Antimicrobial Update. Alison MacDonald Area Antimicrobial Pharmacist NHS Highland April 2018

Transcription

1 Antimicrobial Update Alison MacDonald Area Antimicrobial Pharmacist NHS Highland April 2018

2 Starter Questions Setting the scene...

3 What if antibiotics were no longer effective?

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5 Consider the following scenarios Cancer chemotherapy Operations C-section Bowel surgery Hip or knee replacement Trauma surgery... Pneumonia, sepsis, meningitis...

6 Why is this a possibility? Complex ecological factors No new antibiotics for 30 years Widespread use of antibiotics Travel ONE HEALTH APPROACH

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8 NHS Scotland: Proportion of population receiving antibiotics in primary care % 31.5% 30.6% 29.6% 29.0%

9 NHS Scotland: Use of antibiotics in primary care items/1000/day

10 Primary Care Frequency of Antibiotic Use by Age in Scotland % 90% 80% 70% 60% 50% 40% 30% 20% Zero Items 1 Item 2 Item 3 Item 4 Item 5 Item 6-12 Items >12 10% 0%

11 NHS Scotland: Use of antibiotics in Hospitals DDD per 100 Admissions

12 Best Use of Antibiotics Optimise treatment of infection Want to avoid or minimise Allergy and other adverse effects Collateral damage and resistance How do we do this? Through Antibiotic Stewardship aiming to manage infection so as to ensure optimal outcomes and minimal harm to patients and the wider society

13 What is Antimicrobial Stewardship? Prudent prescribing is not to prescribe as few antibiotics as possible but to identify that small group of patients who really need antibiotic treatment and then explain, reassure and educate the large group of patients who don t. British Journal of General Practice 2009, 50:567

14 Important side effects GENERAL Nausea, vomiting, diarrhoea, rashes, Candida infections Penicillins - hypersensitivity / skin reactions Flucloxacillin & co-amoxiclav - cholestatic jaundice Clindamycin & cephalosporins - C. difficile colitis Macrolides - GI disturbances, hepatitis, Q-T interval Tetracyclines - hepatotoxicity, staining teeth, photosensitivity, dysphagia

15 Penicillin Allergy September 2017 All drug-allergies must be specified on medication charts (with the patient s reaction) In TRUE penicillin allergy* ALL penicillins, cephalosporins and other beta-lactam antibiotics should be avoided Penicillin Allergy Information (see also BNF) CONTRA- INDICATED CAUTION Avoid if serious penicillin allergy (e.g. anaphylaxis/ angioedema) Use with caution if nonsevere allergy (e.g. minor rash only) Antibiotics to be avoided in penicillin allergy Amoxicillin Ampicillin Benzylpenicillin / Penicillin G Co-amoxiclav (Augmentin, Heliclear ) Flucloxacillin (co-fluampicil/ Magnapen ) Phenoxymethylpenicillin / Penicillin V Piperacillin/tazobactam (Tazocin ) Pivmecillinam Temocillin Antibiotics to be avoided or used with caution in penicillin allergy Cephalosporins: Cefaclor, Cefalexin, Cefixime, Cefotaxime, Cefradine, Ceftazidime, Ceftriaxone, Cefuroxime, Ceftolozane/tazobactam Other beta-lactam antibiotics: Aztreonam, Imipenem, Meropenem, Ertapenem CONSIDERED SAFE Antibiotics safe in penicillin allergy (not a complete list) Amikacin Linezolid Azithromycin Metronidazole Ciprofloxacin Nitrofurantoin Clarithromycin Minocycline Clindamycin Oxytetracycline Colistin Rifampicin Co-trimoxazole Sodium Fusidate Daptomycin Teicoplanin Doxycycline Tetracycline Erythromycin Tobramycin Gentamicin Trimethoprim Fosfomycin Tigecycline Levofloxacin Vancomycin *TRUE penicillin allergy includes anaphylaxis, urticaria or rash immediately after penicillin administration In cases of INTOLERANCE to penicillin (e.g. gastrointestinal upset) or a rash occurring >72 hours after administration, penicillins/related antibiotics should not be withheld unnecessarily in severe infection but the patient must be monitored closely after administration Adapted from NHS Greater Glasgow and Clyde, approved by NHS Highland Antimicrobial Management Team September 2017

16 Risk factors for CDI Patient > 65 years of age Immunosuppressed Antibiotic exposure Carriage by patients and staff without symptoms Prolonged hospital stay Other drugs e.g. proton pump inhibitors (omeprazole, lansoprazole) NG tube Environmental Inadequate isolation facilities Inadequate cleaning of ward facilities and equipment Poor Hand Hygiene by patients and staff Increased movement of patients in hospitals More virulent strains emerging e.g. type 027

17 Antibiotics and risk of C. difficile infection High Risk Medium Risk Low Risk Clindamycin Amoxicillin Flucloxacillin Cephalosporins Macrolides Penicillin V Co-amoxiclav Co-trimoxazole Metronidazole Ciprofloxacin (Fluoroquinolones) The 4Cs Piperacillin/ tazobactam Aminoglycosides Trimethoprim Vancomycin Nitrofurantoin Rifampicin Tetracyclines

18 Important drug interactions Enzyme inhibitors such as erythromycin, clarithromycin, metronidazole, ciprofloxacin Absorption - absorption of tetracyclines reduced by antacids/calcium Broad spectrum antimicrobials and warfarin - increased INR Metronidazole - disulfiram-like interaction with alcohol Macrolides (clarithromycin) and Q-T prolonging drugs

19 Antimicrobial Resistance Antibiotic use causes resistance through selective pressure. Broad spectrum antibiotics select for resistant pathogens by eradicating natural flora. Current problems with resistant organisms: MRSA - methicillin resistant Staphylococcus aureus VRE - vancomycin resistant enterococci ESBL - extended spectrum beta-lactamases

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21 Nursing Role in Infection Prevention & Treatment Preventing Infections CA-UTI bundle Wound Care IV to oral switch Optimising Antibiotic Use Give with 60 minutes in sepsis Observations & monitoring Regular administration Review of lab results Patient education

22 Antibiotics and Resistance Link between antibiotic exposure and resistance Individuals prescribed an antibiotic in primary care for a respiratory or urinary tract infection develop bacterial resistance to that antibiotic. Effect greatest in first month but may persist for up to 12 months. BMJ 2010 Costelloe et al

23 Protecting Antibiotics in Hospital Authorisation codes to supply protected antibiotics (control of access to broad spectrum drugs) IV to oral switch recommendations Duration of therapy in guidelines

24 National Quality Prescribing Indicators for 2017/18 Total antibiotic Use in Primary Care. 50% of practices achieve a prescribing rate equal to the lowest 25% of all practices as measured at January to March 2016 baseline achieved Hospital audits focus on review of IV and duration of oral therapy (Raigmore only) achieved 1% reduction in hospital use of total antibiotics, piperacillin/tazobactam and carbapenems from 2015 baseline only piperacillin/tazobactam reduction achieved

25 National Campaign Antibiotic Guardian

26 NHS Scotland 2017 Leaflet & Poster

27 Key Points Antibiotic use affects individual and society we all have a role to play Efforts to reduce resistance vital and explain why to patients and public Go to and take a pledge to

28 Want to know more? Free online course (3 hrs pw for 6/52) bial-stewardship

29 Thank you for listening Any questions?