Appendix A: Human Antimicrobial Drug Use Report 2012/2013 – Methods for data collection and analysis

Appendix A – Methods for Data Collection and Analysis

Physician Diagnosis Data

The Canadian Disease and Therapeutic Index (CDTI) is a quarterly profile that provides information about the patterns and treatments of disease encountered by office-based physicians (specialists and general practitioners, including those with offices in hospitals). These data are presented over three geographic regions in Canada: West (British Columbia, Alberta, Saskatchewan, and Manitoba), Central (Québec and Ontario), and East (New Brunswick, Newfoundland and Labrador, Nova Scotia, and Prince Edward Island).

The sample of physicians represents all major specialties across Canada. Data from 652 physicians were available in 2013, and projection methods were used to extrapolate data to a universe of approximately 55,092 physicians in Canada. Data on physician prescription/recommendations were extracted from the IMS Health Canada database.

For four consecutive quarters, each physician in the CDTI group maintains a practice diary describing information on every patient visit during a randomly selected 48-hour period within the quarter. Information includes patient age and gender, reason for visit, diagnosis, name(s) of the treatment(s) recommended or discussed (including drugs, referrals, environmental, behavioural, or dietary changes, etc.), desired therapeutic effect(s), and the presence of concomitant therapies. If a patient presents to a doctor's office for multiple "diseases", the practitioner will generate one form for each disease. If a person visits multiple times for the same "disease", it is counted in the system separately every time. CDTI data were used to determine the most common diagnoses, defined by the International Classification of Diseases Ninth Revision System (ICD-9), and associated with antimicrobial drug mentions for sampled physicians.

The total number of antimicrobial recommendations and number of diagnoses per 10,000 individuals for a given year, age or region was obtained by dividing by the size of the population in thousands during that year, age group and region (Table A.1 and Table A.2).

Some limitations and caveats should be considered for assessing data from the CDTI dataset:

  • The drugs listed are those that the physician has written or recommended and do not represent actual prescriptions dispensed by pharmacists or products consumed by the patient, as information on patient compliance was not available.
  • Although diagnoses are listed for each visit, diagnoses are not necessarily made at the visit in question, as previous diagnoses are recorded for chronic conditions.
  • The data does not include patient visits to primary care nurses.
  • Visit counts do not translate into number of patients (multiple visits per individual are possible, as well as multiple diagnoses per individual)
  • Drug recommendations are not necessarily tied to a prescription, as samples may be given by the practitioner. Similarly, patients may choose not to fill a prescription.
  • Physicians also record drugs 'previously ordered and continued' for the diagnosis, which would not necessarily tie to a prescription dispensed.
  • Some drug therapy and diagnosis is under-represented due to self-medication (i.e. over-the-counter products).
  • Reliability of the data is dependent on sampling error, so caution should be taken when interpreting those disease categories with a small sample size.

Data is only available at the regional level, where fluctuations may be more or less obvious and specific information for individual provinces could not be determined.

Hospital Purchasing Data

The Canadian Drugstore and Hospital Purchases Audit (CDH) measures the dollar value and unit volume of pharmaceutical and diagnostic products purchased by nearly all Canadian retail pharmacy outlets and hospitals excluding those in the Yukon, Northwest Territories, and Nunavut. Information was collected from a representative sample of over 2,750 retail pharmacy outlets, and over 650 hospitals. A method of geographical projection was used to create projection factors for a "universe" of approximately 9,000 drugstores and over 750 hospitals to reflect all Canadian purchases (including non-participating stores). Data on drug purchases were extracted from the IMS Health Canada database, which included sales from manufacturers and wholesalers. For the purposes of this report, only data on hospital purchases were included in the analyses as pharmacy information was presented using the CompuScript data.

Only information regarding antimicrobials for systemic use was included in the analysis. Defined daily doses (DDDs) were determined according to the World Health Organization's Collaborating Centre for Drug Statistics Methodology. For erythromycin ethylsuccinate, all tablets were classified as erythromycin ethylsuccinate tablets (2g) and all forms other than tablets were classified as erythromycin (1g). For oral pediazole, the DDD for sulfonamides, combinations with other antibacterials (excl. trimethoprim) (2 g) was used. For oral administration of penicillin G, the DDD for benzylpenicillin by parenteral route (3.6 g) was used. Where a DDD was not available for both routes of administration, the available DDD was used (e.g., for benzylpenicillin, kanamycin).

The total amount of active ingredient was obtained by multiplying the number of extended units (real or corrected) by the strength of the product in grams. For combination drugs, the active ingredients of all antimicrobial components were summed to obtain the total number of active ingredients. However, the amount of active ingredient used in the calculation of the total number of DDDs for combination drugs included only the compounds from which the DDDs were derived. For example, for drugs composed of trimethoprim-sulfamethoxazole, only the total number of grams of sulfamethoxazole was used to compute the number of DDDs.
The total number of DDDs per 1,000 inhabitant-days for a given year was obtained by summing all DDDs for each antimicrobial drug and each year.

This number was further divided by the size of the population in thousands during that year, divided by the number of days in that year (365 or 366). The total number of active ingredients (kg) and total cost per 1,000 inhabitants (for oral and parenteral antimicrobials combined) was obtained by dividing the total number of active ingredients or the total cost by the population size in thousands for each year. The cost was then adjusted for inflation using the Bank of Canada Inflation Calculator Footnote 1. Population data were obtained from updated and preliminary post-census estimates based on the results of the 2001 Census. The use of metronidazole  was added in 2005.

The limitations and caveats that should be considered with the CDH dataset include the following:

  • The data is estimated and is not census data.
  • Limited tracking of specific niche markets (due to low volume and/or unique distribution).
  • A small number of products may be excluded due to confidentiality (if they are only sold in one outlet).
  • Some data may be excluded to reflect true market trends (i.e. large stockpiling transactions that occur prior to a potential epidemic).
  • Direct sales for a specific manufacturer may not be available leading to underestimation of a product (higher incidence in the hospital than in drug store purchases).
  • The provinces of Prince Edward Island and Newfoundland and Labrador were grouped due to the small volume within each province.
  • Changes made to the databases are made to the last 72 months only and outside the five year period it is considered a closed dataset as updates cannot be made.
  • Hospital patient days or number of hospital beds was not available for this data; general population information was used for developing rates of purchasing.

Data for CCS, CDH, and CDTI datasets were analyzed using SAS v. 9.3 (SAS Institute Inc., Cary, NC, USA) and Microsoft Excel 2010 (Microsoft Cor., Redmond, WA, USA).

Population sizes used for analysis of all datasets.

Table A.1: Population values for Canadian provinces in 2013
Province Population (000's)
2012 2013
British Columbia 4,599.8 4,638.2
Alberta 3,924.6 4,061.0
Saskatchewan 1,098.6 1,119.5
Manitoba 1,263.5 1,278.2
Ontario 13,564.0 13,688.6
Québec 8,182.6 8,255.5
New Brunswick 767.5 766.6
Nova Scotia 958.4 953.6
Prince Edward Island 147.2 147.3
Newfoundland and Labrador 534.3 534.3
Canada 35,040.5 35,442.9
Table A.2: Population values for age groups, by province in 2013
Province Population (000)
0-5 6-11 12-17 18-39 40-59 60-64 65+
British Columbia 267.2 268.7 302.8 1351.3 1345.6 294.0 808.6
Alberta 315.6 281.1 280.9 1373.0 1126.1 199.2 485.2
Saskatchewan 87.8 80.3 82.8 342.4 294.2 60.8 171.3
Manitoba 95.6 92.7 99.3 381.0 343.8 70.3 195.5
Ontario 864.3 873.9 958.5 4027.0 3966.7 789.6 2208.5
Québec 535.6 480.0 504.3 2392.7 2365.7 521.8 1455.4
New Brunswick 43.5 44.0 49.0 201.9 230.9 53.7 143.5
Nova Scotia 52.6 52.7 60.9 257.4 284.8 65.6 179.7
Prince Edward Island 8.9 9.2 10.3 38.4 43.2 10.1 27.1
Newfouldland and Labrador 29.4 30.8 33.0 138.7 164.8 40.0 97.6
Canada 2300.5 2213.4 2381.8 10503.8 10165.7 2105.2 5772.5

Appendix B – Additional Physician Diagnosis Data

Table B.1: Total number of office-based diagnoses, diagnosis rate, total number of antimicrobial recommendations, antimicrobial recommendation rate, and percentage of diagnoses with antimicrobial recommendations by office-based physicians in Canada, by diagnostic class, 2012Footnote 1
Diagnostic Class Total diagnoses Number of diagnoses
/ 10,000 inhabitants
Antimicrobial recommendations(N) Number of antimicrobial recommendations
/ 10,000 individuals
Percentage of diagnoses with antimicrobial recommendations
Acne 2,137,030 609.87 535,210 152.74 25.04
Acute bronchitis 2,547,010 726.88 1,961,240 559.71 77.00
Acute sinusitis 1,626,800 464.26 1,427,640 408.43 87.76
Chronic bronchitis 1,175,000 335.33 837,670 239.06 71.29
Chronic sinusitis 1,319,090 376.45 676,670 193.11 51.30
Disease of the gastrointestinal system 19,616,280 5,598.18 1,163,000 33.90 5.93
Diseases of the ear 9,054,310 2,583.96 2,425,050 692.07 26.78
Injuries and poisonings 13,093,100 3,736.56 419,120 119.61 3.20
Lower UTI or Cystitis 4,715,880 1,345.84 3,173,210 905.58 67.29
Other diseases of the genitourinary system 14,987,530 4,277.20 1,451,450 414.22 9.68
Other respiratory tract infections 16,063,670 4,584.32 1,059,120 302.26 6.59
Other skin and soft tissue infections 15,835,440 4,519.19 644,330 183.88 4.07
Pneumonia 1,443,120 411.84 1,184,910 338.15 82.11
SSTIs 2,731,830 779.62 1,780,290 508.07 65.17
Symptoms and ill-defined conditions 21,925,630 6,257.23 401,270 114.52 1.83
Upper respiratory tract infections 11,172,760 3,188.53 3,664,680 1,045.84 32.80
TOTAL 28,921,9210 8,2538.61 23,543,270 6,718.88 8.14
Footnote 1
1Data does not represent actual prescriptions dispensed by pharmacists or products consumed by the patient, as information on patient compliance was not available. Diagnosis does not represent the number of times a person visits, but represents every time a diagnosis is provided; if a person presents with multiple diseases each individual disease/diagnosis is recorded separately.

Diagnostic classes were removed from this table if they represented < 1% of antimicrobial mentions in 2013. These classes were: complications of pregnancy, childbirth, and puerperium; congenital anomalities; diseases of the central nervous system; diseases of the circulatory system; diseases of the sense organs; endocrine, nutritional, metabolic, and immunity diseases; musculoskeletal diseases; neoplasms; perinatal conditions; supplementary classifications; and upper UTI or pyelonephritis

Appendix C – Additional Pharmacy Dispensation Data

Table C.1: Anatomical Therapeutic Group (ATC) classification of antimicrobials used in Canada 2000 – 2013

Therapeutic Group ATC Class Antimicrobials
Aminoglycosides J01GA &
J01GB
amikacin
gentamicin
streptomycin
tobramycin
Amphenicols J01BA chloramphenicol
Beta-lactamase sensitive & resistant penicillins J01CE &
J01CF
cloxacillin
flucloxacillin
penicillin g
penicillin v
Carbapenems J01DH ertapenem
imipenem and cilastatin
meropenem
First-generation cephalosporins J01DB cefadroxil
cefazolin
cephalexin
Macrolides, lincosamides and streptogramins J01FA &
J01FF
azithromycin
clarithromycin
clindamycin
erythromycin
lincomycin
spiramycin
Methenamine J01XX methenamine mandelate
Other antibacterials J01X colistin
J01XX daptomycin
A07AA fidaxomicin
J01XX fosfomycin
J01XC fusidic acid
J01XX linezolid
J01XD metronidazole
J01XE nitrofurantoin
J01XA vancomycin
Therapeutic Group ATC Class Antimicrobials
Other cephalosporins and penems J01DD &
J01DE
cefepime
cefixime
cefotaxime
ceftazidime
ceftriaxone
Penicillins with extended spectrum J01CA amoxicillin
amoxicillin and enzyme inhibitor
ampicillin
piperacillin
piperacillin and tazobactam
ticarcillin and clavulanic acid
Quinolone antibacterials J01MA ciprofloxacin
levofloxacin
moxifloxacin
norfloxacin
ofloxacin
Second-generation cephalosporins J01DC cefaclor
cefoxitin
cefprozil
cefuroxime
Sulfonamides J01EC sulfadiazine
sulfamethoxazole
sulfamethoxazole and trimethoprim
Tetracyclines J01AA doxycycline
minocycline
tetracycline
tigecycline
Trimethoprim J01EA trimethoprim
Table C.2: Mass (kg) of active ingredient dispensed by retail pharmacies in Canada; oral antimicrobials (2000-2009), oral and parenteral antimicrobials (2010-2013)
Antimicrobial 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 RankFootnote *
Amoxicillin 53,614 52,547 50,610 50,700 49,441 51,585 52,318 52,402 53,862 55,080 57,380 62,915 61,327 61,685 1
Amoxicillin and enzyme inhibitor 7,148 7,296 7,113 7,470 7,470 8,389 8,931 9,744 10,512 10,989 9,660 12,894 13,877 15,424 4
Ampicillin 1,374 1,179 968 861 739 611 547 473 427 400 376 345 319 285 26
Azithromycin 1,788 2,208 2,504 2,825 2,667 2,911 2,873 2,799 2,865 2,912 2,878 3,811 3,826 3,251 12
Cefadroxil 546 599 641 695 707 730 821 875 926 983 874 779 1,049 1,151 21
Cefazolin                     161 237 286 1,018 22
Cefixime 441 413 372 321 275 282 275 303 322 338 422 458 493 554 25
Cefprozil 2,427 2,833 3,274 3,901 4,377 4,589 4,536 4,183 4,109 4,095 4,092 4,188 3,695 3,328 11
Ceftriaxone                     44 54 62 103 29
Cefuroxime 4,490 3,922 3,218 2,959 2,675 2,739 2,604 2,595 2,571 2,601 2,263 2,565 2,504 2,694 14
Cephalexin 16,148 16,697 17,717 18,988 19,606 20,855 22,160 22,479 23,123 22,635 22,384 24,258 24,867 25,875 2
Ciprofloxacin 12,754 12,005 11,843 12,319 12,618 12,943 13,817 14,426 14,693 14,270 14,741 15,220 14,850 14,235 6
Clarithromycin 12,402 12,693 12,060 12,833 12,724 14,490 15,251 16,125 16,552 16,935 16,727 17,635 16,748 14,572 5
Clindamycin 3,289 3,590 3,896 4,272 4,442 4,500 4,977 5,304 5,551 5,563 6,154 6,175 6,120 6,149 9
Cloxacillin 8,351 8,004 7,376 7,135 6,596 5,861 5,605 5,159 4,775 4,378 5,489 4,036 3,562 3,071 13
Doxycycline 844 819 797 815 818 862 929 1,027 1,116 1,164 1,396 1,541 1,657 1,789 17
Erythromycin 10,698 8,686 6,898 6,278 5,220 4,444 3,959 3,422 3,296 2,699 2,553 1,758 1,652 1,382 19
Levofloxacin 1,495 2,022 1,840 1,874 1,877 1,677 1,535 1,474 1,483 1,424 1,347 1,390 1,359 1,377 20
Metronidazole   4,808 4,927 5,127 5,238 5,311 5,564 5,588 5,789 5,921 6,349 6,395 6,528 6,645 8
Minocycline 2,177 2,250 2,317 2,388 2,396 2,429 2,469 2,440 2,462 2,345 2,543 2,454 2,218 2,102 15
Moxifloxacin 35 486 846 1,120 1,231 1,478 1,828 2,046 2,049 2,094 2,075 2,133 1,971 1,786 18
Nitrofurantoin 935 982 1,020 1,073 1,152 1,211 1,324 1,390 1,503 1,625 1,740 1,862 1,975 1,992 16
Norfloxacin 2,518 2,466 2,349 2,227 2,080 1,919 1,791 1,597 1,480 1,311 1,223 1,119 950 839 23
Penicillin V 15,199 14,363 13,831 13,906 13,037 13,377 13,308 13,056 12,663 12,492 11,579 10,194 9,727 9,038 7
Piperacillin and tazobactam                     239 247 204 697 24
Sulfamethoxazole and trimethoprim 29,691 26,988 24,482 22,972 20,493 18,856 18,520 18,102 18,154 18,208 18,187 18,079 16,903 16,713 3
Tetracycline 11,084 10,088 9,465 8,685 7,823 7,405 6,868 6,217 5,836 5,741 3,120 3,918 4,098 3,840 10
Trimethoprim 316 297 310 307 288 266 266 261 242 257 257 256 259 237 27
Vancomycin 26 28 32 41 70 79 76 84 85 88 193 213 188 231 28
TOTAL 208,984 205,654 196,701 197,214 190,648 193,974 196,013 195,644 197,731 197,508 197,185 207,773 203,720 202,581  
Footnote *
*Ranked from greatest to least mass of active ingredient dispensed in 2013.

Antimicrobials were removed from this table if they represented <0.05% of mass of active ingredient dispensed in 2013. These are: amikacin, bacampicillin, cefaclor, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftobiprole, cephradine, chloramphenicol, colistin, daptomycin, demeclocycline, dicloxacillin, ertapenem, erythromycin ethylsuccinate, fidaxomicin, flucloxacillin, fosfomycin, fusidic acid, gatifloxacin, gemifloxacin, gentamicin,grepafloxacin, imipenem and cilastatin, kanamycin, lincomycin, linezolid, meropenem, methenamine hippurate, methenamine mandelate, nalidixic acid, neomycin, ofloxacin, oxacillin, penicillin g, piperacillin, pivampicillin, pivmecillinam, spiramycin, streptomycin, sulfadiazine, sulfadiazine and trimethoprim, sulfamethizole, sulfamethoxazole, sulfapyridine, sulfisoxazole, sulfonamides, combinations with other antibacterials (excl. trimethoprim), telithromycin, ticarcillin and clavulanic acid, tigecycline, tobramycin, and trovafloxacin.

Table C.3: Prescriptions per 1,000 inhabitants of oral and parenteral antimicrobials dispensed by retail pharmacies in Canada, by province. 2012
Antimicrobial C.-B. Alb. Sask. Man. Ont. Qc N.-B. N.-É. I.-P.-É. T.-N.-L. RankFootnote *
Amoxicilline 141.35 178.84 236.37 186.62 188.57 99.12 150.73 168.80 161.62 262.68 1
Amoxicilline et inhibiteur enzymatique 21.37 30.36 21.48 26.70 18.78 31.74 24.96 25.42 71.68 49.54 8
Ampicilline 0.38 0.24 4.54 0.25 0.59 0.15 0.52 0.63 2.15 6.38 26
Azithromycine 29.81 52.17 73.27 84.93 70.44 52.08 76.48 57.36 65.04 83.07 4
Céfadroxil 0.09 0.19 0.01 0.05 0.19 12.53 0.66 0.09 0.00 0.02 23
Céfixime 6.42 8.62 2.34 3.39 5.78 5.20 4.05 5.79 11.92 9.73 19
Cefprozil 0.57 12.09 4.37 7.72 20.06 20.82 7.35 15.03 4.87 0.49 14
Céfuroxime 10.62 8.34 8.46 4.96 8.65 5.57 25.78 16.82 7.13 28.60 16
Céfalexine 59.57 62.16 98.50 65.44 53.21 15.90 57.65 64.12 62.76 77.14 5
Ciprofloxacine 59.12 61.70 52.36 59.02 48.81 80.99 50.25 50.74 57.23 122.44 3
Clarithromycine 55.32 71.73 40.38 36.78 63.73 61.51 67.14 51.90 66.98 93.65 2
Clindamycine 21.74 28.76 32.90 19.53 22.05 19.67 23.91 22.58 18.61 22.57 10
Cloxacilline 6.25 6.11 11.82 12.86 6.16 4.53 5.01 6.84 12.01 12.56 18
Doxycycline 26.91 19.21 52.74 14.13 11.66 10.66 18.46 28.68 28.19 21.80 12
Érythromycine 5.87 3.79 16.83 5.60 2.83 1.02 3.26 6.51 21.87 5.74 22
Lévofloxacine 1.55 11.53 2.55 14.33 10.83 7.96 2.53 10.03 7.62 2.83 17
Métronidazole 19.41 22.06 22.53 19.74 19.49 16.21 20.24 21.24 18.03 25.85 11
Minocycline 12.58 21.14 6.06 14.49 8.68 24.41 12.98 15.27 9.81 14.48 15
Moxifloxacine 13.88 10.11 12.58 6.43 13.95 25.05 20.50 10.53 25.84 13.85 13
Nitrofurantoïne 43.75 27.91 48.00 21.72 41.49 17.96 33.64 44.77 27.83 26.93 6
Norfloxacine 0.64 3.22 0.26 0.60 8.07 0.72 15.37 2.59 7.62 7.03 21
Pénicilline V 23.57 26.54 15.87 24.55 19.26 32.44 29.54 24.49 26.50 27.12 9
Sulfaméthoxazole et triméthoprime 28.04 30.12 52.33 38.60 29.04 20.92 38.14 44.97 50.62 49.15 7
Tétracycline 4.58 3.20 4.94 4.63 7.08 2.35 2.90 4.35 10.08 4.36 20
Triméthoprime 0.73 1.05 2.63 0.78 1.90 3.84 2.19 0.89 0.63 2.12 24
Vancomycine 0.66 0.36 0.36 0.27 0.34 2.11 0.66 0.70 0.46 0.22 25
TOTAL 595.63 702.33 825.61 674.84 683.00 579.78 700.15 704.22 779.58 972.23  
Footnote *
*Ranked from greatest to least prescribing in 2012.

Antimicrobials were removed from this table if they represented <0.05% of prescribing in 2012. These are: amikacin, cefaclor, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, chloramphenicol, colistin, daptomycin, ertapenem, erythromycin ethylsuccinate, fidaxomicin, fosfomycin, fusidic acid, gentamicin, imipenem and cilastatin, lincomycin, linezolid, meropenem, methenamine mandelate, ofloxacin, penicillin g, piperacillin, piperacillin and tazobactam, spiramycin, streptomycin, sulfadiazine, sulfamethoxazole, ticarcillin and clavulanic acid, tigecycline, and tobramycin.

Table C.4: Defined daily doses per 1,000 inhabitants of oral and parenteral antimicrobials dispensed by retail pharmacies in Canada, by province, 2012
Antimicrobial BC AB SK MB ON QC NB NS PEI NF RankFootnote *
Amoxicillin 4.03 5.17 6.62 5.62 5.44 3.28 4.92 5.13 4.84 8.11 1
Amoxicillin and enzyme inhibitor 0.76 1.05 0.70 0.99 0.70 1.17 0.99 0.96 2.28 1.74 7
Ampicillin 0.01 0.01 0.09 0.00 0.01 0.00 0.01 0.01 0.04 0.14 26
Azithromycin 0.72 0.98 1.16 1.33 1.20 0.74 1.13 0.86 0.79 1.24 5
Cefadroxil <0.01 <0.01 <0.01 <0.01 <0.01 0.16 0.01 <0.01 <0.01 <0.01 24
Cefixime 0.12 0.15 0.03 0.06 0.09 0.07 0.07 0.09 0.24 0.21 21
Cefprozil 0.01 0.23 0.06 0.14 0.37 0.43 0.14 0.29 0.08 0.01 16
Cefuroxime 0.45 0.36 0.33 0.21 0.37 0.25 1.26 0.76 0.29 1.36 12
Cephalexin 1.13 1.23 1.89 1.24 1.07 0.31 1.23 1.38 1.33 1.62 6
Ciprofloxacin 1.13 1.22 1.07 1.17 1.04 1.23 1.01 1.12 1.10 3.24 4
Clarithromycin 2.32 3.11 1.59 1.58 2.66 2.64 3.07 2.32 2.91 4.27 2
Clindamycin 0.38 0.52 0.60 0.37 0.38 0.35 0.47 0.41 0.36 0.42 11
Cloxacillin 0.13 0.13 0.25 0.28 0.14 0.10 0.14 0.15 0.25 0.28 19
Doxycycline 1.97 1.52 4.06 1.32 1.06 0.76 1.17 1.67 1.63 1.53 3
Erythromycin 0.18 0.14 0.45 0.17 0.11 0.04 0.11 0.21 0.64 0.20 20
Levofloxacin 0.04 0.29 0.06 0.34 0.27 0.19 0.07 0.23 0.18 0.08 18
Metronidazole 0.25 0.28 0.29 0.28 0.26 0.21 0.28 0.28 0.26 0.34 17
Minocycline 0.86 1.39 0.31 0.83 0.68 0.97 0.80 1.16 0.69 0.93 8
Moxifloxacin 0.32 0.26 0.27 0.16 0.35 0.59 0.50 0.26 0.65 0.33 13
Nitrofurantoin 0.96 0.69 1.18 0.55 0.93 0.36 0.86 1.11 0.80 0.78 9
Norfloxacin 0.01 0.07 0.01 0.02 0.17 0.01 0.35 0.07 0.16 0.21 22
Ofloxacin 0.01 0.01 <0.01 0.01 0.02 0.02 0.02 0.04 0.06 0.08 25
Penicillin V 0.38 0.44 0.28 0.36 0.30 0.48 0.48 0.40 0.54 0.47 14
Sulfamethoxazole and trimethoprim 0.61 0.67 0.95 0.73 0.53 0.32 0.73 0.83 1.02 1.11 10
Tetracycline 0.34 0.21 0.28 0.32 0.48 0.10 0.24 0.30 0.71 0.39 15
Trimethoprim 0.03 0.04 0.09 0.02 0.06 0.05 0.05 0.03 0.01 0.11 23
TOTAL 17.20 20.21 22.63 18.12 18.70 14.96 20.24 20.15 21.88 29.24  
Footnote *
*Ranked from greatest to least DDDs in 2012.

Antimicrobials were removed from this table if they represented <0.05% of prescribing in 2012. These are: amikacin, cefaclor, cefazolin, cefepime, cefotaxime, cefoxitin, ceftazidime, ceftriaxone, chloramphenicol, colistin, daptomycin, ertapenem, erythromycin ethylsuccinate, fidaxomicin, fosfomycin, fusidic acid, gentamicin, imipenem and cilastatin, lincomycin, linezolid, meropenem, methenamine mandelate, ofloxacin, penicillin g, piperacillin, piperacillin and tazobactam, spiramycin, streptomycin, sulfadiazine, sulfamethoxazole, ticarcillin and clavulanic acid, tigecycline, and tobramycin.

Figure C.1. Defined daily doses and cost per 1,000 inhabitant-days, by antimicrobial class and province, 2013

Figure C.1
Text equivalent for figure C.1
Antimicrobial Therapeutic Class BC AB SK MB ON QC NB NS PEI NL
Extended spectrum penicillins 5.01 6.52 7.67 6.38 6.10 4.52 6.09 6.59 6.98 10.70
Macrolides & lincosamides 3.23 4.13 3.56 3.11 3.61 3.40 3.98 3.71 3.98 5.46
Tetracyclines 3.27 3.14 4.49 2.47 2.16 1.89 2.34 3.47 2.87 2.85
Quinolone antibacterials 1.42 1.70 1.34 1.62 1.72 1.99 1.81 1.61 1.83 3.67
1st-gen cephalosporins 1.17 1.29 1.98 1.31 1.10 0.58 1.32 1.46 1.41 1.72
Other antibacterials 1.24 1.01 1.45 0.84 1.19 0.62 1.15 1.42 1.10 1.19
Sulfonamides 0.60 0.62 0.98 0.71 0.53 0.30 0.73 0.81 0.84 1.14
2nd-gen cephalosporins 0.51 0.54 0.40 0.32 0.75 0.63 1.63 1.01 0.25 1.42
Other penicillins 0.46 0.53 0.48 0.52 0.39 0.55 0.59 0.50 0.58 0.67
Cost / 1,000 inhabitant-days 47.69 53.59 60.78 51.07 50.01 55.54 57.53 57.87 55.26 78.21

Figure C.2. Cost per DDD dispensed by retail pharmacies in Canada, by province (oral antimicrobials 2000 – 2009, oral and parenteral antimicrobials 2010 – 2013)

Figure C.2.
Text equivalent for figure C.2
Province Cost per Defined Daily Dose
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013
BC 3.11 3.15 3.32 3.39 3.34 3.27 3.15 3.08 3.10 3.11 3.18 2.98 2.90 2.79
AB 3.55 3.56 3.56 3.56 3.56 3.51 3.28 3.20 3.23 3.21 3.36 3.18 2.97 2.72
SK 2.86 2.84 2.87 2.92 2.79 2.68 2.57 2.51 2.57 2.68 2.78 2.71 2.65 2.71
MB 2.96 2.99 3.08 3.17 3.24 3.15 3.06 3.05 3.19 3.17 3.20 3.03 3.00 2.94
ON 4.11 3.99 4.03 4.13 4.06 4.03 3.67 3.50 3.45 3.45 3.36 3.05 2.89 2.82
QC 4.63 4.70 4.87 4.82 4.75 4.61 4.36 4.14 3.89 3.84 3.92 3.68 3.57 3.79
NB 3.78 4.01 4.00 4.04 4.00 3.93 3.62 3.41 3.33 3.32 3.44 3.32 3.24 2.90
NS 3.83 3.90 3.89 3.96 3.79 3.68 3.42 3.27 3.27 3.30 3.32 3.09 2.89 2.79
PEI           3.29 3.25 3.14 3.17 3.10 3.11 3.11 2.91 2.75
PEI & NL 3.38 3.46 3.56 3.52 3.32                  
NL           3.16 3.06 3.03 3.04 3.10 3.10 3.01 2.84 2.68

Appendix D – Additional Hospital Purchasing Data

Table D.1: Kilograms of active ingredient purchased by hospitals in Canada, 2001- 2013
Antimicrobial 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 RankFootnote *
Amoxicillin 1,262.73 1,167.00 1,103.41 1,066.42 1,173.60 1,013.37 971.34 973.26 1,044.73 1,100.21 1,159.93 1,197.41 1,263.35 10
Amoxicillin and enzyme inhibitor 272.44 328.61 406.08 451.77 540.86 620.94 478.72 503.34 586.48 590.87 722.51 819.71 830.83 14
Ampicillin 2,275.11 1,341.79 1,295.13 1,318.27 2,050.84 2,210.65 1,357.88 1,118.16 1,056.24 988.52 982.71 953.45 947.68 13
Azithromycin 159.98 189.22 228.95 213.18 226.51 193.11 239.10 261.23 296.26 281.07 330.47 414.45 462.08 16
Cefadroxil 12.45 14.20 17.80 23.45 22.55 25.60 28.60 32.35 40.55 31.35 35.25 37.70 42.70 37
Cefazolin 3,927.45 4,228.99 4,278.14 4,128.03 4,151.53 3,896.28 4,428.73 4,570.26 4,864.67 4,589.91 4,575.73 4,691.44 4,060.75 5
Cefixime 36.78 39.46 35.86 24.04 28.32 29.68 37.16 42.55 53.93 57.10 72.61 95.15 97.04 28
Cefotaxime 593.37 628.39 731.14 765.77 782.82 847.58 838.68 567.25 545.93 317.48 286.02 255.05 195.22 21
Cefoxitin 7,653.08 11,208.45 12,789.57 12,594.00 10,113.11 9,756.92 9,705.48 8,560.82 10,350.01 7,870.20 7,797.13 6,257.71 4,614.48 3
Cefprozil 37.45 40.56 55.23 66.29 51.42 46.98 50.41 52.04 68.47 60.29 55.28 52.39 49.75 31
Ceftazidime 410.93 567.86 457.12 455.27 716.59 512.58 155.81 157.84 151.19 153.87 149.39 156.56 142.80 25
Ceftriaxone 272.36 438.53 615.62 722.56 789.33 843.65 999.33 1,215.56 1,499.93 1,528.40 2,942.70 9,146.01 16,794.88 2
Cefuroxime 1,089.74 916.64 730.68 616.70 554.66 386.42 347.27 298.97 297.41 226.61 257.25 232.23 223.04 19
Cephalexin 1,077.73 1,123.48 1,226.69 1,239.41 1,362.13 1,664.34 1,094.83 1,084.37 1,097.21 1,003.52 1,101.53 1,160.27 1,212.72 11
Ciprofloxacin 1,741.41 1,598.12 1,653.27 1,702.93 1,538.76 1,631.67 1,643.50 1,636.99 1,617.46 1,433.96 1,453.08 1,507.31 1,710.37 6
Clarithromycin 355.57 333.38 311.45 300.86 304.33 294.18 298.57 301.95 317.24 265.43 275.68 248.88 192.19 23
Clindamycin 604.30 588.49 556.90 515.76 547.73 866.25 919.12 907.78 919.97 857.34 882.35 867.61 1,413.53 8
Cloxacillin 1,626.03 1,550.90 1,517.02 1,454.70 1,413.03 1,336.41 1,311.96 1,256.98 1,396.81 1,243.30 1,329.25 1,329.24 1,292.02 9
Doxycycline 47.45 34.43 43.96 49.59 44.68 48.50 80.55 131.47 86.95 93.17 116.76 97.32 106.73 27
Ertapenem     0.80 8.38 20.35 33.89 43.04 64.27 86.45 102.15 143.79 167.09 183.08 24
Erythromycin 263.94 276.17 297.10 201.32 208.89 184.92 179.84 162.23 149.82 115.86 133.60 98.43 82.77 29
Gentamicin 88.41 72.14 53.52 34.70 49.82 91.12 88.95 78.21 68.12 63.98 59.54 57.36 47.85 32
Imipenem 301.09 936.85 1,083.44 215.78 296.05 265.70 278.19 254.51 261.83 242.36 793.08 1,359.70 1,103.93 12
Levofloxacin 458.34 484.23 456.58 412.38 366.77 315.89 312.81 317.94 349.00 302.70 337.08 319.98 307.28 17
Linezolid 3.97 10.73 13.22 15.39 24.60 27.18 33.57 39.74 44.07 39.22 41.07 48.22 44.41 33
Meropenem 142.66 246.43 243.12 261.20 227.46 355.53 400.38 457.76 548.19 538.70 558.06 546.10 591.24 15
Metronidazole 1,018.43 399.58 151.55 147.95 134.03 131.81 129.19 119.69 93.22 99.37 138.97 117.30 122.68 26
Moxifloxacin 22.13 49.42 83.88 174.51 260.60 351.58 374.02 375.16 378.35 331.27 329.58 307.01 257.35 18
Nitrofurantoin 50.21 57.58 58.91 67.74 70.77 71.73 69.92 66.99 67.81 77.14 85.07 85.83 81.50 30
Penicillin G 9,399.67 7,545.75 8,955.94 10,892.43 10,820.07 9,585.90 9,734.76 10,263.17 10,550.84 10,101.52 9,816.04 8,005.56 4,382.57 4
Penicillin V 502.00 595.70 618.66 544.61 505.85 534.06 292.51 315.65 359.91 220.94 403.77 239.56 218.07 20
Piperacillin and enzyme inhibitor 1,898.13 1,230.91 2,312.65 3,043.18 4,046.54 4,636.79 5,741.59 6,324.86 8,862.18 9,234.08 13,477.90 27,751.54 40,097.01 1
Sulfamethoxazole and trimethoprim 1,991.11 1,672.59 1,758.77 1,627.06 1,670.46 1,719.65 1,602.25 1,559.30 1,611.91 1,496.04 1,525.65 1,522.47 1,509.31 7
Tetracycline 107.75 104.65 89.23 77.08 75.10 73.30 89.73 87.58 95.03 40.45 49.53 46.43 43.28 35
Ticarcillin and enzyme inhibitor 1,106.35 2,490.13 2,209.10 925.15 876.93 1,003.16 920.27 967.73 757.74 717.90 310.54 122.69 42.82 36
Tobramycin 62.26 57.53 27.23 18.54 27.94 58.29 62.04 57.01 54.45 51.30 47.53 47.16 43.78 34
Vancomycin 1,982.13 3,237.72 859.70 235.89 266.05 188.14 164.14 175.93 227.34 228.61 304.30 262.04 194.94 22
TOTAL 44,156.45 46,947.12 48,747.87 47,897.84 47,211.50 46,488.19 45,997.73 45,558.15 51,053.92 46,866.71 53,255.74 70,792.27 85,148.84  
Footnote *
*Ranked from greatest to least mass of active ingredient purchased in 2013

Antimicrobials were removed from this table if they represented <0.05% of mass of active ingredient purchased in 2013. These are: amikacin, bacampicillin, cefaclor, cefepime, cefotetan, ceftizoxime, ceftobiprole, cephalothin, chloramphenicol, colistin, daptomycin, demeclocycline, doripenem, fosfomycin, gatifloxacin, gemifloxacin, lincomycin, methenamine hippurate, methenamine mandelate, minocycline, nalidixic acid, netilmicin, norfloxacin, ofloxacin, piperacillin, pivampicillin, pivmecillinam, quinupristin/dalfopristin, spiramycin, streptomycin, sulfadiazine, sulfadiazine and trimethoprim, sulfonamides, combinations with other antibacterials (excl. trimethoprim), telithromycin, tigecycline, trimethoprim, and trovafloxacin.

Table D.2: Defined daily doses per 1,000 inhabitants antimicrobials purchased by Canadian hospitals in 2012
Antimicrobial BC AB SK MB ON QC NB NS PEI & NL RankFootnote *
Amoxicillin 0.13 0.07 0.22 0.45 0.06 0.06 0.07 0.08 0.25 7
Amoxicillin and enzyme inhibitor 0.05 0.06 0.04 0.11 0.03 0.09 0.05 0.04 0.08 12
Ampicillin 0.03 0.03 0.03 0.04 0.04 0.05 0.03 0.04 0.01 18
Azithromycin 0.09 0.06 0.20 0.21 0.10 0.07 0.14 0.07 0.15 6
Cefadroxil   <0.01     <0.01 <0.01 <0.01     39
Cefazolin 0.13 0.17 0.18 0.14 0.09 0.13 0.10 0.15 0.14 5
Cefixime 0.03 0.03 0.08 0.02 0.02 <0.01 <0.01 <0.01 0.01 24
Cefotaxime 0.01 0.01 0.02 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 31
Cefoxitin 0.09 0.02 0.09 0.40 0.05 0.11 0.07 0.09 0.06 8
Cefprozil <0.01 <0.01 <0.01 <0.01 <0.01 0.01 <0.01 <0.01 <0.01 33
Ceftazidime <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.01 <0.01 37
Ceftriaxone 0.36 0.73 0.16 0.67 0.29 0.24 0.61 0.26 0.55 2
Cefuroxime 0.04 0.03 0.04 0.03 0.02 0.03 0.07 0.06 0.06 21
Cephalexin 0.05 0.04 0.05 0.21 0.04 0.02 0.04 0.05 0.08 15
Ciprofloxacin 0.10 0.12 0.11 0.14 0.10 0.21 0.20 0.22 0.19 4
Clarithromycin 0.06 0.05 0.05 0.04 0.02 0.04 0.04 0.04 0.09 17
Clindamycin 0.05 0.05 0.06 0.07 0.03 0.04 0.06 0.04 0.07 16
Cloxacillin 0.09 0.05 0.05 0.09 0.04 0.04 0.07 0.06 0.05 13
Daptomycin 0.01 0.00 0.00 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 35
Doxycycline 0.27 0.08 0.12 0.06 0.04 0.03 0.04 0.06 0.05 9
Ertapenem 0.03 0.02 0.01 0.01 <0.01 0.02 0.01 0.01 0.01 26
Erythromycin 0.02 0.01 0.03 0.03 <0.01 <0.01 <0.01 <0.01 0.02 29
Gentamicin 0.02 0.02 0.02 0.02 0.01 0.02 0.02 0.03 0.02 23
Imipenem <0.01 <0.01 <0.01 <0.01 <0.01 0.05 <0.01 0.49 0.14 20
Levofloxacin 0.02 0.09 0.03 0.11 0.05 0.03 0.04 0.09 0.02 14
Linezolid <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 36
Meropenem 0.03 0.01 0.02 0.02 0.02 0.03 0.02 0.01 0.02 22
Metronidazole <0.01 <0.01 <0.01 <0.01 <0.01 0.02 <0.01 0.04 <0.01 30
Minocycline 0.00 0.00 0.01 0.02 <0.01 <0.01 <0.01 <0.01 <0.01 32
Moxifloxacin 0.07 0.03 0.10 0.02 0.04 0.09 0.09 0.07 0.14 11
Nitrofurantoin 0.07 0.03 0.06 0.09 0.02 0.02 0.02 0.03 0.06 19
Norfloxacin <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 38
Penicillin G 1.45 1.17 1.18 1.21 1.11 0.68 0.94 0.70 0.50 1
Penicillin V 0.02 <0.01 0.01 0.05 <0.01 <0.01 <0.01 <0.01 0.02 28
Piperacillin and enzyme inhibitor 0.08 0.06 0.09 0.15 0.18 0.13 0.32 0.15 0.19 3
Sulfamethoxazole and trimethoprim 0.09 0.06 0.07 0.19 0.04 0.05 0.04 0.08 0.11 10
Tetracycline <0.01 <0.01 0.01 0.02 <0.01 <0.01 <0.01 <0.01 <0.01 34
Vancomycin <0.01 <0.01 <0.01 <0.01 <0.01 0.03 0.00 0.03 0.11 27
TOTAL 3.51 3.16 3.17 4.65 2.50 2.42 3.15 3.06 3.27  
Footnote *
*Ranked from greatest to least DDDs at the national level in 2012

Antimicrobials were removed from this table if they represented <0.05% of DDDs in 2012. These are: amikacin, cefaclor, cefepime, chloramphenicol, colistin, doripenem, fosfomycin, lincomycin, methenamine mandelate, ofloxacin, piperacillin, spiramycin, streptomycin, ticarcillin and enzyme inhibitor, tigecycline, and trimethoprim.

Table D.3: Mass of active ingredient (kg) per 1,000 inhabitants of antimicrobials purchased by Canadian hospitals in 2012
Antimicrobial BC AB SK MB ON QC NB NS PEI & NL RankFootnote *
Amoxicillin 0.05 0.03 0.08 0.16 0.02 0.02 0.03 0.03 0.09 10
Amoxicillin and enzyme inhibitor 0.02 0.02 0.02 0.05 0.01 0.04 0.02 0.02 0.04 14
Ampicillin 0.02 0.02 0.02 0.03 0.03 0.03 0.02 0.03 <0.01 12
Azithromycin 0.01 <0.01 0.02 0.02 0.01 0.01 0.02 <0.01 0.02 16
Cefadroxil   <0.01     <0.01 <0.01 <0.01     38
Cefazolin 0.14 0.19 0.20 0.16 0.10 0.14 0.11 0.17 0.16 5
Cefepime <0.01 <0.01 <0.01   <0.01 <0.01 <0.01 <0.01 <0.01 39
Cefixime <0.01 <0.01 0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 30
Cefotaxime <0.01 <0.01 0.03 <0.01 <0.01 <0.01 <0.01 0.01 0.01 20
Cefoxitin 0.19 0.03 0.21 0.88 0.11 0.24 0.16 0.21 0.12 4
Cefprozil <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 33
Ceftazidime <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.01 0.02 <0.01 25
Ceftriaxone 0.26 0.53 0.12 0.49 0.21 0.17 0.45 0.19 0.41 2
Cefuroxime <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.01 0.02 0.01 23
Cephalexin 0.04 0.03 0.04 0.16 0.03 0.02 0.03 0.04 0.06 11
Ciprofloxacin 0.04 0.04 0.04 0.05 0.03 0.06 0.06 0.06 0.06 7
Clarithromycin 0.01 <0.01 0.01 <0.01 <0.01 <0.01 <0.01 0.01 0.02 21
Clindamycin 0.03 0.03 0.04 0.04 0.02 0.03 0.03 0.03 0.04 13
Cloxacillin 0.06 0.03 0.03 0.06 0.03 0.03 0.05 0.04 0.03 9
Doxycycline <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 29
Ertapenem 0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 24
Erythromycin <0.01 <0.01 0.01 0.01 <0.01 <0.01 <0.01 <0.01 <0.01 28
Gentamicin <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 32
Imipenem 0.01 <0.01 <0.01 <0.01 <0.01 0.06 <0.01 0.72 0.20 8
Levofloxacin <0.01 0.02 <0.01 0.02 <0.01 <0.01 <0.01 0.02 <0.01 17
Linezolid <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 35
Meropenem 0.02 0.01 0.01 0.02 0.01 0.02 0.01 <0.01 0.01 15
Metronidazole 0.00 <0.01 <0.01 <0.01 <0.01 0.01 <0.01 0.02 <0.01 27
Moxifloxacin 0.01 <0.01 0.02 <0.01 <0.01 0.01 0.01 0.01 0.02 18
Nitrofurantoin <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 0.00 <0.01 31
Penicillin G 0.32 0.26 0.26 0.27 0.24 0.15 0.21 0.15 0.11 3
Penicillin V 0.01 <0.01 0.01 0.03 <0.01 <0.01 <0.01 <0.01 0.02 22
Piperacillin <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 <0.01 34
Piperacillin and enzyme inhibitor 0.43 0.35 0.50 0.89 1.02 0.72 1.85 0.84 1.09 1
Sulfamethoxazole and trimethoprim 0.06 0.04 0.05 0.13 0.03 0.04 0.03 0.06 0.08 6
Ticarcillin and enzyme inhibitor <0.01 <0.01     <0.01 0.01 <0.01 <0.01 <0.01 26
Vancomycin <0.01 <0.01 <0.01 <0.01 <0.01 0.02 <0.01 0.02 0.08 19
TOTAL 1.82 1.72 1.76 3.54 1.97 1.91 3.18 2.74 2.74  
Footnote *
*Ranked from greatest to least mass of active ingredient purchased at the national level in 2012

Antimicrobials were removed from this table if they represented <0.05% of mass of active ingredient purchased in 2012. These are: amikacin, cefaclor, chloramphenicol, colistin, daptomycin, doripenem, fosfomycin, lincomycin, methenamine mandelate, minocycline, norfloxacin, ofloxacin, spiramycin, streptomycin, tigecycline, and trimethoprim.

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