Antimicrobial Update Stewardship in Primary Care Clare Colligan Antimicrobial Pharmacist NHS Forth Valley
Setting the Scene!
Consequences of Antibiotic Use? Resistance For an individual patient with urinary tract infection prescribed an antibiotic within the last 2 months what is the increased level of risk of resistance? a) None b) 1.5 fold increase c) 2 fold increase d) 2.5 fold increase e) 4 fold increase Effect of primary care prescribing on resistance in individual patients. BMJ 2010; 340: 1120
Local picture Primary Care Feb 15-Feb 16
Consequences of Antibiotic Use? CDI For an individual patient with an infection, which of the following antibiotics have a greater association with CDI than others? (Choose all that apply) a) CO-AMOXICLAV b) TRIMETHOPRIM c) DOXYCYCLINE d) CIPROFLOXACIN e) CEPHALEXIN
Consequences of Antibiotic Use? Use of antimicrobial agents, for therapy or prophylaxis, is the most important predisposing factor for CDI 8-10 fold increased risk of CDI up to 3 months from prescribing antibiotic Ref: CMI 2009; 15: 427-434
Risk of C. difficile infection High Risk Medium Risk Low Risk Fluoroquinolones Ampicillin/Amoxicillin Aminoglycosides Cephalosporins Co-trimoxazole Metronidazole Co-amoxiclav Clindamycin Macrolides Tazocin Tetracyclines Trimethoprim Rifampicin Vancomycin
HPS Quarterly report Jan 16 CDI Incidence rates
No of Issues Local Picture CDI (all FV) numbers CDI numbers 30 25 20 15 10 5 0 Month
Antimicrobial use is a National priority
Definition of 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
Antimicrobial Stewardship
Stewardship: Prudent Prescribing Is an antibiotic required? Only use when clearly indicated, not self limiting (viral) infections Select appropriate agent from local antimicrobial policy Minimise collateral damage/risk to patient Prescribe optimal dosage for shortest duration Maximise effect but minimise selective pressure Ask specialist/micro for advice if suspect resistance Access unedited antibiogram/c+s results
Antimicrobial Prescribing Policies New empirical Antimicrobial policies for hospitals and primary care in place in all NHS Boards Evidence based guidance on empirical treatment of common infections now with HAI focus Promote use of narrow spectrum agents and restrict agents associated with Clostridium difficile.
Primary Care Prescribing Indicators Annual Report 2014/15 for Scottish Antimicrobial Prescribing Group
NHS Scotland: Number of practices achieving level three quality indicator by NHS board Baseline (Jan-Mar 2013) to Year 2 (Jan-Mar 2015)
NHS Scotland: Use of co-amoxiclav in primary care, proportion of total items, 2010/11-2014/15
NHS Scotland: Use of fluoroquinolones in primary care, proportion of total items, 2010/11-2014/15
NHS Scotland: Use of 3-day trimethoprim in adult females in primary care by NHS board, proportion of all trimethoprim use 2011/12-2014/15
A reduction in the unnecessary use of antibiotics will yield the following benefits: Reduction in the development of antimicrobial resistance at population and individual level, Reduction in CDI, Reduction in avoidable harm through fewer adverse effects, Reduction the medicalisation of self limiting conditions and the associated GP workload, Reduction of NHS prescribing costs.
Primary Care Antimicrobial Guidelines All NHS boards follow management of infection template from Health Protection Agency
Formulary First line Antibiotics Amoxicillin Flucloxacillin Phenoxymethylpenicillin Macrolides Tetracyclines Metronidazole Nitrofurantoin Trimethoprim
Acute cough/bronchitis Pharyngitis/sore throat/tonsillitis UTI female Other Rhinosinusitis, acute Cellulitis Otitis media COPD Community acquired pneumonia UTI male Impetigo Pyelonephritis Otitis externa Number of consultations Cumulative total Audit of management of commonly encountered infection in primary care 600 500 400 300 200 100 0 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% Infection Number of consultations Cumulative % Number of consultations by infection
LOWER RESPIRATORY TRACT INFECTIONS Note: Avoid tetracyclines in pregnancy. Low doses of penicillins are more likely to select out resistance. Ciprofloxacin and ofloxacin have poor activity against pneumococci and should not be used first line unless PROVEN Psuedomonal infection. Obtain sputum for culture if possible but do not delay starting treatment. Penicillin allergic patients on simvastatin or atorvastatin (>20mg) should have doxycycline rather than clarithromycin due to risk of drug interaction. Communityacquired pneumonia - treatment in the community BTS guidelines 2009 Start antibiotics immediately. B- In severely ill antibiotics before admission C. If no response in 48 hours consider admission or add a second antibiotic (clarithromycin or a tetracycline C ) to cover mycoplasma infection (rare in >65 years). If no improvement and/or penicillin allergy discuss options with microbiology. If no response to antibiotics after 2 weeks and/or if severely ill consider possibility of lung cancer or tuberculosis and arrange chest X ray. Seek risk factors for Staph aureus and Legionella. amoxicillin A+ 500mg 1000mg TDS OR if allergy to penicillin doxycyline D 200mg day 1 then 100mg OD OR clarithromycin A- 500mg BD 7-10 days 7-10 days 7-10 days Acute exacerbation of COPD NICE guidance GOLD Treat exacerbations promptly if purulent sputum AND increased shortness of breath and/or increased sputum volume B+ 1 st line Amoxicillin 500mg TDS if allergy to penicillin Doxycycline 200mg day 1 then 100mg OD or Clarithromycin 500mg BD 5 days 5 days 5 days Risk factors for antibiotic resistant organisms include; co-morbid disease, severe COPD, frequent exacerbations, antibiotics in last 3 months If risk factors for resistance or failure of first line treatment Co-amoxiclav 625mg TDS 5 days If penicillin allergic, discuss with microbiology ILLNESS COMMENTS DRUG and DOSE DURATION OF Tx Acute cough, bronchitis Clinical Knowledge Summaries NICE 69 In Primary Care antibiotics have marginal benefits in otherwise healthy adults. A+ Symptom resolution can take 3 weeks Consider 7-14 day delayed antibiotic with symptomatic advice / patient information leaflet A- Consider antibiotics if unwell and >80 years AND ONE of: hospitalisation in past year, oral steroids, diabetic or CCF or >65 years with TWO of above If treatment failure send sputum samples for sensitivity testing Amoxicillin 500mg TDS if allergy to penicillin Doxycycline 200mg day 1 then 100mg OD 5 days 5 days
Exacerbations of COPD Self management Rapid access to antibiotics -> 2 out of 3 symptoms Purulent sputum Increase breathlessness Increase sputum volume Most likely organisms Strep.pneumoniae, H.Influenzae, M.catarrhalis (Viruses influenza, parainfluenza, rhinovirus, RSV)
Choice of antibiotics Amoxicillin Tetracycline (doxycycline) Clarithromycin Course length 5-7 days
Doxycycline PGD Replacing clarithromycin Inclusion Criteria Definite diagnosis of COPD Infective exacerbation characterised by development or increase in sputum purulence and one or more of the following increase in shortness of breath increase in sputum volume Patient has Forth Valley COPD self-management plan agreed with GP which allows for treatment from Community Pharmacist Exclusion Criteria Known allergy to doxycyline Pregnancy Breast Feeding Patients with rare hereditary problems of fructose intolerance, glucose galactose malabsorption or sucrose-isomaltase insufficiency. Myasthenia gravis Systemic lupus erythematosus (SLE) Patients receiving the following medications; methotrexate, oral ciclosporin, oral retinoids. Course of antibiotics within the last month with no resolution of symptoms More than 2 supplies by community pharmacist in any 3 month period Patient does not have Forth Valley COPD self-management plan at time of presentation
Public Awareness Campaigns
Patients resources Videos for waiting rooms
Patient Expectations+++
Validated Material - Booklet for parents Francis et al BMJ 2010
Back Up (delayed) Scripts Evidence to say do work Back date for 48 hours prescription? Leave behind reception if no better in 2 days?
Role of Individual Prescribers Awareness of local antimicrobial prescribing policy Minimise use of non-policy antibiotics and inappropriate dosage or duration Risk assess is it necessary to prescribe for self limiting diagnosis against individual patient circumstance Especially vigilant on antibiotic use in high risk HAI vulnerable groups e.g. Elderly, Nursing Homes
Questions?