Page 5: Human Antimicrobial Use Report – 2014 - Community Dispensing Data

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Community Dispensing Data

The Canadian CompuScript (CCS) dataset tracks the number and size of prescriptions dispensed by community pharmacies in Canada. In 2014, 5,984 pharmacies provided information which was used to project the total number and size of prescriptions dispensed by all 9,406 pharmacies across Canadian provinces. Prescription information for the Yukon, Northwest Territories and Nunavut are not included due to their low volumes and distinct prescribing trends. Information captured in this dataset includes product name, form, strength, province, age or age groups, number of prescriptions, units of product in prescription, and dollars spent monthly for each year.  This dataset is the base data purchased from IMS Health Canada Inc. for analyses performed by the Government of Canada and presented here.

In 2014, outpatient dispensation data were obtained from the First Nations and Inuit Health Branch (FNIHB) of Health Canada. These data describe antimicrobial dispensations through community pharmacies claimed to the Non-Insured Health Benefits (NIHB) program, which is accessible to First Nations and Inuit peoples in Canada. Antibiotic use data from NIHB-covered populations in the Yukon, Northwest Territories and Nunavut were compiled and added to the analyses to provide a more fulsome picture of antimicrobial use in Canada.

Antimicrobials for parenteral administration were added for the years 2010 through 2014. These data were not available to be added for 2000 – 2009. As such, when comparing data from 2010 – 2014 to previous years, it should be assumed that the data from 2000 – 2009 are a slight under-representation of the total volume dispensed. Therefore, any reductions seen in comparison to data from 2000 - 2009 are expected to be smaller than the actual state, and conversely, increases are expected to be slightly inflated.

National utilization

Overall measures of use

On average, 65% of Canadians filled a prescription for an antibiotic in 2014 (Figure 2.1). This use represented $682 million spent in 2014, a slight increase compared to 2013 (Appendix B, Tables B.1 and B.2).  These prescriptions delivered a total of 202,599 kilograms of antimicrobials through community pharmacies in Canada in 2014 (Appendix B, Table B.3).

Community antimicrobial use at the national level remained stable between 2013 and 2014, by DDDs and prescriptions per inhabitant as well as by DDDs per prescription (Figure 2.1). Both DDDs and prescriptions per inhabitant in 2013 and 2014 were at the lowest they have been since the initiation of antimicrobial use surveillance in 2000 (Figure 2.1) and compared to Canadian data from 1995^{Footnote 1}.

Use by age groups

1. Children and young adults (≤ 14 years old)
   In 2014, approximately 63% of children aged 0-14 received an antimicrobial prescription (Figure 2.2). This has remained stable between 2013 and 2014 following a decline from 2011 to 2013.
2. Adults (15-59 years old)
   Fewer adults aged 15-59 in 2014 received an antimicrobial prescription than those aged 0-14 years (children and young adults) (Figure 2.2). For every 100 inhabitants, 58 adults received an antimicrobial prescription in 2014. This has declined slightly since 2011 (from 61 out of 100).
3. Seniors (≥60 years old)
   Antimicrobial prescribing to seniors was higher than prescribing to either of the younger age groups (Figure 2.2). In 2014, on average 86% of seniors received an antimicrobial prescription. Interestingly, although declines in prescribing were seen from 2011 to 2014 for the younger age groups, these declines were not visible in the seniors age group. 
4. DDDs and prescriptions in adults and seniors
   The DDDs and prescriptions per inhabitant measures in Figure 2.2 display that seniors received more antimicrobial prescriptions from 2010 to 2014 compared to the other age groups. However, adults (15-59) received more doses per prescription (approximately 11 days of treatment per prescription for adults, as compared to 10 days of treatment for seniors). This may be due to the elderly receiving lower doses for treatment as a result of declining renal function.

National prescribing at the individual drug level

The most commonly dispensed antimicrobial in 2014 from Canadian community pharmacies was amoxicillin, with approximately 17 of every 100 inhabitants receiving a prescription for this product (Table 2.1). The next most commonly dispensed antimicrobials were azithromycin, ciprofloxacin, and cephalexin, each with 5-6 prescriptions nationally for every 100 inhabitants in 2014. Among the top 29 antimicrobials (which reflect 99.5% of prescriptions in 2014), three were DIRI products: moxifloxacin, fosfomycin, and ertapenem. Combined, these products represented 2.3% of the prescriptions dispensed at the community level.

Among the most commonly dispensed antimicrobials, trends in the prescribing rate are displayed in Figure 2.3. For amoxicillin, since 2004, an overall increase of just over 1 prescription for every 100 inhabitants has occurred; however, use fluctuates from year to year. A decline in the use of clarithromycin has occurred since 2011, resulting in approximately 2 less prescriptions for every 100 inhabitants. In contrast, a slow, steady increase in the use of nitrofurantoin since 2004 has resulted in an increase of approximately 2 prescriptions for every 100 inhabitants.

National doses at the individual drug level

If antimicrobial use among Canadians was perfectly equal, for every individual, approximately 6.5 defined daily doses of antimicrobial were dispensed from Canadian pharmacies in 2014 (Table 2.2). When broken down to individual drug products, a large proportion (29%) of these defined daily doses can be attributed to the use of amoxicillin. Clarithromycin, doxycycline, and amoxicillin with enzyme inhibitor were also products in 2014 with high numbers of defined daily doses dispensed.

Patterns in the number of defined daily doses dispensed per inhabitant for the antimicrobials with the highest number of DDDs dispensed in 2014 are displayed in Figure 2.4. Patterns over time in the DDDs dispensed appear to follow trends seen in the patterns of prescribing for these products over time (Figure 2.3). Interestingly, doxycycline is among the antimicrobials with the highest DDDs dispensed, where it is not seen among these top antimicrobials for prescribing. However this is expected as this is a product for which longer treatment durations are prescribed compared to other high use products. In order to look at this in more depth and to look at any potential temporal changes, all products displayed in Figures 2.3 and 2.4 were added to Figure 2.5, which displays the number of DDDs dispensed per prescription for these products over time.

National average defined daily doses per prescription at the individual drug level

The average number of DDDs per prescription provides a metric for assessing if the dose or duration of treatment is increasing for particular antimicrobials over time. It should be noted that an increase in this metric does not suggest that there is an issue with the use of this product, as prudent use guidelines for many common infections indicate that longer durations of treatment are required.

The number of DDDs dispensed per prescription for the antimicrobials with the highest prescribing and DDDs dispensed in 2014 are displayed in Figure 2.5. Slight increases over time have occurred for clarithromycin, amoxicillin and enzyme inhibitor, amoxicillin, and azithromycin. Slight declines have been seen for nitrofurantoin and sulfamethoxazole with trimethoprim. Doxycycline is highlighted as an antimicrobial with much higher DDDs per prescription than other antimicrobials, which is expected to reflect long-term use of this product for treating acne.

Use by route of administration

The majority of antimicrobials used in the Canadian outpatient population in 2014 were drugs for oral administration; more than 214 prescriptions and 237 DDDs of oral antimicrobials are dispensed for each parenteral antimicrobial prescription at the national level (Table 2.4). The particular antimicrobials dispensed differed based upon the route of administration.

In order to reduce costs in the hospital setting, there has been a move in recent years to treating ambulatory patients at home with parenteral antimicrobials, rather than admitting these inhabitants as patients. Due to this movement, there has been interest in looking at the amount parenteral antimicrobials purchased by hospitals and dispensed by community pharmacies together. These data are presented in Figure 2.6. In 2014, 10% of antimicrobials for parenteral administration in Canada were dispensed by community pharmacies. This was an increase from 7% in 2013 and approximately doubling the proportion dispensed by community pharmacies from 2010 to 2014.

Provincial variation

Overall measures of use

In 2014, Newfoundland and Labrador continues to display much higher prescribing rates than the remaining provinces; with > 20% higher prescribing than the province with the next highest rate (Saskatchewan) (Figure 2.7). In 2014, 0.98 prescriptions per inhabitant were dispensed in Newfoundland and Labrador (Figure 2.8). In other words, 98 out of every 100 inhabitants received an antimicrobial prescription. This is consistent with prior prescribing observed in Newfoundland and Labrador and represents a reduction of 3 prescriptions for every 100 inhabitants since the high of 1.01 prescriptions/inhabitant seen in both 2007 and 2008.

In contrast, prescribing in British Columbia was lowest of all provinces in 2014 (Figure 2.7). This is a change from previous years of surveillance, where Québec has held the lowest prescribing. British Columbia has seen a decline in prescribing from 2008 – 2014 of 8 prescriptions for every 100 inhabitants, where prescribing in Québec has slightly increased by 5 prescriptions for every 100 inhabitants during this time (Figure 2.8).

Although the population included in the Territorial data is restricted to those covered under the Non-Insured Health Benefits program, a steady decline has been observed in the total number of prescriptions per inhabitant between 2004 and 2014. This decrease is approximately 1 prescriptions for every 10 inhabitants (Figure 2.7).

Similar to the prescription rates, the DDDs per inhabitant were highest in Newfoundland and Labrador in 2014; following the trend seen in all previous years of surveillance (Figures 2.8). DDDs in Newfoundland and Labrador in 2014 were > 33% higher than the next highest province (Saskatchewan). In contrast to the prescription rates, DDDs in Québec remained the lowest of all provinces in 2014, while higher than in the territories. DDDs in British Columbia have declined slightly from 2011 to 2014; however, they remain approximately 13% higher than Québec. This suggests that although prescription rates in British Columbia have been declining, these prescriptions are for higher strengths or longer durations. This function is expected to reflect an attention to guidelines for appropriate antimicrobial treatment, which describe that when antimicrobial treatment is required, stronger doses and longer durations of treatment may be more prudent for reducing the probability for selecting for resistant bacteria.

Use at individual level

A considerable amount of variation in antimicrobial prescribing occurred among the provinces at the individual drug level, particularly for the highest use products. For example, although the prescription rate was highest for amoxicillin among all provinces (Table 2.5), prescribing varied from 1 prescription for every 10 inhabitants in Québec to a high of 3 prescriptions for every 10 inhabitants in Newfoundland and Labrador (Table 2.5). Similarly, cephalexin prescribing was approximately 2 prescriptions per 100 inhabitants in Québec, while Saskatchewan had 10 prescriptions for every 100 inhabitants. Ciprofloxacin, azithromycin, and doxycycline also displayed high variability across the provinces in 2014. In contrast, products with lower use (ceftriaxone, fosfomycin, cefazolin, ertapenem, vancomycin) displayed less variation in use among the provinces. It is interesting to note that while Québec displayed the lowest use of many of the drugs commonly used at the national level, Québec had the highest use of many products used infrequently at the national level (ertapenem, cefazolin, ceftriaxone, vancomycin, trimethoprim).

For the DIRI, prescribing of moxifloxacin was highest in Québec and lowest in Manitoba, fosfomycin highest in British Columbia and lowest in PEI, and ertapenem use was highest in Nova Scotia but not used in Saskatchewan, PEI, or the territories.

Variation in the DDDs dispensed at the individual drug level occurred among the provinces (Table 2.6). The greatest variation in DDDs in 2014 occurred for amoxicillin (high of 3.4 DDDs per inhabitant in Newfoundland and Labrador and low of 1.3 DDDs per inhabitant in Québec), doxycycline (high of 1.5 DDDs per inhabitant in Saskatchewan and low of 1 DDD for every 3 inhabitants in Québec), and ciprofloxacin (1 DDD per inhabitant in Newfoundland and Labrador, and 1 DDD for every 3 inhabitants in New Brunswick).

For the DIRI, DDDs of moxifloxacin per inhabitant were highest in Québec and lowest in the territories. Tobramycin DDDs were highest in Newfoundland and Labrador and lowest in the territories (no use) (Table 2.6).

Use by route of administration

The majority of antimicrobials used in the Canadian outpatient population are drugs for oral administration (Table 2.7). When viewed at the provincial level, the variation in use of oral and parenteral antimicrobials differed among the provinces. In 2014, British Columbia dispensed the lowest proportion (<0.04%) of parenteral antimicrobials out of all antimicrobials dispensed from community pharmacies. In contrast, the proportion of parenteral antimicrobials dispensed from community pharmacies in Québec was 1.01% in 2014.

There are large differences between provinces in the rate of prescriptions filled for parenteral antimicrobials (Figure 2.9). Three provinces (Québec, New Brunswick, and Nova Scotia) have much higher rates than the other provinces or territories. These differences in magnitude are likely a reflection of differences in policy with respect to payment for outpatient parenteral antimicrobials. Antimicrobials that are dispensed (and paid for) through hospitals are not represented in these data. Over the last 5 years there has been a steady increase in dispensing of parenteral antimicrobials that is likely a reflection of increasing antimicrobial resistance with concomitant decreases of effective oral therapies.

References

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