5)
J (n=13) 0.0 (0.0, 24.3) 8.3 (1.5, 35.4)
K (n=16) 12.5 (3.5, 36.0) 0.0 (0.0, 19.4)
L (n=19) 15.8 (5.5, 37.6) 0.0 (0.0, 16.8)
S (n=10) 20.0 (5.7, 51.0) 20.0 (5.7, 51.0) 0.0 (0.0, 29.9)
All-Wales: Resistance rates 15.5 (10.6, 22.0) 3.3 (1.4, 7.6) 0 (0.0, 3.3)
All-Wales: Number of isolates 155 150 113
Location Code MUP (95% CI) RIF (95% CI) TET (95% CI)
D (n=18) 16.7 (5.8, 39.2) 5.9 (1.0, 27.0)
F (n=27) 0.0 (0.0, 12.9) 7.7 (2.1, 24.1) 23.1 (11.0, 42.1)
H (n=14) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 28.6 (11.7, 54.6)
J (n=13) 0.0 (0.0, 24.3)
K (n=16) 0.0 (0.0, 19.4) 18.8 (6.6, 43.0)
L (n=19) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8) 15.8 (5.5, 37.6)
S (n=10) 0.0 (0.0, 29.9) 0.0 (0.0, 29.9) 0.0 (0.0, 27.8)
All-Wales: Resistance rates 3.0 (1.2, 7.5) 1.4 (0.4, 5.1) 15.5 (10.6, 22.2)
All-Wales: Number of isolates 133 139 148Key:CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, GEN = gentamicin, LZD = linezolid,
MUP = mupirocin, PEN = pencillin, RIF = rifampicin, TET = tetracycline.
34
Enterococcus spp. (n=489 in 2013)
The All-Wales pattern of antimicrobial resistance in Enterococcus spp. is shown inFigure 10 and Table 26; with no statistically significant changes between 2005 and2013.
Figure 10: All-Wales antimicrobial resistance rates for Enterococcus spp. isolatedfrom blood culture (2005 to 2013)
In 2013, the All-Wales resistance rate for amoxicillin was 46.9% (42.5, 51.4).Susceptibility to amoxicillin is a guide to speciation of the organism, E. faecalis beingnormally susceptible and E. faecium being normally resistant, and suggests that in2013, 53.1% of entercoccal bacteraemias were due to E. faecalis.
Table 26: Enterococcus spp.
2005
2013
0
5
10
15
20
25
30
35
40
45
50
55
AMO VAN
Re
sist
ance
(%)
Enterococcus spp. from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code AMO (95% CI) VAN (95% CI)
A (n=10) 55.6 (26.7, 81.1) 0.0 (0.0, 29.9)
B (n=22) 50.0 (30.7, 69.3) 9.1 (2.5, 27.8)
C (n=25) 35.0 (18.1, 56.7) 8.3 (2.3, 25.8)
D (n=44) 45.5 (31.7, 59.9)
E (n=40) 40.0 (26.3, 55.4) 15.0 (7.1, 29.1)
F (n=114) 60.6 (51.2, 69.2) 14.2 (8.9, 21.8)
G (n=15) 41.7 (19.3, 68.0) 6.7 (1.2, 29.8)
H (n=25) 40.0 (23.4, 59.3) 16.0 (6.4, 34.7)
J (n=34) 35.3 (21.5, 52.1) 15.2 (6.7, 30.9)
K (n=26) 79.2 (59.5, 90.8) 33.3 (18.0, 53.3)
L (=27) 40.7 (24.5, 59.3) 7.4 (2.1, 23.4)
M (n=23) 39.1 (22.2, 59.2)
N (n=11) 54.5 (28.0, 78.7) 9.1 (1.6, 37.7)
P (n=17) 23.5 (9.6, 47.3) 5.9 (1.0, 27.0)
S (n=39) 38.5 (24.9, 54.1) 17.9 (9.0, 32.7)
All-Wales: Resistance rates 46.9 (42.5, 51.4) 15.5 (12.5, 19.1)
All-Wales: Number of isolates 473 464Key: AMO = amoxicillin, VAN = vancomycin.
35
Note: Locally resistance rates for amoxicillin varied from 23.5.8% in UniversityHospital Llandough (P) to 79.2% in Ysbyty Gwynedd (K) and this may simply reflectvariation in the proportion of E. faecalis to E. faecium. Vancomycin resistance variedfrom 0.0% in Bronglais (A) to 33.3% in Ysbyty Gwynedd.
ARHAI Primary data Set
Interpretation Table 27: The table show trends in resistance to a drug/bugcombination in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time.
Table 27: Trends in vancomycin resistance for Enterococcus spp. (2009-2013)
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
N = Prince Charles
P = UHL
S = Singleton
36
Streptococcus pneumoniae (n=295 in 2013)
The All-Wales pattern of antimicrobial resistance is shown in Figure 11 & Table 28;with no statistically significant changes between 2005 and 2013, except tetracyclinewhich has increased from 1.0% (95% CI 0.3, 2.8) in 2005 to 6.0% (95% CI 3.5, 10.0)in 2013.
Figure 11: All-Wales antimicrobial resistance rates for Streptococcus pneumoniaeisolated from blood culture (2005 to 2013)
ERY PEN TET
2005 9.8 2.5 1.0
2006 8.1 4.0 3.0
2007 8.5 3.5 3.0
2008 5.0 2.9 3.9
2009 4.7 2.1 3.5
2010 3.9 1.4 1.1
2011 6.5 2.7 5.2
2012 8.4 2.0 5.2
2013 7.6 4.5 6.0
20
05
20
13
0
2
4
6
8
10
12
14
16
Re
sist
ance
(%)
37
Table 28: Streptococcus pneumoniae
Note: Locally resistance rates for S. pneumoniae bacteraemia from Ysbyty Gwynedd(K) were notably higher than the rest of Wales.
ARHAI Primary data Set
Interpretation Table 29: The table show trends in resistance to a drug/bugcombination in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time.
Table 29: Trends in penicillin resistance for S. pneumoniae (2009-2013)
Streptococcus pneumoniae from blood culturesResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code ERY (95% CI) PEN (95% CI) TET (95% CI)
B (n=11) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 27.8)
C (n=23) 5.0 (0.9, 23.6) 0.0 (0.0, 14.3)
D (n=33) 6.7 (1.8, 21.3) 3.0 (0.5, 15.3) 10.7 (3.7, 27.2)
E (n=13) 7.7 (1.4, 33.3) 7.7 (1.4, 33.3)
F (n=37) 5.9 (1.6, 19.1) 14.7 (6.4, 30.1) 2.9 (0.5, 14.9)
H (n=16) 0.0 (0.0, 19.4)
K (n=14) 28.6 (11.7, 54.6) 21.4 (7.6, 47.6) 14.3 (4.0, 39.9)
L (n=24) 0.0 (0.0, 13.8) 0.0 (0.0, 13.8) 0.0 (0.0, 13.8)
M (n=22) 9.1 (2.5, 27.8) 0.0 (0.0, 14.9) 9.5 (2.7, 28.9)
N (n=18) 13.3 (3.7, 37.9) 5.6 (1.0, 25.8) 13.3 (3.7, 37.9)
S (n=23) 18.2 (7.3, 38.5) 4.3 (0.8, 21.0)
All-Wales: Resistance rates 7.6 (4.8, 11.6) 4.5 (2.6, 7.8) 6.0 (3.5, 10.0)
All-Wales: Number of isolates 238 264 217Key: ERY = erythromycin, PEN = penicillin, TET = tetracycline.
Key:
A= Bronglais
B = Princess of Wales
C = Royal Glamorgan
D = Royal Gwent
E = Morriston
F = UHW
G = Withybush
H = Wrexham Maelor
J = Glangwili
K = Ysbyty Gwynedd
L = Ysbyty Glan Clwyd
M = Nevill Hall
N = Prince Charles
P = UHL
S = Singleton
38
Section 5.2: Antimicrobial resistance rates forurinary coliforms
For the purposes of this report the term coliform refers to organisms that werereported as a ‘coliform’ by the laboratory, or when identified further, were reported asone of the genera belonging to the family Enterobacteriaceae.
The genera included in this section of the report comprise:
Citrobacter Edwardsiella Enterobacter Escherichia Hafnia Klebsiella Kluyvera Morganella Pantoea Proteus Providencia Rahnella Salmonella Serratia Yersinia
It should be noted that data from routinely-submitted urine specimens is more proneto bias than data from blood culture isolates due to variable sampling by clinicians.Thus resistance rates quoted here are likely to be higher due to increased samplingfrom patients who are more likely to have resistant organisms (e.g. patients withrecurrent infections or infections that have failed to respond to initial therapy). Thisshould be factored into any use of the data presented for the design of empirictreatment guidance.
The generation of more specific data reports (e.g. different patient age groups) canbe discussed with the Welsh AR Programme.
39
Table 30: Community Urinary Coliforms
Note: The range of resistance is outlined with boxes e.g. the range of resistance toamoxicillin was 53.1% - 61.1%; individual hospital rates statistically higher than theAll-Wales rate are highlighted in colour. In 2013, a number of local communities hadresistance rates for urinary coliforms that were statistically higher than the All-Walesrate; the most notable were the communities served by UHW (F), Ysbyty Gwynedd(K) and Ysbyty Glan Clwyd (L). Cephalosporin and fluoroquinolone resistance wasgenerally higher in the communities in North Wales.
Community Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) AMO (95% CI) COA (95% CI) IGC (95% CI) 3GC (95% CI)
A (n=2,766) 53.1 (51.2, 55.0) 8.8 (7.8, 9.9) 8.6 (7.6, 9.7) 4.1 (3.4, 4.9)
B (n=521) 61.1 (56.8, 65.2) 5.9 (4.1, 8.3) 9.6 (7.3, 12.4) 5.5 (3.8, 7.8)
C (n=4,077) 58.1 (56.7, 59.5) 17.1 (16.0, 18.2) 10.8 (9.9, 11.8) 3.3 (2.8, 3.9)
D (n=13,835) 57.7 (56.9, 58.5) 10.6 (10.1, 11.2) 9.3 (8.8, 9.8) 1.7 (1.5, 2.0)
F (n=8,859) 59.5 (58.5, 60.5) 12.5 (11.8, 13.2) 10.9 (10.3, 11.7) 4.9 (4.5, 5.4)
G (n=3,793) 53.9 (52.3, 55.5) 11.9 (11.0, 13.0) 7.8 (7.0, 8.8) 4.3 (3.7, 5.1)
H (n=8,855) 56.9 (55.8, 57.9) 3.3 (2.9, 3.7) 9.0 (8.5, 9.7)
J (n=7,407) 55.3 (54.2, 56.5) 5.8 (5.3, 6.4) 6.5 (5.9, 7.1) 5.2 (4.7, 5.7)
K (n=10,111) 57.8 (56.8, 58.7) 9.1 (8.5, 9.7) 12.3 (11.6, 12.9) 7.7 (7.2, 8.2)
L (n=7,573) 58.0 (56.8, 59.2) 11.4 (10.7, 12.1) 7.4 (6.8, 8.0)
M (n=880) 60.0 (56.7, 63.2) 11.9 (10.0, 14.2) 1.9 (1.2, 3.1)
N (n=2,898) 59.0 (57.2, 60.8) 14.4 (13.2, 15.8) 6.9 (5.9, 8.0) 3.2 (2.6, 3.9)
P (n=3,066) 58.6 (56.9, 60.4) 13.0 (11.9, 14.3) 11.1 (10.0, 12.3) 5.5 (4.8, 6.4)
R (299) 58.8 (52.7, 64.6) 6.2 (3.8, 9.8) 5.4 (3.2, 8.8)
S (14,867) 58.3 (57.5, 59.1) 9.9 (9.4, 10.4) 10.0 (9.6, 10.5) 6.1 (5.7, 6.5)
T (n=23) 60.9 (40.8, 77.8) 13.0 (4.5, 32.1) 4.3 (0.8, 21.0)
All-Wales: Resistance rates 57.6 (57.3, 57.9) 10.5 (10.3, 10.7) 9.8 (9.6, 10.0) 5 (4.8, 5.1)
All-Wales: Number of isolates 88,803 82,015 85,462 78,982
Location Code (Number) FQ (95% CI) NIT (95% CI) TRI (95% CI)
A (n=2,766) 8.0 (7.1, 9.1) 9.3 (8.3, 10.5) 33.5 (31.8, 35.3)
B (n=521) 10.8 (8.4, 13.7) 11.2 (8.8, 14.3) 34.1 (30.1, 38.3)
C (n=4,077) 10.0 (9.2, 10.9) 11.2 (10.3, 12.1) 35.2 (33.8, 36.6)
D (n=13,835) 7.8 (7.4, 8.3) 10.8 (10.3, 11.4) 31.7 (30.9, 32.5)
F (n=8,859) 10.9 (10.2, 11.5) 12.2 (11.5, 12.9) 36.3 (35.3, 37.3)
G (n=3,793) 8.1 (7.3, 9.1) 13.9 (12.8, 15.1) 34.1 (32.6, 35.6)
H (n=8,855) 12.0 (11.3, 12.7) 8.3 (7.7, 8.9) 35.4 (34.4, 36.4)
J (n=7,407) 6.7 (6.1, 7.3) 10.6 (9.9, 11.4) 33.2 (32.1, 34.4)
K (n=10,111) 11.4 (10.8, 12.1) 15.2 (14.5, 15.9) 35.9 (35.0, 36.9)
L (n=7,573) 12.9 (12.2, 13.7) 14.2 (13.4, 15.0) 37.2 (36.1, 38.3)
M (n=880) 9.6 (7.8, 11.7) 12.2 (10.2, 14.6) 29.8 (26.8, 33.0)
N (n=2,898) 8.0 (7.0, 9.0) 10.0 (9.0, 11.2) 32.7 (31.0, 34.4)
P (n=3,066) 11.8 (10.7, 13.0) 12.5 (11.3, 13.7) 35.4 (33.8, 37.2)
R (299) 6.5 (4.1, 10.2) 9.6 (6.6, 13.8) 31.5 (26.2, 37.4)
S (14,867) 9.2 (8.7, 9.7) 11.7 (11.2, 12.3) 36.2 (35.4, 37.0)
T (n=23) 4.3 (0.8, 21.0) 4.3 (0.8, 21.0) 21.7 (9.7, 41.9)
All-Wales: Resistance rates 9.8 (9.6, 10.0) 11.8 (11.5, 12.0) 34.8 (34.5, 35.2)
All-Wales: Number of isolates 89,423 88,551 88,701
Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),
FQ = ciprofloxacin &/or levofloaxcin, or norfloxacin, NIT = nitrofurantoin, TRI = trimrthoprim
40
Table 31: Hospital Out-Patient Urinary Coliforms
Note: The resistance rates for out-patient urinary coliforms for UHW (F) and YsbytyGlan Clwyd (L) were statistically higher than the All-Wales rate for the agents asshown.
Out Patient Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) AMO (95% CI) COA (95% CI) IGC (95% CI) 3GC (95% CI)
A (n=119) 49.2 (40.3, 58.1) 4.2 (1.8, 9.5) 2.7 (0.9, 7.6) 0.9 (0.2, 4.7)
B (n=423) 56.9 (52.1, 61.6) 7.2 (5.1, 10.1) 10.2 (7.6, 13.5) 5.3 (3.5, 7.9)
C (n=250) 60.1 (53.9, 66.0) 16.8 (12.7, 21.9) 12.4 (8.2, 18.1) 3.7 (2.0, 6.9)
D (n=868) 61.1 (57.8, 64.3) 12.9 (10.8, 15.3) 2.9 (2.0, 4.3)
E (n=320) 63.8 (58.4, 68.9) 13.1 (9.8, 17.2) 14.9 (11.3, 19.3) 7.6 (5.2, 11.1)
F (n=964) 67.5 (64.5, 70.4) 19.2 (16.8, 21.8) 17.6 (15.3, 20.2) 7.0 (5.5, 8.8)
G (n=365) 50.4 (45.3, 55.5) 9.0 (6.5, 12.4) 3.2 (1.8, 5.6)
H (n=540) 56.3 (52.1, 60.4) 2.5 (1.5, 4.3) 7.2 (5.3, 9.7)
J (n=540) 55.6 (51.2, 59.9) 4.9 (3.3, 7.2) 3.9 (2.5, 5.9)
K (n=375) 62.6 (57.6, 67.4) 9.7 (7.1, 13.2) 9.9 (7.1, 13.7) 6.5 (4.4, 9.5)
L (n=1004) 59.2 (56.1, 62.3) 16.2 (14.0, 18.6) 9.5 (7.9, 11.5)
M (n=176) 54.5 (47.2, 61.7) 8.5 (5.2, 13.6) 2.9 (1.3, 6.7)
N (n=252) 57.8 (51.6, 63.8) 13.5 (9.8, 18.3) 1.6 (0.6, 4.1)
P (n=275) 52.7 (46.8, 58.5) 8.0 (5.3, 11.8) 6.5 (4.1, 10.1) 4.0 (2.3, 7.1)
Q (n=69) 66.2 (54.3, 76.3) 5.8 (2.3, 14.0) 10.2 (4.7, 20.5) 5.9 (2.3, 14.2)
R (n=207) 61.8 (54.7, 68.4) 7.9 (4.8, 12.6) 10.3 (6.7, 15.5) 7.4 (4.4, 12.0)
S (n=142) 53.9 (45.7, 61.9) 10.1 (6.1, 16.3) 9.1 (5.3, 15.2) 7.1 (3.9, 12.6)
T (n=124) 61.0 (52.1, 69.1) 8.1 (4.5, 14.3) 7.6 (4.0, 13.8) 3.3 (1.3, 8.1)
W (n=90) 52.2 (42.0, 62.2) 10.0 (5.4, 17.9) 7.1 (3.3, 14.6) 4.5 (1.8, 11.0)
All-Wales: Resistance rates 59.4 (58.3, 60.5) 11.9 (11.1, 12.7) 11.8 (11.0, 12.6) 5.5 (5.0, 6.1)
All-Wales: Number of isolates 7,113 6,347 6,193 6,443
Location Code (Number) FQ (95% CI) NIT (95% CI) TRI (95% CI)
A (n=119) 5.9 (2.9, 11.7) 1.7 (0.5, 6.0) 22.9 (16.2, 31.2)
B (n=423) 9.3 (6.9, 12.5) 10.3 (7.7, 13.6) 30.4 (26.2, 35.0)
C (n=250) 10.4 (7.2, 14.8) 8.4 (5.6, 12.5) 30.4 (25.0, 36.4)
D (n=868) 8.0 (6.3, 10.0) 11.3 (9.3, 13.6) 32.2 (29.1, 35.4)
E (n=320) 13.8 (10.5, 18.1) 17.0 (13.2, 21.5) 29.1 (24.4, 34.3)
F (n=964) 17.8 (15.6, 20.4) 15.9 (13.7, 18.4) 36.7 (33.7, 39.8)
G (n=365) 9.9 (7.2, 13.4) 13.2 (10.1, 17.1) 29.3 (24.9, 34.2)
H (n=540) 9.6 (7.4, 12.4) 5.4 (3.8, 7.6) 30.9 (27.2, 34.9)
J (n=540) 7.8 (5.7, 10.5) 13.7 (10.9, 17.0) 31.6 (27.6, 35.8)
K (n=375) 13.8 (10.7, 17.7) 15.7 (12.4, 19.8) 33.6 (29.0, 38.6)
L (n=1004) 13.0 (11.1, 15.3) 17.2 (15.0, 19.7) 30.7 (27.9, 33.6)
M (n=176) 8.0 (4.8, 12.9) 4.6 (2.3, 8.8) 20.7 (15.3, 27.3)
N (n=252) 7.7 (5.0, 11.7) 11.2 (7.9, 15.7) 31.3 (25.9, 37.3)
P (n=275) 9.5 (6.5, 13.5) 12.4 (9.0, 16.8) 26.5 (21.7, 32.1)
Q (n=69) 10.1 (5.0, 19.5) 14.5 (8.1, 24.7) 33.3 (23.4, 45.1)
R (n=207) 6.3 (3.6, 10.7) 14.2 (10.0, 19.9) 31.1 (24.9, 38.0)
S (n=142) 9.9 (6.0, 16.0) 10.1 (6.1, 16.2) 29.1 (22.2, 37.0)
T (n=124) 3.3 (1.3, 8.1) 13.8 (8.8, 21.0) 30.1 (22.7, 38.7)
W (n=90) 5.6 (2.4, 12.4) 6.7 (3.1, 13.8) 28.9 (20.5, 39.0)
All-Wales: Resistance rates 11.0 (10.3, 11.8) 12.9 (12.1, 13.7) 31.3 (30.2, 32.4)
All-Wales: Number of isolates 7,120 7,062 7,072Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),
FQ = ciprofloxacin &/or levofloaxcin, or norfloxacin, NIT = nitrofurantoin, TRI = trimrthoprim
41
Table 32: Hospital In-Patient Urinary Coliforms
In 2013, the All-Wales resistance rates for in-patients urinary coliforms werestatistically higher for all the agents listed than those for community or out-patients(Tables 30, 31 & 32). In 2013, a number of hospitals had resistance rates for urinarycoliforms that were statistically higher than the All-Wales rate; the most notable wereUniversity Hospital of Wales (F), University Hospital Llandough (P) and West WingCRI (W). Cephalosporin and fluoroquinolone resistance was generally higher in theacute hospitals in North Wales.
Resistance rates for West Wing CRI (W) were high to most agents e.g. co-amoxiclav(COA): 27.7% (19.9, 31.7), and nitrofurantoin: 24.8% (17.4, 34.0). West Wing is along-term elderly care unit; the proportion of patients that are catheterized is higherthan the other hospitals included in this report, the proportion of patients receivinglong-term medical prophylaxis for recurrent UTI is also higher, and both of thesefactors may influence resistance. West Wing is included in this report to demonstratethis point.
In Patient Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) AMO (95% CI) COA (95% CI) IGC (95% CI) 3GC (95% CI)
A (n=268) 59.7 (53.7, 65.4) 12.7 (9.3, 17.3) 6.1 (3.8, 9.6)
B (n=703) 65.9 (62.3, 69.3) 9.8 (7.8, 12.3) 11.9 (9.6, 14.6) 7.3 (5.6, 9.5)
C (n=896) 68.2 (65.1, 71.2) 20.5 (18.0, 23.3) 3.3 (2.3, 4.8)
D (n=1,573) 62.3 (59.9, 64.7) 13.7 (12.1, 15.5) 2.3 (1.7, 3.2)
E (n=1,197) 67.3 (64.5, 69.9) 18.3 (16.2, 20.6) 17.7 (15.5, 20.1) 9.4 (7.8, 11.2)
F (n=1,873) 69.6 (67.5, 71.7) 23.2 (21.4, 25.2) 7.0 (5.9, 8.3)
G (n=487) 59.1 (54.7, 63.4) 13.6 (10.8, 16.9) 7.1 (5.1, 9.8)
H (n=1,288) 66.2 (63.6, 68.8) 6.6 (5.3, 8.2) 16.0 (14.1, 18.1)
J (n=646) 62.7 (58.7, 66.5) 11.9 (9.5, 14.7) 7.9 (6.0, 10.4)
K (n=1,301) 65.8 (63.2, 68.4) 15.4 (13.5, 17.5) 12.2 (10.5, 14.1)
L (n=1,353) 15.9 (14.1, 18.0) 11.5 (9.9, 13.4)
M (n=626) 59.3 (55.4, 63.0) 13.7 (11.3, 16.7) 3.6 (2.3, 5.4)
N (n=509) 67.2 (63.0, 71.1) 22.6 (19.2, 26.4) 5.9 (4.1, 8.3)
P (n=781) 68.9 (65.6, 72.0) 21.6 (18.9, 24.7) 7.8 (6.1, 10.0)
Q (n=84) 59.5 (48.8, 69.4) 11.9 (6.6, 20.5) 4.8 (1.9, 11.6)
R (n=268) 57.1 (51.0, 63.1) 12.4 (8.9, 17.1) 7.1 (4.6, 11.0)
S (n=504) 66.3 (62.1, 70.3) 20.4 (17.1, 24.1) 19.3 (15.9, 23.4) 9.9 (7.6, 12.9)
T (n=328) 61.6 (56.1, 66.7) 20.3 (16.3, 25.1) 19.4 (15.1, 24.6) 12.5 (9.3, 16.6)
W (n=101) 75.2 (66.0, 82.6) 27.7 (19.9, 37.1) 10.5 (5.8, 18.3)
All-Wales: Resistance rates 65.7 (64.9, 66.5) 17.4 (16.7, 18.0) 19.7 (18.8, 20.6) 7.6 (7.2, 8.1)
All-Wales: Number of isolates 13,690 13,427 7,792 13,071
Location Code (Number) FQ (95% CI) NIT (95% CI) TRI (95% CI)
A (n=268) 9.7 (6.7, 13.8) 10.8 (7.6, 15.1) 38.8 (33.2, 44.8)
B (n=703) 13.2 (10.8, 15.9) 14.8 (12.3, 17.7) 38.5 (34.9, 42.2)
C (n=896) 12.9 (10.9, 15.3) 17.5 (15.2, 20.2) 36.6 (33.6, 39.9)
D (n=1,573) 10.1 (8.7, 11.7) 14.4 (12.7, 16.3) 29.0 (26.8, 31.4)
E (n=1,197) 13.4 (11.6, 15.5) 22.0 (19.7, 24.5) 38.1 (35.4, 40.9)
F (n=1,873) 16.8 (15.2, 18.6) 19.3 (17.6, 21.1) 40.9 (38.7, 43.2)
G (n=487) 8.0 (5.9, 10.8) 16.5 (13.5, 20.1) 36.6 (32.4, 40.9)
H (n=1,288) 20.6 (18.5, 22.9) 13.2 (11.5, 15.2) 40.3 (37.7, 43.0)
J (n=646) 7.1 (5.3, 9.5) 16.3 (13.5, 19.5) 31.9 (28.2, 35.7)
K (n=1,301) 16.0 (14.1, 18.1) 21.5 (19.4, 23.9) 40.7 (38.1, 43.4)
L (n=1,353) 16.3 (14.5, 18.4) 17.4 (15.5, 19.5) 38.8 (36.2, 41.4)
M (n=626) 9.9 (7.8, 12.5) 15.2 (12.5, 18.3) 30.5 (26.9, 34.3)
N (n=509) 10.3 (7.9, 13.3) 17.8 (14.7, 21.4) 34.6 (30.6, 38.9)
P (n=781) 19.0 (16.4, 21.8) 18.5 (15.9, 21.4) 45.6 (42.2, 49.1)
Q (n=84) 11.9 (6.6, 20.5) 15.5 (9.3, 24.7) 28.6 (20.0, 39.0)
R (n=268) 6.0 (3.7, 9.7) 18.4 (14.1, 23.7) 34.0 (28.4, 40.1)
S (n=504) 13.2 (10.5, 16.5) 17.2 (14.2, 20.9) 36.2 (32.1, 40.5)
T (n=328) 18.1 (14.3, 22.7) 20.3 (16.2, 25.0) 43.1 (37.8, 48.6)
W (n=101) 18.8 (12.4, 27.5) 24.8 (17.4, 34.0) 42.6 (33.4, 52.3)
All-Wales: Resistance rates 14.1 (13.6, 14.7) 17.5 (16.9, 18.1) 37.6 (36.8, 38.4)
All-Wales: Number of isolates 14,727 14,560 14,598Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),
FQ = ciprofloxacin &/or levofloaxcin, or norfloxacin, NIT = nitrofurantoin, TRI = trimrthoprim
42
Community Urinary Coliforms (n=90,466 in 2013)
The All-Wales pattern of antimicrobial resistance for community urinary coliforms isshown in Figure 12 & Table 30.
Figure 12: All-Wales antimicrobial resistance rates for coliforms from communityurine samples (2005 to 2013)
There was a statistically significant decrease in co-amoxiclav resistance between2011 and 2013 (17.2% to 10.5%), whilst resistance to trimethoprim continues to rise.he high rates of resistance, notably for trimethoprim, may reflect an element ofselective testing within the community. The true rate of resistance to trimethoprim inpatients presenting with uncomplicated UTI in the community is likely to beconsiderably lower, and trimethoprim remains the suggested first-line empiricaltherapy for most of these patients.
20
05
20
13
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
1GC 3GC AMO COA FQ NIT TRI
2005 7.1 3.7 51.2 9.4 5.8 11.2 26.8
2006 7.9 3.9 52.5 10.8 7.0 11.6 29.0
2007 9.4 4.4 53.1 12.3 8.0 11.3 30.5
2008 9.8 4.7 56.0 12.9 9.1 11.1 30.7
2009 10.2 4.7 57.0 14.0 9.5 10.8 30.9
2010 10.1 4.8 57.3 14.6 9.7 10.3 31.5
2011 9.8 4.3 58.4 17.2 9.9 10.7 32.5
2012 9.3 4.0 57.9 12.3 9.9 11.1 34.0
2013 9.8 5.0 57.6 10.5 9.8 11.8 34.8
Re
sist
ance
(%)
43
Out-patient Urinary Coliforms (n=7,217 in 2013)
The All-Wales pattern of antimicrobial resistance for out-patient urinary coliforms isshown in Figure 13 & Table 31. There has been a statistically significant decrease inco-amoxiclav resistance between 2011 and 2013.
Figure 13: All-Wales antimicrobial resistance rates for coliforms from out-patienturine samples (2005 to 2013)
20
05
20
13
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
1GC 3GC AMO COA FQ NIT TRI
2005 8.9 5.9 51.1 10.2 7.6 11.9 26.2
2006 9.4 6.1 53.9 12.5 8.7 13.4 27.9
2007 12.2 7.2 55.2 15.8 10.4 14.6 30.5
2008 11.8 6.9 56.8 14.7 11.4 13.8 29.3
2009 10.9 5.1 57.3 14.7 9.2 12.3 28.6
2010 10.6 5.0 57.7 15.2 10.2 11.0 29.7
2011 10.6 4.7 58.5 17.1 11.0 11.6 30.1
2012 10.8 4.3 58.3 13.6 10.5 11.9 29.8
2013 11.8 5.5 59.4 11.9 11.0 12.9 31.3
Re
sist
ance
(%)
44
In-patient Urinary Coliforms (n=14,903 in 2013)
The All-Wales pattern of antimicrobial resistance for in-patient urinary coliforms isshown in Figure 14 & Table 32. There was no significant difference in resistancerates for urinary coliforms from in-patient samples between 2012 and 2013; thedecrease in co-amoxiclav resistance described in 2012 levelled off in 2013.
Figure 14: All-Wales antimicrobial resistance rates for coliforms from in-patienturine samples (2005 to 2013)
0
5
10
15
20
25
30
35
40
45
50
55
60
65
70
1GC 3GC AMO COA FQ NIT TRI
2005 12.7 8.2 57.4 15.8 11.8 16.8 29.1
2006 15.1 10.5 59.6 18.6 14.0 18.3 32.3
2007 16.9 11.5 61.0 21.8 15.6 17.6 33.7
2008 16.4 10.1 63.3 21.5 15.5 17.6 34.2
2009 16.3 9.0 65.3 21.9 15.2 17.2 33.9
2010 16.2 7.9 65.3 21.7 14.5 16.6 34.1
2011 17.9 6.9 66.7 24.4 15.5 15.4 35.7
2012 17.8 6.2 66.2 18.0 14.4 15.4 36.7
2013 19.7 7.6 65.7 17.4 14.1 17.5 37.6
Re
sist
ance
(%)
45
Section 5.3: Antimicrobial resistance rates forStaphylococcus aureus
The data in this section is presented to reflect the antimicrobial susceptibility oforganisms causing skin and soft tissue infections occurring in the community, and isbased on the specimen description ‘wound swab’. However, it should be noted thatthere is a significant sampling bias in this data. Royal Gwent and Nevill Hall are notincluded in the MSSA or MRSA data sets as they do not use the specimen typedescription ‘wound swab’ in their laboratory management systems.
46
Tables 33: Meticillin Sensitive Staphylococcus aureus (MSSA) from communitywound swabs
Tables 34: Meticillin Sensitive Staphylococcus aureus (MSSA) from in-patientwound swabs
Table 35: Meticillin Sensitive Staphylococcus aureus (MSSA) from out-patientwound swabs
Meticillin Sensitive Staphylococcus aureus from community wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
A (n=601) 8.8 (6.8, 11.4) 14.3 (11.7, 17.3) 6.7 (4.9, 8.9)
B (n=72) 0.0 (0.0, 5.8) 11.1 (5.5, 21.2) 17.5 (10.0, 28.6) 4.8 (1.6, 13.1)
C (n=766) 1.2 (0.6, 2.2) 5.3 (3.9, 7.1)
F (n=882) 12.7 (11.0, 14.7) 13.9 (11.8, 16.4) 12.2 (10.2, 14.6) 4.3 (3.2, 5.9)
G (n=499) 9.6 (7.3, 12.5) 13.6 (10.9, 16.9) 4.2 (2.8, 6.3)
H (n=1,170) 11.2 (9.5, 13.1) 14.3 (12.5, 16.5) 17.9 (15.8, 20.2)
J (n=1,032) 11.8 (10.0, 13.9) 14.9 (12.9, 17.2) 4.7 (3.6, 6.2)K (n=1,166) 12.5 (10.7, 14.6) 17.4 (15.2, 19.7) 5.9 (4.7, 7.5)
L (n=1,058) 16.5 (14.4, 18.9) 21.6 (19.3, 24.2) 7.0 (5.6, 8.7)
N (n=43) 2.3 (0.4, 11.8) 4.8 (1.3, 15.8) 11.9 (5.2, 25.0) 2.3 (0.4, 12.1)
P (n=294) 15.5 (12.3, 19.4) 17.0 (13.1, 21.7) 14.3 (10.7, 18.7) 5.8 (3.6, 9.1)
R (n=55) 9.1 (3.9, 19.6) 14.5 (7.6, 26.2) 1.8 (0.3, 9.6)
S (n=3,434) 13.0 (11.9, 14.2) 18.4 (17.1, 19.7) 4.9 (4.2, 5.6)
T (n=20) 10.5 (2.9, 31.4) 15.8 (5.5, 37.6) 21.1 (8.5, 43.3)
All-Wales: Resistance rates 9.6 (8.9, 10.3) 14.0 (13.3, 14.6) 17.6 (16.8, 18.4) 5.3 (4.9, 5.8)
All-Wales: Number of isolates 7310 10238 8497 9777
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
Meticillin Sensitive Staphylococcus aureus from In-Patient wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
A (n=59) 7.0 (2.8, 16.7) 14.0 (7.3, 25.3) 12.3 (6.1, 23.2)
B (n=145) 0.9 (0.2, 4.8) 8.8 (4.8, 15.4)
C (n=186) 2.2 (0.8, 5.4) 5.4 (3.0, 9.7)
E (n=522) 10.5 (6.6, 16.4) 14.0 (11.3, 17.3) 15.4 (12.5, 18.8) 5.1 (3.5, 7.4)
F (n=366) 14.1 (11.3, 17.5) 17.3 (13.8, 21.5) 11.8 (8.9, 15.5) 7.1 (4.9, 10.3)
G (n=97) 9.3 (5.0, 16.7) 15.5 (9.6, 24.0) 4.1 (1.6, 10.1)
H (n=240) 16.0 (11.9, 21.2) 18.4 (14.0, 23.8) 10.0 (6.8, 14.5)
J (n=131) 11.5 (7.1, 18.0) 15.3 (10.1, 22.4) 2.3 (0.8, 6.5)
K (n=234) 14.3 (10.4, 19.6) 16.6 (12.3, 22.0) 4.0 (2.1, 7.5)
L (n=238) 12.2 (8.6, 17.0) 17.2 (13.0, 22.5) 8.0 (5.2, 12.2)
N (n=11) 0.0 (0.0, 25.9) 18.2 (5.1, 47.7) 9.1 (1.6, 37.7) 9.1 (1.6, 37.7)
P (n=108) 14.2 (9.5, 20.7) 15.0 (9.4, 22.9) 15.0 (9.4, 22.9) 2.8 (1.0, 7.9)
Q (n=32) 9.3 (3.7, 21.6) 12.5 (5.0, 28.1) 12.5 (5.0, 28.1) 0.0 (0.0, 10.7)
R (n=37) 16.2 (7.7, 31.1) 18.9 (9.5, 34.2) 2.7 (0.5, 13.8)
S (n=145) 14.9 (10.0, 21.7) 17.0 (11.7, 24.1) 9.2 (5.5, 15.1)
T (n=43) 16.7 (8.3, 30.6) 7.1 (2.5, 19.0) 4.9 (1.3, 16.1)
All-Wales: Resistance rates 11.2 (9.9, 12.8) 15.1 (13.7, 16.6) 14.4 (13.0, 16.0) 5.6 (4.8, 6.7)
All-Wales: Number of isolates 1823 2399 2180 2337
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
Meticillin Sensitive Staphylococcus aureus from Out-Patient wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
A (n=19) 5.3 (0.9, 24.6) 10.5 (2.9, 31.4) 5.3 (0.9, 24.6)
B (n=74) 1.5 (0.3, 7.9) 14.5 (8.1, 24.7) 20.3 (12.5, 31.2) 4.3 (1.5, 12.0)
C (n=64) 1.6 (0.3, 8.5) 11.3 (5.6, 21.5)
E (n=618) 9.9 (6.4, 14.9) 10.4 (8.2, 13.0) 14.3 (11.7, 17.3) 4.6 (3.2, 6.6)
F (n=183) 9.6 (6.5, 14.0) 11.5 (7.6, 16.9) 12.6 (8.5, 18.2) 3.3 (1.5, 7.0)
G (n=40) 15.0 (7.1, 29.1) 17.5 (8.7, 32.0) 5.0 (1.4, 16.5)
H (n=179) 10.1 (6.5, 15.3) 14.0 (9.6, 19.8) 26.8 (20.9, 33.7)
J (n=88) 8.0 (3.9, 15.5) 11.4 (6.3, 19.7) 8.0 (3.9, 15.5)
K (n=138) 17.8 (12.2, 25.1) 24.4 (18.0, 32.3) 8.9 (5.2, 14.9)
L (n=174) 15.5 (10.9, 21.6) 27.6 (21.5, 34.7) 8.1 (4.9, 13.2)
N (n=10) 0.0 (0.0, 27.8) 20.0 (5.7, 51.0) 10.0 (1.8, 40.4) 0.0 (0.0, 27.8)
P (n=21) 9.4 (3.2, 24.2) 19.0 (7.7, 40.0) 33.3 (17.2, 54.6) 4.8 (0.8, 22.7)
Q (n=28) 2.9 (0.5, 14.5) 7.4 (2.1, 23.4) 3.6 (0.6, 17.7) 3.6 (0.6, 17.7)
R (n=22) 0.0 (0.0, 14.9) 4.5 (0.8, 21.8) 4.5 (0.8, 21.8)
S (n=153) 11.6 (7.4, 17.9) 32.2 (25.2, 40.1) 4.1 (1.9, 8.7)
T (n=27) 23.1 (11.0, 42.1) 15.4 (6.1, 33.5) 3.8 (0.7, 18.9)
All-Wales: Resistance rates 8.3 (6.8, 10.1) 12.8 (11.3, 14.5) 19.6 (17.8, 21.6) 5.6 (4.6, 6.8)
All-Wales: Number of isolates 1823 1,771 1,654 1655
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
47
MSSA ( n=16,321 in 2013)
Community MSSA (n=11,102 in 2013)The All-Wales pattern of antimicrobial resistance for MSSA from community woundswabs are shown in Figure 15 and Table 33 with a small but statistically significantdifference in fusidic acid resistance rates between 2012 and 2013, and a notableincrease in trend for erythromycin resistance.
Figure 15: All-Wales antimicrobial resistance rates for MSSA from communityWound swabs (2005 to 2013)
In 2013, the All-Wales resistance rates for community, out-patients and in-patientsMSSA were comparable for most of the antimicrobials listed: erythromycin (ERY),gentamicin (GEN), mupirocin (MUP), penicillin (PEN) and tetracycline (TET) seeTables 33, 34 and 35.
At different times in the eight year period 2005 to 2013, there were increases inresistance to different agents in different geographical areas, but there was no setpattern of increasing or high resistance in any particular community or hospital, andthis probably reflects the varying presence of epidemic strains.
Resistance to fusidic acid (FUS) was higher for out-patient MSSA comparedto in-patient and community rates.
Vancomycin resistance remained undetected in MSSA between 2005 & 2013.
20
05
20
13
0
10
20
30
40
50
60
70
80
90
100
ERY FUS GEN PEN TET
Re
sist
ance
(%)
48
Tables 36: Meticillin Resistant Staphylococcus aureus (MRSA) from communitywound swabs
Tables 37: Meticillin Resistant Staphylococcus aureus (MRSA) from in-patientwound swabs
Table 38: Meticillin Resistant Staphylococcus aureus (MRSA) from out-patientwound swabs
There were no confirmed cases of vancomycin intermediate/resistant MRSA (VISA)between 2005 and 2012
Meticillin Resistant Staphylococcus aureus from community wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
A (n=48) 51.1 (37.0, 65.0) 62.2 (47.6, 74.9) 15.6 (7.7, 28.8)
C (n=117) 60.3 (51.2, 68.8) 23.9 (17.1, 32.4)
F (n=129) 61.3 (53.5, 68.5) 69.0 (60.6, 76.3) 17.8 (12.2, 25.3) 13.2 (8.4, 20.1)
G (n=45) 24.4 (14.2, 38.7) 37.8 (25.1, 52.4) 7.0 (2.4, 18.6) 6.8 (2.3, 18.2)
H (n=190) 61.7 (54.6, 68.4) 63.7 (56.6, 70.2) 48.9 (41.9, 56.0) 42.6 (35.8, 49.7)
J (n=127) 52.4 (43.7, 60.9) 63.5 (54.8, 71.4) 7.3 (3.9, 13.2) 10.3 (6.1, 16.9)
K (n=233) 70.8 (64.7, 76.3) 19.7 (15.1, 25.3) 25.3 (20.2, 31.3)
L (n=254) 67.3 (61.3, 72.8) 40.2 (34.3, 46.3) 32.7 (27.2, 38.7)
P (n=48) 63.9 (51.4, 74.8) 63.8 (49.5, 76.0) 8.5 (3.4, 19.9) 19.1 (10.4, 32.5)
S (n=308) 53.8 (47.8, 59.7) 24.6 (19.8, 30.2) 5.3 (3.2, 8.8)
All-Wales: Resistance rates 45.7 (42.6, 48.9) 62.6 (60.1, 65.1) 25.6 (23.4, 27.9) 21.4 (19.4, 23.6)
All-Wales: Number of isolates 954 1429 1416 1465
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
Meticillin Resistant Staphylococcus aureus from In-Patient wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
A (n=13) 58.3 (32.0, 80.7) 75.0 (46.8, 91.1) 0.0 (0.0, 24.3)B (n=33)
C (n=65) 78.8 (67.5, 86.9) 6.2 (2.4, 14.8)E (n=96) 42.3 (32.0, 53.4) 10.3 (5.3, 19.0) 9.1 (4.5, 17.6)
F (n=82) 64.5 (55.3, 72.9) 67.9 (57.1, 77.1) 11.1 (6.0, 19.8) 12.3 (6.8, 21.3)
G (n=14) 35.7 (16.3, 61.2) 42.9 (21.4, 67.4) 0.0 (0.0, 24.3) 0.0 (0.0, 21.5)
H (n=76) 75.0 (64.2, 83.4) 77.6 (67.1, 85.5) 42.1 (31.6, 53.3) 40.0 (29.7, 51.3)
J (n=12) 41.7 (19.3, 68.0) 58.3 (32.0, 80.7) 9.1 (1.6, 37.7) 8.3 (1.5, 35.4)
K (n=96) 74.0 (64.4, 81.7) 8.3 (4.3, 15.6) 12.5 (7.3, 20.6)
L (n=105) 79.0 (70.3, 85.7) 41.0 (32.0, 50.5) 35.2 (26.8, 44.7)
P (n=26) 64.9 (48.8, 78.2) 65.4 (46.2, 80.6) 7.7 (2.1, 24.1) 11.5 (4.0, 29.0)
S (n=17)
T (n=15)
All-Wales: Resistance rates 51.3 (46.6, 56.0) 67.0 (63.1, 70.6) 19.0 (16.0, 22.3) 16.9 (14.2, 20.0)
All-Wales: Number of isolates 425 600 595 627
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
Meticillin Resistant Staphylococcus aureus from Out-Patient wound swabsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)
B (n=12)
C (n=11) 70.0 (39.7, 89.2) 50.0 (23.7, 76.3)
E (n=62)
F (n=25) 69.2 (53.6, 81.4) 70.8 (50.8, 85.1) 12.5 (4.3, 31.0) 16.7 (6.7, 35.9)
H (n=20) 50.0 (29.9, 70.1) 50.0 (29.9, 70.1) 60.0 (38.7, 78.1) 55.0 (34.2, 74.2)
J (n=12) 66.7 (39.1, 86.2) 75.0 (46.8, 91.1) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3)
K (n=27) 77.8 (59.2, 89.4) 22.2 (10.6, 40.8) 25.9 (13.2, 44.7)
L (n=23) 78.3 (58.1, 90.3) 47.8 (29.2, 67.0) 26.1 (12.5, 46.5)
All-Wales: Resistance rates 55.2 (47.0, 63.0) 66.3 (59.3, 72.7) 24.7 (19.1, 31.4) 19.9 (14.9, 26.1)
All-Wales: Number of isolates 145 187 186 191
Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline
49
MRSA (n=2,410 in 2013)
Community MRSA (n=1,518 in 2013)The All-Wales pattern of antimicrobial resistance for MRSA from community woundswabs is shown in Figure 16 and Table 36, with no statistically significant changes inthe resistance rates for any of the agents listed between 2012 and 2013, but with anincreasing trend in resistance for fusidic acid and tetracycline.
Figure 16: All-Wales antimicrobial resistance rates for MRSA from communityWound swabs (2005 to 2013)
Locally, there was wide variability in resistance rates within Wales; with notably highrates in some areas e.g. fusidic acid and tetracycline resistance in communitiesserved by the laboratories in Wrexham Maelor (H), and Ysbyty Glan Clwyd (L), seeTable 36.
Hospital In-Patient and Out-Patient MRSA (n=892 in 2013)The trends in antimicrobial resistance for both hospital in-patient and out-patientMRSA are similar to those seen in the community, with no statistically significantchanges in the resistance rates for any of the agents listed between 2012 and 2013.Some of the same local patterns of resistance seen in the community were alsoreflected in hospital patients from the same geographical area, with notably highfusidic acid and tetracycline rates in patients from Wrexham Maelor (H) and YsbytyGlan Clwyd (L): See Tables 37 and 38.
20
05
20
13
0
10
20
30
40
50
60
70
80
90
100
ERY FQ FUS GEN LZD MUP RIF TET
Re
sist
ance
(%)
50
Section 5.4: Antimicrobial resistance rates for otherpathogens.
The data in this section of the report comprises other pathogens which maycommonly cause important infections other than bacteraemia. The data is for allspecimens from all locations (community, in-patient and out-patient).
Haemophilus influenzae Streptococcus pneumoniae Streptococcus pyogenes Campylobacter species Neisseria gonorrhoeae
51
Table 39: Haemophilus influenzae - all specimens and all locations
Note: The range of resistance is outlined with boxes e.g. the range of resistance toamoxicillin was 0.0% - 32.9%; individual hospital rates statistically higher than the All-Wales rate are highlighted in colour.
Haemophilus influenzae, all specimens all locationsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code (number) AMO (95% CI) COA (95% CI) TET (95% CI)
A (n=231) 32.9 (27.2, 39.2) 14.3 (10.4, 19.4) 0.0 (0.0, 1.6)
B (n=178) 26.0 (20.1, 32.9) 9.6 (6.1, 14.8) 0.0 (0.0, 2.1)
C (n=460) 25.8 (22.0, 30.0) 9.8 (7.4, 12.9) 1.5 (0.7, 3.1)
D (n=1548) 23.3 (21.2, 25.5) 6.5 (5.4, 7.9) 0.7 (0.4, 1.3)
E (n=105) 32.0 (23.8, 41.6) 14.3 (8.9, 22.2) 0.0 (0.0, 3.5)
F (n=830) 28.0 (25.0, 31.1) 15.7 (13.4, 18.3) 1.4 (0.8, 2.5)
G (n=131) 25.2 (18.5, 33.3) 9.2 (5.3, 15.3) 2.3 (0.8, 6.5)
H (n=635) 24.2 (20.9, 28.0) 0.9 (0.4, 2.1) 0.9 (0.4, 2.1)
J (n=464) 30.8 (26.8, 35.2) 9.3 (7.0, 12.3) 0.9 (0.3, 2.2)
K (n=770) 26.8 (23.8, 30.0) 9.1 (7.3, 11.4) 0.4 (0.2, 1.3)
L (n=657) 30.4 (27.0, 33.9) 9.8 (7.8, 12.3) 0.2 (0.0, 0.9)
M (n=184) 25.0 (19.3, 31.7) 7.6 (4.6, 12.4) 0.0 (0.0, 2.0)
N (n=412) 24.8 (20.9, 29.2) 11.4 (8.7, 14.8) 1.2 (0.5, 2.8)
P (n=364) 23.1 (19.0, 27.7) 14.4 (11.1, 18.4) 0.8 (0.3, 2.4)
Q (n=12) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3)
R (n=84) 29.8 (21.0, 40.2) 4.8 (1.9, 11.6) 0.0 (0.0, 4.4)
S (n=1051) 30.0 (27.3, 32.9) 16.6 (14.4, 18.9) 0.3 (0.1, 0.8)
T (n=37) 16.2 (7.7, 31.1) 5.4 (1.5, 17.7) 0.0 (0.0, 9.4)
All-Wales: Resistance rates 26.8 (25.8, 27.8) 10.3 (9.6, 11.0) 0.7 (0.6, 0.9)
All-Wales: Number of isolates 8078 8078 7904Key: ERY = erythromycin, PEN = penicillin, TET = tetracycline.
52
Haemophilus influenzae (n=8,175 in 2013)
The All-Wales pattern of antimicrobial resistance for Haemophilus influenzae from allspecimens/locations is shown in Figure 17 & Table 39; with an increase in the trendof resistance amoxicillin and to co-amoxiclav.
Figure 17: All-Wales antimicrobial resistance rates for H. influenzae; all specimensand all locations (2005 to 2013)
Locally, there was variability in co-amoxiclav resistance rates within Wales withhigher rates of resistance being seen in the hospitals and the communities served bylaboratories at UHW (F), and Singleton (S) .
20
05
20
13
0
2
4
6
8
10
12
14
16
18
20
22
24
26
28
30
AMO COA TET
Res
ista
nce
(%)
53
Table 40: Streptococcus pneumoniae - all specimens and all locations
Streptococcus pneumoniae, all specimens all locationsResistance rates including (95% Confidence Intervals)
Duplicate Cut Off: ≤14 days
Time period: 1 January - 31 December 2013
Location Code ERY (95% CI) PEN (95% CI) TET (95% CI)
A (n=73) 6.8 (3.0, 15.1) 1.4 (0.2, 7.4) 2.7 (0.8, 9.5)
B (n=54) 13.0 (6.4, 24.4) 0.0 (0.0, 6.6) 13.7 (6.8, 25.7)
C (n=121) 9.0 (5.0, 15.8) 2.5 (0.8, 7.0) 6.1 (3.0, 12.0)
D (n=502) 10.3 (7.9, 13.3) 3.6 (2.3, 5.6) 8.1 (6.0, 10.9)
E (n=77) 9.1 (4.5, 17.6) 3.9 (1.4, 11.0)
F (n=308) 12.1 (8.9, 16.3) 8.6 (5.9, 12.2) 8.9 (6.2, 12.6)
G (n=55) 5.5 (1.9, 14.9) 0.0 (0.0, 6.5) 5.5 (1.9, 14.9)
H (n=310) 13.4 (9.8, 18.0) 7.4 (4.9, 10.9) 12.9 (9.3, 17.8)
J (n=193) 13.5 (9.4, 19.0) 4.1 (2.1, 8.0) 6.3 (3.6, 10.6)
K (n=245) 9.5 (6.4, 13.8) 5.3 (3.2, 8.9) 4.9 (2.8, 8.4)
L (n=273) 9.5 (6.6, 13.6) 5.5 (3.4, 8.9) 8.1 (5.4, 11.9)
M (n=76) 9.2 (4.5, 17.8) 5.3 (2.1, 12.8) 9.3 (4.6, 18.0)
N (n=108) 14.6 (9.0, 22.6) 4.6 (2.0, 10.4) 12.4 (7.4, 20.0)
P (n=106) 17.0 (11.0, 25.3) 12.3 (7.3, 19.9) 7.6 (3.9, 14.3)
R (n=32) 16.7 (7.3, 33.6) 6.3 (1.7, 20.1) 13.3 (5.3, 29.7)
S (n=361) 11.5 (8.5, 15.2) 3.6 (2.1, 6.1)
All-Wales: Resistance rates 11.4 (10.2, 12.6) 5.1 (4.3, 5.9) 8.2 (7.2, 9.3)
All-Wales: Number of isolates 2727 2887 2707Key: ERY = erythromycin, PEN = penicillin, TET = tetracycline.
54
Streptococcus pneumoniae (n=2,909 in 2013)
The All-Wales pattern of antimicrobial resistance for Streptococcus pneumoniae fromall specimens and all locations is shown in Figure 18 & Table 40; with a small butstatistically significant increase in the resistance rates to all three agents between2010 and 2013.
Figure 18: All-Wales antimicrobial resistance rates for S. pneumoniae;All specimens and all locations (2005 to 2013)
The rates for all three agents are higher than the rates for S. pneumoniae isolatesfrom blood culture: See Figure 11.There was some variation in the penicillinresistance across Wales with higher rates being seen in University HospitalLlandough (P).
ERY PEN TET
2005 9.7 3.6 3.5
2006 11.7 4.5 4.9
2007 9.3 3.9 5.0
2008 7.9 3.5 4.5
2009 6.2 3.3 4.2
2010 7.1 2.7 4.8
2011 9.4 4.4 6.5
2012 11.2 4.3 7.4
2013 11.4 5.1 8.2
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Streptococcus pyogenes (n=3,925 in 2013)
The All-Wales pattern of antimicrobial resistance for Streptococcus pyogenes from allspecimens/locations is shown in Figure 19; with statistically significant changes inresistance between 2012 and 2013.
Figure 19: All-Wales antimicrobial resistance rates for S. pyogenes; all specimensand all locations (2005 to 2013)
There were no validated cases of penicillin resistant S. pyogenes in Wales from 2005to 2013.
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56
Campylobacter species (n=3,067 in 2012)
The All-Wales pattern of antimicrobial resistance for Campylobacter spp. from alllocations is shown in Figure 20; with a statistically significant change in the rate forciprofloxacin between 2012 and 2013.
Figure 20: All-Wales antimicrobial resistance rates for Campylobacter spp.; allspecimens and all locations (2005 to 2013)
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57
Neisseria gonorrhoeae (n=550 in 2013)
The All-Wales pattern of antimicrobial resistance for Neisseria gonorrhoeae from allspecimens and all locations is shown in Figure 21; with no statistically significantdifference in the resistance rates for any of the agents listed between 2012 and 2013.
Figure 21: All-Wales antimicrobial resistance rates for N. gonorrhoeae; allspecimens and all locations (2005 to 2012)
Note: GRASP (Gonococcal Resistance to Antimicrobials Surveillance Programme) isa national sentinel surveillance programme which has monitored trends and drifts insusceptibility in gonococcal isolates since 2000. It collects isolates from consecutivepatients attending a network of 26 genitourinary medicine (GUM) clinics that giveregional representation in England and Wales. The 2012 GRASP report published bythe Public Health England reported the following Key Points:
There is evidence of isolates exhibiting decreased susceptibility to ceftriaxone(MIC≥ 0.125mg/l) for the first time since it was reported in 2009.
There has been continued decline in the proportion of isolates exhibitingdecreased susceptibility to cefixime (MIC≥ 0.125mg/l), particularly in isolates infecting MSM and women.
Overall prevalence to azithromycin resistance (MIC≥ 1mg/l) increased slightly to 0.7% in 2012, with two isolates showing very high azithromycin resistanceof ≥ 256mg/l for the first time since 2007.
Between 2011 and 2012, dual prescribing of doxycycline and ceftriaxone forMSM declined and dual prescribing of azithromycin and ceftriaxone increasedin line with treatment guidelines.
Compliance of recommend treatment guidelines continued to increase in allregions of England and Wales.
http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/GRASPReports/1310GRASP2012/
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