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Chapter 3: Human Antimicrobial Drug Use Report 2012/2013 – Hospital purchasing data

Table of Contents

Contributors

Executive Summary

List of Figures

List of Tables

What's New in the 2012/2013 Report

1. Physician Diagnosis Data

2. Pharmacy Dispensation Data

3. Hospital Purchasing Data

Appendix A – Methods for Data Collection and Analysis

Appendix B – Additional Physician Diagnosis Data

Appendix C – Additional Pharmacy Dispensation Data

Appendix D – Additional Hospital Purchasing Data

Table of Contents

3. Hospital Purchasing Data

National Purchasing

Overall measures

The three measures of hospital antimicrobial purchasing in Canada displayed different patterns over the period of surveillance 2001 – 2013. A slight decrease in DIDs occurred overall, and the DID value seen in 2013 was lower than in any previous year (2.69 DIDs). A decline in the cost per 1,000 inhabitants has also occurred over the 2001 – 2013 time frame, with a quite dramatic decline from 2007 to 2013 ($5,659 / 1,000 inhabitants to $2,869 /1,000 inhabitants). In contrast, following a period of relative stability 2001 – 2010, the kilograms of active antimicrobial ingredient purchased by hospitals increased dramatically from 2010 to 2013 (1.37 kg / 1,000 inhabitants to 2.40 kg / 1,000 inhabitants, a 75% increase).

Figure 3.1: DIDs, kilograms of active ingredient, and cost per 1,000 inhabitants of antimicrobials purchased by Canadian hospitals, 2001 – 2013.

Text equivalent for figure 3.1

DIDs, kilograms of active ingredient, and cost per 1,000 inhabitants of antimicrobials purchased by Canadian hospitals, 2001 – 2013

Measure of use

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

DIDs

2.97

2.71

2.84

3.01

3.00

2.83

2.79

2.83

2.91

2.70

2.80

2.83

2.69

Kilograms of active ingredient per 1000 inhabitants

1.42

1.49

1.53

1.49

1.46

1.42

1.39

1.36

1.51

1.37

1.54

2.02

2.40

Cost per 1000 inhabitants

5110

5401

5552

5384

5503

5659

5453

4389

4227

3658

3566

3343

2869

Individual drug purchasing

a. Defined daily doses per 1,000 inhabitant-days (DIDs)

The antimicrobials with the greatest DIDs in 2013 were ceftriaxone (0.65 DIDs), penicillin g (0.56 DIDs), and piperacillin with enzyme inhibitor (0.20 DIDs). From 2010 – 2013, there were large increases among the DIDs for ceftriaxone and piperacillin with enzyme inhibitor. In contrast, the use of penicillin g decreased by > 60% between 2009 and 2013 (1.42 to 0.56 DIDs) (Table 3.1, Figure 3.2).

Table 3.1: DIDs for antimicrobials purchased by hospitals in Canada, 2001 - 2013

Antimicrobial

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Amoxicillin

0.11

0.10

0.09

0.10

0.08

0.09

0.10

Amoxicillin and enzyme inhibitor

0.02

0.03

0.04

0.03

0.04

0.05

Ampicillin

0.10

0.06

0.09

0.06

0.05

0.04

Azithromycin

0.05

0.06

0.05

0.06

0.07

0.08

0.07

0.08

0.10

Cefadroxil

<0.01

Cefazolin

0.12

0.11

0.12

0.13

0.12

0.10

Cefepime

<0.01

0.01

0.03

0.01

<0.01

Cefixime

0.01

0.02

Cefotaxime

0.01

0.02

0.01

<0.01

Cefoxitin

0.11

0.16

0.18

0.14

0.13

0.12

0.14

0.10

0.08

0.06

Cefprozil

<0.01

0.01

<0.01

0.01

<0.01

Ceftazidime

0.01

0.02

0.01

<0.01

Ceftriaxone

0.01

0.02

0.03

0.04

0.05

0.06

0.12

0.36

0.65

Cefuroxime

0.08

0.06

0.05

0.04

0.03

Cephalexin

0.05

0.06

0.07

0.05

0.04

0.05

Ciprofloxacin

0.17

0.16

0.17

0.15

0.16

0.15

0.13

0.16

Clarithromycin

0.06

0.05

0.04

0.03

Clindamycin

0.03

0.04

0.05

0.04

0.07

Cloxacillin

0.07

0.06

0.05

0.06

0.05

Colistin

<0.01

Daptomycin

<0.01

Doxycycline

0.04

0.03

0.04

0.07

0.11

0.07

0.09

0.08

Ertapenem

<0.01

0.01

Erythromycin

0.02

0.01

Gentamicin

0.03

0.02

0.01

0.02

0.03

0.02

Imipenem

0.01

0.02

<0.01

0.01

<0.01

0.02

0.03

0.02

Levofloxacin

0.08

0.07

0.06

0.05

0.06

0.05

Linezolid

<0.01

Meropenem

0.01

0.02

Metronidazole

0.06

0.02

0.01

Minocycline

0.01

0.00

0.01

<0.01

Moxifloxacin

<0.01

0.01

0.02

0.04

0.06

0.07

0.08

0.07

0.06

0.05

Nitrofurantoin

0.02

0.03

Norfloxacin

0.01

<0.01

Penicillin G

1.38

1.09

1.29

1.55

1.52

1.34

1.40

1.42

1.35

1.29

1.04

0.56

Penicillin V

0.02

0.03

0.02

0.01

0.02

0.01

Piperacillin And Enzyme Inhibitor

0.01

0.02

0.03

0.05

0.07

0.14

0.20

Sulfamethoxazole and trimethoprim

0.09

0.08

0.07

0.06

Tetracycline

0.01

<0.01

Tobramycin

0.02

0.01

0.02

0.01

Trimethoprim

<0.01

Vancomycin

0.09

0.14

0.04

0.01

TOTAL

2.97

2.71

2.84

3.01

3.00

2.83

2.79

2.83

2.91

2.70

2.80

2.83

2.69

Footnote *

Ranked from greatest to least DIDs in 2013

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

Figure 3.2: Change in DIDs from 2001 – 2013 for penicillin g, ceftriaxone, and piperacillin and enzyme inhibitor, as purchased by Canadian hospitals.

Text equivalent for figure 3.2

Number of prescriptions and kilograms of active ingredient per 1,000 inhabitants of antimicrobials dispensed by Canadian retail pharmacies, 2000 – 2013

Antimicrobial

DIDs

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Penicillin G

1.38

1.09

1.29

1.55

1.52

1.34

1.40

1.42

1.35

1.29

1.04

0.56

Ceftriaxone

0.01

0.02

0.03

0.04

0.05

0.06

0.12

0.36

0.65

Piperacillin And Enzyme Inhibitor

0.01

0.02

0.03

0.05

0.07

0.14

0.20

b. Mass (kg) of active ingredient purchased per 1,000 inhabitants

In 2013, the antimicrobial for which the most volume of active ingredient was purchased by Canadian hospitals was piperacillin with enzyme inhibitor (1.13 kg / 1,000 inhabitants) (Table 3.2). Ceftriaxone (0.47 kg / 1,000 inhabitants) and cefoxitin (0.13 kg / 1,000 inhabitants) were ranked second and third, respectively.

The purchasing of piperacillin with enzyme inhibitor has increased more than 18-fold over the 2001 – 2013 time frame, with the most dramatic increases from 2010 - 2013 (Table 3.2, Figure 3.3). Ceftriaxone purchasing has also increased dramatically during this time frame, increasing from < 0.08 kg / 1,000 inhabitants in 2011 to the high of 0.47 kg / 1,000 inhabitants seen in 2013 (Table 3.2, Figure 3.3). The two antimicrobials with the greatest reduction in mass purchased over this time frame were cefoxitin (0.25 kg / 1,000 inhabitants to 0.13kg / 1,000 inhabitants) and penicillin G (0.30 kg / 1,000 inhabitants to 0.12 kg / 1,000 inhabitants) (Table 3.2, Figure 3.3).

Table 3.2: Mass (kg) of active ingredients purchased by hospitals in Canada, 2001 - 2013

Antimicrobial

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Amoxicillin

0.04

0.03

0.04

0.03

0.04

Amoxicillin and enzyme inhibitor

0.01

0.02

0.01

0.02

Ampicillin

0.07

0.04

0.06

0.07

0.04

0.03

Azithromycin

0.01

Cefadroxil

<0.01

Cefazolin

0.13

0.12

0.13

0.14

0.13

0.11

Cefixime

<0.01

Cefotaxime

0.02

0.03

0.02

0.01

Cefoxitin

0.25

0.36

0.40

0.39

0.31

0.30

0.29

0.26

0.31

0.23

0.18

0.13

Cefprozil

<0.01

Ceftazidime

0.01

0.02

0.01

0.02

<0.01

Ceftriaxone

0.01

0.02

0.03

0.04

0.08

0.26

0.47

Cefuroxime

0.03

0.02

0.01

Cephalexin

0.03

0.04

0.05

0.03

Ciprofloxacin

0.06

0.05

0.04

0.05

Clarithromycin

0.01

Clindamycin

0.02

0.03

0.02

0.04

Cloxacillin

0.05

0.04

Doxycycline

<0.01

Ertapenem

<0.01

0.01

Erythromycin

0.01

<0.01

Gentamicin

<0.01

Imipenem

0.01

0.03

0.01

0.02

0.04

0.03

Levofloxacin

0.01

0.02

0.01

Linezolid

<0.01

Meropenem

<0.01

0.01

0.02

Metronidazole

0.03

0.01

<0.01

Moxifloxacin

<0.01

0.01

Nitrofurantoin

<0.01

Penicillin G

0.30

0.24

0.28

0.34

0.33

0.29

0.31

0.30

0.28

0.23

0.12

Penicillin V

0.02

0.01

Piperacillin and enzyme inhibitor

0.06

0.04

0.07

0.09

0.12

0.14

0.17

0.19

0.26

0.27

0.39

0.79

1.13

Sulfamethoxazole and trimethoprim

0.06

0.05

0.06

0.05

0.04

Tetracycline

<0.01

Ticarcillin and enzyme inhibitor

0.04

0.08

0.07

0.03

0.02

0.01

<0.01

Tobramycin

<0.01

Vancomycin

0.06

0.10

0.03

0.01

<0.01

0.01

TOTAL

1.42

1.49

1.53

1.49

1.46

1.42

1.39

1.36

1.51

1.37

1.54

2.02

2.40

Footnote *

Ranked from greatest to least mass in 2013

Figure 3.3: Patterns in mass (kg) of active ingredients for antimicrobials with the greatest absolute difference in purchasing from 2001 to 2013

Text equivalent for figure 3.3

Patterns in mass (kg) of active ingredients for antimicrobials with the greatest absolute difference in purchasing from 2001 to 2013

Antimicrobial

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Piperacillin and enzyme inhibitor

0.06

0.04

0.07

0.09

0.12

0.14

0.17

0.19

0.26

0.27

0.39

0.79

1.13

Ceftriaxone

0.01

0.02

0.03

0.04

0.08

0.26

0.47

Cefoxitin

0.25

0.36

0.40

0.39

0.31

0.30

0.29

0.26

0.31

0.23

0.18

0.13

Penicillin G

0.30

0.24

0.28

0.34

0.33

0.29

0.31

0.30

0.28

0.23

0.12

c. Dollars spent per 1,000 inhabitants

In 2013, the antimicrobials with the greatest dollars spent per 1,000 inhabitants by Canadian hospitals were piperacillin and enzyme inhibitor ($421), meropenem ($389), and ertapenem ($264) (Table 3.3). The greatest changes between 2012 and 2013 were reductions in spending; increases were relatively minor in comparison. The antimicrobials for which these decreases occurred were: meropenem ($554 to $389 / 1,000 inhabitants), piperacillin and enzyme inhibitor (506 to 421/ 1,000 inhabitants), and ceftriaxone ($506 to $421/ 1,000 inhabitants) (Table 3.3, Figure 3.4). The greatest increases from 2012 to 2013 were: ampicillin ($85 to $121 / 1,000 inhabitants), ertapenem ($242 to $264 / 1,000 inhabitants), and daptomycin ($129 to $147 / 1,000 inhabitants) (Table 3.3, Figure 3.4).

Table 3.3: Dollars spent per 1,000 individuals for antimicrobials purchased by hospitals in Canada, 2001 - 2013

Antimicrobial

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Amikacin

10.88

10.54

9.36

4.14

14.35

19.24

17.20

16.44

20.65

18.07

14.36

22.26

19.62

Amoxicillin

11.98

10.17

9.93

8.78

9.77

8.75

8.99

9.30

10.30

11.30

10.21

11.25

11.94

Amoxicillin and enzyme inhibitor

25.59

25.89

25.05

22.50

22.96

22.64

17.49

17.11

20.45

19.88

19.15

18.05

16.51

Ampicillin

47.89

43.29

40.17

38.69

38.20

36.93

40.09

32.70

37.02

38.54

45.40

85.19

120.51

Azithromycin

192.39

217.68

246.89

229.99

234.73

161.00

143.54

146.04

160.31

80.09

67.02

68.18

61.26

Cefazolin

200.25

210.37

203.68

181.72

181.10

160.96

191.11

159.83

163.92

222.04

176.81

130.84

90.21

Cefepime

0.77

2.59

17.43

30.56

16.53

13.67

12.36

11.29

12.43

10.05

11.21

10.33

10.08

Cefixime

12.20

12.85

11.32

7.28

8.37

8.49

10.62

11.90

15.12

15.91

19.28

24.75

25.22

Cefotaxime

135.83

155.17

172.68

174.54

175.92

183.87

173.79

112.56

107.15

60.60

51.22

40.74

26.11

Cefoxitin

55.96

60.37

70.54

74.26

65.57

70.44

66.42

51.40

48.69

30.71

30.30

22.24

21.47

Cefprozil

9.11

9.76

12.65

14.67

11.22

10.02

9.72

6.18

6.45

5.74

4.26

3.91

3.03

Ceftazidime

168.02

186.79

142.96

114.00

81.20

50.19

42.31

39.33

42.00

37.96

33.44

37.95

37.41

Ceftriaxone

749.69

737.63

781.56

884.94

932.02

938.22

639.22

245.78

188.65

96.52

102.90

141.61

94.39

Cefuroxime

203.05

148.83

111.91

70.03

63.76

41.58

36.61

27.85

28.15

31.94

28.73

23.87

20.45

Cephalexin

15.96

15.83

18.62

17.52

18.43

21.65

15.24

14.75

14.18

13.88

15.27

17.20

16.80

Chloramphenicol

1.46

1.18

0.99

1.60

1.26

1.68

0.41

1.89

1.19

2.27

1.38

0.59

1.87

Ciprofloxacin

940.18

977.78

1023.96

956.55

887.59

912.49

703.04

287.30

94.21

75.44

61.93

48.60

54.90

Clarithromycin

90.28

84.09

75.79

70.85

71.50

66.53

62.45

36.52

28.76

23.68

23.63

19.14

13.72

Clindamycin

102.77

91.53

77.61

65.30

63.98

116.74

122.17

119.18

122.28

105.90

104.35

120.60

114.47

Cloxacillin

44.38

45.28

47.29

48.36

50.47

52.38

59.20

57.28

81.72

78.73

86.82

70.86

52.94

Colistin

21.86

25.60

22.68

19.45

16.09

22.17

23.04

22.63

17.24

25.37

23.84

23.62

30.72

Daptomycin

<0.01

2.14

27.11

48.39

81.25

129.89

146.82

Doxycycline

7.95

4.79

6.42

5.48

4.82

4.68

7.42

8.70

4.50

4.56

6.96

3.73

3.70

Ertapenem

<0.01

1.55

15.66

36.85

58.98

72.58

104.41

138.59

159.54

214.07

242.25

264.35

Erythromycin

14.91

14.81

29.23

20.06

16.08

18.93

19.21

19.02

13.85

11.25

18.44

18.78

17.11

Gentamicin

51.29

41.68

29.48

20.66

32.93

68.65

94.38

87.20

87.17

83.19

73.35

79.57

83.59

Imipenem

222.20

237.75

228.00

193.93

258.29

224.58

230.59

203.19

204.75

179.16

57.16

72.64

42.93

Levofloxacin

379.28

393.82

353.33

306.20

208.24

147.40

145.46

152.60

158.58

118.36

124.41

68.52

24.78

Linezolid

20.33

55.15

63.57

74.63

117.13

124.05

150.41

171.58

189.89

161.76

163.81

189.63

174.48

Meropenem

272.35

461.38

436.81

454.39

389.77

587.77

645.89

716.05

852.92

818.61

812.41

553.58

388.66

Metronidazole

29.31

42.07

14.97

15.21

12.99

12.47

14.98

10.93

8.39

8.90

11.40

9.56

9.73

Moxifloxacin

11.43

24.95

50.76

131.75

224.14

299.36

329.84

336.74

315.97

214.35

205.34

185.65

155.18

Nitrofurantoin

4.97

6.62

7.19

9.00

9.61

9.58

9.92

9.99

10.61

10.98

12.53

13.26

12.54

Penicillin G

22.78

21.79

23.91

22.65

21.94

20.42

21.34

21.22

48.21

23.89

27.99

40.26

37.72

Piperacillin

81.55

8.85

35.58

28.60

17.39

9.80

7.32

3.79

3.77

2.54

4.14

4.28

1.61

Piperacillin and enzyme inhibitor

356.84

223.41

411.52

539.00

684.43

761.33

929.53

746.74

529.89

442.58

515.70

506.24

421.16

Sulfamethoxazole and trimethoprim

29.04

32.20

35.67

37.65

36.57

37.49

34.98

34.90

38.23

32.38

32.00

37.47

39.05

Ticarcillin and enzyme inhibitor

167.52

312.81

260.46

106.65

98.58

105.83

93.98

96.76

73.39

67.71

28.01

11.31

3.95

Tigecycline

0.00

12.73

31.13

60.98

59.34

45.13

44.32

37.64

Tobramycin

95.31

86.93

66.22

60.56

71.49

97.16

95.80

94.72

98.36

86.86

80.07

79.24

64.24

Vancomycin

113.18

155.33

134.90

148.88

165.45

119.34

121.66

92.74

118.92

106.00

110.09

102.78

89.33

TOTAL

5110.38

5401.04

5552.30

5383.86

5503.24

5658.81

5453.15

4388.97

4226.61

3657.82

3566.17

3342.82

2868.88

Footnote *

Ranked from greatest to least prescribing in 2013

Antimicrobials were removed from this table if they represented <0.05% of costs in 2013. These are: bacampicillin, cefaclor, cefadroxil, cefotetan, ceftizoxime, ceftobiprole, cephalothin, demeclocycline, doripenem, erythromycin ethylsuccinate, fosfomycin, gatifloxacin, gemifloxacin, lincomycin, methenamine hippurate, methenamine mandelate, minocycline, nalidixic acid, netilmicin, norfloxacin, ofloxacin, penicillin v, pivampicillin, pivmecillinam, quinupristin/dalfopristin, spiramycin, streptomycin, sulfadiazine, sulfadiazine and trimethoprim, sulfonamides, combinations with other antibacterials (excl. trimethoprim), telithromycin, tetracycline, trimethoprim, and trovafloxacin.

Figure 3.4: Patterns in spending on antimicrobials by Canadian hospitals for antimicrobials with the greatest change in spending from 2001 to 2013.

Text equivalent for figure 3.4

Patterns in spending on antimicrobials by Canadian hospitals for antimicrobials with the greatest change in spending from 2001 to 2013

Dollars spent per 1,000 inhabitants

Antimicrobial

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Ampicillin

47.9

43.3

40.2

38.7

38.2

36.9

40.1

32.7

37.0

38.5

45.4

85.2

120.5

Ceftriaxone

749.7

737.6

781.6

884.9

932.0

938.2

639.2

245.8

188.7

96.5

102.9

141.6

94.4

Daptomycin

2.1

27.1

48.4

81.3

129.9

146.8

Ertapenem

1.5

15.7

36.8

59.0

72.6

104.4

138.6

159.5

214.1

242.3

264.3

Meropenem

272.4

461.4

436.8

454.4

389.8

587.8

645.9

716.0

852.9

818.6

812.4

553.6

388.7

Piperacillin and enzyme inhibitor

356.8

223.4

411.5

539.0

684.4

761.3

929.5

746.7

529.9

442.6

515.7

506.2

421.2

Purchasing by route of administration

In contrast with use in the community as displayed in the pharmacy dispensation data (Table 2.3), the volume of parenteral antimicrobials outweighed the volume of oral antimicrobials in the hospital purchasing data. By mass (kg) of active ingredient, parenteral antimicrobials were purchased at a rate 9 times higher than oral antimicrobials in 2013 (Table 3.4, Figure 3.5). Similarly, overall spending for parenteral products was 7.2 times the spending on oral products, and parenteral DIDs were 2.9 times the oral DIDs in 2013 (Table 3.4, Figure 3.5).

Table 3.4: Overall measures of antimicrobial drug purchasing by Canadian hospitals 2001 – 2013, by route of administration

Route of administration

Measure

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

Oral

DIDs

3.17

3.28

3.23

2.70

2.38

2.02

1.95

1.71

1.68

1.53

1.34

1.35

1.24

KG / 1,000 inhabitants

0.30

0.29

0.28

0.25

0.23

0.25

0.24

Cost (000's) / 1,000 inhabitants

0.97

0.95

0.98

0.80

0.70

0.59

0.56

0.51

0.49

0.41

0.39

0.38

0.35

Parenteral

DIDs

5.33

6.36

6.23

5.67

6.00

6.83

6.68

5.24

4.86

4.54

4.35

3.93

3.61

KG / 1,000 inhabitants

1.11

1.20

1.24

1.21

1.18

1.14

1.11

1.25

1.14

1.29

1.78

2.16

Cost (000's) / 1,000 inhabitants

4.15

4.45

4.57

4.59

4.80

5.07

4.90

3.88

3.74

3.25

3.18

2.96

2.52

Figure 3.5: Kilograms of active ingredients, defined daily doses, and dollars per 1,000 inhabitants for antimicrobials purchased by Canadian hospitals 2001 – 2013, by route of administration

Text equivalent for figure 3.5

Oral antimicrobials

Measure of use

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

DDDs / 1,000 inhabitant-days

3.17

3.28

3.23

2.70

2.38

2.02

1.95

1.71

1.68

1.53

1.34

1.35

1.24

Dollars (000's) / 1,000 inhabitants

0.97

0.95

0.98

0.80

0.70

0.59

0.56

0.51

0.49

0.41

0.39

0.38

0.35

KG active ingredients / 1,000 inhabitants

0.30

0.29

0.28

0.25

0.23

0.25

0.24

Parenteral antimicrobials

Measure of use Measure of use

2001

2002

2003

2004

2005

2006

2007

2008

2009

2010

2011

2012

2013

DDDs / 1,000 inhabitant-days

5.33

6.36

6.23

5.67

6.00

6.83

6.68

5.24

4.86

4.54

4.35

3.93

3.61

Dollars (000's) / 1,000 inhabitants

4.15

4.45

4.57

4.59

4.80

5.07

4.90

3.88

3.74

3.25

3.18

2.96

2.52

KG active ingredients / 1,000 inhabitants

1.11

1.20

1.24

1.21

1.18

1.14

1.11

1.25

1.14

1.29

1.78

2.16

Provincial Purchasing

Overall measures

Similar to the variation seen in the pharmacy dispensing data, there was a large amount of variation in hospital purchasing of antimicrobials in 2013 among the provinces. As in 2012, the province with the highest DIDs was Manitoba (5.1 DIDs) and lowest was Ontario (2.1 DIDs) (Figure 3.6).

Kilograms of active ingredient purchased per 1,000 inhabitants ranged from 1.7 in Québec to 5.3 in Manitoba. Interestingly, although DIDs and kilograms of active ingredient were highest in Manitoba, cost per 1,000 inhabitants was highest in British Columbia ($3,856), and lowest in Ontario ($1,994) (Figure 3.6).

Figure 3.6: DIDs, kilograms of active ingredient, and cost per 1,000 inhabitants of antimicrobials purchased by hospitals in Canada, by province (2013)

Text equivalent for figure 3.6

DIDs, kilograms of active ingredient, and cost per 1,000 inhabitants of antimicrobials purchased by hospitals in Canada,

by province (2013)

Measure of use

PEI & NL

DID

3.1

2.9

2.5

5.1

2.1

2.5

4.4

3.3

4.2

Kilograms active ingredient / 1,000 inhabitants

2.3

2.5

2.1

5.3

2.3

1.7

4.5

3.8

4.6

Dollars / 1,000 inhabitants

3.9

2.7

3.0

3.1

2.0

3.8

2.4

2.9

3.6

Individual drug purchasing

a. Defined daily doses per 1,000 inhabitant-days

Ceftriaxone was the antimicrobial with the largest number of DIDs purchased by hospitals in the majority of provinces in 2013. Interestingly however, this was not true of Ontario, Québec, or New Brunswick, where penicillin G held the highest DID ranking (Table 3.5) (ceftriaxone was the second highest rank in Ontario and New Brunswick, third highest in Québec).

The use of ceftriaxone in Manitoba appears to be driving the high DID values seen for this province; DIDs for ceftriaxone in Manitoba were 40% higher than in any other province. The use of this product ranged from 0.15 DIDs in Québec to 2.11DIDs in Manitoba (Table 3.5). Penicillin G purchasing ranged from 0.07 DIDs purchased in British Columbia to 0.96 DIDs in Québec (Table 3.5).

b. Mass of active ingredient (kg / 1,000 inhabitants)

By mass of active ingredient purchased (kg / 1,000 inhabitants), piperacillin and enzyme inhibitor was the antimicrobial with the most variation among the provinces (minimum 0.62 in Québec to maximum of 2.65 in New Brunswick) (Table 3.6). This product was the highest ranked drug in all provinces in 2013 with the exception of British Columbia, where ceftriaxone held the highest mass of active ingredient purchased. Ceftriaxone was among the top 3 ranked products among all provinces in 2013 with the exception of Québec (Table 3.6).

Purchasing by route of administration

In all provinces in 2013, the majority of antimicrobials were purchased for parenteral administration in the hospital setting (Tables 3.7 and 3.8). However, the proportion of oral and parenteral products purchased among the provinces varied dramatically.

a. Defined daily doses per 1,000 inhabitants

In Saskatchewan in 2013, DIDs for parenteral products accounted for 56% of hospital purchasing (Table 3.7). In contrast, purchasing in New Brunswick was more heavily weighted towards parenteral products, with 84% of antimicrobials purchased for parenteral administration by this measure. Provincial drug-level DID data from 2012 can be found in Appendix D, Table D.2.

b. Mass (kg) of active ingredient per 1,000 inhabitants

The kilograms of active ingredient per 1,000 inhabitants displayed a similar pattern to the DIDs for the proportion of oral and parenteral products, though the variation was less dramatic (Table 3.8). Again, the lowest proportion of parenteral products was seen in Saksatchewan for 2013 (85%) and highest in New Brunswick (94%). Provincial drug-level mass of active ingredient data from 2012 can be found in Appendix D, Table D.3.

Table 3.5: DIDs for antimicrobials purchased by hospitals in Canadian provinces, 2013

Antimicrobial

PEI & NL

Rank

Amoxicillin

0.15

0.08

0.14

0.48

0.07

0.05

0.07

0.08

0.28

Amoxicillin and enzyme inhibitor

0.06

0.05

0.04

0.12

0.03

0.08

0.06

0.05

0.09

Ampicillin

0.03

0.04

0.03

0.04

0.03

0.04

0.02

Azithromycin

0.14

0.06

0.21

0.17

0.10

0.08

0.05

0.11

Cefadroxil

<0.01

0.01

<0.01

Cefazolin

0.01

0.16

0.02

0.13

0.10

0.13

0.21

0.16

0.14

Cefepime

<0.01

0.01

<0.01

Cefixime

0.03

0.04

0.08

0.02

0.01

Cefotaxime

0.01

<0.01

0.01

<0.01

0.01

Cefoxitin

0.07

0.04

0.10

0.29

0.03

0.07

0.08

0.03

Cefprozil

<0.01

0.01

<0.01

Ceftazidime

<0.01

0.01

<0.01

Ceftriaxone

1.37

1.14

0.75

2.11

0.35

0.15

0.88

0.79

1.51

Cefuroxime

0.04

0.03

0.04

0.03

0.02

0.07

0.06

0.08

Cephalexin

0.06

0.05

0.06

0.22

0.04

0.02

0.04

0.06

0.09

Ciprofloxacin

0.10

0.11

0.10

0.14

0.12

0.24

0.17

0.36

0.25

Clarithromycin

0.04

0.03

0.02

0.03

0.04

0.07

Clindamycin

0.07

0.08

0.09

0.13

0.05

0.14

0.12

0.16

Cloxacillin

0.09

0.04

0.05

0.08

0.04

0.07

0.06

Colistin

<0.01

Daptomycin

0.01

<0.01

0.01

<0.01

Doxycycline

0.25

0.08

0.10

0.06

0.03

0.05

0.07

0.04

Ertapenem

0.03

0.02

0.01

0.02

<0.01

0.01

0.03

Erythromycin

0.02

0.01

0.03

0.02

<0.01

0.01

Gentamicin

0.01

0.02

0.01

0.02

0.01

0.02

Imipenem

0.01

<0.01

0.03

<0.01

0.50

<0.01

Levofloxacin

0.02

0.08

0.03

0.10

0.05

0.03

0.08

0.07

0.01

Linezolid

<0.01

Meropenem

0.03

0.02

0.04

0.01

0.02

Metronidazole

<0.01

0.02

<0.01

0.05

<0.01

Minocycline

0.01

<0.01

0.02

0.01

<0.01

0.01

<0.01

0.01

Moxifloxacin

0.07

0.01

0.08

0.02

0.04

0.08

0.03

0.06

0.14

Nitrofurantoin

0.06

0.03

0.06

0.07

0.02

0.03

0.07

Norfloxacin

<0.01

0.02

Penicillin G

0.07

0.46

0.11

0.08

0.59

0.96

1.67

0.12

0.28

Penicillin V

0.02

<0.01

0.01

0.05

0.01

<0.01

0.01

0.02

Piperacillin and enzyme inhibitor

0.11

0.16

0.14

0.36

0.25

0.11

0.46

0.29

0.43

Sulfamethoxazole and trimethoprim

0.07

0.06

0.07

0.26

0.04

0.05

0.14

Tetracycline

0.01

<0.01

0.01

<0.01

0.01

Tobramycin

<0.01

0.01

0.02

0.01

0.02

Trimethoprim

<0.01

Vancomycin

<0.01

0.03

<0.01

0.01

<0.01

TOTAL

3.07

2.94

2.49

5.10

2.15

2.55

4.37

3.34

4.21

Footnote *

Ranked from greatest to least DDDs at the national level in 2013

Antimicrobials were removed from this table if they represented <0.05% of DDDs in 2013. These are: amikacin, cefaclor, chloramphenicol, fosfomycin, lincomycin, methenamine mandelate, ofloxacin, piperacillin, spiramycin, streptomycin, ticarcillin and enzyme inhibitor, and tigecycline.

Table 3.6: Mass of active ingredient purchased by hospitals in Canadian provinces, by antimicrobial, 2013

Antimicrobial

PEI & NL

Rank

Amoxicillin

0.05

0.03

0.05

0.18

0.02

0.03

0.10

Amoxicillin and enzyme inhibitor

0.03

0.02

0.05

0.01

0.04

0.03

0.02

0.04

Ampicillin

0.02

0.03

0.02

0.03

0.02

0.03

0.01

Azithromycin

0.02

0.01

0.02

0.01

0.02

0.01

Cefadroxil

<0.01

Cefazolin

0.01

0.18

0.02

0.15

0.11

0.14

0.23

0.17

0.16

Cefixime

<0.01

0.01

<0.01

Cefotaxime

0.01

0.02

0.01

<0.01

0.01

Cefoxitin

0.14

0.09

0.22

0.63

0.06

0.16

0.17

0.07

Cefprozil

<0.01

Ceftazidime

<0.01

0.01

<0.01

Ceftriaxone

1.00

0.83

0.55

1.54

0.26

0.11

0.64

0.58

1.10

Cefuroxime

0.01

<0.01

0.01

0.02

0.01

0.02

Cephalexin

0.04

0.03

0.04

0.16

0.03

0.01

0.03

0.04

0.06

Ciprofloxacin

0.04

0.03

0.05

0.04

0.06

0.05

0.08

0.09

Clarithromycin

0.01

<0.01

0.01

Clindamycin

0.04

0.05

0.08

0.03

0.09

0.08

0.10

Cloxacillin

0.06

0.03

0.06

0.03

0.05

0.04

0.05

Doxycycline

0.01

<0.01

Ertapenem

0.01

<0.01

0.01

<0.01

0.01

<0.01

0.01

Erythromycin

0.01

<0.01

0.01

<0.01

Gentamicin

<0.01

Imipenem

0.01

<0.01

0.04

<0.01

0.73

<0.01

Levofloxacin

<0.01

0.02

0.01

0.02

0.01

<0.01

Linezolid

<0.01

Meropenem

0.02

0.01

0.02

0.01

0.03

0.01

Metronidazole

<0.01

0.01

<0.01

0.03

<0.01

Moxifloxacin

0.01

<0.01

0.01

<0.01

0.01

<0.01

0.01

0.02

Nitrofurantoin

<0.01

0.01

<0.01

0.01

Penicillin G

0.02

0.10

0.02

0.13

0.21

0.37

0.03

0.06

Penicillin V

0.01

<0.01

0.01

0.04

<0.01

0.02

Piperacillin and enzyme inhibitor

0.62

0.90

0.78

2.06

1.44

0.62

2.65

1.65

2.49

Sulfamethoxazole and trimethoprim

0.05

0.04

0.05

0.18

0.03

0.04

0.10

Tetracycline

<0.01

Ticarcillin and enzyme inhibitor

<0.01

Tobramycin

<0.01

Vancomycin

<0.01

0.02

<0.01

0.01

<0.01

TOTAL

2.27

2.46

2.05

5.32

2.29

1.70

4.47

3.85

4.57

Footnote *

Ranked from greatest to least mass at the national level in 2013

Antimicrobials were removed from this table if they represented <0.05% of mass in 2013. These are: amikacin, cefaclor, cefepime, chloramphenicol, colistin, daptomycin, fosfomycin, lincomycin, methenamine mandelate, minocycline, norfloxacin, ofloxacin, piperacillin, spiramycin, streptomycin, tigecycline, and trimethoprim.

Table 3.7. Defined daily doses per 1,000 inhabitants for antimicrobials purchased by Canadian pharmacies, by antimicrobial and province, 2013

Antimicrobial

Route of administration

PEI & NL

Amoxicillin

Oral

0.15

0.08

0.14

0.48

0.07

0.05

0.07

0.08

0.28

Amoxicillin and enzyme inhibitor

Oral

0.06

0.05

0.04

0.12

0.03

0.08

0.06

0.05

0.09

Ampicillin

Oral

<0.01

Parenteral

0.03

0.04

0.03

0.04

0.03

0.04

0.01

Azithromycin

Oral

0.14

0.05

0.20

0.16

0.09

0.03

0.06

0.05

0.09

Parenteral

0.01

0.06

0.02

<0.01

0.01

Cefazolin

Parenteral

0.01

0.16

0.02

0.13

0.10

0.13

0.21

0.16

0.14

Cefoxitin

Parenteral

0.07

0.04

0.10

0.29

0.03

0.07

0.08

0.03

Ceftriaxone

Parenteral

1.37

1.14

0.75

2.11

0.35

0.15

0.88

0.79

1.51

Cefuroxime

Oral

0.04

0.03

0.04

0.03

0.02

0.07

0.06

0.08

Parenteral

<0.01

Cephalexin

Oral

0.06

0.05

0.06

0.22

0.04

0.02

0.04

0.06

0.09

Ciprofloxacin

Oral

0.10

0.11

0.10

0.14

0.11

0.10

0.09

0.23

Parenteral

<0.01

0.02

0.13

0.07

0.27

0.02

Clarithromycin

Oral

0.04

0.03

0.02

0.03

0.04

0.07

Clindamycin

Oral

0.02

0.05

0.01

0.03

Parenteral

0.04

0.06

0.07

0.09

0.03

0.04

0.13

0.11

0.14

Cloxacillin

Oral

0.01

0.03

<0.01

0.01

0.03

0.02

Parenteral

0.08

0.04

0.05

0.04

0.03

0.06

0.03

0.05

Doxycycline

Oral

0.25

0.08

0.10

0.06

0.03

0.05

0.07

0.04

Levofloxacin

Oral

0.02

0.08

0.03

0.10

0.05

0.03

0.08

0.07

0.01

Parenteral

<0.01

Moxifloxacin

Oral

0.05

0.01

0.05

0.02

0.03

0.07

0.02

0.04

0.10

Parenteral

0.02

<0.01

0.03

<0.01

0.01

0.02

0.05

Nitrofurantoin

Oral

0.06

0.03

0.06

0.07

0.02

0.03

0.07

Penicillin G

Parenteral

0.07

0.46

0.11

0.08

0.59

0.96

1.67

0.12

0.28

Piperacillin and enzyme inhibitor

Parenteral

0.11

0.16

0.14

0.36

0.25

0.11

0.46

0.29

0.43

Sulfamethoxazole and trimethoprim

Oral

0.07

0.06

0.07

0.26

0.04

0.05

0.13

Parenteral

<0.01

TOTAL

Oral

1.14

0.75

1.10

1.87

0.62

0.60

0.70

0.77

1.43

Parenteral

1.93

2.19

1.39

3.23

1.52

1.95

3.67

2.57

2.78

Antimicrobials were removed from this table if they represented <1% of DIDs in 2013. These are: amikacin, cefaclor, cefadroxil, cefepime, cefixime, cefotaxime, ceftazidime, ertapenem, gentamicin, imipenem, lincomycin, linezolid, meropenem, methenamine mandelate, metronidazole, minocycline, norfloxacin, ofloxacin, penicillin v, streptomycin, trimethoprim, and vancomycin

Table 3.8. Kilograms of active ingredient per 1,000 inhabitants for antimicrobials purchased by Canadian pharmacies, by antimicrobial and province, 2013

Antimicrobial

Route of administration

PEI & NL

Amoxicillin

Oral

0.05

0.03

0.05

0.18

0.02

0.03

0.10

Ampicillin

Oral

<0.01

Parenteral

0.02

0.03

0.02

0.03

0.02

0.03

0.01

Cefazolin

Parenteral

0.01

0.18

0.02

0.15

0.11

0.14

0.23

0.17

0.16

Cefoxitin

Parenteral

0.14

0.09

0.22

0.63

0.06

0.16

0.17

0.07

Ceftriaxone

Parenteral

1.00

0.83

0.55

1.54

0.26

0.11

0.64

0.58

1.10

Cephalexin

Oral

0.04

0.03

0.04

0.16

0.03

0.01

0.03

0.04

0.06

Ciprofloxacin

Oral

0.04

0.03

0.05

0.04

0.03

0.09

Parenteral

<0.01

0.02

0.01

0.05

<0.01

Clindamycin

Oral

0.01

0.02

0.01

<0.01

0.01

Parenteral

0.03

0.04

0.05

0.06

0.02

0.03

0.09

0.07

0.09

Cloxacillin

Oral

<0.01

0.02

<0.01

0.02

0.01

Parenteral

0.06

0.03

0.04

0.03

0.02

0.05

0.02

0.03

Imipenem

Parenteral

0.01

0.00

0.04

0.73

Penicillin G

Parenteral

0.02

0.10

0.02

0.13

0.21

0.37

0.03

0.06

Piperacillin and enzyme inhibitor

Parenteral

0.62

0.90

0.78

2.06

1.44

0.62

2.65

1.65

2.49

Sulfamethoxazole and trimethoprim

Oral

0.05

0.04

0.05

0.18

0.03

0.09

Parenteral

<0.01

TOTAL

Oral

0.30

0.23

0.30

0.77

0.19

0.21

0.25

0.50

Parenteral

1.97

2.23

1.75

4.55

2.10

1.50

4.25

3.60

4.07

Antimicrobials were removed from this table if they represented <1% of mass in 2013. These are: amikacin, amoxicillin and enzyme inhibitor, azithromycin, cefaclor, cefadroxil, cefepime, cefixime, cefotaxime, cefprozil, ceftazidime, cefuroxime, chloramphenicol, clarithromycin, colistin, daptomycin, doxycycline, ertapenem, erythromycin, fosfomycin, gentamicin, levofloxacin, lincomycin, linezolid, meropenem, methenamine mandelate, metronidazole, minocycline, moxifloxacin, nitrofurantoin, norfloxacin, ofloxacin, penicillin v, piperacillin, spiramycin, streptomycin, tetracycline, ticarcillin and enzyme inhibitor, tigecycline, tobramycin, trimethoprim, and vancomycin.

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Date modified:

2021-08-24

2015-05-08