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Report on the Paediatric andNeonatal Point Prevalence Survey

of Antimicrobial Prescribing inHospitals in Wales in 2011

(The survey was conducted as part of the 2011 PPS of antimicrobialprescribing in Secondary Care in Wales, and as part of the AntibioticResistance and Prescribing in European Children (ARPEC) Project).

Authors: Maggie HeginbothomRobin Howe

Date: 12/06/2012 Status: Final

Version: 1Paediatric & Neonatal PPS - Wales

Page: 1 of 31Welsh Antibacterial ResistanceProgramme: Surveillance Unit

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ACKNOWLEDGMENTS

For their co-operation, hard-work and support, our sincere thanks to theHeads of Pharmacy, the Antimicrobial Pharmacists, Ward Pharmacists, andInfection, Prevention and Control Teams at:

Bronglais General Hospital Aberystwyth Glangwili Hospital, Carmarthen Morriston Hospital, Swansea Nevill Hall Hospital, Abergavenny Prince Charles Hospital, Merthyr Princess of Wales Hospital, Bridgend Royal Gwent Hospital, Newport Singleton Hospital, Swansea University Hospital of Wales, Cardiff Withybush Hospital, Haverfordwest Wrexham Maelor Hospital, Wrexham Ysbyty Gwynedd, Bangor Ysbyty Glan Clwyd, Rhyl

Also for their advice and support throughout the PPS, Ann Versporten andNico Draper, ARPEC Project, Antwerp..

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EXECUTIVE SUMMARY

This is the first Point Prevalence Survey of Antimicrobial use inpaediatrics and neonates in Wales performed as part of a comparativeEuropean project (ARPEC) and using appropriate diagnostic categoriesfor these patient groups.

o 391 paediatric and neonatal patients were surveyedo 85 from neonatal or maternity wards (22%)o 306 from paediatric wards (78%)

Overall 104 patients (26.6%) were prescribed a systemicantimicrobial/s

o 102 (26.0%) received a systemic antibacterial/s

o 8 (2%) received a systemic antifungals

o 1 (0.3%) received a systemic antiviral

o 1 (0.3%) received TB drugs

Prescribing was highest on specialist haematology-oncology wards(67%) and lowest on general neonatal medical wards (10%). Ongeneral paediatric medicine wards, 30.4% of patients received anantimicrobial.

On paediatric wards,o The commonest indication for antimicrobials was community-

acquired infection - 75%o The commonest reasons for treatment were:

Bacterial lower respiratory tract infection – 15% Prophylaxis for medical problems – 15% Skin or soft tissue infections – 14% Sepsis – 13%

On neonatal wards,o The commonest indication for antimicrobials was medical

prophylaxis – 59%o The commonest reasons for treatment were:

Prophylaxis for maternal risk factors – 33% Sepsis – 31% Prophylaxis for newborn risk factors – 22%

In neonates the commonest antimicrobials were benzylpenicillin andgentamicin which, between them, accounted for 67% of antimicrobialuse

In paediatrics there was more variability in antimicrobial use, thecommonest agents being 3rd generation cephalosporins that accountedfor 18% of antimicrobial use.

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Dosing of antimicrobials was variable. Mean gentamicin dosing for the<1 month age group was 4.0 mg/kg/day; while mean dosing for the 2-17 year age group was 7.1 mg/kg/day.

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INTRODUCTION

There is relatively little knowledge and understanding about antimicrobial usein paediatrics and neonates. Antimicrobial usage data based on pharmacystock information such as that published by the Welsh AntimicrobialResistance Programme is difficult to interpret due to variable dosing indifferent age groups, and previous European Antimicrobial Point PrevalenceSurveys (PPS) have focused mainly on adults, using methodology designedaround prescribing for adults. With a view to optimizing antimicrobialprescribing in children, the Directorate General for Health and ConsumerPolicy (DG SANCO) of the European Commission funded the project‘Antibiotic Resistance and Prescribing in European Children (ARPEC)http://www.arpecproject.eu/. The paediatric and neonatal PPS builds on theexisting European funded ESAC system on antimicrobial prescribing. TheARPEC work package 5 is lead by Professor Herman Goosens, University ofAntwerp, Belgium and Professor Mike Sharland, St Georges UniversityHospital London.

In Wales, the paediatric and neonatal PPS of antimicrobial prescribing wascarried out on November 18th 2011 to mark European antibacterial awarenessday, and to provide data to the ARPEC survey of antimicrobial prescribing inEuropean children.

The current report provides a simple overview of data for paediatrics andneonates collected as part of the fourth All-Wales Point Prevalence Survey ofantimicrobial usage in secondary care; the data include all antibacterial,antiviral, antifungal, and TB agents, which are collectively described asantimicrobials. However, much of the analysis concentrates on antibacterialprescribing only.

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METHODOLOGY

Data were collected by the hospital pharmacists using a pro-forma based onARPEC methodology (for the PPS forms see the Appendix).

The pharmacists were instructed to survey all patients resident on the wardsat 08.00 am on the day of the survey, and to document those receivingantimicrobials; assigning a clinical indication (see Table 1), and a reason fortreatment to each drug. Unlike the adult PPS, pharmacists were also asked toassign a maximum of three underlying diagnosis to each patient (for the listsof ‘Reasons for Treatment and ‘Underlying Diagnosis’ see the Appendix).

Table 1: Indication Codes for Paediatric and Neonatal PPS

A Community acquiredinfection

Symptoms or antibiotics started <48h after patient wasadmitted to hospital

B Hospital acquiredinfection i.e. symptomsstart 48h after admissionto hospital

B1 Post-operative infection (within 30 days aftersurgery or 1 year after implant surgery)

B2 IV catheter related infection

B4 Other hospital acquired infection including VAP andCAPD.

B5 Infection present on admission from another hospitalC Surgical prophylaxis C1 Single dose C2 one day C3 >1 dayD Medical prophylaxis

U Unknown Indication unknown

* VAP= ventilator Associated Pneumonia; CAPD= Continuous Ambulatory peritonealdialysis

The paediatric and neonatal departments were subdivided into ward types:

Table 2: Ward Types

Department Ward TypesPaediatrics General paediatric medicine

Haematology-oncology specialised medicinePaediatric SurgeryPaediatric intensive care unit (PICU)

Neonates Normal NICU providing special care (NICU-level 1)Medium NICU (level 2) providing high dependency care, shortterm intensive care and low birth weight newborns careLarge NICU (level 3) providing tertiary referral care for very lowbirth weight neonatesGeneral neonatal medical ward for all other neonates notbelonging to the definition of NICU, including babies onmaternity

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2011 PPS DEMOGRAPHICS

391 paediatric and neonatal patients were surveyed 85 of the patients were from neonatal or maternity wards (22%) and

306 were from paediatric wards (78%) 239 of the patients were medical patients (61%) 79 of the patients were surgery patients (20%) 73 of the patients were ICU patients (19%)

Of the 391 patients surveyed in the 2011 PPS, 104 were prescribed asystemic antimicrobial/s (26.6%).

102 were prescribed regimens which included systemic antibacterials,excluding TB regimens (26.0%).

8 were prescribed regimens which included systemic antifungals (2%)

1 was prescribed a regimen that included a systemic antiviral (0.3%)

1 was prescribed a regimen that comprised TB drugs (0.3%)

The age group and gender of the 104 patients prescribed antimicrobials isshown in Figure 1.

44 of patients were 2-17 years in age (42%) 41 of patients were <1 month in age (39%) 19 of patients were 1-23 months in age (18%)

Of the 104 paediatric and neonatal patients prescribed antimicrobials, 61%were male and 39% were female. Data for all hospitals on age group andgender is shown in Appendix Table 1.

Figure 1: Age group & gender of patients prescribed antimicrobials

0

5

10

15

20

25

30

<1 month 1-23 months 2-17years

F 16 9 16

M 25 10 28

Num

ber

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Figure 2 shows the proportion of antimicrobial prescribing by ward type.Prescribing prevalence ranged from 67% in the specialist haematology-oncology wards (SPM) to 10% in the general neonatal medical wards(GNMW).

Figure 2: Antimicrobial prescribing by ward types

Key: SPM - Haematology-oncology specialised medical ward; NICU - Neonatal intensive care unit (LI - level 1; L2 -level 2; L3 - level 3); GPM – General paediatric medicine; PS – Paediatric surgery; PICU – Paediatric intensive careunit; GNWM – General neonatal medical ward.

Figure 3 shows the indications assigned to the antimicrobial prescribing byage groups. Note: some patients were prescribed more than one antimicrobialfor more than one indication e.g. A/D = prescribing for a community acquiredinfection and medical prophylaxis.

Treatment for community acquired infections (A) was the most commonindication for antibacterial prescribing in the 2-17 years & 1-23 monthsage groups, accounting for 77% and 68% of prescribing respectively.

For the <1 month age group medical prophylaxis (D) was the mostcommon indication for antibacterial prescribing (46%). (NOTE: medicalprophylaxis is the category used to describe prophylactic/pre-emptiveuse of antimicrobials in neonates with identified maternal or neonatalrisk factors for infection.)

Hospital acquired infections (B) were most common in the <1 monthage group (22%), compared with 10% in the 1-23 months age groupand 2% in the 2-17years group. Hospital acquired infection was definedas ‘symptoms starting 48 hours or more after admission to hospital’.

No antimicrobials were prescribed for surgical prophylaxis in this PPS.

0

10

20

30

40

50

60

70

SPM NICU-L2 GPM NICU-L1 PS NICU-L3 PICU GNMW

Ward Type 66.7 32.4 30.4 30.0 27.8 26.3 20.0 10.3

Pro

po

rtio

no

fA

Mp

resc

rib

ing

(%)

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Figure 3: Indications for antimicrobial prescribing by age group (%)

Key: A - community acquired infection; B - hospital acquired infection: D - medical prophylaxis.

Figure 4 shows the indications assigned to the antimicrobial prescribing byward type. For some wards the number of patients prescribed antimicrobialswere too small to make conclusions, but generally medical prophylaxis wasmore commonly prescribed in NICU, PICU and specialised medical wards;treatment for community acquired infections was more common on generalpaediatric medicine, paediatric surgery and NICU-level 1, and treatment forhospital acquired infection was more common on NICUs and PICU.

Figure 4: Indications for antimicrobial prescribing by ward type (%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 month (n=41) 1-23 months (n=19) 2-17 years (n=44)

B&D 1 2

A&D 1 2

D 19 3 5

B 9 2 1

A 12 13 34

Ind

icat

ion

(%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Ind

icat

ion

(%)

B&D

A&D

D

B

A

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Figure 5 shows the route of administration for systemic antimicrobials by agegroup. For neonates aged <1 month 93% of antimicrobials were administeredparenterally compared to 61% in the 1-23 month age group, and 52% in the 2-17 year age group. Overall, 70% antimicrobials were parenteral and 30% oral.

Figure 5: Antimicrobial prescribing by route and age group (%)

Figure 6 shows the route of administration for systemic antibacterials by wardtype. For NICUs and general neonatal medical wards >92% of antimicrobialswere administered parenterally compared to 60% for the general paediatricmedicine; this largely reflects the difference in age between the ward types,with <1 month neonates receiving parenteral therapy rather than oral.

Figure 6: Antimicrobial prescribing by route and ward type (%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 month 1-23 months 2-17years

Parenteral 66 17 39

Oral 5 11 36

Ro

ute

(%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

NICU-L1 NICU-L2 NICU-L3 GNMW PICU GPM PS SPM

Parenteral 6 20 15 12 5 52 10 2

Oral 1 1 1 1 36 8 4

Rout

e(%

)

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Figure 7 shows the number of antibacterials prescribed per patient by agegroup; the proportion of patients receiving monotherapy varied from 63% inthe 1-23 month age group to 39% in the <1 month group. Dual therapy wasthe commonest regimen for the < 1 month group (59%).

Figure 7: Number of antibacterials prescribed per patient by age group (%)

Figure 8 shows the number of antibacterials prescribed by ward type; forsome wards the numbers of patients were too small to draw conclusions, butgenerally dual therapy (2 antibacterials) was more commonly prescribed inNICU and general neonatal medical wards.

Figure 8: Number of antibacterials prescribed per patient by ward type (%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

<1 month 1-23 months 2-17years

3+ 1 2 5

2 24 5 13

1 16 12 26

Nu

mn

er

of

anti

bac

teri

als

(%)

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

SPM PICU GPM NICU-L3 PS NICU-L2 GNMW NICU-L1

3+ 1 6 1

2 17 5 4 7 6 3

1 4 2 32 5 5 5 1

Nu

mb

er

of

anti

bac

teri

als

(%)

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ANTIMICROBIAL INFORMATION

Table 1 shows the antimicrobials prescribed as treatment/medical prophylaxisfor neonates and paediatrics in the 2011 PPS; 33 different antimicrobials wereprescribed comprising 174 issues to 104 patients.

Table 1: Antimicrobial prescribingAntimicrobial No. Antimicrobial No. Antimicrobial No.

Gentamicin 25 Tobramycin 4 Aciclovir 1

Benzylpenicillin 22 Clarithromycin 3 Amikacin 1

Flucloxacillin 20 Co-trimoxazole 3 Cefalexin 1

Cefotaxime 14 Phenoxymethylpenicillin 3 Cefuroxime 1

Amoxicillin 13 Trimethoprim 3 Erythromycin 1

Co-amoxiclav 11 Amphotericin B 2 Ethambutol 1

Ceftriaxone 8 Ceftazidime 2 Fusidic acid 1

Azithromycin 7 Fluconazole 2 Isoniazid 1

Metronidazole 6 Rifampicin 2 Itraconazole 1

Meropenem 5 Vancomycin 2 Pyrazinamide 1

Piperacillin /tazobactam 4 Voriconazole 2 Teicoplanin 1

Total numbers of antimicrobials prescribed 174

Total numbers of antibacterials prescribed 161

The Top 6 antimicrobials were all antibacterials: Gentamicin, benzylpenicillin,flucloxacillin, cefotaxime, amoxicillin and co-amoxiclav accounted for 60% ofantimicrobial prescribing.

Figure 9 compares antibacterial prescribing in neonatal wards (NICUs andgeneral neonatal medical wards) with prescribing in paediatric wards (generalpaediatric medicine, paediatric surgery, paediatric ICU & specialised medicinewards).

The most notable difference is prescribing of aminoglycosides (mainlygentamicin) and beta-lactamase sensitive penicillins (benzyl penicillin);these two agents accounted for 67% of all antibacterial prescribing inneonates compared with 17% in paediatrics.

For paediatrics, the third generation cephalosporins (cefotaxime,ceftazidime and ceftriaxone) were the most commonly prescribedantibacterial group accounting for 18% of total prescribing. However,there was no clear choice of agent, with prescribing was spreadamongst beta-lactamase resistant penicillins (flucloxacillin),combinations of penicillins including beta-lactamase inhibitors (mainlyco-amoxiclav), and penicillins with an extended spectrum (amoxicillin)and aminoglycosides.

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Figure 9: Antibacterial prescribing in neonatal and paediatric wards (%)

0.0

5.0

10.0

15.0

20.0

25.0

30.0

35.0

40.0

Neonatal Paediatric

Am

ingl

yco

sid

es

36.4

%

Be

ta-l

acta

mse

nsi

tive

pe

nci

llin

s30

.9%

Pro

po

rtio

no

fp

resc

rib

ing

(%)

Aminglycosides Beta-lactam sensitive pencillins

Third-generation cephalosporins Beta-lactam resistant pencillins

Combinations of pencillins, incl. beta-lactamse inhibitors Penicillins with extended spectrum

Macrolides Imidazole derivatives

Carbapenems Trimethoprim & derivatives

Combinations of sulphonamides & trimethoprim Glycopeptides

First-generation cephalosporins Second-generation cephalosporins

Steroid antibacterials

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Table 2 shows the 22 different antibacterial combinations prescribed.

51 of the 102 patients in this PPS that were prescribed antibacterialswere prescribed a combination of antibacterials (50%).

The most common antibacterial combination was an aminoglycoside(gentamicin) plus narrow spectrum penicillin (benzylpenicillin); thiscombination accounted for one third of antibacterial combinations.

Table 2: Antibacterial combinations (excluding TB therapy)Antimicrobial No.

Aminoglycoside & narrow spectrum penicillin 17

Broad spectrum penicillin & third generation cephalosporin 5

Third-generation cephalosporin & macrolide 4

Aminoglycoside & beta-lactam resistant penicillin 4

Narrow spectrum penicillin & beta-lactam resistant penicillin 3

Aminoglycoside & combinations of penicillins, incl. beta-lactamase inhibitors 2

Aminoglycoside, broad spectrum penicillin & beta-lactam resistant penicillin 1

Aminoglycoside, combinations of penicillins, incl. beta-lactamase inhibitors & imidazole 1

Aminoglycoside, beta-lactam resistant penicillin, carbapenem & macrolide 1

Aminoglycoside, imidazole derivative & macrolide 1

Aminoglycoside & third-generation cephalosporin 1

Aminoglycoside, beta-lactam resistant penicillin & third-generation cephalosporin 1

Aminoglycoside & carbapenem 1

Narrow spectrum penicillin, beta-lactam resistant penicillin & imidazole 1

Beta-lactam resistant penicillin & steroid antibacterial 1

Broad spectrum penicillin & macrolide 1

Combinations of penicillins, incl. beta-lactamase inhibitors & beta-lactam resistantpenicillin 1

First-generation cephalosporin & imidazole derivative 1

Second-generation cephalosporin & imidazole derivative 1

Third-generation cephalosporin & imidazole derivative 1

Third-generation cephalosporin & glycopeptide 1

Glycopeptide & rifampicin 1

Total numbers of patients prescribed antibacterial combinations 51

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REASON FOR TREATMENT

Table 3 shows the reason for antibacterial treatment/prophylaxis in paediatrics andneonates e.g. in paediatrics 16 of the 106 antibacterial prescribed were for thetreatment of bacterial lower respiratory tract infection (LRTI). For paediatrics, themost common reasons for treatment/prophylaxis were bacterial LRTI, prophylaxis formedical problems (e.g. chronic lung disease), skin soft tissue infections, and sepsis:Accounting for 57% of antibacterial prescribing in paediatrics.

For neonates, the most common reasons for antibacterial treatment/prophylaxiswere prophylaxis for maternal risk factors e.g. prolonged rupture of membranes,sepsis, and prophylaxis for newborn risk factors e.g. treatment for prematurenewborns: Accounting for 86% of antibacterial prescribing in neonates.

Table 3: Reason for treatmentPAEDIATRICSReason for treatment No. %

Bacterial LRTI 16 15

Prophylaxis for medical problems 16 15

Skin or soft tissue infections 15 14

Sepsis 14 13

URTI 9 8

Treatment for surgical disease 7 7

UTI (upper and lower) 7 7

Febrile neutropenia/Fever in oncologic patients 5 5

CNS infections 2 2

Catheter related blood stream infection (CRBSI) 2 2

GI tract infections 2 2

Joint/Bone infections 2 2

Lymphadenitis 2 2

Other/Unknown 2 2

Pyrexia of unknown origin 2 2

Total 106 100%

NEONATES

Reason for treatment No. %

Prophylaxis for maternal risk factors 18 33

Sepsis 17 31

Prophylaxis for newborn risk factors 12 22

Prophylaxis for medical problems 3 5

LRTI 2 4

Catheter related blood stream infection (CRBSI) 1 2

Joint/Bone infections 1 2

UTI (upper and lower) 1 2

Total 55 100%

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Figure 10 shows the 4 most common reasons for antibacterial treatment/prophylaxisin paediatrics by antibacterial group:

Bacterial LRTI (blue line) Prophylaxis for medical problems (red line) Sepsis (green line) Skin, soft tissue infection (purple line)

For the treatment of bacterial LRTI in paediatrics, third generation cephalosporins(cefotaxime, ceftazidime and ceftriaxone), combinations of penicillins including beta-lactamase inhibitors (co-amoxiclav), and penicillins with an extended spectrum(amoxicillin) accounted for 63% of prescribing.

For prophylaxis of medical problems in paediatrics prescribing was spread across anumber of antibacterial groups: as this category includes prophylaxis in children withsickle cell disease, urinary tract infection, immunosuppression, nephrotic syndrome,chronic lung disease, rheumatic fever etc. the group is too diverse to make anymeaningful conclusions.

For the treatment of sepsis in paediatric patients, third generation cephalosporins(cefotaxime and ceftriaxone), penicillins with extended spectrum (amoxicillin) andglycopeptides accounted for 86% of prescribing.

For the treatment of skin and soft tissue infections (SSTI) in paediatrics, beta-lactamase resistant penicillins (flucloxacillin), & beta-lactamase sensitive penicillins(benzyl penicillin & phenoxymethyl penicillin) accounted for 80% of prescribing.

Figure 10: Antibacterial prescribing for the most common reasons to treat inpaediatric patients (%)

0 10 20 30 40 50 60

Penicillins with extended spectrum

Beta-lactam sensitive pencillins

Beta-lactam resistant pencillins

Combinations of pencillins, incl. beta-lactamse…

Third-generation cephalosporins

Carbapenems

Trimethoprim & derivatives

Combinations of sulphonamides & trimethoprim

Macrolides

Aminglycosides

Glycopeptides

Imidazole derivatives

Proportion of AB prescribing (%)

Skin/Soft Tissue Infections Sepsis Prophylaxis for medical problems Bacterial LRTI

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Figure 11 shows the 3 most common reasons for antibacterial treatment/prophylaxisin neonates by antibacterial group:

Prophylaxis for maternal risk factors Sepsis Prophylaxis for new born risk factors

For prophylaxis for maternal risk factors (maternal fever during labour, prolongedrupture of membranes etc.) aminoglycosides (gentamicin), and beta-lactamasesensitive penicillins (benzyl penicillin) accounted for 100% of prescribing.

For the treatment of sepsis in neonates aminoglycosides (gentamicin), and beta-lactamase sensitive penicillins (benzyl penicillin), and beta-lactamase resistantpenicillins (flucloxacillin) accounted for 72% of prescribing.

For prophylaxis for new born risk factors (prophylaxis for premature newborns)aminoglycosides (gentamicin), and beta-lactamase sensitive penicillins (benzylpenicillin), and third generation cephalosporins (cefotaxime) accounted for 92% ofprescribing.

Figure 11: Antibacterial prescribing for the most common reasons to treat inneonatal patients (%)

0 10 20 30 40 50 60

Penicillins with extended spectrum

Beta-lactam sensitive pencillins

Beta-lactam resistant pencillins

Combinations of pencillins, incl. beta-lactamseinhibitors

Third-generation cephalosporins

Carbapenems

Aminglycosides

Glycopeptides

Proportion of AB prescribing (%)

Sepsis Prophylaxis for newborn risk factors Prophylaxis for maternal risk factors

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TYPE OF INDICATION

Figures 12 & 13 show the indication for prescribing in paediatrics and neonates. Inpaediatrics the most common indication for prescribing was treatment for acommunity acquired infection (75%), whilst in neonates the most common indicationwas medical prophylaxis (59%).

Figure 12: Indications for antibacterial prescribing in paediatric patients (%)

Figure 13: Indications for antibacterial prescribing in neonatal patients (%)

Communityacquired infection

75%

Hospital acquiredinfection

7%

Medical prophylaxis18%

Paediatric

Communityacquired infection

14%

Hospital acquiredinfection

27%Medical prophylaxis

59%

Neonatal

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Figures 14 show the types of hospital acquired infection (HAI) in paediatrics andneonates. In paediatrics the numbers were small and infections were relativelyevenly split across the four categories, whilst in neonates the most common type ofHAI was ‘other hospital infections, including VAP and CAPD’ (80%).

Figure 14: Types of HAI in paediatric and neonatal patients (%)

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10

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30

40

50

60

70

80

90

Neonatal Paediatric

Pro

po

rtio

no

fH

AI

typ

e(%

)

Post-operative infection

IV catheter intervention relatedinfections

Other hospital acquired infectionincluding VAP, CAPD

Infection present on admission

from another hospital

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VARIATION IN DOSING

Figures 15 the variation in gentamicin dosing for paediatric and neonatal patients;dosing is defined as (dose*times a day)/current weight of the child.

The mean dosing for the <1 month age group was 4.014 mg/kg/day, and the meandosing for the 2-17 year age group was 7.117 mg/kg/day.

For the < 1 age group dosing ranged from 2.9 mg/kg/day to 5.0 mg/kg/day, and forthe 2-17 year age group dosing ranged from 6.9 mg/kg/day to 7.5 mg/kg/day

This small data set shows a wide variation in dosing for gentamicin.

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APPENDIX

Table 1: Age group and Gender of patients prescribed antimicrobials

Hospital Female Male <1 month 2-23 months 2-17 years

Bronglais 1 1 1 1Glangwili 2 3 2 1 2Morriston 2 3 2 3Nevill Hall 2 3 1 2 2Prince Charles 1 2 3Princess of Wales 3 6 6 1 2Royal Glamorgan 2 3 1 4Royal Gwent Hospital 4 6 3 4 3Singleton 2 2 4University Hospital of Wales 9 23 10 7 15Withybush 3 1 2 1 1Wrexham Maelor 2 6 3 5Ysbyty Glan Clwyd 4 4 3 5Ysbyty Gwynedd 4 2 1 1Grand Total 41 63 41 19 44

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GLOSSARY

Indications

A Community Acquired Infection A3 – C. difficile associated diarrhoea

B Hospital Acquired Infection B1 – Post-operative infection B2 – Other intervention related infections B4 – Other hospital acquired infection B5 – Infection present on admission from another hospital

D Medical Prophylaxis

General Acronyms

ARPEC Antibiotic Resistance and Prescribing in European ChildrenATC Anatomical Therapeutic Chemical (ATC) classificationCAI Community Acquired InfectionCAPD Continuous Ambulatory Peritoneal DialysisGNWM General Neonatal Medical WardGPM General Paediatric MedicineHAI Hospital Acquired InfectionNICU Neonatal Intensive Care UnitPICU Paediatric intensive care unitPPS Point Prevalence SurveyPS Paediatric Surgery WardLRTI Lower Respiratory Tract InfectionSCBU Special Care Baby UnitSPM Haematology-Oncology Specialised Medical WardSSTI Skin, Soft issue InfectionsUTI Urinary Tract InfectionVAP Ventilator Associated Pneumonia

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PPS FORMS & INFORMATION

NEONATAL Ward Form

Please fill in one form for each ward included in PPS

Date of survey

Person completing form(Auditor code)

Hospital

Name Department/Ward

Department/Type:

Place a tick against the type ofdepartment

Neonatal departments

NICU-Level 1: Special care normal Neonatal Units

NICU-Level 2: Medium Neonatal Units. High dependencycare plus short term Intensive Care. Low BW newborns care.

NICU-Level 3: Large Neonatal Units. Tertiary referral care.Very low birth weight.

GNMW: General Neonatal Medical Ward.

Activity: Please tick asappropriate. Medicine Surgery Intensive Care

Total number of patients on theward present at 8.00 am day ofPPS by specialty.

Total number of beds on theward at 8:00 am day of PPS byspeciality

Include only patients admitted before 0:00 hours the day of the PPS.

Do not include patients admitted after 8 am on the day of the PPS.

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ANNEX 1: NEONATAL PATEINTS

UNDERLYING DIAGNOSES GROUPS: NEONATAL PATIENTS

(Select a maximum of 3 diagnoses out of the 14 categories below).

1. Maternal prolonged rupture of membranes (>18 hours before delivery) orsuspected or proven maternal peri-partum infection.

2. Intra Uterine Growth Retardation/Growth restriction.

3. Respiratory: Respiratory Distress Syndrome (RDS), Meconium aspirationsyndrome, Chronic Lung Disease (Oxygen-dependency beyond 28th day oflife). Persistent pulmonary hypertension of the newborn.

4. Cardiovascular: Congenital Heart Disease, including treated PDA.

5. Gastrointestinal: Necrotizing Enterocolitis.

6. Surgical problems/Malformation including all the malformations and surgicalproblems with the exception of NEC and CHD, e.g. Gut and CNSMalformations, Cleft Palate, Hydrocephalus [including post hemorrhagichydrocephalus], Ambiguous Genitals, etc.

7. Confirmed or suspected chromosomal/single gene/metabolic disorders.

8. Electrolyte/Glycaemia disorders including iatrogenic if requiring activemanagement.

9. Neonatal immune deficiency, including haematological malignancies.

10. Neurological conditions including neonatal seizures, severe asphyxia, hypoxic-ischaemic encephalopathy etc.

11. Haematological disease including indirect hyperbilirubinaemia requiringtreatment.

12. Toxicological problems, such as monitoring for neonatal abstinence syndrome.

13. Other/Unknown.

14. No underlying disease.

ANNEX 2: NEONATAL PATIENTS

LIST OF REASONS FOR TREATMENT, NEONATAL PATIENTS

(For each antimicrobial select only 1 out of the 17 categories below. If more categories are

possible, write the one most applicable.)

1. Treatment for Surgical disease: suspected or proven infection, except necrotizingenterocolitis (NEC).

2. Prophylaxis for Surgical disease: prevention of infection. Prophylaxis for any surgeryand ANY case in which antibiotics are used for prophylaxis and not to treat a suspectinfection for a surgical condition, etc.

3. Prophylaxis for Medical problems (but see 4. and 5. for newborn prophylaxis for earlyonset sepsis).

4. Newborn prophylaxis for maternal risk factors (maternal fever during labor, prolongedrupture of membranes etc.).

5. Newborn prophylaxis for newborn risk factors in the absence of maternal risk factors(prophylaxis treatment to premature newborns, etc.).

6. Decolonization for bacterial carriage, for example of MRSA on surface swabs

7. Sepsis (includes cases of presumed sepsis/bacteremia).

8. Presence of CVC infection = tunnel or exit site infection of a CVC with no positiveblood culture (if positive blood culture see 9).

9. Suspected or proven catheter related blood stream infection = CRBSI – without signsof skin infection.

10. Central Nervous System (CNS) infections (includes cases of presumedmeningitis/meningo-encephalitis).

11. LRTI (Includes all cases treated for onset of respiratory distress symptoms, increaseof respiratory rate, etc. unless clear alternative diagnosis applies).

12. Skin/Soft Tissue Infections.

13. Urinary Tract Infections (UTI).

14. Joint/Bone infections.

15. Cardiac Infections.

16. Abdominal or GI infections including NEC.

17. Other/Unknown.

ANNEX 3: NEONATAL & PAEDIATRIC PATIENTS

INDICATION CODES FOR NICU/GNMW PPS 2011

A Community acquired infection Symptoms or antibiotics start <48h after admission to hospital

B Hospital acquired infection

Symptoms or antibiotics start 48hafter admission to hospital

B1 Post-operative infection (within 30 days after surgery or

1 year after implant surgery)

B2 IV catheter intervention related infections

B4 Other hospital acquired infection including VAP and CAPD*

B5 Infection present on admission from another hospital

C Surgical prophylaxis** C1 Single dose C2 multiple doses within one day C3 >1 day

D Medical prophylaxis All medical prophylaxis

* VAP= ventilator Associated Pneumonia; CAPD= Continuous Ambulatory peritoneal dialysis

** For surgical patients, administration of prophylactic antimicrobials should be checked in the previous

24 hours in order to encode the duration of prophylaxis as either one dose, multiple doses given on one

day or >1 day.

Type of treatment – E versus T

Empirical treatment (E) = empiric – when the antibiotic is being used as per a localguideline – as a best guess - treatment by means which experience has proved tobe beneficial.

Targeted treatment (T) = based upon microbiological culture and/or sensitivitytesting, the action of the remedies given are directed against the cause of thedisease (e.g. positive blood or sputum culture).

Note down the information which is available at the time of survey (e.g. empirical evenwhen confirmation positive blood culture day after survey)

Ventilated – Note down the status at 8am on the day of the survey.

Inv.V = yes, invasive ventilation

NonInv.V = yes, non-invasive ventilation. These include continuous positive airwaypressure (CPAP), nasal continuous positive airflow pressure (nCPAP) and Bi-LevelPositive Airway Pressure (BiPAP)

No vent. = no ventilation

NEONATAL PATIENT FORM (Please fill in one form per patient on antimicrobial treatment)Ward

Name/codePatient

Identifier 1Survey

Number 2

Age

(in Days)

Gender

M or F

CurrentWeight

(in kg, 2 decimals)

Birth Weight(in kg, 2

decimals)

GestationalAge

(in weeks)

VentilatedInv.V / Non-Inv.V

No Vent.

UNDERLYING DIAGNOSES

(See Annex 1 for categories numbers)

Enter category numbers 1 to 15 – MAXIMUM of three categories can be entered.

Drug

(Antimicrobial name, generic orbranded)

SingleDose

3

Numeric

Unit

mg or IU

Dosesper day

4 Route5

P, O, R

Reason forTreatment

See Annex 2Enter category

Indication7

A, B1-B5,C1-C3 or D

TreatmentE=EmpiricalT = TargetedSee Annex 3

Reason innotes

(Yes/No)

Ceftriaxone 34 mg 1 P 8 A T Yes

1

2

3

4

5

1Enter the patient’s unique hospital number to allow local linkage to patient records for more detailed audit if required. This identifier will not be entered onto theelectronic database and is for internal use only.

2Survey Number: a unique but non-identifiable number given for each patient by the ARPEC WebPPS - please leave blank. But, note down this number after

patient has been recorded in the ARPEC online database!3”Single” dose per administration in mg or IU. For combination products, e.g. co-amoxiclav 125/31 mg (amoxicillin 125 mg + clavulanic acid 31 mg as potassium

salt) should be entered as 125 mg (see protocol).4Provide fractions of doses if necessary, e.g. every 16h = 1.5 doses per day, every 36h = 0.67 doses per day, every 48h = 0.5 doses per day

5Route of administration: P: Parenteral, O: Oral, R: Rectal, (Inhalation, Intrathecal, Intraperitoneal, Intramuscular = P); exclude topical use applied on skin.

6A = community acquired; B1 = hosp. acquired, post-operative infection; B2 = hosp. acquired, IV catheter related infection; B4 = other hospital acquired infection

including VAP & CAPD; B5 = infection present on admission from another hospital; C1 = surgical prophylaxis – single dose; C2 = surgical prophylaxis – multipledoses given in one day; C3 = surgical prophylaxis >1 day; D = medical prophylaxis: See protocol Annex 3.

PAEDIATRIC PATIENT FORM (Please fill in one form per patient on antimicrobial treatment)Ward

Name/codeActivity 1

(M, S or IC)

PatientIdentifier 2

SurveyNumber 3

Patient Age GenderM or F

Weight(in kg, 2

decimals)

VentilatedInv.V / Non-Inv.V /

No Vent.Years Months Days

UNDERLYING DIAGNOSES

(See Annex 4 for categories numbers)

Enter category numbers 1 to 14 – MAXIMUM of three categories can be entered.

Drug

(Antimicrobial name, generic orbranded)

SingleDose

4

Numeric

Unit

mg or IU

Dosesper day

5 Route6

P, O, R

Reason forTreatment

See Annex 5Enter category

Indication7

A, B1-B5, C1-C3 or D

TreatmentE=EmpiricalT = TargetedSee Annex 3

Reason innotes

(Yes/No)

Co-amoxiclav 125 mg 3 O 10 A E Yes

1

2

3

4

5

1Activity: specify only when the department is a mixed department (M: Medicine, S; Surgery, IC: Intensive care)

2Enter the patient’s unique hospital number to allow local linkage to patient records for more detailed audit if required. This identifier will not be entered onto theelectronic database and is for internal use only.

3Survey Number: a unique but non-identifiable number given for each patient by the ARPEC WebPPS - please leave blank. But, note down this number after

patient has been recorded in the ARPEC online database!4”Single” dose per administration in mg or IU. For combination products, e.g. co-amoxiclav 125/31 mg (amoxicillin 125 mg + clavulanic acid 31 mg as potassium

salt) should be entered as 125 mg (see protocol).5Provide fractions of doses if necessary, e.g. every 16h = 1.5 doses per day, every 36h = 0.67 doses per day, every 48h = 0.5 doses per day

6Route of administration: P: Parenteral, O: Oral, R: Rectal, (Inhalation, Intrathecal, Intraperitoneal, Intramuscular = P); exclude topical use applied on skin.

7A = community acquired; B1 = hosp. acquired, post-operative infection; B2 = hosp. acquired, IV catheter related infection; B4 = other hospital acquired infection

including VAP & CAPD; B5 = infection present on admission from another hospital; C1 = surgical prophylaxis – single dose; C2 = surgical prophylaxis – multipledoses given in one day; C3 = surgical prophylaxis >1 day; D = medical prophylaxis: See protocol Annex 3.

PAEDIATRIC Ward Form

Please fill in one form for each ward included in PPS

Date of survey

Person completing form(Auditor code)

Hospital

Name Department/Ward

Department/Type:Place a tick against the type ofdepartment

Paediatric departmentsGPMW (General Paediatric Medical Ward)

HO-SPMW (Haematology-Oncology Special PMW)

C-SPMW (Cardiology Special PMW)

T-SPMW (Transplant (BMT/Solid) Special PMW)

Other-SPMW (All other Special PMWs)

PSW (Paediatric Surgical Ward)

PICU (Paediatric Intensive Care Unit)

Mixed Department Yes No

Activity: Please tick as appropriate.In case of mixed departments, tick allthe encountered specialities Medicine Surgery Intensive Care

Total number of patients on theward present at 8.00 am day of PPSby specialty.

In case of mixed department, fill the totalnumber of patients corresponding toeach of the encountered specialities.

Total number of beds on the wardat 8:00 am day of PPS by speciality

For mixed departments fill in the totalnumber of beds corresponding to each ofthe encountered specialities.

Include only patients admitted before 0:00 hours the day of the PPS.

Do not include patients admitted after 8am on the day of the PPS.

ANNEX 4: PAEDIATRIC PATIENTS

UNDERLYING DIAGNOSES GROUPS: PAEDIATRIC PATIENTS

(Select a maximum of 3 diagnoses out of the 14 categories below).

1. Surgical disease/Malformations including all problems requiring surgical intervention/ follow

up, e.g. gut malformations/atresia, Urinary malformations, Sacral agenesis, Central Nervous

System malformations, skin anomalies treated surgically including abscesses, any device

insertion including gastrostomies, urinary catheter or Ventricular-peritoneal shunt, etc.

2. Chronic Neurological and Psychiatric disorders including Cerebral Palsy, Global

Developmental Delay (GDD), all seizure disorders (epilepsy, West syndrome, etc.),

progressive neurological and neuromuscular syndromes.

3. Gastroenterological disease including inflammatory bowel disorders, Gastro esophageal

reflux requiring treatment, Celiac disease, chronic non-infectious liver diseases, etc.

4. Congenital Heart Disease (CHD) including all the cardiac malformations and acquired cardiac

disease e.g. Kawasaki, and cardiac surgery

5. Oncologic/Hematologic diseases and Bone Marrow Transplantation except immune

deficiencies unless after bone marrow transplantation and all Solid Organ Transplantation.

6. Chronic Endocrinological Diseases including Cushing syndrome, thyroid disorders, pituitary

gland disorders, etc.

7. Chronic Renal Disease, including Vesico-ureteric reflux.

8. Chromosomal/Single gene/Metabolic disorders (diabetes).

9. Rheumatological, autoimmune and chronic inflammatory diseases such as LED, sarcoidosis

etc.

10.Chronic lung diseases including cystic fibrosis and chronic lung disease in ex preterm patients.

11.Chronic infectious diseases such as HIV, tuberculosis with ongoing treatment and chronic

hepatitis B or C infection or primary immunodeficiencies.

12.Allergies (only drug allergies and no other allergies).

13.Other/Unknown

14.No underlying disease

ANNEX 5: PAEDIATRIC PATIENTS

LIST OF REASONS FOR TREATMENT, PAEDIATRIC PATIENTS

(For each antimicrobial select only 1 out of the 20 categories below. If more categories

are possible, write the one most applicable.)

1. Treatment for Surgical disease: PROVEN OR SUSPECTED INFECTION e.g. peritonitis,

appendicitis, abscess, epdidymitis, ANY case of acute abdominal problem admitted under the

surgical team, mediastinitis, etc.

2. Prophylaxis for Surgical disease: PREVENTION OF AN INFECTION e.g. prophylaxis for any

surgery and ANY case in which antibiotics are used for prophylaxis and not to treat a suspect

infection for a surgical condition, etc.

3. Prophylaxis for Medical problems e.g. prophylaxis in people with sickle cell disease, urinary

tract infection, immunosuppression, nephritic/nephrotic syndrome, chronic lung disease,

chronic rheumatological diseases, rheumatic fever, etc.

4. Sepsis (includes cases of suspected Sepsis syndrome or presumed bacteremia/septicaemia).

5. Central Nervous System (CNS) infections (includes possible, probable and definitive

meningitis, encephalitis, meningo-encephalitis, myelitis, etc.).

6. Cardiac Infections including endocarditis, pericarditis, myocarditis, etc., but not endocarditis

prophylaxis during surgical procedures.

7. Upper Respiratory Tract Infections (URTI) including rhinitis, sinusitis, pharyngitis, tonsillitis,

adenoitidis, laryngitis, laryngo-tracheitis, epiglottitis, etc., but not acute otitis media (see

below).

8. Acute Otitis Media (AOM)

9. Proven or probable Viral Lower Respiratory Tract Infections (LRTI) including bronchitis,

bronchiolitis, etc.

10.Proven or probable Bacterial LRTI including pneumonia/empyema

11.Tuberculosis (TB).

12.Lymphadenitis unless requiring surgical intervention.

13.Urinary Tract Infections (UTI): Cystitis and pyelonephritis including urinary catheter-related

UTI.

14.Skin/Soft Tissue Infections including Staphylococcal Scalded Skin Syndrome, cellulitis,

folliculitis, etc.

15.Joint/Bone Infections including septic arthritis, osteomyelitis, etc.

16.Pyrexia of Unknown Origin (PUO) with exception of fever in oncologic patients and febrile

neutropenia.

17.Febrile neutropenia/Fever in oncologic patients.

18.GI tract infections including shigellosis, salmonellosis, giardiasis etc.

19.Probable or proven Catheter Related Blood Stream Infection (CRBSI).

20.Other/Unknown.