Download European Antibiotics Awarness Day

Antibiotic prescribing
For GPs
Richard Bellamy
Infectious Diseases Physician, JCUH
Contents of this presentation
• What is inappropriate prescribing
• Consequences of antibiotic resistance -Emerging resistant
strains-
• GP dillemas- what you can do differently
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Antibiotic resistance –
a quick survey
• Hands up who has seen a patient with?
– MRSA
– C difficile
– ESBL-producing E coli
– An infection where they had no antibiotic options at all
3
Trends in antibiotic resistance (invasive infections), 2002-2008. Source: European Antimicrobial Resistance
Surveillance System (EARSS), 2009.
What is misuse of antibiotics?
Misuse of antibiotics include18:
• Prescribing antibiotics unnecessarily
• Delaying antibiotic treatment in critically ill patients;
• Using broad-spectrum antibiotics too generously, or
narrow-spectrum antibiotics incorrectly;
• Using lower or higher antibiotic dose than
appropriate for the specific patient;
• Inappropriate duration of antibiotic treatment - too
short or too long;
• Not streamlining antibiotic treatment according to
microbiological culture data results.
• Omitting or delaying doses of prescribed antibiotics
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18. Gyssens IC, van den Broek PJ, Kullberg BJ, Hekster Y, van der Meer JW. Optimizing antimicrobial therapy. A method for antimicrobial drug use evaluation. J Antimicrob Chemother. 1992 Nov;30(5):724-7.
Use selects resistance
• Acquired resistance absent from bacteria collected pre1940
• Resistance repeatedly followed introduction of new
antibiotics
• Resistance greatest where use heaviest (figure 1)
• Resistant mutants selected in therapy
Antibiotics are essentially the only drugs we
use which harm people who are not taking
them.
• The pipeline for new antibiotics is discouraging
• Although C difficile and MRSA are in decline
it is not all good news;
– ESBLs are an increasing problem
– MDR-pseudomonas outbreak in Gateshead ICU
– MDR-Acinetobacter from Middle East conflicts
– Carbapenemase-producing enterobacteria
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Trends in antibiotic resistance (invasive infections), 2002-2008. Source: European Antimicrobial Resistance
Surveillance System (EARSS), 2009.
Misuse of antibiotics drives antibiotic resistance
Effects
• Patients become colonised or infected with
– (MRSA),
– vancomycin-resistant enterococci (VRE) and
– highly-resistant Gram-negative bacilli.13-14
• increased incidence of Clostridium difficile infections.15-17
This is because of disruption of protective gut microbial flora.
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13. Safdar N, Maki DG. The commonality of risk factors for nosocomial colonization and infection with antimicrobial-resistant Staphylococcus aureus, enterococcus, gram-negative bacilli, Clostridium difficile, and
Candida. Ann Intern Med. 2002 Jun 4;136(11):834-44.
14. Tacconelli E, De Angelis G, Cataldo MA, Mantengoli E, Spanu T, Pan A, et al. Antibiotic usage and risk of colonization and infection with antibiotic-resistant bacteria: a hospital population-based study. Antimicrob
Agents Chemother. 2009 Oct;53(10):4264-9.
15. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 15. 2005(4):CD003543.
16. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
17. Fowler S, Webber A, Cooper BS, Phimister A, Price K, Carter Y, et al. Successful use of feedback to improve antibiotic prescribing and reduce Clostridium difficile infection: a controlled interrupted time series. J
Antimicrob Chemother. 2007 May;59(5):990-5.
Multifaceted strategies can address and
decrease antibiotic resistance
• Antibiotic prescribing practices and decreasing antibiotic
resistance can be addressed through multifaceted
strategies (Antimicrobial Stewardship) including:29-31
 Use of ongoing education
 Use of evidence-based antibiotic guidelines and policies
 Restrictive measures
 Feedback on volume of prescribing
29. Davey P, Brown E, Fenelon L, Finch R, Gould I, Hartman G, et al. Interventions to improve antibiotic prescribing practices for hospital inpatients. Cochrane Database Syst Rev. 2005(4):CD003543.
30. Carling P, Fung T, Killion A, Terrin N, Barza M. Favorable impact of a multidisciplinary antibiotic management program conducted during 7 years. Infect Control Hosp Epidemiol. 2003 Sep;24(9):699-706.
31. Byl B, Clevenbergh P, Jacobs F, Struelens MJ, Zech F, Kentos A, et al. Impact of infectious diseases specialists and microbiological data on the appropriateness of antimicrobial therapy for bacteremia. Clin
Infect Dis. 1999 Jul;29(1):60-6; discussion 7-8.
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A few case scenarios
• I am a hospital physician.
• I have never worked in primary care.
• I have strong views on what is not acceptable in hospital practice.
– Nurses should never take samples for microbiology without
discussion with a doctor unless they are nurse prescribers.
– Never take a microbiology specimen to diagnose an infection only
to determine what antibiotic to use.
• I may not be in the best position to assess what is feasible in general
practice.
• For the cases that come I am interested in your views. I may not have
the right answers for you!
Case scenario 1: bacteriuria
• A 65-year-old woman presents with a 3-day history of
dysuria and increased urinary frequency. She was
previously well.
• Would you give empirical treatment and if so what?
• Would you send a urine sample?
• What are the advantages and disadvantages of sending a
urine sample?
• If you did and they cultured a resistant organism would
you recall the patient for review?
• Please discuss in pairs for 5 minutes.
Case scenario 2: bacteriuria
• A 74 year-old woman seems more confused than normal.
She has longstanding dementia and lives in a nursing
home. She has a long-term indwelling urinary catheter. A
district nurse sends a catheter-specimen of urine which
grows an ESBL-producing E coli.
• Reported sensitivities: nitrofurantoin, fosfomycin,
pivmecillinam, gentamicin, ertapenem, meropenem.
• For 5 minutes discuss in pairs what you would do.
Case scenario 3: bacteriuria
• A 54-year-old woman has had five episodes of cystitis in
the last 2 years. She requests antibiotic prophylaxis to
prevent further episodes.
• What do you think are the advantages and disadvantages
of antibiotic prophylaxis in this situation?
• For 5 minutes discuss in pairs what you would do.
Case scenario 4: cellulitis
• A 44 year-old man has experienced 3 episodes of cellulitis
in the last 5 years. Each episode required admission to
hospital for intravenous antibiotics.
• Do you think he would benefit from antibiotic prophylaxis?
• For 5 minutes discuss in pairs what you would do.
Case scenario 5: leg ulcers
• A 64 year-old man has had swelling of both legs for
several years. He has had an ulcer over the anterior aspect
of the shin of the right leg for several months. The ulcer is
clean and relatively dry and there is no tissue necrosis.
– How would you assess the leg?
– Would you perform a wound swab and if so why?
– Would you use topical anti-microbials?
• If a wound swab was performed what would you do if you
grew
– Meticillin-sensitive S aureus?
– Pseudomonas aeruginosa?
– MRSA?
• For 5 minutes discuss in pairs what you would do.
Case scenario 6: previous MRSA
• A 44 year-old man presents with a 3-day history of fever,
chest pain, cough productive of green phlegm and
breathlessness. Clinically you feel he has pneumonia but
his CURB score is 0. He was found to be MRSA positive on
a wound swab after a hernia repair in 2013 but had a
negative MRSA screen last month.
• Does he need antibiotics and if so what?
• Does he need re-screening for MRSA?
• What does a negative MRSA screen tell you?
• For 5 minutes discuss in pairs what you would do.
Case scenario 6: Clostridium difficile
• A 74 year-old woman presents with a 5-day history of
diarrhoea. She was discharged from hospital 2 weeks
previously after an episode of pneumonia. A stool sample
is sent and you are called by the lab to report that the
Clostridium difficile test is positive.
• What would you do?
• Does the patient need treatment?
• Does the patient need admission to hospital?
• For 5 minutes discuss in pairs what you would do.
Final word of warning
• Drug companies try to persuade you to prescribe the ‘best’
(ie most broad spectrum) antibiotic for every infection
• If you do this you may save a handful of extra lives today
– This is very selfish
• Public health has to override individual wishes in this case
• If it doesn’t you and your children will pay a heavy price:
– Untreatable infections
– Huge increases in case fatality rates from common illnesses
– Increases in infant mortality etc
• Practice what you preach. Doctors are not entitled
to privileged care that compromises the safety of
others.
THANK YOU!
• For more information on data sources and references,
please visit:
– http://www.dh.gov.uk/en/Publichealth/Antibioticresistanc
e/index.htm
– http://antibiotic.ecdc.europa.eu
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