Protected: Qi06 – Penicillin V and amoxicillin v0.2

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Operationalisation

Denominator

Number of dispensations of amoxicillin (J01CA04), phenoxymethylpenicillin (J01CE02), amoxicillin + clavulanic acid (J01CR02), cephalosporins (J01DB-E), macrolides (J01FA), and doxycycline (J01AA02) for patients in the respective age group

Numerator

Qi6_1-3: Number of dispensations of phenoxymethylpenicillin (ATC J01CE02) among all dispensations defined in the denominator.

Qi6_4-6: Number of dispensations of phenoxymethylpenicillin (ATC J01CE02) or amoxicillin (J01CA04) among all dispensations defined in the denominator.

Exclusions (Numerator, denominator)

Dispensations to individuals not belonging to the defined age range (age range refers to age at the end of the year).

Notes

Phenoxymethylpenicillin is the most narrow-spectrum antibiotic. Nevertheless, in many European countries, use of amoxicillin (penicillin with extended spectrum), or amoxicillin/clavulanic acid is more common, and clinical guidelines also recommend amoxicillin in the first line for many infections (1–4). After long-term decreasing trends in the use of phenoxymethylpenicillin, market reasons may act against its reuptake. In Finland, phenoxymethylpenicillin products are not currently reimbursed.

Sources of Data

  • Outpatient medication dispensations register

Information about the indicator set

Purpose

  • The quality indicator set is intended for comparison of effectiveness and/or safety aspects of prescribing across Nordic countries and subnational regions.
  • Further comparisons across population subgroups (e.g., socioeconomic position, immigration background) can inform equity considerations.
  • Further comparisons in relation to expenditures can inform efficiency considerations

Limitations

  • The indicators in the set use medication dispensings and/or sales data as a proxy for appropriate prescribing and medication use. This is to allow comparisons using register data, which have the advantage of being readily available and comprehensive in terms of population coverage and over time (5–7).
  • Register data are not without limitations. Medications may have been prescribed, but not collected from the pharmacy by the user. Collected medications may not have been (appropriately) used by the patient. Sales data may not be fully comparable across countries.
  • Register data are collected primarily for other purposes than quality assessment. Thus, discontinuities over time due to, e.g., legislative changes and administrative reforms need to be acknowledged in the interpretation of the results.
  • Indicators need to be updated regularly because clinical guidelines and the range of available medications change over time.
  • ATC-codes are based on WHO Collaborating Centre for Drug Statistics Methodology ATC/DDD Index version 2024

Background and literature related to the proposed indicator

Similar or related indicators in Nordic or European quality assessment

Swedish Association of Local Authorities and Regions quality indicators (Vården i siffror)

  • Share of phenoxymethylpenicillin prescriptions of all prescriptions of antibiotics commonly used for respiratory track infections for 0-6-year-olds (15)
  • Share of prescriptions of penicillin V of all prescriptions of antibiotics (J01 except J01XX05) (16)

 The Norwegian Directorate of Health

  • Share of phenoxymethylpenicillin prescriptions of all prescriptions of antibiotics commonly used for respiratory track infections for 0–9-year-olds (17)
  • Share of phenoxymethylpenicillin prescriptions of all prescriptions of antibiotics commonly used for respiratory track infections for 10–79-year-olds (18)

Set quality targets

  • The Swedish strategic program against antibiotic resistance (STRAMA (19)) has set a target of phenoxymethylpenicillin accounting for at least 80% of all dispensed antibiotics commonly used for respiratory tract infections for 0–6-year-olds.
  • The Danish National Action Plan for Antibiotics (20) for 2017–2020 set a target of Penicillin V accounting for 36% of total antibiotic consumption in primary care in 2020, measured in prescriptions/1000 inhabitants.

Similar or related indicators in international scientific literature

  • First-line antibiotics / second-line antibiotics prescriptions in nursing homes (target: > 1) = Number of prescriptions of amoxicillin (J01CA04) + amoxicillin clavulanate (J01CR02) / number of prescriptions of quinolones (J01M) + cephalosporins (J01D) + macrolides, lincosamides, streptogramins, and ketolides (J01F) (21)
  • Amoxicillin / second-line antibiotics prescriptions in general practice (target: > 1) = Number of prescriptions of amoxicillin (J01CA04) / Number of prescriptions of amoxicillin-clavulanic acid (J01CR02) + quinolones (J01M) + cephalosporins (J01D) + MLSK (macrolides, lincosamides, streptogramins and ketolides) (J01F) (22)
  • Amoxicillin / second-line antibiotics prescriptions for children in general practice (target: > 1) = Number of prescriptions of amoxicillin (J01CA04) / Number of prescriptions of amoxicillin/clavulanic acid (J01CR02) + quinolones (J01M) + cephalosporins (J01D) + macrolides, lincosamides, streptogramins and ketolides (J01F) (J01F) (23)
  • The amoxicillin index (AI)= The proportion of amoxicillin users (J01CA04) among all antibiotic users (J01), stratified by country, age categories and calendar year (24)
  • The amoxicillin to broad-spectrum ratio (A/B ratio) = The ratio between the number of amoxicillin users (J01CA04) and the number of users of broad-spectrum penicillins, cephalosporins and macrolides [J01CR, J01DC, J01DD and J01F (without erythromycin)], stratified by country, age categories and calendar year (24)
  • Relative use of first line penicillins for children in primary care: DDD penicillins/total DDD antibiotics = DDD penicillins (Benzylpenicillin (DDD=3600 mg), Procaine benzylpenicillin (900) Phenoxymethylpenicillin Benzathine (1500), Phenoxymethylpenicillin (2000), Amoxycillin (1000)) / total DDD antibiotics (25)
  • A low rate of prescribing of broad spectrum antibiotics such as co-amoxiclav compared with oral amoxicillin or penicillin for first-line treatment (26)
  • Prescriptions for amoxicillin/clavulanic acid divided by the number of prescriptions for all oral antibiotics x 100%, low score is desirable (27)
  • Paediatric dosage forms (syrup, drop, chewable and dispersible tablet formulations): Amoxicillin & clavulanic acid / amoxicillin (lower ratio preferred) (28)

References

  1. Skarpeid PL, Høye S. Phenoxymethylpenicillin Versus Amoxicillin for Infections in Ambulatory Care: A Systematic Review. Antibiotics. 2018 Sep;7(3):81.
  2. Bruyndonckx R, Adriaenssens N, Hens N, Versporten A, Monnet DL, Molenberghs G, et al. Consumption of penicillins in the community, European Union/European Economic Area, 1997–2017. J Antimicrob Chemother. 2021 Jul 1;76(Supplement_2):ii14–21.
  3. Malley M, Monaghan I, Driver K, Costelloe M, Jefferson L, Poole L, et al. Phenoxymethylpenicillin or amoxicillin for paediatric tonsillopharyngitis: a case of head versus heart? Arch Dis Child. 2021 Aug 1;106(8):830–1.
  4. Bergene EH, Holst L, Rø TB, Steinsbekk A. Considering formulation characteristics when prescribing and dispensing medicinal products for children: a qualitative study among GPs and pharmacists. Fam Pract. 2019 May 23;36(3):351–6.
  5. Bronzwaer SLAM, Cars O, Buchholz U, Mölstad S, Goettsch W, Veldhuijzen IK, et al. The Relationship between Antimicrobial Use and Antimicrobial Resistance in Europe. Emerg Infect Dis. 2002 Mar;8(3):278–82.
  6. Browne AJ, Chipeta MG, Haines-Woodhouse G, Kumaran EPA, Hamadani BHK, Zaraa S, et al. Global antibiotic consumption and usage in humans, 2000–18: a spatial modelling study. Lancet Planet Health. 2021 Dec 1;5(12):e893–904.
  7. Coenen S, Ferech M, Haaijer-Ruskamp FM, Butler CC, Vander Stichele RH, Verheij TJM, et al. European Surveillance of Antimicrobial Consumption (ESAC): quality indicators for outpatient antibiotic use in Europe. Qual Saf Health Care. 2007 Dec;16(6):440–5.
  8. Goossens H, Ferech M, Vander Stichele R, Elseviers M. Outpatient antibiotic use in Europe and association with resistance: a cross-national database study. The Lancet. 2005 Feb 12;365(9459):579–87.
  9. Malhotra-Kumar S, Lammens C, Coenen S, Van Herck K, Goossens H. Effect of azithromycin and clarithromycin therapy on pharyngeal carriage of macrolide-resistant streptococci in healthy volunteers: a randomised, double-blind, placebo-controlled study. The Lancet. 2007 Feb 10;369(9560):482–90.
  10. Bruyndonckx R, Adriaenssens N, Versporten A, Hens N, Monnet DL, Molenberghs G, et al. Consumption of antibiotics in the community, European Union/European Economic Area, 1997–2017: data collection, management and analysis. J Antimicrob Chemother. 2021 Jul 1;76(Supplement_2):ii2–6.
  11. AMC | European Centre for Disease Prevention and Control [Internet]. [cited 2024 May 2]. Available from: https://qap.ecdc.europa.eu/public/extensions/AMC2_Dashboard/AMC2_Dashboard.html#who-aware-tab
  12. Laugesen K, Ludvigsson JF, Schmidt M, Gissler M, Valdimarsdottir UA, Lunde A, et al. Nordic Health Registry-Based Research: A Review of Health Care Systems and Key Registries. Clin Epidemiol. 2021 Dec 31;13:533–54.
  13. Furu K, Wettermark B, Andersen M, Martikainen JE, Almarsdottir AB, Sørensen HT. The Nordic countries as a cohort for pharmacoepidemiological research. Basic Clin Pharmacol Toxicol. 2010 Feb;106(2):86–94.
  14. Rasmussen L, Wettermark B, Steinke D, Pottegård A. Core concepts in pharmacoepidemiology: Measures of drug utilization based on individual-level drug dispensing data. Pharmacoepidemiol Drug Saf. 2022;31(10):1015–26.
  15. Penicillin V vid behandling av barn med luftvägsinfektion [Internet]. [cited 2024 May 7]. Available from: https://vardenisiffror.se/indikator/4a491d8d-0e65-4050-a16c-6d7b44246d79?datefrom=2013-01-01&dateto=2018-12-31&gender&periodtype=year&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=se&units=18&units=09&units=04&units=14&units=19&units=23&units=17&units=10&units=21&units=25&units=05&units=07&units=12&units=03&units=20&units=01&units=24&units=13&units=08&units=06&units=22
  16. Penicillin V som andel av all antibiotika [Internet]. [cited 2024 May 7]. Available from: https://vardenisiffror.se/indikator/315fd21e-363c-4486-ab91-e0741bfa7886?datefrom=2022-11-01&dateto=2023-04-30&gender&relatedmeasuresbyentry=keyword&relatedmeasuresbyid=lakemedelsbehandling&showtarget=false&units=se&units=18&units=09&units=04&units=14&units=19&units=23&units=17&units=10&units=21&units=25&units=05&units=07&units=12&units=03&units=20&units=01&units=24&units=13&units=08&units=06&units=22
  17. Helsedirektoratet [Internet]. [cited 2024 May 7]. Antibiotikabehandling ved luftveisinfeksjon hos barn mellom 0-9 år. Available from: https://www.helsedirektoratet.no/statistikk/kvalitetsindikatorer/legemidler/antibiotikabehandling-ved-luftveisinfeksjon-hos-barn-mellom-0-9-%C3%A5r
  18. Helsedirektoratet [Internet]. [cited 2024 May 7]. Antibiotikabehandling ved luftveisinfeksjon hos befolkningen mellom 10-79 år. Available from: https://www.helsedirektoratet.no/statistikk/kvalitetsindikatorer/legemidler/antibiotikabehandling-ved-luftveisinfeksjon-hos-befolkningen-mellom-10-79-%C3%A5r
  19. Strama | Samverkan mot antibiotikaresistens [Internet]. [cited 2024 May 6]. Available from: https://strama.se/
  20. Regeringen.dk [Internet]. [cited 2024 May 7]. National handlingsplan for antibiotika til mennesker. Available from: https://www.regeringen.dk/aktuelt/tidligere-publikationer/national-handlingsplan-for-antibiotika-til-mennesker/
  21. Simon M, Pereira O, Hulscher MEJL, Schouten J, Thilly N, Pulcini C. Quantity Metrics and Proxy Indicators to Estimate the Volume and Appropriateness of Antibiotics Prescribed in French Nursing Homes: A Cross-sectional Observational Study Based on 2018 Reimbursement Data. Clin Infect Dis. 2021 May 15;72(10):e493–500.
  22. Thilly N, Pereira O, Schouten J, Hulscher ME, Pulcini C. Proxy indicators to estimate appropriateness of antibiotic prescriptions by general practitioners: a proof-of-concept cross-sectional study based on reimbursement data, north-eastern France 2017. Euro Surveill Bull Eur Sur Mal Transm Eur Commun Dis Bull. 2020 Jul;25(27):1900468.
  23. Thilly N, Pereira O, Schouten J, Hulscher MEJL, Pulcini C. Proxy indicators to estimate the appropriateness of medications prescribed by paediatricians in infectious diseases: a cross-sectional observational study based on reimbursement data. JAC-Antimicrob Resist. 2020 Oct 22;2(4):dlaa086.
  24. de Bie S, Kaguelidou F, Verhamme KMC, De Ridder M, Picelli G, Straus SMJM, et al. Using Prescription Patterns in Primary Care to Derive New Quality Indicators for Childhood Community Antibiotic Prescribing. Pediatr Infect Dis J. 2016 Dec;35(12):1317–23.
  25. Urrusuno RF, Balosa MCM, de la Pisa BP, Mateos SJ, Calvo CB. Developing indicators of prescribing quality for primary care paediatricians. J Pharm Health Serv Res. 2010;1(4):167–73.
  26. Okechukwu I, Bennett K, Feely J. General practitioners’ ranking of evidence-based prescribing quality indicators: a comparative study with a prescription database. Br J Clin Pharmacol. 2006;62(2):218–24.
  27. Muijrers PEM, Janknegt R, Sijbrandij J, Grol RPTM, Knottnerus JA. Prescribing indicators. Eur J Clin Pharmacol. 2004 Dec 1;60(10):739–46.
  28. Robertson J, Fryer JL, O’Connell DL, Smith AJ, Henry DA. Limitations of Health Insurance Commission (HIC) data for deriving prescribing indicators. Med J Aust. 2002 May 6;176(9):419–24.