Antimicrobial Resistance, Everyone s Fight. Charlotte Makanga Consultant Antimicrobial Pharmacist Betsi Cadwaladr University Health Board

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1 Antimicrobial Resistance, Everyone s Fight Charlotte Makanga Consultant Antimicrobial Pharmacist Betsi Cadwaladr University Health Board

2 Antimicrobial Resistance Antimicrobial resistance happens when microorganisms (such as bacteria, fungi, viruses, and parasites) change when they are exposed to antimicrobial drugs (such as antibiotics, antifungals, antivirals, antimalarials, and anthelmintics). Microorganisms that develop antimicrobial resistance are sometimes referred to as superbugs. As a result, the medicines become ineffective and infections persist in the body, increasing the risk of spread to others WHO February 2018

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6 Do your patients know what is a virus/bacteria? Eisteddfod 2017 (own simple survey) 87 people surveyed 54 had no idea what the difference between a virus and bacteria 62% Exploring Patient Awareness and Perceptions of the Appropriate Use of Antibiotics: A Mixed- Methods Study M Davis et al. 53% incorrectly believed that antibiotics work well for treating viral infections.

7 What about the rest of the world? WHO multi-country awareness survey 2015 : 65% of respondents report having taken antibiotics in the past six months, including 35% who took antibiotics within the past month. antibiotic use is higher lower income countries 42% of people say they used antibiotics within the past month compared with 29% of people surveyed in higher income countries. Young people more likely to have used antibiotics within the past month: 37% of 16 to 24-year-olds, versus 24% of respondents aged 65 years and older. Where people get their antibiotics most people (81%) say they were prescribed or provided by a doctor or nurse (range between countries: 56%-93%), and 93% say they obtained the drugs from a pharmacy or medical store (range between countries: 83%-97%).

8 What can we do?

9 Antimicrobial Stewardship The term 'antimicrobial stewardship' is defined as 'an organisational or healthcare-system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness'. NICE guideline [NG15] August 2015

10 My Taid with his great grandson Taid is 96 if he was developed a UTI would he get treated as you would want to be?

11 BCUHB Primary Care What have we done to improve antimicrobial stewardship? Focus on high usage GP practices, UTI prescribing including prophylaxis and inappropriate usage

Quick wins Engage with the primary care teams. Use data- both at practice level and prescriber level within practice. Use the resources Available- Target tool kit/ Public Health Wales.

12 Quick wins Engage with the primary care teams. Use data- both at practice level and prescriber level within practice. Use the resources Available- Target tool kit/ Public Health Wales. Ensure patient information leaflets are integrated with GP computer systems. Easy access to Microguide. Discuss practices where they have had success- what worked for them. 15/10/

Antibiotic Information Leaflet TARGET: Patient Information Leaflets All sections can be personalised and added to by the GP Usually lasts section

13 Antibiotic Information Leaflet TARGET: Patient Information Leaflets All sections can be personalised and added to by the GP Usually lasts section educates patients about when to consult Safety netting Back-up prescription Information about antibiotics & resistance

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16 Repeated antibiotics given for UTIs Urinary Tract Infections The problem.. Patients continued on long term prophylactic antibiotics for UTIs indefinitely. Increased antibiotic resistance rates to coliforms from community urine samples across Wales. GPs reluctant to stop antibiotics started by Urology. Increased incidence of Clostridium difficile in BCUHB Limited knowledge of healthcare professionals around diagnosis & management of UTIs. Welsh government target of 50% reduction in Gram ve bacteraemias by 2020.

17 BCUHB the UTI plan Urine dipstick??? Care home education Hydration All Wales Guidelines Revised and re-published August 2018

18 Investigation of suspected urinary tract infection in older people BMJ 2014; 349 Do not use urine dipstick tests to diagnose urinary tract infection in older people; If done at all only a negative result should be considered useful in excluding a urinary tract infection In patients who are able to provide a history, urinary tract infection should be diagnosed only in the presence of a combination of at least three acute urinary symptoms or signs, such as dysuria, urgency, frequency, or suprapubic tenderness In patients who are unable to provide a history, urinary tract infection should be diagnosed only when evidence exists of acute inflammation (for example, fever/hypothermia or raised white cell count or C reactive protein) associated with bacteriuria on urine culture and no other more likely cause of their acute illness exists Asymptomatic bacteriuria is common in older people; avoid treating bacteriuria in patients with non-specific symptoms that cannot be attributed to urinary tract infection, as this confers no benefit and may cause harm 18

19 Best practice: Urinary Tract Infections >65yrs National Guidelines: People >65 years should have a clinical assessment before being diagnosed with UTI (NICE) Do not use urine dipstick testing in the diagnosis of older people with possible UTI (SIGN) Do not use dipstick testing to diagnose UTI in adults with urinary catheters (NICE)

20 No dipstick >65yrs really?? 50 % 40% 100 % Urine dipstick will be positive for nitrites and leucocytes... But doesn t tell us if it is an infection or not! Often antibiotics are then prescribed inappropriately

21 More harm than good? Antibiotics are powerful & precious drugs Giving an older person antibiotics when they don t really need them can lead to: Side-effects such as rashes & stomach upsets C.diff diarrhoea which can be life-threatening Antibiotic resistance so antibiotics won t work when the person really does need them

22 Urine Cultures When should I send a urine for culture? Pregnancy Suspected Pyelonephritis (loin pain & fever) Suspected UTI in men Failed antibiotic treatment or persistent symptoms Recurrent UTI, Renal impairment more likely to have resistant strain Is follow-up urine sample required? Not usually, unless treating asymptomatic bacteriuria in pregnancy

23 BCUHB guidelines Care homes 23

24 Information sheets: How to obtain a midstream specimen of urine (MSU) for men and women How to obtain a catheter specimen of urine (CSU) 15/10/

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26 Hydration 15/10/

27 Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections JAMA2018 Findings In this randomized clinical trial of 140 premenopausal women experiencing recurrent cystitis who report drinking less than 1.5 L of total fluid daily, cystitis episodes were significantly less frequent in women who drank more water for 12 months compared with women who maintained their usual fluid intake. 15/10/

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30 If antibiotics then what to prescribe? All Wales guidelines Local guidance, Microguide Duration, review, clear instructions to patient 30

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32 Back to Taid Hydration Not to dipstick All Wales UTI guidelines following change in resistance Safeguarding antibiotics for his great grandson 32

33 Any Questions? 15/10/

34 References Exploring Patient Awareness and Perceptions of the Appropriate Use of Antibiotics: A Mixed-Methods Study Marion E. Davis,*, Tsai-Ling Liu ID, Yhenneko J. Taylor, Lisa Davidson, Monica Schmid, Traci Yates, Janice Scotton and Melanie D. Spencer. Antibiotics Antimicrobial Stewardship: systems and processes for effective antimicrobial medicines use. NICE guidelines [NG15] August 2015 Investigation of suspected urinary tract infection in older people BMJ 2014; 349 doi: (Published 03 July 2014) Effect of Increased Daily Water Intake in Premenopausal Women With Recurrent Urinary Tract Infections A Randomized Clinical Trial. Thomas M. Hooton, MD,et al. JAMA Intern Med. Published online October 1, 2018.

Cork and Kerry SARI Newsletter; Vol. 2 (2), December 2006

Cork and Kerry SARI Newsletter; Vol. 2 (2), December 2006 Cork and SARI Newsletter; Vol. 2 (2), December 6 Item Type Newsletter Authors Murray, Deirdre;O'Connor, Nuala;Condon, Rosalind Download date 31/1/18 15:27:31 Link to Item http://hdl.handle.net/1147/67296