GP Small Group education April/May 2015 Antibiotics Resistance is futile
Acknowledgements This material was prepared by the Clinical Quality and Education team with help gratefully received from: Topic preparation team Ben Hudson Small Group Leader, GP Jeanette Hight Small Group Leader, Practice Nurse Tim Vincent Small Group Leader, Community Pharmacist Others consulted Rosemary Ikram Consultant Microbiologist Steve Chambers Infectious Diseases Consultant, CBHB Ben Harris Medical Liaison, Infection Control Team, CSCL Andrew Meads Medical Director, Acute Demand Sharon Gardiner Antimicrobial Pharmacist CDHB Geraldine Wilson GP, Lecturer, University of Otago Paul Bridgford Team Leader, Reporting and Analysts, Pegasus Health Richard Everts Infectious Diseases Physician, Nelson This clinical resource was prepared by the Clinical Quality and Education Team, Pegasus Health. Any statement of preference made is a recommendation only. It is not intended to compel or unduly influence independent prescribing choices made by clinicians. References not listed are available on request. All clinical documents produced by Pegasus Health are dated with the date they were originally produced or updated, and reflect analysis of available evidence and practice that was current at that time. Any person accessing any clinical documents must exercise their own clinical judgment on the validity and applicability of the information in the current environment, and to the individual patient. The educational material developed for delivery at this education session remains the intellectual property of Pegasus Health. This material is not to be redelivered, on sold to any individual or organisation, or made publicly available on any website or in any publication, without written permission from Pegasus Health (Charitable) Ltd. Pegasus Health (Charitable) Ltd June 2013
Setting the scene The time may come when penicillin can be bought by anyone in the shops. Then there is the danger that the ignorant man may easily underdose himself and by exposing his microbes to nonlethal quantities of the drug, make them resistant. Alexander Fleming, from his Nobel Prize acceptance speech in 1945.
Worldwide antibiotic use (NZMJ)
National antibiotic use 2005-2012 (NZMJ)
Local antibiotic use
Case 1 Fred 23 yr old Presents with a blocked nose and sore throat which started 4/7 ago, coughing with a small amount of yellow sputum Has a stag do to go to in 5/7 time Fred asks for a course of antibiotics
Case 1 Does Fred need antibiotics? How can we assess Fred s health literacy? What does the average patient know about antibiotics, and potential harms?
How do you talk to patients about URTIs? Adapted from Sinus and Allergy Health Partnership (SAHP) Otolaryngol Head Neck Surg. 2004;130(1 Suppl):1-45
What are Fred s expectations? How do you explain to Fred that an antibiotic is not needed? So, doc are you going to give me some antibiotics?
Why do antibiotics get prescribed? Perceived pressure from patients Pressure on ourselves The patient has paid for a consult Work medical certificate is needed (otherwise the patient would not be attending) Uncertainty about diagnosis Because they ve been prescribed for the same thing in the past Fear (patient s and/or doctor s) Because there is an infection that needs it
How can we change it so that Because there is an infection that needs it is top of the list?
What about back pocket scripts? Do you use them? What discussion do you have with the patient? How do you use them? Postdate them? Give them to the patient (40% will be dispensed) Give them to PN (28% will be dispensed)? Give them to the pharmacist? How do you let PN and pharmacist know that it is a back pocket script?
Fred returns: A few days later: Anorexia Right-sided chest pain T 39.5C, RR 30, O2 sats 93% We want to minimise unnecessary antibiotic use BUT how do we ensure those who really need them get them?
Case 2 - Jane 53 yr old Mild varicose eczema Sore right lower leg 3/7 now swollen, erythematous Feeling a bit flu-y What else do you need to know? Would you do any investigations? Do you routinely do bloods?
Criteria for IV antimicrobials IV therapy is indicated if patient has any of the following: Sepsis clinical symptoms of infection (fever, sweats, chills or rigors) and at least 2 of the following: temperature: > 38 ºC or < 36 ºC tachycardia > 90 beats per minute tachypnoea > 20 breaths per minute WBC count > 12 or < 4x10 9 /L, or the presence of immature neutrophils Febrile neutropenia or immunosuppression Specific indications eg. endocarditis, meningitis, septic arthritis, osteomyelitis or abscess Oral route compromised [Adapted from CDHB Antimicrobial Guidelines]
Acute Demand In Canterbury we can use the Acute Demand service for cellulitis: This means being able to give IV antibiotics in General Practice or at the 24 Hour Surgery without admitting the patient to hospital. The practice is funded to give the antibiotics and follow up the patient
What dose of oral flucloxacillin would you prescribe for Jane? Why did you choose this dose? What patient factors would make you choose a higher/lower dose? Oral flucloxacillin should be started without delay. How do you ensure this? What if Jane can t afford the script?
Case 3 - Joe 7 yr old Sent home from school with spots on his face Mum very upset at implication of lack of hygiene How are you going to treat Joe?
What do you use for impetigo? Why? Oral antibiotics? Topical treatments? Combination of oral and topical antibiotics? What if a child refuses flucloxacillin?
15g Tubes Topical antibiotics Fusidic acid and mupirocin dispensed in Canterbury (2006 to 2013) 30,000 25,000 20,000 Total 15,000 10,000 5,000 Fusidic acid Crm&Ointmnt Mupirocin 2%Crm - 2006 2007 2008 2009 2010 2011 2012 2013 Why has there been such an increase in overall prescribing since 2006?
Decolonisation Prevention of infection is the ideal Use of antiseptic skin cleanser is important Can be considered for recurrent Staph skin infections Labour intensive, microbiologically effective in about 70% of cases
Take home messages Is that antibiotic needed? If you prescribe, use an appropriate antibiotic & adequate dose NNT are high to prevent complications such as mastoiditis and pneumonia Antibiotics have significant risk of side effects There is no universally accepted treatment for impetigo Bugs do not become resistant we selectively breed them Think about what you will change as a result of this round