Antimicrobial Resistance in Wales 2005-2013 Final on... · 2015-10-27 · Antimicrobial...

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A Report from Public Health WalesAntimicrobial Resistance Programme Surveillance Unit:

Antibacterial ResistanceIn Wales 2005-2013

Authors: Maggie Heginbothom andRobin Howe

Date: 18/11/2014 Status: Final

Version: 1 Antibacterial Resistance in Wales2005 - 2013

Page: 1 of 58Antimicrobial ResistanceProgramme: Surveillance Unit

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Table of Contents

Table of Contents.................................................................................................... 2Section 1: Introduction ........................................................................................... 3Section 2: Key points of interest............................................................................ 4Section 3: Methods ................................................................................................. 5

Resistance data ....................................................................................................................5Section 4: Monitoring Trends in Resistance ......................................................... 9UK 5 Year Antimicrobial Resistance Strategy....................................................... 9

Background...........................................................................................................................9ARHAI Primary Data Set ................................................................................................... 10

Section 5.1: Antimicrobial resistance rates for the most common organismscausing bacteraemia............................................................................................. 11

Background........................................................................................................................ 11Escherichia coli ................................................................................................................. 12Enterobacter spp., Serratia spp., Proteus spp., and Ps. Aeruginosa .......................... 22Enterobacter spp ............................................................................................................... 23Serratia spp ........................................................................................................................ 24Proteus spp ........................................................................................................................ 25Pseudomonas aeruginosa................................................................................................ 26Staphylococcus aureus .................................................................................................... 27Meticillin Sensitive Staphylococcus aureus................................................................... 30Meticillin Resistant Staphylococcus aureus .................................................................. 32Enterococcus spp.............................................................................................................. 34Streptococcus pneumoniae ............................................................................................. 36

Section 5.2: Antimicrobial resistance rates for urinary coliforms ..................... 38Community Urinary Coliforms ......................................................................................... 42Out-patient Urinary Coliforms .......................................................................................... 43In-patient Urinary Coliforms ............................................................................................. 44

Section 5.3: Antimicrobial resistance rates for Staphylococcus aureus .......... 45MSSA .................................................................................................................................. 47MRSA .................................................................................................................................. 49

Section 5.4: Antimicrobial resistance rates for other pathogens. ..................... 50Haemophilus influenzae ................................................................................................... 52Streptococcus pneumoniae ............................................................................................ 54Streptococcus pyogenes.................................................................................................. 55Campylobacter species .................................................................................................... 56Neisseria gonorrhoeae...................................................................................................... 57

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Section 1: Introduction

Antimicrobial resistance is an increasing problem that can result in difficulty intreating infections, leading to failed therapy and potential complications. Treatmentfor most infections is started empirically before antimicrobial susceptibilities areknown. A particular problem with the spread of antimicrobial resistance is that itbecomes more difficult to select empirical therapy that will have reliable activity.

The aim of this report from the Welsh Antimicrobial Resistance ProgrammeSurveillance Unit is to provide data that can be used to design empirical therapyguidance, and to track antimicrobial resistance trends in Wales from 2005 to 2013.The report has had to be selective in what is presented, and concentrates on themajor acute hospitals and district general hospitals in Wales, and the localcommunity health boards.

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Section 2: Key points of interest

UK 5 Year Antimicrobial Resistance StrategyThe Wales resistance trends for drug-bug combinations reported by ARHAI as part ofthe UK 5 year Antimicrobial Resistance Strategy are comparable to the aggregatedrates and trends for the UK (page 10). However, in some cases there is considerablevariability in resistance rates between different areas and hospitals.

E. coli (the commonest cause of blood stream infections in Wales) Resistance to co-amoxiclav, fluoroquinolones and 3rd generation

cephalosporins remains high, but stable. Resistance to gentamicin and piperacillin-tazobactam appears to be

increasing, with particularly high rates emerging in some hospitals. Carbapenem resistance has emerged in Wales

Staphylococcus aureus Flucloxacillin resistance rates for Staphylococcus aureus bacteraemias were

variable between hospitals and ranged from 3.3% in the University HospitalLlandough to 38.8% in Ysbyty Glan Clwyd (page 28).

Tetracycline resistanceThere has been an increase in usage of tetracyclines across Wales in the last fewyears. This may be responsible for increasing resistance rate emerging in variousorganisms.

Resistance in MRSA (meticillin resistant S. aureus from blood cultures andwound swabs has increased to 15-20% with rates of >50% in some areas.

Resistance in Streptococcus pneumoniae has risen to 8.2%

Urinary tract infections

“Coliforms” (the commonest cause of urinary tract infections in Wales) Resistance to most antimicrobials has increased over the last 9 years (page

39):o Trimethoprim (first-line empirical therapy for uncomplicated UTI in the

community) resistance has increased to 34.8%. This high rate ofresistance reflects an element of selective testing. The true rate ofresistance in patients presenting with uncomplicated UTI in thecommunity is likely to be considerably lower, and trimethoprimremains the suggested first-line empirical therapy for these patients.

o Co-amoxiclav resistance decreased from 17.2% in 2011 to 10.5% in2013.

o Ciprofloxacin resistance remained unchanged at 10%.o Nitrofurantoin resistance remained stable at approximately 12%.

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Section 3: Methods

Resistance data

Data presentedAntimicrobial resistance data is provided for the following selected areas and specificpathogens:

Top ten bacteraemia pathogens Urinary coliforms (community & hospital) Wound swab isolates (community & hospital)

o Staphylococcus aureus including MRSA from wound swabs All specimens (community & hospital)

o Streptococcus pneumoniaeo Streptococcus pyogeneso Haemophilus influenzaeo Campylobacter spp.o Neisseria gonorrhoeae

“Community” data is from samples referred from a general practice and hospital datais from samples submitted from hospital in-patients or out-patients as described.

Data sourcesAntimicrobial susceptibility testing data was extracted from the regional DataStoresystems. Data from Nevill Hall Hospital for 2005 & 2006 is not included in this reportas it was not available for this period. Community data is presented by DataStore sitee.g. data for specimens processed by the laboratories at Prince Philip and WestWales General hospitals will both be reported together as Carmarthen communitydata (J). The DataStore sites, and the codes and abbreviations for community andhospital data included in this report are shown in Table 1.

Data interpretation

As with all surveillance schemes, appropriate interpretation of the data, with anappreciation of the potential biases, is key. The main potential biases which shouldbe considered in the data presented herein are:

Sampling biaso This occurs if the submission of samples to the microbiology

laboratory does not represent all patients presenting with thatinfection, but is selective in some way. If this is the case, the publishedresistance rate may be skewed, and not representative of the true ratein patients presenting with uncomplicated infection. This effect is likelyto be more of an issue with certain sample types. For examplebacteraemia data is felt to be fairly representative, since most patientspresenting with sepsis will have a blood culture sent. However ifgeneral practitioners only submit urine samples from patients whohave failed initial therapy, the published rates of resistance will befalsely high.

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Selective testingo This occurs if a laboratory only tests susceptibility to a certain agent

against selected organisms. For example, a laboratory might only testsome agents when an organism is resistant to first-line drugs. Thiswould result in falsely high published rates of resistance. In order toreduce the effect of selective testing on the published rates, data isonly included if >80% of a given isolate from a given specimen istested against the agent.

Methodological variabilityo There are many methods available for antimicrobial susceptibility

testing which may give inconsistent results. In order to reduce thiseffect on the published rates the Welsh Antimicrobial ChemotherapyGroup is working to standardize testing across Wales. All but onelaboratory use a combination of the BSAC (British Society forAntimicrobial Chemotherapy) standardized disc sensitivity method,and the BD Phoenix automated AST/ID system.

Duplicate testingo This occurs if a patient has multiple specimens tested from a single

infection episode. Potentially this can skew the resistance data. Inorder reduce the effect of this; duplicate isolates are removed fromanalysis by a sub-routine in DataStore. Isolates are deemed to beduplicates if the same organism with the same antibiogram is grownfrom the same sample type within 14 days (for hospital in-patients) or91 days (for community patients).

All Wales data

The All-Wales resistance rates for each antimicrobial comprise an aggregate of datafrom a number of different laboratories. All-Wales resistance rates are only presentedfor organisms where no testing bias occurred at individual hospital level – see below.

Individual Hospital/Laboratory data

Individual hospital or laboratory resistance rates are only presented for organismswhere ≥80% of such isolates from the given sample type was tested and where the number of isolates tested exceeds 9.

Duplicates

Data from duplicate isolates was removed prior to analysis. For community data,organisms from the same patient, with the same identification and susceptibilitypattern isolated ≤ 91 days from the date of the initial isolate were excluded, and for hospital data the cut-off was ≤ 14 days.

Antimicrobial Groups

Although there has been a move towards standardization of antimicrobials used forAST, some variation between laboratories remains (e.g. differences in choice andnumber of third generation cephalosporins tested). In such cases data is aggregatedand resistance rates are expressed at group level.

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Generally, most laboratories only test a single agent from antimicrobial groups suchas fluoroquinolones and carbapenems where appropriate, but the choice of agentoften varies between laboratories. The antimicrobial groups included in this reportcomprise of the following aggregated susceptibility data:

Fluoroquinolones – ciprofloxacin &/or levofloxacin, norfloxacin Third generation cephalosporins (3GC) – ceftazidime &/or cefotaxime,

ceftriaxone, cefpodoxime. Carbapenems – imipenem &/or meropenem, ertapenem.

Susceptibility results

Throughout data is presented in tables and on graphs as resistance rates with 95%confidence intervals (95% CI). 1 For the purpose of this report susceptibility resultsrecorded as ‘intermediate’ are included in the category ‘resistant’, and in the case ofpenicillin susceptibility results for S. pneumoniae results recorded as intermediate,low- level or high-level resistance are included in the category ‘resistant’.

1. Newcombe, Robert G. "Two-Sided Confidence Intervals for the SingleProportion: Comparison of Seven Methods," Statistics in Medicine, 17, 857-872 (1998).

Other surveillance schemes

This report focuses on comparisons of data collected for Wales in the calendar years2005 and 2013. To provide some external context to the data presented, it has beenalso been compared to surveillance data from other sources – see websites:

Public Health England (PHE):http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/AntimicrobialResistance/

British Society for Antimicorbial Chemotherapy (BSAC):http://www.bsac.org.uk/

European Centre for Disease Prevention and Control (EARS-Net):http://www.ecdc.europa.eu/en/healthtopics/antimicrobial_resistance/database/Pages/database.aspx

All of the above surveillance schemes are also susceptible to potential biases,particularly selective coverage and selective reporting. Thus comparisons with thepresented data should be treated with caution.

NB. Throughout this document all resistance rates quoted from PHE publicationsrelate to England, Wales and Northern Ireland (unless otherwise stated), and dataquoted from EARS-Net website database relate to the United Kingdom (UK).

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Table 1: Codes for hospital and community data

Hospital Hospital Code DataStore Site

Princess of Wales B

SwanseaNeath Port Talbot T

Singleton S

Morriston E

Nevill Hall MNewport

Royal Gwent D

Wrexham Maelor H Wrexham

Ysbyty Gwynedd K Bangor

Ysbyty Glan Clwyd L Rhyl

University Hospital of Wales FCardiff

University Hospital Llandough P

Prince Charles N Merthyr

Royal Glamorgan C Pontypridd

Glangwili JCarmarthen

Prince Philip R

Bronglais A Aberystwyth

Withybush G Haverfordwest

All-Wales Z

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Section 4: Monitoring Trends in ResistanceUK 5 Year Antimicrobial Resistance Strategy

Background

In 2014, a sub-group of ARHAI was established to recommend surveillance outputsto support the UK Five Year Antimicrobial Resistance Strategy. Appendix C“Monitoring Trends in Resistance” of the Strategy document states: “Changes in thelevel of resistance to antibiotics like the carbapenems, which are often the last optionfor hard to treat infections, will be monitored”.

The agreed “drug-bug” combinations for monitoring resistance are listed in Table 2;the combinations were ratified by the Department of Health (DoH) High-LevelSteering Group. Public Health Wales provided the Wales data to ARHAI for thissurveillance project.

Blood specimens (except N. gonorrhoeae data) 14 day episode de-duplication Non-susceptible (NS) is resistant and intermediate isolate totals combined Where two antimicrobials from the same class are listed an ‘or’ relationship is

applied, the more resistant result takes priority

Table 2: ARHAI Drug-Bug Combinations

Specimen Organism Data Set Antimicrobial

Blood Culture

Escherichia coliPrimary

cefotaxime or ceftazidime

imipenem or meropenem

ciprofloxacin

gentamicin

Secondary piperacillin/tazobactam

Klebsiella pneumoniaePrimary



ciprofloxacin

gentamicin

Secondary piperacillin/tazobactam

Klebsiella oxytoca Primary



ciprofloxacin

gentamicin

piperacillin/tazobactam

Pseudomonas spp. Primaryceftazidime


Acinetobacter spp. Secondary colistin

Enterococcus spp. Secondary vancomycin

Staphylococcus aureus Secondary meticillin

Streptococcus pneumoniae Primary penicillin

All specimensNeisseria gonorrhoeae Primary

ceftriaxone

azithromycin

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ARHAI Primary Data Set

Table 3 shows the resistance rates for Wales compared with the UK aggregate ratesfor the primary data set drug-bug combinations. There are small differences in someof the resistance rates, but generally the trends in resistance are comparable.

Table 3: ARHAI Primary Data Set

ARHAI Primary data set

Escherichia coli 2009 2010 2011 2012 2013

Cefotaxime &/or ceftazidimeWales 14 14 13 16 13

*UK 11 10 11 11 10

CiprofloxacinWales 22 22 21 23 20

*UK 20 19 19 19 18

GentamicinWales 6 9 9 10 11

*UK 8 9 9 10 10

Imipenem &/or meropenemWales 0.0 0.0 0.0 0.0 0.1

*UK 0.1 0.0 0.1 0.1 0.1

Klebsiella pneumoniae 2009 2010 2011 2012 2013

Cefotaxime &/or ceftazidimeWales 14 10 8 9 10

*UK 11 11 10 11 11

CiprofloxacinWales 12 10 8 9 10

*UK 10 10 9 10 11

GentamicinWales 7 7 4 3 3

*UK 7 7 7 7 8

Imipenem &/or meropenemWales 0.0 0.4 0.7 0.3 0.6

*UK 0.3 0.6 0.8 0.7 0.8

Pseudomonas spp. 2009 2010 2011 2012 2013

CeftazidimeWales 8 12 8 6 6

*UK 8 8 8 7 7

Imipenem &/or meropenemWales 10 13 10 11 4

*UK 12 10 11 10 9

Streptococcus pneumoniae 2009 2010 2011 2012 2013

PenicillinWales 2 2 3 2 5

*UK 2 3 3 3 3

*UK rates include data for England, Scotland, Wales and Northern Ireland provided by ARHAIsub-group.

The secondary data set has not been published by ARHAI as yet, and cannot bepresented in this report.

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Section 5.1: Antimicrobial resistance rates for themost common organisms causing bacteraemia

Background

The 2013 top ten bacteraemia report for Wales comprises the commonest organismsisolated from blood cultures in Wales, see Table 4 below.Internet: http://www.wales.nhs.uk/sites3/page.cfm?orgId=379&pid=13066#zIntranet: http://howis.wales.nhs.uk/sites3/page.cfm?orgid=379&pid=18707#topt

Table 4: Top Ten Bacteraemias

Rank Organism Rate per 100,000 bed days

1 Escherichia coli (E. coli) 742 Staphylococcus aureus (MSSA) 253 Enterococcus species 164 Klebsiella species 165 Streptococcus pneumoniae 96 Coagulase-negative Staphylococcus 87 Pseudomonas aeruginosa 68 Proteus species 69 Staphylococcus aureus (MRSA) 5

10 Enterobacter species 5

The datasets include infections originating from community and hospital sources (in-patient and out-patient), and so may be affected by local clonal strains which canresult in marked variability in resistance rates between hospitals/regions; resultsshould be interpreted with caution.

Since coagulase negative staphylococci are frequently contaminants when isolatedfrom blood cultures, data on susceptibility are not presented here. However, althoughSerratia species have dropped out of the ‘top 10’, resistance data for the genus willbe presented as it has appeared in previous reports.

The data in this report is not presented in rank order, but rather an order to alloweasy comparison of resistances for related bacteria.

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Escherichia coli (n=2135 in 2013)

E. coli is the commonest organism grown from blood cultures in Wales and the UK.The All-Wales patterns of resistance for 2005 to 2013 are shown in Figure 1, and theindividual hospital resistance rates for ARHAI primary drug set are shown in Table5.The data for 2013 shows a statistically significant decrease in resistance to co-amoxiclav compared with the 2012 rates. Imipenem and meropenem resistance ratesremain below 1% in the UK.

Figure 1: All-Wales resistance rates for E. coli bacteraemia (2005 to 2013).

20

05

20

12

20

13

0

5

10

15

20

25

30

35

40

45

50

3GC COA CARB CXM FQ GEN PTZ

Re

sist

ance

(%)

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Table 5: Escherichia coli

Note: The range of resistance is outlined with boxes e.g. the range for co-amoxiclav(COA) was 16.7% to 49.6%; individual hospital resistance rates statistically higherthan the All-Wales rate are highlighted in blue. Resistance rates are not recordedwhen <80% of the isolates were tested (All-Wales rate shown in red). The resistancerates for E. coli bacteraemia in Wrexham Maelor (H) and Ysbyty Gwynedd (K) werenotably high to a number of agents suggesting a higher incidence of multi-resistantstrains locally. Imipenem and/or meropenem resistant E. coli were reported in UHWand Withybush.

Escherichia coli from blood culturesResistance rates including (95% Confidence Intervals)

Duplicate Cut Off: ≤14 days

Time period: 1 January - 31 December 2013

Location Code (Number) COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)

A (n=54) 37.3 (25.3, 51.0) 6.3 (2.1, 16.8) 8.3 (3.3, 19.6) 0.0 (0.0, 7.4)B (n=126) 19.8 (13.8, 27.7) 6.4 (3.3, 12.1) 7.9 (4.4, 14.0) 2.4 (0.8, 6.8)

C (n=125) 50.0 (41.4, 58.6) 5.7 (2.8, 11.4) 10.3 (6.1, 16.9) 0.8 (0.1, 4.5)

D (n=208) 36.5 (30.3, 43.3) 9.8 (6.4, 14.6) 10.6 (7.1, 15.5) 2.4 (1.0, 5.6)

E (n=84) 34.5 (25.2, 45.2) 10.7 (5.7, 19.1) 8.3 (4.1, 16.2) 2.4 (0.7, 8.3)

F (n=258) 45.3 (39.3, 51.6) 8.1 (5.3, 12.2) 9.3 (6.3, 13.6) 2.0 (0.9, 4.7)G (n=90) 22.2 (14.9, 31.8) 7.0 (3.2, 14.4) 5.6 (2.4, 12.4) 1.2 (0.2, 6.3)

H (n=191) 20.7 (15.6, 27.1) 27.5 (21.6, 34.3) 15.5 (11.0, 21.4)

J (n=148) 23.8 (17.5, 31.4) 2.2 (0.7, 6.2) 2.8 (1.1, 7.1) 0.0 (0.0, 2.7)

K (n=126) 38.4 (30.3, 47.2) 14.3 (9.2, 21.5) 20.0 (13.9, 27.9) 8.8 (5.0, 15.1)

L (n=156) 45.8 (38.2, 53.7) 4.5 (2.2, 9.0) 14.7 (10.0, 21.2) 1.9 (0.7, 5.5)

M (n=121) 36.1 (28.1, 45.1) 5.9 (2.9, 11.6)N (n=104) 44.8 (35.6, 54.3) 8.0 (4.1, 15.0)

P (n=63) 39.7 (28.5, 52.0) 12.7 (6.6, 23.1) 4.8 (1.6, 13.1) 1.6 (0.3, 8.5)

Q (n=12) 18.2 (5.1, 47.7) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)

R (n=53) 32.1 (21.1, 45.5) 8.0 (3.2, 18.8) 5.7 (1.9, 15.4) 0.0 (0.0, 7.1)

S (n=195) 30.9 (24.8, 37.7) 3.6 (1.8, 7.3) 6.7 (3.9, 11.1) 0.5 (0.1, 2.9)

T (n=15) 40.0 (19.8, 64.3) 13.3 (3.7, 37.9) 13.3 (3.7, 37.9) 13.3 (3.7, 37.9)

All-Wales: Resistance rates 36.5 (34.3, 38.6) 8.5 (7.4, 9.8) 10.7 (9.5, 12.1) 3.4 (2.7, 4.2)

All-Wales: Number of isolates 1925 2025 2101 2018

Location Code (Number) AMO (95% CI) 3GC (95% CI) AMI (95% CI) FQ (95% CI)

A (n=54) 18.0 (9.8, 30.8) 2.2 (0.4, 11.3) 27.1 (16.6, 41.0)

B (n=126) 61.1 (52.4, 69.2) 13.5 (8.6, 20.5) 17.7 (12.0, 25.4)C (n=125) 66.1 (57.3, 73.9) 20.0 (13.9, 27.9) 3.4 (1.3, 8.4) 20.6 (14.5, 28.5)

D (n=208) 61.0 (54.2, 67.4) 12.0 (8.3, 17.1) 1.5 (0.5, 4.2) 18.8 (14.0, 24.6)

E (n=84) 65.5 (54.8, 74.8) 14.3 (8.4, 23.3) 19.0 (12.1, 28.7)

F (n=258) 63.2 (57.0, 68.9) 10.9 (7.6, 15.4) 1.2 (0.4, 3.5) 20.7 (16.1, 26.2)

G (n=90) 61.8 (51.4, 71.2) 5.6 (2.4, 12.4) 1.2 (0.2, 6.4) 15.6 (9.5, 24.4)

H (n=191) 68.9 (62.0, 75.1) 41.6 (34.8, 48.7)

J (n=148) 12.2 (7.8, 18.4) 9.9 (6.0, 16.0)

K (n=126) 64.3 (55.6, 72.1) 24.8 (18.1, 33.0) 1.6 (0.4, 5.6) 24.0 (17.4, 32.2)

L (n=156) 54.2 (46.3, 61.8) 17.3 (12.2, 24.0) 0.0 (0.0, 2.4) 25.0 (18.9, 32.3)

M (n=121) 57.5 (48.6, 66.0) 11.7 (7.1, 18.6) 1.7 (0.5, 6.0) 15.0 (9.7, 22.5)

N (n=104) 56.4 (46.7, 65.7) 11.4 (6.7, 18.9) 13.3 (8.1, 21.1)

P (n=63) 58.7 (46.4, 70.0) 12.7 (6.6, 23.1) 4.8 (1.6, 13.1) 20.6 (12.5, 32.2)

Q (n=12) 54.5 (28.0, 78.7) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 27.8)

R (n=53) 66.7 (52.5, 78.3) 3.8 (1.0, 12.8) 0.0 (0.0, 7.4) 11.3 (5.3, 22.6)S (n=195) 62.1 (55.1, 68.6) 11.3 (7.6, 16.5) 15.0 (10.7, 20.7)

T (n=15) 60.0 (35.7, 80.2) 6.7 (1.2, 29.8) 13.3 (3.7, 37.9)

All-Wales: Resistance rates 62.1 (59.9, 64.2) 13.3 (11.9, 14.9) 1.6 (1.1, 2.3) 20.4 (18.7, 22.2)All-Wales: Number of isolates 2038 1943 1635 2103

Location Code (Number) ERT (95% CI) IMI (95% CI) MER (95% CI) IMI or MER (95% CI)

A (n=54) 0.0 (0.0, 7.9) 0.0 (0.0, 7.4) 0.0 (0.0, 7.4)B (n=126) 0.0 (0.0, 3.0) 0.0 (0.0, 3.0)

C (n=125) 0.0 (0.0, 3.2) 0.0 (0.0, 3.2) 0.0 (0.0, 3.0) 0.0 (0.0, 3.0)

D (n=208) 0.0 (0.0, 1.8) 0.0 (0.0, 1.9) 0.0 (0.0, 1.8) 0.0 (0.0, 1.8)

E (n=84) 0.0 (0.0, 5.3) 0.0 (0.0, 4.4) 0.0 (0.0, 4.4) 0.0 (0.0, 4.4)

F (n=258) 0.4 (0.1, 2.3) 0.0 (0.0, 1.5) 0.4 (0.1, 2.3)

G (n=90) 0.0 (0.0, 4.3) 1.2 (0.2, 6.3)

H (n=191)

J (n=148) 0.0 (0.0, 2.7) 0.0 (0.0, 2.7)K (n=126) 0.0 (0.0, 3.3) 0.0 (0.0, 3.0)

L (n=156) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4) 0.0 (0.0, 2.4)

M (n=121) 0.9 (0.2, 4.7) 0.0 (0.0, 3.4) 0.0 (0.0, 3.1) 0.0 (0.0, 3.1)

N (n=104) 0.0 (0.0, 4.0) 0.0 (0.0, 3.6)

P (n=63) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7)

Q (n=12) 0.0 (0.0, 29.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)R (n=53) 0.0 (0.0, 7.4) 0.0 (0.0, 6.8) 0.0 (0.0, 6.8)

S (n=195) 0.0 (0.0, 2.4) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9) 0.0 (0.0, 1.9)

T (n=15) 0.0 (0.0, 20.4) 0.0 (0.0, 20.4) 0.0 (0.0, 20.4)


All-Wales: Number of isolates 1224 1632 1778 1976Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,

3GC = resistance to ceftazidime &/or cefotaxime, cefpodoxime, ceftriaxone, AMI = amikacin, FQ = resistance to ciprofloxacin &/or levofloxacin,

ERT = ertapenem, IMI = imipenem, MER = meropenem, IMI or MER = resistance to either or both agents

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ARHAI Primary data Set

Interpretation Tables 6-10: The tables show trends in resistance to drug/bugcombinations in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time. The first column in thetables show the hospital code and the median number of isolates tested across thetime period e.g. in Table 6, hospital code A (43) denotes Bronglais hospital with amedian number of 43 isolates tested per year across the five year period. Note:Individual hospital or laboratory resistance rates are only presented for organismswhere ≥80% of such isolates from the given sample type was tested and where the number of isolates tested exceeds 9. It is important to remember when interpretingthis data set that hospital level data often represents small numbers of organisms,and single isolate resistance within these numbers can produce misleadingly largechanges in resistance.

Table 6: Trends in third generation cephalosporin resistance for E. coli by hospital(2009-2013)

Key:

A= Bronglais

B = Princess of Wales

C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd

L = Ysbyty Glan Clwyd

M = Nevill Hall

N = Prince Charles

P = UHL

Q = Velindre

R = Prince Philip

S = Singleton

T = Neath Port Talbot

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Table 7: Trends in fluoroquinolone resistance for E. coli by hospital (2009-2013)

Table 8: Trends in gentamicin resistance for E. coli by hospital (2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

Q = Velindre

R = Prince Philip

S = Singleton


16

Table 9: Trends in piperacillin/tazobactam resistance for E. coli (2009-2013)

Table 10: Trends in imipenem/meropenem resistance for E. coli (2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

Q = Velindre

R = Prince Philip

S = Singleton


17

Klebsiella spp. (n=474 in 2013)

The All-Wales patterns of antimicrobial resistance in Klebsiella spp. are shown inFigure 2 and Table 11; with no significant difference in resistance rates between2012 and 2013. Imipenem and meropenem resistance rates remain below 1% in theUK.

Figure 2: All-Wales antimicrobial resistance rates for Klebsiella species; isolatedfrom blood culture (2005 to 2013)

20

05

20

06

20

13

0

2

4

6

8

10

12

14

16

18

20

22

24

26

28

30

32

34

3GC COA CARB CXM FQ GEN PTZ

Re

sist

ance

(%)

18

Table 11: Klebsiella spp.

Note: The resistance rates for Klebsiella spp. bacteraemia at hospital level were notstatistically different to the All-Wales rates except for co-amoxiclav resistance inBronglais and gentamicin resistance in Princess of Wales (B). Imipenem and/ormeropenem resistant Klebsiella spp. were reported in Bronglais (A), UHW (F) andSingleton (S). Resistance rates are not recorded if the organisms are intrinsicallyresistant to an antibacterial agent e.g. for amoxicillin, or when <80% of the isolateswere tested (All-Wales rate shown in red).

Klebsiella spp. from blood culturesResistance rates including (95% Confidence Intervals)



Location Code (Number) COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)

A (n=11) 54.5 (28.0, 78.7) 18.2 (5.1, 47.7) 9.1 (1.6, 37.7) 9.1 (1.6, 37.7)

B (n=29) 20.7 (9.8, 38.4) 10.7 (3.7, 27.2) 17.2 (7.6, 34.5) 10.7 (3.7, 27.2)

C (n=22) 9.1 (2.5, 27.8) 4.5 (0.8, 21.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)

D (n=43) 11.6 (5.1, 24.5) 4.8 (1.3, 15.8) 2.3 (0.4, 12.1) 0.0 (0.0, 8.4)

E (n=34) 14.7 (6.4, 30.1) 11.8 (4.7, 26.6) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2)

F (n=67) 16.4 (9.4, 27.1) 9.0 (4.2, 18.2) 4.5 (1.5, 12.4) 4.5 (1.5, 12.4)

G (n=17) 5.9 (1.0, 27.0) 6.3 (1.1, 28.3) 11.8 (3.3, 34.3) 0.0 (0.0, 19.4)

H (n=32) 21.9 (11.0, 38.8) 0.0 (0.0, 10.7) 0.0 (0.0, 10.7)

J (n=29) 3.4 (0.6, 17.2) 0.0 (0.0, 12.1) 0.0 (0.0, 11.7) 0.0 (0.0, 12.1)

K (n=32) 28.1 (15.6, 45.4) 15.6 (6.9, 31.8) 6.3 (1.7, 20.1) 3.1 (0.6, 15.7)

L (n=42) 23.8 (13.5, 38.5) 2.4 (0.4, 12.3) 7.1 (2.5, 19.0) 0.0 (0.0, 8.4)

M (n=23) 26.1 (12.5, 46.5) 5.3 (0.9, 24.6) 4.5 (0.8, 21.8) 0.0 (0.0, 16.8)

N (n=23) 8.7 (2.4, 26.8) 0.0 (0.0, 15.5) 0.0 (0.0, 22.8)

P (n=13) 7.7 (1.4, 33.3) 7.7 (1.4, 33.3) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)

R (n=12) 8.3 (1.5, 35.4) 0.0 (0.0, 24.3) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)

S (n=35) 20.6 (10.3, 36.8) 15.2 (6.7, 30.9) 5.7 (1.6, 18.6) 3.0 (0.5, 15.3)

All-Wales: Resistance rates 16.7 (13.5, 20.4) 8.6 (6.4, 11.6) 4.3 (2.8, 6.5) 2 (1.1, 3.8)



A (n=11) _ 18.2 (5.1, 47.7) 0.0 (0.0, 25.9) 9.1 (1.6, 37.7)

B (n=29) _ 17.2 (7.6, 34.5) 21.4 (10.2, 39.5)

C (n=22) _ 4.5 (0.8, 21.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)

D (n=43) _ 4.7 (1.3, 15.5) 0.0 (0.0, 8.2) 0.0 (0.0, 8.2)

E (n=34) _ 8.8 (3.0, 23.0) 0.0 (0.0, 14.3) 0.0 (0.0, 10.2)

F (n=67) _ 10.4 (5.2, 20.0) 0.0 (0.0, 5.4) 9.0 (4.2, 18.2)

G (n=17) _ 5.9 (1.0, 27.0) 0.0 (0.0, 19.4) 0.0 (0.0, 18.4)

H (n=32) _ 12.5 (5.0, 28.1)

J (n=29) _ 0.0 (0.0, 11.7) 0.0 (0.0, 13.3) 0.0 (0.0, 11.7)

K (n=32) _ 18.8 (8.9, 35.3) 0.0 (0.0, 10.7) 15.6 (6.9, 31.8)

L (n=42) _ 11.9 (5.2, 25.0) 0.0 (0.0, 8.6) 16.7 (8.3, 30.6)

M (n=23) _ 0.0 (0.0, 14.3) 0.0 (0.0, 15.5) 0.0 (0.0, 14.3)

N (n=23) _ 4.3 (0.8, 21.0) 8.7 (2.4, 26.8)

P (n=13) _ 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)

R (n=12) _ 0.0 (0.0, 24.3) 0.0 (0.0, 25.9)

S (n=35) _ 5.7 (1.6, 18.6) 14.7 (6.4, 30.1)




A (n=11) 9.1 (1.6, 37.7) 0.0 (0.0, 25.9) 9.1 (1.6, 37.7)

B (n=29) 0.0 (0.0, 12.1) 0.0 (0.0, 12.1)

C (n=22) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)

D (n=43) 0.0 (0.0, 8.4) 0.0 (0.0, 8.4) 0.0 (0.0, 8.2) 0.0 (0.0, 8.2)

E (n=34) 0.0 (0.0, 11.7) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2) 0.0 (0.0, 10.2)

F (n=67) 0.0 (0.0, 5.4) 1.5 (0.3, 8.0) 1.5 (0.3, 8.0)

G (n=17) 0.0 (0.0, 19.4) 0.0 (0.0, 19.4)

H (n=32)

J (n=29) 0.0 (0.0, 13.3) 0.0 (0.0, 12.1) 0.0 (0.0, 11.7)

K (n=32) 0.0 (0.0, 11.4) 0.0 (0.0, 10.7)

L (n=42) 2.4 (0.4, 12.3) 0.0 (0.0, 8.4) 0.0 (0.0, 8.4)

M (n=23) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8) 0.0 (0.0, 14.9) 0.0 (0.0, 14.9)

N (n=23) 0.0 (0.0, 16.8) 0.0 (0.0, 17.6) 0.0 (0.0, 14.9)

P (n=13) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8)

R (n=12) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9)

S (n=35) 2.9 (0.5, 14.9) 2.9 (0.5, 14.9) 2.9 (0.5, 14.9)


All-Wales: Number of isolates 270 373 388 440Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,



19


Interpretation Tables 12-16: The tables show trends in resistance to drug/bugcombinations in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time. Note 1: The data isdifferent to that shown in Table 3 (page 11); Table 3 shows the rates for Klebsiellapneumoniae as per ARHAI instructions, but the following tables show the data for allKlebsiella species to allow comparisons with previous reports. Note 2: Individualhospital or laboratory resistance rates are only presented for organisms where ≥80% of such isolates from the given sample type was tested and where the number ofisolates tested exceeds 9. It is important to remember when interpreting this data setthat hospital level data often represents small numbers of organisms, and singleisolate resistance within these numbers can produce misleadingly large changes inresistance.

Table 12: Trends in third generation cephalosporin resistance for Klebsiella spp.(2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

R = Prince Philip

S = Singleton

20

Table 13: Trends in fluoroquinolone resistance for Klebsiella spp. (2009-2013)

Table 14: Trends in gentamicin resistance for Klebsiella spp. (2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

R = Prince Philip

S = Singleton

21

Table 15: Trends in piperacillin/tazobactam resistance for Klebsiella spp.

(2009-2013)

Table 16: Trends in imipenem/meropenem resistance for Klebsiella spp.

(2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

R = Prince Philip

S = Singleton

22

Enterobacter spp., Serratia spp., Proteus spp., and Ps. Aeruginosa

Table 17: Enterobacter spp., Serratia spp., Proteus spp., and Ps. aeruginosa

Note: The numbers shown in red denote that <80% of total isolates were testedagainst the particular antibacterial agent. Resistance rates are not recorded if theorganisms are intrinsically resistant to an antibacterial agent e.g. for amoxicillin.When <80% of all isolates were tested, the All-Wales rate is shown in red.

Enterobacter spp., Serratia spp., Proteus spp., and Pseudomonas aeruginosa from blood culturesResistance rates including (95% Confidence Intervals)



Oragnism COA (95% CI) PTZ (95% CI) GEN (95% CI) PTZ+GEN (95% CI)

Enterobacter spp. _ 13.9 (9.2, 20.5) 8.1 (4.7, 13.5) 2.1 (0.7, 5.9)

All-Wales: Number of isolates 144 149 144

Serratia spp. _ 9.8 (5.2, 17.6) 0.0 (0.0, 3.9) 0.0 (0.0, 4.0)


Proteus spp. 17.6 (12.4, 24.5) 1.3 (0.4, 4.5) 15.3 (10.6, 21.7) 0.6 (0.1, 3.5)

All-Wales: Number of isolates 153.0 157 163 157

* Pseudomonas aeruginosa _ 4.9 (2.5, 9.4) 3.0 (1.3, 6.9) 1.3 (0.3, 4.5)



Enterobacter spp. _ 28.0 (21.3, 35.8) 0.0 (0.0, 3.1) 3.4 (1.5, 7.7)


Serratia spp. _ 29.3 21.0, 39.3) 1.4 (0.2, 7.4) 21.1 (14.1, 30.3)


Proteus spp. _ 3.9 (1.8, 8.3) 2.5 (0.9, 7.1) 10.6 (6.7, 16.4)





Enterobacter spp. 7.1 (3.5, 14.0) 1.6 (0.4, 5.7) 0.8 (0.1, 4.2) 1.4 (0.4, 5.0)


Serratia spp. 2.0 (0.4, 10.5) 0.0 (0.0, 4.9) 0.0 (0.0, 4.4) 0.0 (0.0, 4.0)


Proteus spp. 1.2 (0.2, 6.7) 6.8 (3.5, 12.8) 0.0 (0.0, 7.4) 5.2 (2.7, 10.0)




Key: COA = co-amoxiclav, PTZ = piperacillin/tazobactam, GEN = gentamicin, PTZ/GEN = combined resistance to both agents, AMO = amoxicillin,



23

Enterobacter spp. (n=154 in 2013)

The All-Wales patterns of antimicrobial resistance for Enterobacter spp. are shown inFigure 3 & Table 17. There has been a significant decrease in fluoroquinoloneresistance across time, and in piperacillin/tazobactam resistance between 2010 and2013.

Figure 3: All-Wales antimicrobial resistance rates for Enterobacter species;isolated from blood culture (2005 to 2013)

The resistance rates for piperacillin/tazobactam resistance are generally lower in theWales data than the PHE data e.g. in 2012 the Wales rate was 9% compared with aUK rate of 20%. Although the rates of carbapenem resistance in Wales are higherthan those reported by the PHE, the Wales figure includes ertapenem resistancedata, and not only imipenem and meropenem data.

Table 18: PHE data for Enterobacter species bacteraemia 2005-2012

Enterobacter spp. 2005 2006 2007 2008 2009 2010 2011 2012

Total reports: 2,522 2,613 2,675 2,414 2,208 2,037 2,052 1,917

Piperacillin/Tazobactam

% NS 23% 24% 21% 18% 17% 18% 16% 20%

No. reports 1,368 1,594 1,884 1,774 1,554 1,484 1,582 1,499

Imipenem/Meropenem

% NS 1% 1.2% 1.1% 0.7% 0.4% <1% <1% <1%

No. reports 1,506 1,732 1,984 1,909 1,662 1,524 1,561 1,486

Cefotaxime% NS 40% 42% 37% 38% 35% 33% 29% 26%

No. reports 1,040 1,213 1,271 1,195 1,081 993 1,012 999

Ceftazidime% NS 42% 41% 36% 36% 32% 32% 30% 29%

No. reports 1,334 1,519 1,769 1,612 1,376 1,370 1,391 1,317

Ciprofloxacin% NS 15% 14% 10% 8% 6% 5% 5% 5%

No. reports 1,860 2,092 2,237 1,987 1,693 1,638 1,683 1,6585

Gentamicin% NS 12% 11% 9% 7% 7% 5% 6% 6%

No. reports 1,988 2,108 2,337 2,139 1,844 1,723 1,803 1,708

Key: % NS = percentage of non-susceptible isolates

20

05

20

13

0

5

10

15

20

25

30

35

40

45

50

55

60

65

3GC CARB FQ GEN PTZ

Re

sist

ance

(%)

24

Serratia spp. (n=97 in 2013)

The All-Wales patterns of antimicrobial resistance for Serratia spp. are shown inFigure 4 and Table 17. There has been a statistically significant decrease inresistance rates third generation cephalosporins (3GC), fluoroquinolones (FQ) andpiperacillin/tazobactam (PTZ) between 2005 and 2013.

Figure 4: All-Wales antimicrobial resistance rates for Serratia species; isolatedfrom blood culture (2005 to 2013)

The significant decrease in resistance between 2008 and 2012 reported by PHE isreflected in the Welsh data. Although the rates of carbapenem resistance in Walesare generally higher than those reported by the PHE, the Wales figure includesertapenem resistance data, and not only imipenem and meropenem data.

Table 19: PHE data for Serratia species bacteraemia 2005-2012

Serratia spp. 2005 2006 2007 2008 2009 2010 2011 2012

Total reports: 1,158 1,270 1,208 1,071 992 943 887 827


% NS 20% 20% 16% 16% 12% 15% 10% 8%

No. reports 604 774 828 764 712 712 707 657

Imipenem/Meropenem

% NS 0% 1% 0.3% 0.6% 0.1% 0.5% 0.4% <1%

No. reports 642 807 888 821 780 735 701 675

Cefotaxime% NS 27% 29% 28% 28% 30% 29% 21% 19%

No. reports 426 548 582 537 541 497 458 454

Ceftazidime% NS 18% 16% 14% 22% 20% 21% 16% 14%

No. reports 549 681 742 678 647 681 643 620

Ciprofloxacin% NS 26% 25% 20% 16% 12% 12% 11% 9%

No. reports 854 996 1,007 864 800 794 756 709

Gentamicin% NS 2% 2% 1% 3% 3% 2% 1% 1%

No. reports 1,002 1,002 1.046 917 855 838 824 762


20

05

20

13

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

75

3GC CARB FQ GEN PTZ

Re

sist

ance

(%)

25

Proteus spp. (n=166 in 2013)

The All-Wales patterns of antimicrobial resistance in Proteus spp. are shown inFigure 5 & Table 17, with a statistically significant decrease in carbapenem andgentamicin resistance between 2012 and 2013 Note: Due to known issues withsusceptibility testing of carbapenems with automated systems the reliability of thehigh carbapenem resistance is uncertain.

Figure 5: All-Wales antimicrobial resistance rates for Proteus species; isolatedfrom blood culture (2005 to 2013)

The PHE data for Proteus spp., Morganella morganii & Providencia spp. bacteraemiashows that 89% of bacteraemias from this group were Proteus mirabilis and 4% wereProteus vulgaris. The PHE resistance rates for Proteus mirabilis 2006-2012 areshown for comparison with the Welsh data (see Figure 5 and Table 20).

Table 20: PHE data for Proteus mirabilis bacteraemia 2006-2012

Proteus mirabilis 2006 2007 2008 2009 2010 2011 2012

Total reports: 1,671 1,842 2,083 2,133 2,091 2,091 2,238

Amoxicillin% NS 35% 30% 31% 32% 33% 34% 34%

No. reports 1,289 1,459 1,719 1,660 1,690 1,793 1,909

Cefuroxime% NS 5% 2% 2% 1% 2% 2% 1%

No. reports 1,234 1,369 1,476 1,323 1,311 1,458 1,477

Cefotaxime% NS 5% 1% 1% 0% 1% 2% 2%

No. reports 743 858 983 1,044 1,005 1,0734 1,160

Ceftazidime% NS 2% 1% 1% 1% 1% 2% 2%

No. reports 916 1,190 1,355 1,380 1,383 1,517 1,512

Ciprofloxacin% NS 7% 7% 6% 6% 6% 7% 9%

No. reports 1,293 1,460 1,648 1,622 1,677 1,775 1,857

Gentamicin% NS 4% 4% 3% 6% 7% 7% 10%

No. reports 1,296 1,527 1,816 1,779 1,795 1,897 2,000

Imipenem% NS 1% 2% 4% 6% 8% 9% 5%

No. reports 389 529 591 524 407 339 247


20

05

20

13

0

5

10

15

20

25

30

35

40

45

50

55

3GC AMO COA CARB CXM FQ GEN PTZ

Re

sist

ance

(%)

26

Pseudomonas aeruginosa (n=173 in 2013)

The All-Wales patterns of antimicrobial resistance in Pseudomonas aeruginosa areshown in Figure 6 & Table 17. The data is different to that shown in Table 3 (page11); Table 3 shows the rates for Pseudomonas spp as per ARHAI instructions, butthe following tables show the data for Ps. aeruginosa to allow comparisons withprevious reports.

Figure 6: All-Wales antimicrobial resistance rates for Pseudomonas aeruginosa;isolated from blood culture (2005 to 2013)

There was a statistically significant decrease in ciprofloxacin resistance between2011 and 2013. The PHE rates are shown below for comparison with the Welsh data(see Figure 6 and Table 21).http://www.hpa.org.uk/Topics/InfectiousDiseases/InfectionsAZ/Bacteraemia/

Table 21: PHE data for Pseudomonas aeruginosa bacteraemia 2005-2012

Pseudomonas aeruginosa 2006 2007 2008 2009 2010 2011 2012

Total reports: 2,866 3,090 3,987 3,927 3,833 3,694 3,743


% NS 4% 5% 6% 8% 7% 7% 9%

No. reports 1,985 2,324 2,490 2,509 2,570 2,544 2,654

Imipenem % NS 11% 12% 9% 13% 12% 14% 13%

No. reports 965 1,147 1,110 1,172 1,038 926 926

Meropenem% NS 10% 9% 10% 11% 9% 9% 9%

No. reports 1,087 1,396 1,713 1,785 2,017 2,210 2,3

Ceftazidime% NS 7% 8% 7% 8% 8% 8% 6%

No. reports 2,213 2,514 2,484 2,461 2,530 2,526 2,595

Ciprofloxacin% NS 12% 12% 11% 11% 10% 11% 9%

No. reports 2,393 2,646 2,657 2,709 2,696 2,703 2,728

Gentamicin% NS 5% 5% 4% 4% 5% 6% 4%

No. reports 2,415 2,754 2,785 2,778 2,812 2,810 2,864


20

05

20

13

0

5

10

15

20

25

30

35

CARB CAZ CIP GEN PTZ

Re

sist

ance

(%)

27

Staphylococcus aureus

The All-Wales resistance rates for Staphylococcus aureus at hospital level are shownin Table 22, the data includes all Staphylococcus aureus both MSSA and MRSA. In2013, flucloxacillin resistance rates for S. aureus bacteraemias in Ysbyty Glan Clwydand Ysbyty Gwynedd were notably high; 38.8% and 32.7% respectively.Flucloxacillin resistance reflects the proportion of S. aureus bacteraemias that wereMRSA; the proportions of MRSA bacteraemias were notably higher in these localitiesthan other acute hospitals in Wales.

Surveillance data was obtained from the Welsh Healthcare Associated Programme(WHAIP). Figure 7 shows the numbers of Staphylococcus aureus bacteraemias from2005 to 2013. Across time both the number of Staphylococcus aureus (SAUR) andMeticillin Resistant Staphylococcus aureus (MRSA) bacteraemias has decreased,whilst the numbers of Meticillin Sensitive Staphylococcus aureus (MSSA)bacteraemias increased significantly between 2011 and 2013.

Figure 7: All-Wales Staphylococcus aureus bacteraemia numbers (2005 to 2013)

407

164

632

759

1039

923

0

200

400

600

800

1000

1200

2005 2006 2007 2008 2009 2010 2011 2012 2013

MRSA 407 341 363 344 286 229 203 180 164

MSSA 632 682 658 638 681 664 661 701 759

SAUR 1039 1023 1021 982 967 893 864 881 923

Nu

mb

er

of

bac

tera

em

ias

28

Table 22: Staphylococcus aureus (MSSA & MRSA)

Staphylococcus aureus from blood cultures (MSSA & MRSA)Resistance rates including (95% Confidence Intervals)



Location Code CLI (95% CI) ERY (95% CI) FLU (95% CI)

A (n=13) 18.2 (5.1, 47.7) 18.2 (5.1, 47.7) 23.1 (8.2, 50.3)

B (n=51) 2.0 (0.3, 10.3) 7.8 (3.1, 18.5) 11.8 (5.5, 23.4)

C (n=56) 6.5 (2.2, 17.5) 12.5 (6.2, 23.6) 12.5 (6.2, 23.6)

D (n=85) 14.3 (8.4, 23.3) 6.0 (2.6, 13.2) 21.2 (13.8, 31.0)

E (n=65) 10.8 (5.3, 20.6) 12.3 (6.4, 22.5)

F (n=162) 16.4 (11.2, 23.4) 15.6 (10.8, 22.0) 16.0 (11.2, 22.5)

G (n=46) 8.7 (3.4, 20.3) 14.3 (6.7, 27.8) 10.9 (4.7, 23.0)

H (n=56) 17.9 (10.0, 29.8) 7.7 (3.0, 18.2) 25.0 (15.5, 37.7)

J (n=50) 28.0 (17.5, 41.7) 12.5 (5.9, 24.7) 26.0 (15.9, 39.6)

K (n=49) 3.7 (0.7, 18.3) 32.7 (21.2, 46.6)

L (n=49) 38.8 (26.4, 52.8)

M (n=35) 12.1 (4.8, 27.3) 11.8 (4.7, 26.6) 5.7 (1.6, 18.6)

N (n=40) 12.8 (5.6, 26.7) 10.0 (4.0, 23.1)

P (n=30) 10.7 (3.7, 27.2) 17.2 (7.6, 34.5) 3.3 (0.6, 16.7)

R (n=21) 19.0 (7.7, 40.0) 4.8 (0.8, 22.7) 14.3 (5.0, 34.6)

S (n=71) 8.6 (4.0, 17.5) 14.1 (7.8, 24.0)

All-Wales: Resistance rates 12.8 (10.6, 15.5) 11.5 (9.5, 13.8) 17.7 (15.3, 20.4)


Location Code FUS (95% CI) GEN (95% CI) LZD (95% CI)

A (n=13)

B (n=51) 29.4 (18.7, 43.0) 0.0 (0.0, 7.4)

C (n=56) 23.6 (14.4, 36.3) 3.7 (1.0, 12.5) 0.0 (0.0, 6.9)

D (n=85) 27.2 (18.7, 37.7) 6.1 (2.6, 13.5) 0.0 (0.0, 4.5)

E (n=65) 27.7 (18.3, 39.6) 1.5 (0.3, 8.2) 1.6 (0.3, 8.5)

F (n=162) 27.0 (20.7, 34.4) 6.9 (3.9, 12.0) 2.5 (1.0, 6.3)

G (n=46) 14.0 (6.6, 27.3) 2.4 (0.4, 12.6)

H (n=56) 0.0 (0.0, 6.4)

J (n=50) 28.6 (17.2, 43.6) 0.0 (0.0, 8.4) 2.4 (0.4, 12.3)

K (n=49) 21.2 (10.7, 37.8) 6.1 (2.1, 16.5)

L (n=49) 44.9 (31.9, 58.7) 6.1 (2.1, 16.5)

M (n=35) 15.2 (6.7, 30.9) 8.8 (3.0, 23.0) 0.0 (0.0, 10.7)

N (n=40) 17.6 (8.3, 33.5) 10.8 (4.3, 24.7) 0.0 (0.0, 10.7)

P (n=30) 17.2 (7.6, 34.5) 6.9 (1.9, 22.0) 3.4 (0.6, 17.2)

R (n=21) 26.3 (11.8, 48.8) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8)

S (n=71) 32.9 (23.0, 44.5) 2.8 (0.8, 9.7) 3.1 (0.8, 10.5)



Location Code MUP (95% CI) RIF (95% CI) TET (95% CI)

A (n=13)

B (n=51) 0.0 (0.0, 7.0) 0.0 (0.0, 7.0) 0.0 (0.0, 7.4)

C (n=56) 0.0 (0.0, 6.9) 0.0 (0.0, 6.8) 3.6 (1.0, 12.3)

D (n=85) 5.0 (2.0, 12.2) 6.3 (2.7, 14.0)

E (n=65) 1.6 (0.3, 8.5) 0.0 (0.0, 5.7) 3.2 (0.9, 10.9)

F (n=162) 0.6 (0.1, 3.5) 1.3 (0.3, 4.5) 7.5 (4.4, 12.7)

G (n=46) 0.0 (0.0, 7.7) 0.0 (0.0, 8.2) 4.3 (1.2, 14.5)

H (n=56)

J (n=50) 0.0 (0.0, 8.4) 6.1 (1.7, 19.6)

K (n=49) 2.1 (0.4, 11.1) 12.2 (5.7, 24.2)

L (n=49) 2.0 (0.4, 10.7) 0.0 (0.0, 7.3) 8.2 (3.2, 19.2)

M (n=35) 3.1 (0.6, 15.7)

N (n=40) 0.0 (0.0, 9.6) 2.6 (0.5, 13.5)

P (n=30) 6.9 (1.9, 22.0) 0.0 (0.0, 11.7) 6.9 (1.9, 22.0)

R (n=21) 0.0 (0.0, 16.8)

S (n=71) 0.0 (0.0, 5.7) 0.0 (0.0, 5.7) 2.8 (0.8, 9.7)


All-Wales: Number of isolates 725 724 797Key:CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, GEN = gentamicin, LZD = linezolid,

MUP = mupirocin, PEN = pencillin, RIF = rifampicin, TET = tetracycline.

29


Interpretation Table 23: The table show trends in resistance to a drug/bugcombination in the ARHAI primary data set at hospital level, across time. The tablesuse a colour gradation based on the lowest resistance to the highest resistancefigures, to highlight local patterns of resistance across time.

Table 23: Trends in meticillin resistance for Staphylococcus aureus (2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

R = Prince Philip

S = Singleton

30

Meticillin Sensitive Staphylococcus aureus (n=734 in 2013)

The All-Wales pattern of antimicrobial resistance in MSSA is shown in Figure 8 andTable 24; with no statistically significant changes between 2005 and 2013.

Figure 8: All-Wales antimicrobial resistance rates for Meticillin SensitiveStaphylococcus aureus (MSSA) isolated from blood culture (2005 to 2013)

The All-Wales antimicrobial resistance rates for MSSA are largely comparable tothose published by BSAC for the UK except for clindamycin resistance whichappears higher in Wales. In 2013, the All-Wales clindamycin resistance rate was6.7% compared with the UK rate of 1.1%. The All-Wales rate is skewed by high localrates in some areas including Glangwili (16.2%), Bronglais (11.1%) and Nevill Hallhospitals (9.7%). This presumably reflects the varying presence of epidemic strains.

In 2013, the All-Wales resistance rate for penicillin was 84.6%, and resistance tolinezolid and vancomycin remained undetected.

20

05

20

05

20

13

20

13

0

2

4

6

8

10

12

14

16

18

20

ERY FUS GEN MUP RIF TET

Re

sist

ance

(%)

31

Table 24: Meticillin Sensitive Staphylococcus aureusMeticillin Sensitive Staphylococcus aureus from blood culturesResistance rates including (95% Confidence Intervals)



Location Code CLI (95% CI) ERY (95% CI) FUS (95% CI)

A (n=10) 11.1 (2.0, 43.5) 20.0 (5.7, 51.0)

B (n=45) 0.0 (0.0, 7.9) 8.9 (3.5, 20.7) 20.0 (10.9, 33.8)

C (n=48) 4.5 (1.3, 15.1) 14.3 (7.1, 26.7) 14.6 (7.2, 27.2)

D (n=67) 3.0 (0.8, 10.4) 7.6 (3.3, 16.5) 7.9 (3.4, 17.3)

E (n=57) 9.8 (3.9, 22.5) 12.3 (6.1, 23.2) 17.5 (9.8, 29.4)

F (n=136) 8.3 (4.6, 14.7) 18.7 (13.0, 26.1) 16.5 (11.2, 23.8)

G (n=41) 7.3 (2.5, 19.4) 14.6 (6.9, 28.4) 7.5 (2.6, 19.9)

H (n=42) 7.1 (2.5, 19.0) 10.5 (4.2, 24.1) 12.5 (5.5, 26.1)

J (n=37) 16.2 (7.7, 31.1) 16.2 (7.7, 31.1) 6.7 (1.8, 21.3)

K (n=33) 9.1 (3.1, 23.6) 21.2 (10.7, 37.8)

L (n=30) 16.7 (7.3, 33.6) 10.0 (3.5, 25.6)

M (n=33) 9.7 (3.3, 24.9) 12.5 (5.0, 28.1) 9.7 (3.3, 24.9)

N (n=36) 13.9 (6.1, 28.7) 10.0 (3.5, 25.6)

P (n=29) 7.4 (2.1, 23.4) 17.9 (7.9, 35.6) 17.9 (7.9, 35.6)

R (n=18) 5.6 (1.0, 25.8) 5.6 (1.0, 25.8) 12.5 (3.5, 36.0)

S (n=61) 9.8 (4.6, 19.8) 23.0 (14.2, 34.9)



Location Code GEN (95% CI) LZD (95% CI) MUP (95% CI)

A (n=10)

B (n=45) 0.0 (0.0, 7.9) 0.0 (0.0, 7.9)

C (n=48) 4.3 (1.2, 14.2) 0.0 (0.0, 7.9) 0.0 (0.0, 7.9)

D (n=67) 6.3 (2.5, 15.0) 0.0 (0.0, 5.7) 1.6 (0.3, 8.6)

E (n=57) 1.8 (0.3, 9.3) 0.0 (0.0, 6.5) 0.0 (0.0, 6.5)

F (n=136) 2.3 (0.8, 6.4) 0.0 (0.0, 2.8) 0.8 (0.1, 4.1)

G (n=41) 0.0 (0.0, 9.4) 0.0 (0.0, 8.6)

H (n=42) 0.0 (0.0, 8.4)

J (n=37) 0.0 (0.0, 11.4) 0.0 (0.0, 11.4)

K (n=33) 3.0 (0.5, 15.3)

L (n=30) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)

M (n=33) 9.4 (3.2, 24.2) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)

N (n=36) 9.1 (3.1, 23.6) 0.0 (0.0, 11.7)

P (n=29) 3.6 (0.6, 17.7) 0.0 (0.0, 12.1) 7.1 (2.0, 22.6)

R (n=18) 0.0 (0.0, 19.4) 0.0 (0.0, 19.4)

S (n=61) 0.0 (0.0, 5.9) 0.0 (0.0, 6.5) 0.0 (0.0, 6.6)

All-Wales: Resistance rates 3 (1.9, 4.7) 0 (0.0, 0.6) 1.4 (0.7, 2.6)


Location Code PEN (95% CI) RIF (95% CI) TET (95% CI)

A (n=10) 88.9 (56.5, 98.0)

B (n=45) 77.8 (63.7, 87.5) 0.0 (0.0, 7.9) 0.0 (0.0, 8.4)

C (n=48) 91.3 (79.7, 96.6) 0.0 (0.0, 7.7) 4.2 (1.2, 14.0)

D (n=67) 86.7 (75.8, 93.1) 6.5 (2.5, 15.4)

E (n=57) 83.9 (72.2, 91.3) 0.0 (0.0, 6.5) 1.8 (0.3, 9.4)

F (n=136) 0.0 (0.0, 2.8) 4.5 (2.1, 9.5)

G (n=41) 75.6 (60.7, 86.2) 0.0 (0.0, 9.0) 0.0 (0.0, 8.6)

H (n=42)

J (n=37) 0.0 (0.0, 11.4)

K (n=33) 81.8 (65.6, 91.4) 3.2 (0.6, 16.2) 9.1 (3.1, 23.6)

L (n=30) 0.0 (0.0, 11.4) 3.3 (0.6, 16.7)

M (n=33) 81.3 (64.7, 91.1)

N (n=36) 80.0 (64.1, 90.0) 0.0 (0.0, 10.7) 2.9 (0.5, 14.9)

P (n=29) 100.0 (86.2, 100) 0.0 (0.0, 12.1) 3.6 (0.6, 17.7)

R (n=18) 0.0 (0.0, 19.4)

S (n=61) 88.3 (77.8, 94.2) 0.0 (0.0, 6.5) 3.3 (0.9, 11.2)




32

Meticillin Resistant Staphylococcus aureus (n=158 in 2013)

The All-Wales pattern of antimicrobial resistance in MRSA is shown in Figure 9 &Table 25; with a statistically increase in tetracycline resistance between 2005 and2013.

Figure 9: All-Wales antimicrobial resistance rates for Meticillin ResistantStaphylococcus aureus (MRSA) isolated from blood culture (2005 to 2013)

The All-Wales antimicrobial resistance rates for MRSA for 2005 to 2012 are largelycomparable to those published by BSAC for the UK. BSAC have not as yet publishedantimicrobial resistance rates for MRSA for 2013, however the clindamycinresistance rates for Wales in 2013 were notably high at 45.9% compared with theBSAC rate of 13.1% in 2012.

Resistance to vancomycin and linezolid has remained undetected.

20

05

2007

20

13

0

10

20

30

40

50

60

70

80

90

100

ERY FUS GEN MUP RIF TET

Re

sist

ance

(%)

33

Table 25: Meticillin Resistant Staphylococcus aureus

The number of MRSA bacteraemias has reduced markedly over the past few yearsand so the number of individual hospitals with 10 isolates or more has reduced, andso the table is small. When <80% of all isolates were tested, the All-Wales rate isshown in red.

Meticillin Resistant Staphylococcus aureus from blood culturesResistance rates including (95% Confidence Intervals)



Location Code CLI (95% CI) ERY (95% CI) FQ (95% CI)

D (n=18) 55.6 (33.7, 75.4) 55.6 (33.7, 75.4) 94.4 (74.2, 99.0)

F (n=27) 65.0 (43.3, 81.9) 73.1 (53.9, 86.3) 80.8 (62.1, 91.5)

H (n=14) 50.0 (26.8, 73.2) 50.0 (26.8, 73.2)

J (n=13) 61.5 (35.5, 82.3) 61.5 (35.5, 82.3) 83.3 (55.2, 95.3)

K (n=16) 87.5 (64.0, 96.5)

L (n=19) 89.5 (68.6, 97.1) 100 (83.2, 100)

S (n=10) 70.0 (39.7, 89.2) 100 (70.1, 100)



Location Code FUS (95% CI) GEN (95% CI) LZD (95% CI)

D (n=18) 5.6 (1.0, 25.8) 0.0 (0.0, 17.6) 0.0 (0.0, 17.6)

F (n=27) 30.8 (16.5, 50.0) 3.8 (0.7, 18.9) 0.0 (0.0, 12.9)

H (n=14) 21.4 (7.6, 47.6) 0.0 (0.0, 21.5) 0.0 (0.0, 21.5)

J (n=13) 0.0 (0.0, 24.3) 8.3 (1.5, 35.4)

K (n=16) 12.5 (3.5, 36.0) 0.0 (0.0, 19.4)

L (n=19) 15.8 (5.5, 37.6) 0.0 (0.0, 16.8)

S (n=10) 20.0 (5.7, 51.0) 20.0 (5.7, 51.0) 0.0 (0.0, 29.9)

All-Wales: Resistance rates 15.5 (10.6, 22.0) 3.3 (1.4, 7.6) 0 (0.0, 3.3)


Location Code MUP (95% CI) RIF (95% CI) TET (95% CI)

D (n=18) 16.7 (5.8, 39.2) 5.9 (1.0, 27.0)

F (n=27) 0.0 (0.0, 12.9) 7.7 (2.1, 24.1) 23.1 (11.0, 42.1)

H (n=14) 0.0 (0.0, 22.8) 0.0 (0.0, 22.8) 28.6 (11.7, 54.6)

J (n=13) 0.0 (0.0, 24.3)

K (n=16) 0.0 (0.0, 19.4) 18.8 (6.6, 43.0)

L (n=19) 0.0 (0.0, 16.8) 0.0 (0.0, 16.8) 15.8 (5.5, 37.6)

S (n=10) 0.0 (0.0, 29.9) 0.0 (0.0, 29.9) 0.0 (0.0, 27.8)




34

Enterococcus spp. (n=489 in 2013)

The All-Wales pattern of antimicrobial resistance in Enterococcus spp. is shown inFigure 10 and Table 26; with no statistically significant changes between 2005 and2013.

Figure 10: All-Wales antimicrobial resistance rates for Enterococcus spp. isolatedfrom blood culture (2005 to 2013)

In 2013, the All-Wales resistance rate for amoxicillin was 46.9% (42.5, 51.4).Susceptibility to amoxicillin is a guide to speciation of the organism, E. faecalis beingnormally susceptible and E. faecium being normally resistant, and suggests that in2013, 53.1% of entercoccal bacteraemias were due to E. faecalis.

Table 26: Enterococcus spp.

2005

2013

0

5

10

15

20

25

30

35

40

45

50

55

AMO VAN

Re

sist

ance

(%)

Enterococcus spp. from blood culturesResistance rates including (95% Confidence Intervals)



Location Code AMO (95% CI) VAN (95% CI)

A (n=10) 55.6 (26.7, 81.1) 0.0 (0.0, 29.9)

B (n=22) 50.0 (30.7, 69.3) 9.1 (2.5, 27.8)

C (n=25) 35.0 (18.1, 56.7) 8.3 (2.3, 25.8)

D (n=44) 45.5 (31.7, 59.9)

E (n=40) 40.0 (26.3, 55.4) 15.0 (7.1, 29.1)

F (n=114) 60.6 (51.2, 69.2) 14.2 (8.9, 21.8)

G (n=15) 41.7 (19.3, 68.0) 6.7 (1.2, 29.8)

H (n=25) 40.0 (23.4, 59.3) 16.0 (6.4, 34.7)

J (n=34) 35.3 (21.5, 52.1) 15.2 (6.7, 30.9)

K (n=26) 79.2 (59.5, 90.8) 33.3 (18.0, 53.3)

L (=27) 40.7 (24.5, 59.3) 7.4 (2.1, 23.4)

M (n=23) 39.1 (22.2, 59.2)

N (n=11) 54.5 (28.0, 78.7) 9.1 (1.6, 37.7)

P (n=17) 23.5 (9.6, 47.3) 5.9 (1.0, 27.0)

S (n=39) 38.5 (24.9, 54.1) 17.9 (9.0, 32.7)

All-Wales: Resistance rates 46.9 (42.5, 51.4) 15.5 (12.5, 19.1)

All-Wales: Number of isolates 473 464Key: AMO = amoxicillin, VAN = vancomycin.

35

Note: Locally resistance rates for amoxicillin varied from 23.5.8% in UniversityHospital Llandough (P) to 79.2% in Ysbyty Gwynedd (K) and this may simply reflectvariation in the proportion of E. faecalis to E. faecium. Vancomycin resistance variedfrom 0.0% in Bronglais (A) to 33.3% in Ysbyty Gwynedd.



Table 27: Trends in vancomycin resistance for Enterococcus spp. (2009-2013)

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


N = Prince Charles

P = UHL

S = Singleton

36

Streptococcus pneumoniae (n=295 in 2013)

The All-Wales pattern of antimicrobial resistance is shown in Figure 11 & Table 28;with no statistically significant changes between 2005 and 2013, except tetracyclinewhich has increased from 1.0% (95% CI 0.3, 2.8) in 2005 to 6.0% (95% CI 3.5, 10.0)in 2013.

Figure 11: All-Wales antimicrobial resistance rates for Streptococcus pneumoniaeisolated from blood culture (2005 to 2013)

ERY PEN TET

2005 9.8 2.5 1.0

2006 8.1 4.0 3.0

2007 8.5 3.5 3.0

2008 5.0 2.9 3.9

2009 4.7 2.1 3.5

2010 3.9 1.4 1.1

2011 6.5 2.7 5.2

2012 8.4 2.0 5.2

2013 7.6 4.5 6.0

20

05

20

13

0

2

4

6

8

10

12

14

16

Re

sist

ance

(%)

37

Table 28: Streptococcus pneumoniae

Note: Locally resistance rates for S. pneumoniae bacteraemia from Ysbyty Gwynedd(K) were notably higher than the rest of Wales.



Table 29: Trends in penicillin resistance for S. pneumoniae (2009-2013)

Streptococcus pneumoniae from blood culturesResistance rates including (95% Confidence Intervals)



Location Code ERY (95% CI) PEN (95% CI) TET (95% CI)

B (n=11) 0.0 (0.0, 25.9) 0.0 (0.0, 25.9) 0.0 (0.0, 27.8)

C (n=23) 5.0 (0.9, 23.6) 0.0 (0.0, 14.3)

D (n=33) 6.7 (1.8, 21.3) 3.0 (0.5, 15.3) 10.7 (3.7, 27.2)

E (n=13) 7.7 (1.4, 33.3) 7.7 (1.4, 33.3)

F (n=37) 5.9 (1.6, 19.1) 14.7 (6.4, 30.1) 2.9 (0.5, 14.9)

H (n=16) 0.0 (0.0, 19.4)

K (n=14) 28.6 (11.7, 54.6) 21.4 (7.6, 47.6) 14.3 (4.0, 39.9)

L (n=24) 0.0 (0.0, 13.8) 0.0 (0.0, 13.8) 0.0 (0.0, 13.8)

M (n=22) 9.1 (2.5, 27.8) 0.0 (0.0, 14.9) 9.5 (2.7, 28.9)

N (n=18) 13.3 (3.7, 37.9) 5.6 (1.0, 25.8) 13.3 (3.7, 37.9)

S (n=23) 18.2 (7.3, 38.5) 4.3 (0.8, 21.0)


All-Wales: Number of isolates 238 264 217Key: ERY = erythromycin, PEN = penicillin, TET = tetracycline.

Key:

A= Bronglais


C = Royal Glamorgan

D = Royal Gwent

E = Morriston

F = UHW

G = Withybush

H = Wrexham Maelor

J = Glangwili

K = Ysbyty Gwynedd


M = Nevill Hall

N = Prince Charles

P = UHL

S = Singleton

38

Section 5.2: Antimicrobial resistance rates forurinary coliforms

For the purposes of this report the term coliform refers to organisms that werereported as a ‘coliform’ by the laboratory, or when identified further, were reported asone of the genera belonging to the family Enterobacteriaceae.

The genera included in this section of the report comprise:

Citrobacter Edwardsiella Enterobacter Escherichia Hafnia Klebsiella Kluyvera Morganella Pantoea Proteus Providencia Rahnella Salmonella Serratia Yersinia

It should be noted that data from routinely-submitted urine specimens is more proneto bias than data from blood culture isolates due to variable sampling by clinicians.Thus resistance rates quoted here are likely to be higher due to increased samplingfrom patients who are more likely to have resistant organisms (e.g. patients withrecurrent infections or infections that have failed to respond to initial therapy). Thisshould be factored into any use of the data presented for the design of empirictreatment guidance.

The generation of more specific data reports (e.g. different patient age groups) canbe discussed with the Welsh AR Programme.

39

Table 30: Community Urinary Coliforms

Note: The range of resistance is outlined with boxes e.g. the range of resistance toamoxicillin was 53.1% - 61.1%; individual hospital rates statistically higher than theAll-Wales rate are highlighted in colour. In 2013, a number of local communities hadresistance rates for urinary coliforms that were statistically higher than the All-Walesrate; the most notable were the communities served by UHW (F), Ysbyty Gwynedd(K) and Ysbyty Glan Clwyd (L). Cephalosporin and fluoroquinolone resistance wasgenerally higher in the communities in North Wales.

Community Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)



Location Code (Number) AMO (95% CI) COA (95% CI) IGC (95% CI) 3GC (95% CI)

A (n=2,766) 53.1 (51.2, 55.0) 8.8 (7.8, 9.9) 8.6 (7.6, 9.7) 4.1 (3.4, 4.9)

B (n=521) 61.1 (56.8, 65.2) 5.9 (4.1, 8.3) 9.6 (7.3, 12.4) 5.5 (3.8, 7.8)

C (n=4,077) 58.1 (56.7, 59.5) 17.1 (16.0, 18.2) 10.8 (9.9, 11.8) 3.3 (2.8, 3.9)

D (n=13,835) 57.7 (56.9, 58.5) 10.6 (10.1, 11.2) 9.3 (8.8, 9.8) 1.7 (1.5, 2.0)

F (n=8,859) 59.5 (58.5, 60.5) 12.5 (11.8, 13.2) 10.9 (10.3, 11.7) 4.9 (4.5, 5.4)

G (n=3,793) 53.9 (52.3, 55.5) 11.9 (11.0, 13.0) 7.8 (7.0, 8.8) 4.3 (3.7, 5.1)

H (n=8,855) 56.9 (55.8, 57.9) 3.3 (2.9, 3.7) 9.0 (8.5, 9.7)

J (n=7,407) 55.3 (54.2, 56.5) 5.8 (5.3, 6.4) 6.5 (5.9, 7.1) 5.2 (4.7, 5.7)

K (n=10,111) 57.8 (56.8, 58.7) 9.1 (8.5, 9.7) 12.3 (11.6, 12.9) 7.7 (7.2, 8.2)

L (n=7,573) 58.0 (56.8, 59.2) 11.4 (10.7, 12.1) 7.4 (6.8, 8.0)

M (n=880) 60.0 (56.7, 63.2) 11.9 (10.0, 14.2) 1.9 (1.2, 3.1)

N (n=2,898) 59.0 (57.2, 60.8) 14.4 (13.2, 15.8) 6.9 (5.9, 8.0) 3.2 (2.6, 3.9)

P (n=3,066) 58.6 (56.9, 60.4) 13.0 (11.9, 14.3) 11.1 (10.0, 12.3) 5.5 (4.8, 6.4)

R (299) 58.8 (52.7, 64.6) 6.2 (3.8, 9.8) 5.4 (3.2, 8.8)

S (14,867) 58.3 (57.5, 59.1) 9.9 (9.4, 10.4) 10.0 (9.6, 10.5) 6.1 (5.7, 6.5)

T (n=23) 60.9 (40.8, 77.8) 13.0 (4.5, 32.1) 4.3 (0.8, 21.0)

All-Wales: Resistance rates 57.6 (57.3, 57.9) 10.5 (10.3, 10.7) 9.8 (9.6, 10.0) 5 (4.8, 5.1)

All-Wales: Number of isolates 88,803 82,015 85,462 78,982

Location Code (Number) FQ (95% CI) NIT (95% CI) TRI (95% CI)

A (n=2,766) 8.0 (7.1, 9.1) 9.3 (8.3, 10.5) 33.5 (31.8, 35.3)

B (n=521) 10.8 (8.4, 13.7) 11.2 (8.8, 14.3) 34.1 (30.1, 38.3)

C (n=4,077) 10.0 (9.2, 10.9) 11.2 (10.3, 12.1) 35.2 (33.8, 36.6)

D (n=13,835) 7.8 (7.4, 8.3) 10.8 (10.3, 11.4) 31.7 (30.9, 32.5)

F (n=8,859) 10.9 (10.2, 11.5) 12.2 (11.5, 12.9) 36.3 (35.3, 37.3)

G (n=3,793) 8.1 (7.3, 9.1) 13.9 (12.8, 15.1) 34.1 (32.6, 35.6)

H (n=8,855) 12.0 (11.3, 12.7) 8.3 (7.7, 8.9) 35.4 (34.4, 36.4)

J (n=7,407) 6.7 (6.1, 7.3) 10.6 (9.9, 11.4) 33.2 (32.1, 34.4)

K (n=10,111) 11.4 (10.8, 12.1) 15.2 (14.5, 15.9) 35.9 (35.0, 36.9)

L (n=7,573) 12.9 (12.2, 13.7) 14.2 (13.4, 15.0) 37.2 (36.1, 38.3)

M (n=880) 9.6 (7.8, 11.7) 12.2 (10.2, 14.6) 29.8 (26.8, 33.0)

N (n=2,898) 8.0 (7.0, 9.0) 10.0 (9.0, 11.2) 32.7 (31.0, 34.4)

P (n=3,066) 11.8 (10.7, 13.0) 12.5 (11.3, 13.7) 35.4 (33.8, 37.2)

R (299) 6.5 (4.1, 10.2) 9.6 (6.6, 13.8) 31.5 (26.2, 37.4)

S (14,867) 9.2 (8.7, 9.7) 11.7 (11.2, 12.3) 36.2 (35.4, 37.0)

T (n=23) 4.3 (0.8, 21.0) 4.3 (0.8, 21.0) 21.7 (9.7, 41.9)


All-Wales: Number of isolates 89,423 88,551 88,701

Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),

FQ = ciprofloxacin &/or levofloaxcin, or norfloxacin, NIT = nitrofurantoin, TRI = trimrthoprim

40

Table 31: Hospital Out-Patient Urinary Coliforms

Note: The resistance rates for out-patient urinary coliforms for UHW (F) and YsbytyGlan Clwyd (L) were statistically higher than the All-Wales rate for the agents asshown.

Out Patient Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)




A (n=119) 49.2 (40.3, 58.1) 4.2 (1.8, 9.5) 2.7 (0.9, 7.6) 0.9 (0.2, 4.7)

B (n=423) 56.9 (52.1, 61.6) 7.2 (5.1, 10.1) 10.2 (7.6, 13.5) 5.3 (3.5, 7.9)

C (n=250) 60.1 (53.9, 66.0) 16.8 (12.7, 21.9) 12.4 (8.2, 18.1) 3.7 (2.0, 6.9)

D (n=868) 61.1 (57.8, 64.3) 12.9 (10.8, 15.3) 2.9 (2.0, 4.3)

E (n=320) 63.8 (58.4, 68.9) 13.1 (9.8, 17.2) 14.9 (11.3, 19.3) 7.6 (5.2, 11.1)

F (n=964) 67.5 (64.5, 70.4) 19.2 (16.8, 21.8) 17.6 (15.3, 20.2) 7.0 (5.5, 8.8)

G (n=365) 50.4 (45.3, 55.5) 9.0 (6.5, 12.4) 3.2 (1.8, 5.6)

H (n=540) 56.3 (52.1, 60.4) 2.5 (1.5, 4.3) 7.2 (5.3, 9.7)

J (n=540) 55.6 (51.2, 59.9) 4.9 (3.3, 7.2) 3.9 (2.5, 5.9)

K (n=375) 62.6 (57.6, 67.4) 9.7 (7.1, 13.2) 9.9 (7.1, 13.7) 6.5 (4.4, 9.5)

L (n=1004) 59.2 (56.1, 62.3) 16.2 (14.0, 18.6) 9.5 (7.9, 11.5)

M (n=176) 54.5 (47.2, 61.7) 8.5 (5.2, 13.6) 2.9 (1.3, 6.7)

N (n=252) 57.8 (51.6, 63.8) 13.5 (9.8, 18.3) 1.6 (0.6, 4.1)

P (n=275) 52.7 (46.8, 58.5) 8.0 (5.3, 11.8) 6.5 (4.1, 10.1) 4.0 (2.3, 7.1)

Q (n=69) 66.2 (54.3, 76.3) 5.8 (2.3, 14.0) 10.2 (4.7, 20.5) 5.9 (2.3, 14.2)

R (n=207) 61.8 (54.7, 68.4) 7.9 (4.8, 12.6) 10.3 (6.7, 15.5) 7.4 (4.4, 12.0)

S (n=142) 53.9 (45.7, 61.9) 10.1 (6.1, 16.3) 9.1 (5.3, 15.2) 7.1 (3.9, 12.6)

T (n=124) 61.0 (52.1, 69.1) 8.1 (4.5, 14.3) 7.6 (4.0, 13.8) 3.3 (1.3, 8.1)

W (n=90) 52.2 (42.0, 62.2) 10.0 (5.4, 17.9) 7.1 (3.3, 14.6) 4.5 (1.8, 11.0)




A (n=119) 5.9 (2.9, 11.7) 1.7 (0.5, 6.0) 22.9 (16.2, 31.2)

B (n=423) 9.3 (6.9, 12.5) 10.3 (7.7, 13.6) 30.4 (26.2, 35.0)

C (n=250) 10.4 (7.2, 14.8) 8.4 (5.6, 12.5) 30.4 (25.0, 36.4)

D (n=868) 8.0 (6.3, 10.0) 11.3 (9.3, 13.6) 32.2 (29.1, 35.4)

E (n=320) 13.8 (10.5, 18.1) 17.0 (13.2, 21.5) 29.1 (24.4, 34.3)

F (n=964) 17.8 (15.6, 20.4) 15.9 (13.7, 18.4) 36.7 (33.7, 39.8)

G (n=365) 9.9 (7.2, 13.4) 13.2 (10.1, 17.1) 29.3 (24.9, 34.2)

H (n=540) 9.6 (7.4, 12.4) 5.4 (3.8, 7.6) 30.9 (27.2, 34.9)

J (n=540) 7.8 (5.7, 10.5) 13.7 (10.9, 17.0) 31.6 (27.6, 35.8)

K (n=375) 13.8 (10.7, 17.7) 15.7 (12.4, 19.8) 33.6 (29.0, 38.6)

L (n=1004) 13.0 (11.1, 15.3) 17.2 (15.0, 19.7) 30.7 (27.9, 33.6)

M (n=176) 8.0 (4.8, 12.9) 4.6 (2.3, 8.8) 20.7 (15.3, 27.3)

N (n=252) 7.7 (5.0, 11.7) 11.2 (7.9, 15.7) 31.3 (25.9, 37.3)

P (n=275) 9.5 (6.5, 13.5) 12.4 (9.0, 16.8) 26.5 (21.7, 32.1)

Q (n=69) 10.1 (5.0, 19.5) 14.5 (8.1, 24.7) 33.3 (23.4, 45.1)

R (n=207) 6.3 (3.6, 10.7) 14.2 (10.0, 19.9) 31.1 (24.9, 38.0)

S (n=142) 9.9 (6.0, 16.0) 10.1 (6.1, 16.2) 29.1 (22.2, 37.0)

T (n=124) 3.3 (1.3, 8.1) 13.8 (8.8, 21.0) 30.1 (22.7, 38.7)

W (n=90) 5.6 (2.4, 12.4) 6.7 (3.1, 13.8) 28.9 (20.5, 39.0)


All-Wales: Number of isolates 7,120 7,062 7,072Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),


41

Table 32: Hospital In-Patient Urinary Coliforms

In 2013, the All-Wales resistance rates for in-patients urinary coliforms werestatistically higher for all the agents listed than those for community or out-patients(Tables 30, 31 & 32). In 2013, a number of hospitals had resistance rates for urinarycoliforms that were statistically higher than the All-Wales rate; the most notable wereUniversity Hospital of Wales (F), University Hospital Llandough (P) and West WingCRI (W). Cephalosporin and fluoroquinolone resistance was generally higher in theacute hospitals in North Wales.

Resistance rates for West Wing CRI (W) were high to most agents e.g. co-amoxiclav(COA): 27.7% (19.9, 31.7), and nitrofurantoin: 24.8% (17.4, 34.0). West Wing is along-term elderly care unit; the proportion of patients that are catheterized is higherthan the other hospitals included in this report, the proportion of patients receivinglong-term medical prophylaxis for recurrent UTI is also higher, and both of thesefactors may influence resistance. West Wing is included in this report to demonstratethis point.

In Patient Urinary Coliforms (including E.coli and Proteus spp. )Resistance rates including (95% Confidence Intervals)




A (n=268) 59.7 (53.7, 65.4) 12.7 (9.3, 17.3) 6.1 (3.8, 9.6)

B (n=703) 65.9 (62.3, 69.3) 9.8 (7.8, 12.3) 11.9 (9.6, 14.6) 7.3 (5.6, 9.5)

C (n=896) 68.2 (65.1, 71.2) 20.5 (18.0, 23.3) 3.3 (2.3, 4.8)

D (n=1,573) 62.3 (59.9, 64.7) 13.7 (12.1, 15.5) 2.3 (1.7, 3.2)

E (n=1,197) 67.3 (64.5, 69.9) 18.3 (16.2, 20.6) 17.7 (15.5, 20.1) 9.4 (7.8, 11.2)

F (n=1,873) 69.6 (67.5, 71.7) 23.2 (21.4, 25.2) 7.0 (5.9, 8.3)

G (n=487) 59.1 (54.7, 63.4) 13.6 (10.8, 16.9) 7.1 (5.1, 9.8)

H (n=1,288) 66.2 (63.6, 68.8) 6.6 (5.3, 8.2) 16.0 (14.1, 18.1)

J (n=646) 62.7 (58.7, 66.5) 11.9 (9.5, 14.7) 7.9 (6.0, 10.4)

K (n=1,301) 65.8 (63.2, 68.4) 15.4 (13.5, 17.5) 12.2 (10.5, 14.1)

L (n=1,353) 15.9 (14.1, 18.0) 11.5 (9.9, 13.4)

M (n=626) 59.3 (55.4, 63.0) 13.7 (11.3, 16.7) 3.6 (2.3, 5.4)

N (n=509) 67.2 (63.0, 71.1) 22.6 (19.2, 26.4) 5.9 (4.1, 8.3)

P (n=781) 68.9 (65.6, 72.0) 21.6 (18.9, 24.7) 7.8 (6.1, 10.0)

Q (n=84) 59.5 (48.8, 69.4) 11.9 (6.6, 20.5) 4.8 (1.9, 11.6)

R (n=268) 57.1 (51.0, 63.1) 12.4 (8.9, 17.1) 7.1 (4.6, 11.0)

S (n=504) 66.3 (62.1, 70.3) 20.4 (17.1, 24.1) 19.3 (15.9, 23.4) 9.9 (7.6, 12.9)

T (n=328) 61.6 (56.1, 66.7) 20.3 (16.3, 25.1) 19.4 (15.1, 24.6) 12.5 (9.3, 16.6)

W (n=101) 75.2 (66.0, 82.6) 27.7 (19.9, 37.1) 10.5 (5.8, 18.3)




A (n=268) 9.7 (6.7, 13.8) 10.8 (7.6, 15.1) 38.8 (33.2, 44.8)

B (n=703) 13.2 (10.8, 15.9) 14.8 (12.3, 17.7) 38.5 (34.9, 42.2)

C (n=896) 12.9 (10.9, 15.3) 17.5 (15.2, 20.2) 36.6 (33.6, 39.9)

D (n=1,573) 10.1 (8.7, 11.7) 14.4 (12.7, 16.3) 29.0 (26.8, 31.4)

E (n=1,197) 13.4 (11.6, 15.5) 22.0 (19.7, 24.5) 38.1 (35.4, 40.9)

F (n=1,873) 16.8 (15.2, 18.6) 19.3 (17.6, 21.1) 40.9 (38.7, 43.2)

G (n=487) 8.0 (5.9, 10.8) 16.5 (13.5, 20.1) 36.6 (32.4, 40.9)

H (n=1,288) 20.6 (18.5, 22.9) 13.2 (11.5, 15.2) 40.3 (37.7, 43.0)

J (n=646) 7.1 (5.3, 9.5) 16.3 (13.5, 19.5) 31.9 (28.2, 35.7)

K (n=1,301) 16.0 (14.1, 18.1) 21.5 (19.4, 23.9) 40.7 (38.1, 43.4)

L (n=1,353) 16.3 (14.5, 18.4) 17.4 (15.5, 19.5) 38.8 (36.2, 41.4)

M (n=626) 9.9 (7.8, 12.5) 15.2 (12.5, 18.3) 30.5 (26.9, 34.3)

N (n=509) 10.3 (7.9, 13.3) 17.8 (14.7, 21.4) 34.6 (30.6, 38.9)

P (n=781) 19.0 (16.4, 21.8) 18.5 (15.9, 21.4) 45.6 (42.2, 49.1)

Q (n=84) 11.9 (6.6, 20.5) 15.5 (9.3, 24.7) 28.6 (20.0, 39.0)

R (n=268) 6.0 (3.7, 9.7) 18.4 (14.1, 23.7) 34.0 (28.4, 40.1)

S (n=504) 13.2 (10.5, 16.5) 17.2 (14.2, 20.9) 36.2 (32.1, 40.5)

T (n=328) 18.1 (14.3, 22.7) 20.3 (16.2, 25.0) 43.1 (37.8, 48.6)

W (n=101) 18.8 (12.4, 27.5) 24.8 (17.4, 34.0) 42.6 (33.4, 52.3)


All-Wales: Number of isolates 14,727 14,560 14,598Key: AMO = amoxicillin, COA= co-amoxiclav, 1GC = first generation cephalosporin, 3GC = third generation cephalosporin (cefpodoxime),


42

Community Urinary Coliforms (n=90,466 in 2013)

The All-Wales pattern of antimicrobial resistance for community urinary coliforms isshown in Figure 12 & Table 30.

Figure 12: All-Wales antimicrobial resistance rates for coliforms from communityurine samples (2005 to 2013)

There was a statistically significant decrease in co-amoxiclav resistance between2011 and 2013 (17.2% to 10.5%), whilst resistance to trimethoprim continues to rise.he high rates of resistance, notably for trimethoprim, may reflect an element ofselective testing within the community. The true rate of resistance to trimethoprim inpatients presenting with uncomplicated UTI in the community is likely to beconsiderably lower, and trimethoprim remains the suggested first-line empiricaltherapy for most of these patients.

20

05

20

13

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70

1GC 3GC AMO COA FQ NIT TRI

2005 7.1 3.7 51.2 9.4 5.8 11.2 26.8

2006 7.9 3.9 52.5 10.8 7.0 11.6 29.0

2007 9.4 4.4 53.1 12.3 8.0 11.3 30.5

2008 9.8 4.7 56.0 12.9 9.1 11.1 30.7

2009 10.2 4.7 57.0 14.0 9.5 10.8 30.9

2010 10.1 4.8 57.3 14.6 9.7 10.3 31.5

2011 9.8 4.3 58.4 17.2 9.9 10.7 32.5

2012 9.3 4.0 57.9 12.3 9.9 11.1 34.0

2013 9.8 5.0 57.6 10.5 9.8 11.8 34.8

Re

sist

ance

(%)

43

Out-patient Urinary Coliforms (n=7,217 in 2013)

The All-Wales pattern of antimicrobial resistance for out-patient urinary coliforms isshown in Figure 13 & Table 31. There has been a statistically significant decrease inco-amoxiclav resistance between 2011 and 2013.

Figure 13: All-Wales antimicrobial resistance rates for coliforms from out-patienturine samples (2005 to 2013)

20

05

20

13

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70


2005 8.9 5.9 51.1 10.2 7.6 11.9 26.2

2006 9.4 6.1 53.9 12.5 8.7 13.4 27.9

2007 12.2 7.2 55.2 15.8 10.4 14.6 30.5

2008 11.8 6.9 56.8 14.7 11.4 13.8 29.3

2009 10.9 5.1 57.3 14.7 9.2 12.3 28.6

2010 10.6 5.0 57.7 15.2 10.2 11.0 29.7

2011 10.6 4.7 58.5 17.1 11.0 11.6 30.1

2012 10.8 4.3 58.3 13.6 10.5 11.9 29.8

2013 11.8 5.5 59.4 11.9 11.0 12.9 31.3

Re

sist

ance

(%)

44

In-patient Urinary Coliforms (n=14,903 in 2013)

The All-Wales pattern of antimicrobial resistance for in-patient urinary coliforms isshown in Figure 14 & Table 32. There was no significant difference in resistancerates for urinary coliforms from in-patient samples between 2012 and 2013; thedecrease in co-amoxiclav resistance described in 2012 levelled off in 2013.

Figure 14: All-Wales antimicrobial resistance rates for coliforms from in-patienturine samples (2005 to 2013)

0

5

10

15

20

25

30

35

40

45

50

55

60

65

70


2005 12.7 8.2 57.4 15.8 11.8 16.8 29.1

2006 15.1 10.5 59.6 18.6 14.0 18.3 32.3

2007 16.9 11.5 61.0 21.8 15.6 17.6 33.7

2008 16.4 10.1 63.3 21.5 15.5 17.6 34.2

2009 16.3 9.0 65.3 21.9 15.2 17.2 33.9

2010 16.2 7.9 65.3 21.7 14.5 16.6 34.1

2011 17.9 6.9 66.7 24.4 15.5 15.4 35.7

2012 17.8 6.2 66.2 18.0 14.4 15.4 36.7

2013 19.7 7.6 65.7 17.4 14.1 17.5 37.6

Re

sist

ance

(%)

45

Section 5.3: Antimicrobial resistance rates forStaphylococcus aureus

The data in this section is presented to reflect the antimicrobial susceptibility oforganisms causing skin and soft tissue infections occurring in the community, and isbased on the specimen description ‘wound swab’. However, it should be noted thatthere is a significant sampling bias in this data. Royal Gwent and Nevill Hall are notincluded in the MSSA or MRSA data sets as they do not use the specimen typedescription ‘wound swab’ in their laboratory management systems.

46

Tables 33: Meticillin Sensitive Staphylococcus aureus (MSSA) from communitywound swabs

Tables 34: Meticillin Sensitive Staphylococcus aureus (MSSA) from in-patientwound swabs

Table 35: Meticillin Sensitive Staphylococcus aureus (MSSA) from out-patientwound swabs

Meticillin Sensitive Staphylococcus aureus from community wound swabsResistance rates including (95% Confidence Intervals)



Location Code (Number) CLI (95% CI) ERY (95% CI) FUS (95% CI) TET (95% CI)

A (n=601) 8.8 (6.8, 11.4) 14.3 (11.7, 17.3) 6.7 (4.9, 8.9)

B (n=72) 0.0 (0.0, 5.8) 11.1 (5.5, 21.2) 17.5 (10.0, 28.6) 4.8 (1.6, 13.1)

C (n=766) 1.2 (0.6, 2.2) 5.3 (3.9, 7.1)

F (n=882) 12.7 (11.0, 14.7) 13.9 (11.8, 16.4) 12.2 (10.2, 14.6) 4.3 (3.2, 5.9)

G (n=499) 9.6 (7.3, 12.5) 13.6 (10.9, 16.9) 4.2 (2.8, 6.3)

H (n=1,170) 11.2 (9.5, 13.1) 14.3 (12.5, 16.5) 17.9 (15.8, 20.2)

J (n=1,032) 11.8 (10.0, 13.9) 14.9 (12.9, 17.2) 4.7 (3.6, 6.2)K (n=1,166) 12.5 (10.7, 14.6) 17.4 (15.2, 19.7) 5.9 (4.7, 7.5)

L (n=1,058) 16.5 (14.4, 18.9) 21.6 (19.3, 24.2) 7.0 (5.6, 8.7)

N (n=43) 2.3 (0.4, 11.8) 4.8 (1.3, 15.8) 11.9 (5.2, 25.0) 2.3 (0.4, 12.1)

P (n=294) 15.5 (12.3, 19.4) 17.0 (13.1, 21.7) 14.3 (10.7, 18.7) 5.8 (3.6, 9.1)

R (n=55) 9.1 (3.9, 19.6) 14.5 (7.6, 26.2) 1.8 (0.3, 9.6)

S (n=3,434) 13.0 (11.9, 14.2) 18.4 (17.1, 19.7) 4.9 (4.2, 5.6)

T (n=20) 10.5 (2.9, 31.4) 15.8 (5.5, 37.6) 21.1 (8.5, 43.3)



Key: CLI = clindamycin, ERY = erythromycin, FUS = fusidic acid, TET = tetracycline

Meticillin Sensitive Staphylococcus aureus from In-Patient wound swabsResistance rates including (95% Confidence Intervals)




A (n=59) 7.0 (2.8, 16.7) 14.0 (7.3, 25.3) 12.3 (6.1, 23.2)

B (n=145) 0.9 (0.2, 4.8) 8.8 (4.8, 15.4)

C (n=186) 2.2 (0.8, 5.4) 5.4 (3.0, 9.7)

E (n=522) 10.5 (6.6, 16.4) 14.0 (11.3, 17.3) 15.4 (12.5, 18.8) 5.1 (3.5, 7.4)

F (n=366) 14.1 (11.3, 17.5) 17.3 (13.8, 21.5) 11.8 (8.9, 15.5) 7.1 (4.9, 10.3)

G (n=97) 9.3 (5.0, 16.7) 15.5 (9.6, 24.0) 4.1 (1.6, 10.1)

H (n=240) 16.0 (11.9, 21.2) 18.4 (14.0, 23.8) 10.0 (6.8, 14.5)

J (n=131) 11.5 (7.1, 18.0) 15.3 (10.1, 22.4) 2.3 (0.8, 6.5)

K (n=234) 14.3 (10.4, 19.6) 16.6 (12.3, 22.0) 4.0 (2.1, 7.5)

L (n=238) 12.2 (8.6, 17.0) 17.2 (13.0, 22.5) 8.0 (5.2, 12.2)

N (n=11) 0.0 (0.0, 25.9) 18.2 (5.1, 47.7) 9.1 (1.6, 37.7) 9.1 (1.6, 37.7)

P (n=108) 14.2 (9.5, 20.7) 15.0 (9.4, 22.9) 15.0 (9.4, 22.9) 2.8 (1.0, 7.9)

Q (n=32) 9.3 (3.7, 21.6) 12.5 (5.0, 28.1) 12.5 (5.0, 28.1) 0.0 (0.0, 10.7)

R (n=37) 16.2 (7.7, 31.1) 18.9 (9.5, 34.2) 2.7 (0.5, 13.8)

S (n=145) 14.9 (10.0, 21.7) 17.0 (11.7, 24.1) 9.2 (5.5, 15.1)

T (n=43) 16.7 (8.3, 30.6) 7.1 (2.5, 19.0) 4.9 (1.3, 16.1)




Meticillin Sensitive Staphylococcus aureus from Out-Patient wound swabsResistance rates including (95% Confidence Intervals)




A (n=19) 5.3 (0.9, 24.6) 10.5 (2.9, 31.4) 5.3 (0.9, 24.6)

B (n=74) 1.5 (0.3, 7.9) 14.5 (8.1, 24.7) 20.3 (12.5, 31.2) 4.3 (1.5, 12.0)

C (n=64) 1.6 (0.3, 8.5) 11.3 (5.6, 21.5)

E (n=618) 9.9 (6.4, 14.9) 10.4 (8.2, 13.0) 14.3 (11.7, 17.3) 4.6 (3.2, 6.6)

F (n=183) 9.6 (6.5, 14.0) 11.5 (7.6, 16.9) 12.6 (8.5, 18.2) 3.3 (1.5, 7.0)

G (n=40) 15.0 (7.1, 29.1) 17.5 (8.7, 32.0) 5.0 (1.4, 16.5)

H (n=179) 10.1 (6.5, 15.3) 14.0 (9.6, 19.8) 26.8 (20.9, 33.7)

J (n=88) 8.0 (3.9, 15.5) 11.4 (6.3, 19.7) 8.0 (3.9, 15.5)

K (n=138) 17.8 (12.2, 25.1) 24.4 (18.0, 32.3) 8.9 (5.2, 14.9)

L (n=174) 15.5 (10.9, 21.6) 27.6 (21.5, 34.7) 8.1 (4.9, 13.2)

N (n=10) 0.0 (0.0, 27.8) 20.0 (5.7, 51.0) 10.0 (1.8, 40.4) 0.0 (0.0, 27.8)

P (n=21) 9.4 (3.2, 24.2) 19.0 (7.7, 40.0) 33.3 (17.2, 54.6) 4.8 (0.8, 22.7)

Q (n=28) 2.9 (0.5, 14.5) 7.4 (2.1, 23.4) 3.6 (0.6, 17.7) 3.6 (0.6, 17.7)

R (n=22) 0.0 (0.0, 14.9) 4.5 (0.8, 21.8) 4.5 (0.8, 21.8)

S (n=153) 11.6 (7.4, 17.9) 32.2 (25.2, 40.1) 4.1 (1.9, 8.7)

T (n=27) 23.1 (11.0, 42.1) 15.4 (6.1, 33.5) 3.8 (0.7, 18.9)


All-Wales: Number of isolates 1823 1,771 1,654 1655


47

MSSA ( n=16,321 in 2013)

Community MSSA (n=11,102 in 2013)The All-Wales pattern of antimicrobial resistance for MSSA from community woundswabs are shown in Figure 15 and Table 33 with a small but statistically significantdifference in fusidic acid resistance rates between 2012 and 2013, and a notableincrease in trend for erythromycin resistance.

Figure 15: All-Wales antimicrobial resistance rates for MSSA from communityWound swabs (2005 to 2013)

In 2013, the All-Wales resistance rates for community, out-patients and in-patientsMSSA were comparable for most of the antimicrobials listed: erythromycin (ERY),gentamicin (GEN), mupirocin (MUP), penicillin (PEN) and tetracycline (TET) seeTables 33, 34 and 35.

At different times in the eight year period 2005 to 2013, there were increases inresistance to different agents in different geographical areas, but there was no setpattern of increasing or high resistance in any particular community or hospital, andthis probably reflects the varying presence of epidemic strains.

Resistance to fusidic acid (FUS) was higher for out-patient MSSA comparedto in-patient and community rates.

Vancomycin resistance remained undetected in MSSA between 2005 & 2013.

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Tables 36: Meticillin Resistant Staphylococcus aureus (MRSA) from communitywound swabs

Tables 37: Meticillin Resistant Staphylococcus aureus (MRSA) from in-patientwound swabs

Table 38: Meticillin Resistant Staphylococcus aureus (MRSA) from out-patientwound swabs

There were no confirmed cases of vancomycin intermediate/resistant MRSA (VISA)between 2005 and 2012

Meticillin Resistant Staphylococcus aureus from community wound swabsResistance rates including (95% Confidence Intervals)




A (n=48) 51.1 (37.0, 65.0) 62.2 (47.6, 74.9) 15.6 (7.7, 28.8)

C (n=117) 60.3 (51.2, 68.8) 23.9 (17.1, 32.4)

F (n=129) 61.3 (53.5, 68.5) 69.0 (60.6, 76.3) 17.8 (12.2, 25.3) 13.2 (8.4, 20.1)

G (n=45) 24.4 (14.2, 38.7) 37.8 (25.1, 52.4) 7.0 (2.4, 18.6) 6.8 (2.3, 18.2)

H (n=190) 61.7 (54.6, 68.4) 63.7 (56.6, 70.2) 48.9 (41.9, 56.0) 42.6 (35.8, 49.7)

J (n=127) 52.4 (43.7, 60.9) 63.5 (54.8, 71.4) 7.3 (3.9, 13.2) 10.3 (6.1, 16.9)

K (n=233) 70.8 (64.7, 76.3) 19.7 (15.1, 25.3) 25.3 (20.2, 31.3)

L (n=254) 67.3 (61.3, 72.8) 40.2 (34.3, 46.3) 32.7 (27.2, 38.7)

P (n=48) 63.9 (51.4, 74.8) 63.8 (49.5, 76.0) 8.5 (3.4, 19.9) 19.1 (10.4, 32.5)

S (n=308) 53.8 (47.8, 59.7) 24.6 (19.8, 30.2) 5.3 (3.2, 8.8)




Meticillin Resistant Staphylococcus aureus from In-Patient wound swabsResistance rates including (95% Confidence Intervals)




A (n=13) 58.3 (32.0, 80.7) 75.0 (46.8, 91.1) 0.0 (0.0, 24.3)B (n=33)

C (n=65) 78.8 (67.5, 86.9) 6.2 (2.4, 14.8)E (n=96) 42.3 (32.0, 53.4) 10.3 (5.3, 19.0) 9.1 (4.5, 17.6)

F (n=82) 64.5 (55.3, 72.9) 67.9 (57.1, 77.1) 11.1 (6.0, 19.8) 12.3 (6.8, 21.3)

G (n=14) 35.7 (16.3, 61.2) 42.9 (21.4, 67.4) 0.0 (0.0, 24.3) 0.0 (0.0, 21.5)

H (n=76) 75.0 (64.2, 83.4) 77.6 (67.1, 85.5) 42.1 (31.6, 53.3) 40.0 (29.7, 51.3)

J (n=12) 41.7 (19.3, 68.0) 58.3 (32.0, 80.7) 9.1 (1.6, 37.7) 8.3 (1.5, 35.4)

K (n=96) 74.0 (64.4, 81.7) 8.3 (4.3, 15.6) 12.5 (7.3, 20.6)

L (n=105) 79.0 (70.3, 85.7) 41.0 (32.0, 50.5) 35.2 (26.8, 44.7)

P (n=26) 64.9 (48.8, 78.2) 65.4 (46.2, 80.6) 7.7 (2.1, 24.1) 11.5 (4.0, 29.0)

S (n=17)

T (n=15)




Meticillin Resistant Staphylococcus aureus from Out-Patient wound swabsResistance rates including (95% Confidence Intervals)




B (n=12)

C (n=11) 70.0 (39.7, 89.2) 50.0 (23.7, 76.3)

E (n=62)

F (n=25) 69.2 (53.6, 81.4) 70.8 (50.8, 85.1) 12.5 (4.3, 31.0) 16.7 (6.7, 35.9)

H (n=20) 50.0 (29.9, 70.1) 50.0 (29.9, 70.1) 60.0 (38.7, 78.1) 55.0 (34.2, 74.2)

J (n=12) 66.7 (39.1, 86.2) 75.0 (46.8, 91.1) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3)

K (n=27) 77.8 (59.2, 89.4) 22.2 (10.6, 40.8) 25.9 (13.2, 44.7)

L (n=23) 78.3 (58.1, 90.3) 47.8 (29.2, 67.0) 26.1 (12.5, 46.5)




49

MRSA (n=2,410 in 2013)

Community MRSA (n=1,518 in 2013)The All-Wales pattern of antimicrobial resistance for MRSA from community woundswabs is shown in Figure 16 and Table 36, with no statistically significant changes inthe resistance rates for any of the agents listed between 2012 and 2013, but with anincreasing trend in resistance for fusidic acid and tetracycline.

Figure 16: All-Wales antimicrobial resistance rates for MRSA from communityWound swabs (2005 to 2013)

Locally, there was wide variability in resistance rates within Wales; with notably highrates in some areas e.g. fusidic acid and tetracycline resistance in communitiesserved by the laboratories in Wrexham Maelor (H), and Ysbyty Glan Clwyd (L), seeTable 36.

Hospital In-Patient and Out-Patient MRSA (n=892 in 2013)The trends in antimicrobial resistance for both hospital in-patient and out-patientMRSA are similar to those seen in the community, with no statistically significantchanges in the resistance rates for any of the agents listed between 2012 and 2013.Some of the same local patterns of resistance seen in the community were alsoreflected in hospital patients from the same geographical area, with notably highfusidic acid and tetracycline rates in patients from Wrexham Maelor (H) and YsbytyGlan Clwyd (L): See Tables 37 and 38.

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Section 5.4: Antimicrobial resistance rates for otherpathogens.

The data in this section of the report comprises other pathogens which maycommonly cause important infections other than bacteraemia. The data is for allspecimens from all locations (community, in-patient and out-patient).

Haemophilus influenzae Streptococcus pneumoniae Streptococcus pyogenes Campylobacter species Neisseria gonorrhoeae

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Table 39: Haemophilus influenzae - all specimens and all locations

Note: The range of resistance is outlined with boxes e.g. the range of resistance toamoxicillin was 0.0% - 32.9%; individual hospital rates statistically higher than the All-Wales rate are highlighted in colour.

Haemophilus influenzae, all specimens all locationsResistance rates including (95% Confidence Intervals)



Location Code (number) AMO (95% CI) COA (95% CI) TET (95% CI)

A (n=231) 32.9 (27.2, 39.2) 14.3 (10.4, 19.4) 0.0 (0.0, 1.6)

B (n=178) 26.0 (20.1, 32.9) 9.6 (6.1, 14.8) 0.0 (0.0, 2.1)

C (n=460) 25.8 (22.0, 30.0) 9.8 (7.4, 12.9) 1.5 (0.7, 3.1)

D (n=1548) 23.3 (21.2, 25.5) 6.5 (5.4, 7.9) 0.7 (0.4, 1.3)

E (n=105) 32.0 (23.8, 41.6) 14.3 (8.9, 22.2) 0.0 (0.0, 3.5)

F (n=830) 28.0 (25.0, 31.1) 15.7 (13.4, 18.3) 1.4 (0.8, 2.5)

G (n=131) 25.2 (18.5, 33.3) 9.2 (5.3, 15.3) 2.3 (0.8, 6.5)

H (n=635) 24.2 (20.9, 28.0) 0.9 (0.4, 2.1) 0.9 (0.4, 2.1)

J (n=464) 30.8 (26.8, 35.2) 9.3 (7.0, 12.3) 0.9 (0.3, 2.2)

K (n=770) 26.8 (23.8, 30.0) 9.1 (7.3, 11.4) 0.4 (0.2, 1.3)

L (n=657) 30.4 (27.0, 33.9) 9.8 (7.8, 12.3) 0.2 (0.0, 0.9)

M (n=184) 25.0 (19.3, 31.7) 7.6 (4.6, 12.4) 0.0 (0.0, 2.0)

N (n=412) 24.8 (20.9, 29.2) 11.4 (8.7, 14.8) 1.2 (0.5, 2.8)

P (n=364) 23.1 (19.0, 27.7) 14.4 (11.1, 18.4) 0.8 (0.3, 2.4)

Q (n=12) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3) 0.0 (0.0, 24.3)

R (n=84) 29.8 (21.0, 40.2) 4.8 (1.9, 11.6) 0.0 (0.0, 4.4)

S (n=1051) 30.0 (27.3, 32.9) 16.6 (14.4, 18.9) 0.3 (0.1, 0.8)

T (n=37) 16.2 (7.7, 31.1) 5.4 (1.5, 17.7) 0.0 (0.0, 9.4)



52

Haemophilus influenzae (n=8,175 in 2013)

The All-Wales pattern of antimicrobial resistance for Haemophilus influenzae from allspecimens/locations is shown in Figure 17 & Table 39; with an increase in the trendof resistance amoxicillin and to co-amoxiclav.

Figure 17: All-Wales antimicrobial resistance rates for H. influenzae; all specimensand all locations (2005 to 2013)

Locally, there was variability in co-amoxiclav resistance rates within Wales withhigher rates of resistance being seen in the hospitals and the communities served bylaboratories at UHW (F), and Singleton (S) .

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Table 40: Streptococcus pneumoniae - all specimens and all locations

Streptococcus pneumoniae, all specimens all locationsResistance rates including (95% Confidence Intervals)



Location Code ERY (95% CI) PEN (95% CI) TET (95% CI)

A (n=73) 6.8 (3.0, 15.1) 1.4 (0.2, 7.4) 2.7 (0.8, 9.5)

B (n=54) 13.0 (6.4, 24.4) 0.0 (0.0, 6.6) 13.7 (6.8, 25.7)

C (n=121) 9.0 (5.0, 15.8) 2.5 (0.8, 7.0) 6.1 (3.0, 12.0)

D (n=502) 10.3 (7.9, 13.3) 3.6 (2.3, 5.6) 8.1 (6.0, 10.9)

E (n=77) 9.1 (4.5, 17.6) 3.9 (1.4, 11.0)

F (n=308) 12.1 (8.9, 16.3) 8.6 (5.9, 12.2) 8.9 (6.2, 12.6)

G (n=55) 5.5 (1.9, 14.9) 0.0 (0.0, 6.5) 5.5 (1.9, 14.9)

H (n=310) 13.4 (9.8, 18.0) 7.4 (4.9, 10.9) 12.9 (9.3, 17.8)

J (n=193) 13.5 (9.4, 19.0) 4.1 (2.1, 8.0) 6.3 (3.6, 10.6)

K (n=245) 9.5 (6.4, 13.8) 5.3 (3.2, 8.9) 4.9 (2.8, 8.4)

L (n=273) 9.5 (6.6, 13.6) 5.5 (3.4, 8.9) 8.1 (5.4, 11.9)

M (n=76) 9.2 (4.5, 17.8) 5.3 (2.1, 12.8) 9.3 (4.6, 18.0)

N (n=108) 14.6 (9.0, 22.6) 4.6 (2.0, 10.4) 12.4 (7.4, 20.0)

P (n=106) 17.0 (11.0, 25.3) 12.3 (7.3, 19.9) 7.6 (3.9, 14.3)

R (n=32) 16.7 (7.3, 33.6) 6.3 (1.7, 20.1) 13.3 (5.3, 29.7)

S (n=361) 11.5 (8.5, 15.2) 3.6 (2.1, 6.1)



54

Streptococcus pneumoniae (n=2,909 in 2013)

The All-Wales pattern of antimicrobial resistance for Streptococcus pneumoniae fromall specimens and all locations is shown in Figure 18 & Table 40; with a small butstatistically significant increase in the resistance rates to all three agents between2010 and 2013.

Figure 18: All-Wales antimicrobial resistance rates for S. pneumoniae;All specimens and all locations (2005 to 2013)

The rates for all three agents are higher than the rates for S. pneumoniae isolatesfrom blood culture: See Figure 11.There was some variation in the penicillinresistance across Wales with higher rates being seen in University HospitalLlandough (P).

ERY PEN TET

2005 9.7 3.6 3.5

2006 11.7 4.5 4.9

2007 9.3 3.9 5.0

2008 7.9 3.5 4.5

2009 6.2 3.3 4.2

2010 7.1 2.7 4.8

2011 9.4 4.4 6.5

2012 11.2 4.3 7.4

2013 11.4 5.1 8.2

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Streptococcus pyogenes (n=3,925 in 2013)

The All-Wales pattern of antimicrobial resistance for Streptococcus pyogenes from allspecimens/locations is shown in Figure 19; with statistically significant changes inresistance between 2012 and 2013.

Figure 19: All-Wales antimicrobial resistance rates for S. pyogenes; all specimensand all locations (2005 to 2013)

There were no validated cases of penicillin resistant S. pyogenes in Wales from 2005to 2013.

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Campylobacter species (n=3,067 in 2012)

The All-Wales pattern of antimicrobial resistance for Campylobacter spp. from alllocations is shown in Figure 20; with a statistically significant change in the rate forciprofloxacin between 2012 and 2013.

Figure 20: All-Wales antimicrobial resistance rates for Campylobacter spp.; allspecimens and all locations (2005 to 2013)

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Neisseria gonorrhoeae (n=550 in 2013)

The All-Wales pattern of antimicrobial resistance for Neisseria gonorrhoeae from allspecimens and all locations is shown in Figure 21; with no statistically significantdifference in the resistance rates for any of the agents listed between 2012 and 2013.

Figure 21: All-Wales antimicrobial resistance rates for N. gonorrhoeae; allspecimens and all locations (2005 to 2012)

Note: GRASP (Gonococcal Resistance to Antimicrobials Surveillance Programme) isa national sentinel surveillance programme which has monitored trends and drifts insusceptibility in gonococcal isolates since 2000. It collects isolates from consecutivepatients attending a network of 26 genitourinary medicine (GUM) clinics that giveregional representation in England and Wales. The 2012 GRASP report published bythe Public Health England reported the following Key Points:

There is evidence of isolates exhibiting decreased susceptibility to ceftriaxone(MIC≥ 0.125mg/l) for the first time since it was reported in 2009.

There has been continued decline in the proportion of isolates exhibitingdecreased susceptibility to cefixime (MIC≥ 0.125mg/l), particularly in isolates infecting MSM and women.

Overall prevalence to azithromycin resistance (MIC≥ 1mg/l) increased slightly to 0.7% in 2012, with two isolates showing very high azithromycin resistanceof ≥ 256mg/l for the first time since 2007.

Between 2011 and 2012, dual prescribing of doxycycline and ceftriaxone forMSM declined and dual prescribing of azithromycin and ceftriaxone increasedin line with treatment guidelines.

Compliance of recommend treatment guidelines continued to increase in allregions of England and Wales.

http://www.hpa.org.uk/Publications/InfectiousDiseases/HIVAndSTIs/GRASPReports/1310GRASP2012/

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