rates adjusted for age, sex, infection subclass, and type of antibiotic treatment used) by British Medical Journal Publishing Group

Transcription

1 Antibiotic treatment failure in four common infections in UK primary care : longitudinal analysis Craig J Currie BMJ 2014;349:g September 2014 More than one in 10 initial antibiotic monotherapies for upper and lower respiratory tract skin and soft tissue infections were associated with failure over a 22 year period in UK primary care Overall antibiotic treatment failure rates increased from 1991 to 2012 by more than 10%, Treatment failure rates increased in some notable cases, especially when the antibiotic selected was not considered first choice for the indications studied

2 Fig 2 Consultation rates for selected infection classes, proportion of infections in selected classes treated with antibiotic, rate of antibiotic treatment failure by infection class, and fully adjusted d and indexed d treatment t t failure rates (indexed d to 1991=100, 100 antibiotic treatment t t failure rates adjusted for age, sex, infection subclass, and type of antibiotic treatment used). Currie C J et al. BMJ 2014;349:bmj.g by British Medical Journal Publishing Group

3 We use a lot of antibiotics in Ireland Antibiotic use is mid to high hcompared with other EU countries itants per Day Def fined Daily Dosess per 1000 Inhab (DID) Switzerland Romania Latvia Estonia Netherlands Russian Federation Sweden Slovenia Germany Norway Austria Denmark Hungary UK Finland Czech Republic Bulgaria Iceland Spain Lithuania Ireland Croatia Malta Israel Portugal Poland Slovakia Belgium Luxembourg Italy France Cyprus Greece 80% community consumption Fig : Total outpatient antibiotic use in Europe 2004 to 2009 expressed in DDD per 1000 inhabitants per day. Data from the European Surveillance of Antimicrobial Consumption (ESAC) project. Data source: HPSC 3

4 MDR K. pneumonia

5 EARSS 2013 % MDR E. coli: 14.7% Commentary: Number and % ESBL-positive and MDR E. coli are the highest since surveillance began in 2002 ESBL-positive and MDR E. coli have been increasing since 2004 Invasive E. coli infections Number Invasive E. coli cases: 2,52626 Number ESBL-positive E. coli cases: 262 (of 2,510 tested) % ESBL-positive E. coli: 10.4% Number MDR E. coli cases: 370 (of 2,520 tested)

6 Proportion of bloodstream infections caused by resistant bacteria, 2004 to % 40% Meticllin resistant Staph aureus (MRSA) Pro oportion resistanc ce 35% 30% 25% 20% 15% 10% Vancomycin resistant enterococcus (VRE) Quinolone resistant E coli Penicillin resistant Strep pneumoniae Erythromicin i resistant it ts pneumoniae 5% Multiple resistant E coli 0% Year Cephalosporin resistant E coli Data source: HPSC

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8 C. Difficile Infoscan & CUH.

9 HALT 2013 Reasons & Sites for which Antimicrobials were Prescribed LTCF > 12 month 9% Urinary tract 14% Respiratory tract 43% Skin or Wound 34% Other 9.3%residents were on an antibiotic

10 HALT 2013 Breakdown of prophylaxis and treatment, by body site LTCF <12 month 11.2 % residents were on an antibiotic 14% 11% 20% 86% 34% 34% Urinary tract Respiratory tract Skin or Wound Other Prophylaxis 17% 83% Treatment

11 HALT 2013 Breakdown of prophylaxis and treatment, by body site> 12 month LTCF The vast majorityof of prophylaxis was for UTIprevention (76%). Treatment of RTI (45%) and UTI (25%) were the most frequent indications for therapeutic antimicrobials 4% 7% 13% 20% 10% 25% Urinary tract Respiratory tract 76% 45% Skin or Wound Other Prophylaxis Treatment 39% 61%

12 What were the most common HCAI types in the Ireland 2010 & 2011 HALT surveys?

13 Urinary Pathogens Infoscan GP Hosp coli prot strep staph pseud other

14 E. coli. Gram Negative Bacilli Coliforms or Enterobacteraciae. Klebsiella pneumoniae. Enterobacter. Acinetobacter spp. Serratia. Proteus. Pseudomonas. Also

15 Hospital UTI Resistance Rates % CUH Hosp 1992 Hosp /6 Hosp 2013 GP Amp Aug Cep Tri Nal Cip Nitro

16 CUH Urinary resistance rates 2013

17 CUH Urinary resistance rates 2013

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19 National Guidelines UTI Symptoms and signs suggestive of urinary tract infection include: Dysuria Frequency Urgency New Onset Incontinence Fever >38 C Suprapubic Tenderness Haematuria

20 National Guidelines Uncomplicated UTI Trimethoprim 200mg BD Nitrofurantoin* mg QDS for 7 days (*Avoid in renal impairment) Or based on local resistance rates Cephalexin 500mg BD Co-amoxiclav 625mg TDS

21 CUH Urinary resistance rates 2013

22 Urinary Tract Infections. Mid stream urine. SAMPLES. Fresh less than 2 hours. Store in fridge. Boric Acid (>5mls).

23 Urinary Tract Infections. Significant bacteriuria. > 100, cfu per ml. pure culture. Low counts may be significant in supra pubic tap specimens

24 Urinary Tract Infections. Contamination. 10, to 1,000 +/- mixture of colonies.

25 Pyuria. Urinary Tract Infections. >15 white cells per cmm. Significant RBCS >7 per cmm. Epithelial cells---contamination.

26 Urinary Tract Infections. Pyuria & no growth. Antibiotics. Chlamydia/gonococci? myco TB. Glomerulonephritis. Urethral syndrome. Fastidious bacteria.

27 Urinary Tract Infections. Bacteruria and no pyuria. Contaminants. Significant in pregnant. Significant if abnormal renal tract.

28 Urine Culture and Microscopy Microscopy White blood cells >500 per cmm Red blood cells 30 per cmm Organisms + Culture Proteus mirabilis > 100,000 organisms per ml Amoxycillin S Ciprofloxacin s Augmentin S Nitrofurantoin R Cephalexin S Trimethoprim R

29 Urine Culture and Microscopy Urine Culture and Microscopy Technically Validated (Q) Microscopy White blood cells >500 per cmm Red blood cells 10 per cmm ^Organisms + Culture Escherichia coli > 100,000 organisms per ml Main organism in a mixed growth Amoxycillin R Ciprofloxacin r Augmentin S Nitrofurantoin S Cephalexin R Trimethoprim R

30 Urine Culture and Microscopy Microscopy White blood cells 40 per cmm Red blood cells 0 per cmm Organisms + Epithelial cells + Culture Mixed growth > 100, organisms per ml

31 Urine Culture and Microscopy Microscopy White blood cells 10 per cmm Red blood cells 10 per cmm Yeasts + Culture Candida da sp. 0B > 100,000 organisms s per ml Main organism in a mixed growth

32 All patients 8 weeks period suspected UTI MSU sent for lab analysis Only 20 % positive Yet 56% received and antimicrobial Of those treated only 14% received the correct antibiotic for the bug grown in their urine. Huge variation in first line antibiotic only 38% followed guideline recommendation. Antimicrobial management and the appropriateness of treatment of urinary tract infection in General Practice in Ireland Akke Vellinga1*, Martin Cormican2,3, Belinda Hanahoe2, Kathleen Bennett4 and Andrew W Murphy1

33 Poor adherence to national guidelines Co-amoxyclav 33% Trimethoprim 26% Fluroquinolones 17% In this study high h local l resistance levels l to trimethoprim caution as first line but nitrofurantoin t i would have been appropriate for most positive urines, cheaper and less potential for developing resistance than ciproxin

34 KEY MESSAGES Residents in long term care facilities have high rates of abnormal dipstick and urine test results WITHOUT infection necessarily being present. Antibiotic therapy in these cases does not reduce mortality or prevent symptomatic episodes, rather it increases side effects and leads to antibiotic resistance. DO NOT ROUTINELY USE ANTIBIOTIC PROPHYLAXIS TO PREVENT URINARY TRACT INFECTION