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Antibiotic Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists February 2011 Coventry and Warwickshire Pathology Objectives of the session • By the end of the session you will be able to: • Describe the factors that need to considered when making the choice to prescribe an antibiotic • Develop an understanding of key pathogens and their susceptibility to antibiotics. You will be able to relate this to the antibiotic policy within your Trust • Define what is meant by the term Antibiotic stewardship • Be aware of key DOH guidelines (Clostridium difficile) that direct the development of antibiotic policies • Name the antibiotics associated with Clostridium difficile • State the minimum requirements of how to prescribe an antibiotic • Name the key issues around route and duration of antibiotics and how this affects patients Coventry and Warwickshire Pathology Antibiotic stewardship • Ensures the optimisation of antibiotic use – – – – Only use when necessary Control who uses what Control route and duration Respond to changing needs – Respond to changing Evidence/Policies – Robust policing, review and stop strategies – E prescribing Coventry and Warwickshire Pathology A bit of background A potted history of Antibiotics • The use of antimicrobials in the treatment of infection is one of the triumphs of modern medicine. Coventry and Warwickshire Pathology History of Antibiotics • Before the discovery of the sulphur drugs in 1932, treatment of infectious disease was limited to mercury, arsenic, and quinine. • Penicillin was discovered in 1929. Alexander Fleming Coventry and Warwickshire Pathology History of Antibiotics • Penicillin was not manufactured on a large scale for nonmilitary use until 1949. Coventry and Warwickshire Pathology History of Antibiotics Decade Antibiotics 1940s & 1950s Streptomycin Synthetic penicillins Cephalosporins Chloramphenicol Tetracyclines. 1960s Quinolones 2000s Oxazolidinone (Linezolid®) Glycylcycline (Tigecycline®) 2010s ?? Long acting glycopeptides – phase 3 trials Coventry and Warwickshire Pathology Resistance always develops Examples Staphylococcus aureus Penicillin resistance 1950/60s MRSA - Meticillin resistance since 1970s VRSA - Vancomycin resistance in 2001 Enterococci VRE: Vancomycin Resistant Enterococci Coliforms Quinolone resistance ESBLs: Extended Spectrum Beta-lactamases Metallo Beta-lactamases (NDM-1) Coventry and Warwickshire Pathology Antimicrobial resistance • Multiple resistance genes • Plasmids • Spread • Factors leading to resistance: – Inappropriate clinical use of ABx – Poor infection control – Excessive ABx use in non clinical settings: • animal husbandry • shipping Coventry and Warwickshire Pathology Coventry and Warwickshire Pathology Coventry and Warwickshire Pathology Key antibiotic changes – Stop use of cefuroxime throughout the Trust – Use lower risk augmentin (but monitor C.difficile rates) – Reduce use of ciprofloxacin (consider penicillin allergy) – Antibiotic policy available under Clinical Guidelines on the intranet – Antibiotic guideline credit cards distributed Coventry and Warwickshire Pathology Apr-07 Coventry and Warwickshire Pathology Mar-11 Feb-11 Jan-11 Dec-10 Nov-10 Oct-10 Sep-10 Aug-10 Jul-10 Jun-10 £2,000 May-10 £2,500 Apr-10 £3,000 Mar-10 Feb-10 Jan-10 Dec-09 Nov-09 Oct-09 Sep-09 Aug-09 Jul-09 Jun-09 May-09 Apr-09 Mar-09 Feb-09 Jan-09 Dec-08 Nov-08 Oct-08 Sep-08 Aug-08 Jul-08 Jun-08 May-08 Apr-08 Mar-08 Feb-08 Jan-08 Dec-07 Nov-07 Oct-07 Sep-07 Aug-07 Jul-07 Jun-07 May-07 Expenditure Cefuroxime Spend by UHCW NHS Trust Diagnostics and Service Division Medicine and Emergency Division Rugby St Cross Specialised Networks Division Surgery Division Women and Childrens TRUST TOTAL £1,500 £1,000 £500 £0 Total Oral Ciprofloxacin spend by UHCW NHS Trust (Includes inpatient, TTO & outpatient issues) £700 Diagnostics and Service Division Medicine and Emergency Division Rugby St Cross £600 Specialised Networks Division Surgery Division £500 Women and Childrens £400 £300 £200 £100 Coventry and Warwickshire Pathology Mar-11 Jan-11 Feb-11 Dec-10 Oct-10 Nov-10 Sep-10 Jul-10 Aug-10 Jun-10 Apr-10 May-10 Mar-10 Jan-10 Feb-10 Dec-09 Oct-09 Nov-09 Sep-09 Jul-09 Aug-09 Jun-09 Apr-09 May-09 Mar-09 Jan-09 Feb-09 Dec-08 Oct-08 Nov-08 Sep-08 Jul-08 Aug-08 Jun-08 Apr-08 May-08 Mar-08 Jan-08 Feb-08 Dec-07 Oct-07 Nov-07 Sep-07 Jul-07 Aug-07 Jun-07 Apr-07 £0 May-07 Expenditure TRUST TOTAL Antibiotic stewardship • Ensures the optimisation of antibiotic use – – – – Only use when necessary Control who uses what Control route and duration Respond to changing needs – Respond to changing Evidence/Policies – Robust policing, review and stop strategies – E prescribing Coventry and Warwickshire Pathology Antibiotic prescribing What’s important? • When – Is there an infection? • How – To diagnose. What specimens? • Why – What is the indication/Likely pathogens? • What – What antibiotic/route/duration Coventry and Warwickshire Pathology When? • Diagnosing infection is a CLINICAL skill • Basic signs and symptoms of infection • Please remember apart from sterile sites (urine/csf/blood etc) most areas you culture WILL grow bacteria Coventry and Warwickshire Pathology When not to • CSU-urine cloudy • ?Chest infection with no evidence on CXR • Wound with serous exudate • Sloughy Ulcers • Isolated spikes of temp • To treat a high WCC Coventry and Warwickshire Pathology How? • How to diagnose Infection??? • What specimens do you need to take? • What investigations do you need to ask for? Coventry and Warwickshire Pathology Why? • Why are we giving Antibiotics – Empirical/Prophylactic/Targeted • Know your basic Microbiology • The indication (UTI/LRTI etc) • The setting (Pt+environment) – Hospital v Community (feasibility) • The likely pathogens (CRRS) Coventry and Warwickshire Pathology Prophylaxis • Therapy given to prevent an infection • Often given around surgery • Given to patients prone to particular infections – Contacts of Neisseria meningitidis meningitis • Given to patients who are specifically immunocompromised – Splenectomy – PCP prophylaxis in HIV Coventry and Warwickshire Pathology Surgical prophylaxis • Used to be given for several days • Evidence now suggests that peri-operative antibiotics adequate for most ‘clean’ operations Coventry and Warwickshire Pathology Principles of antibiotic prophylaxis • The use of antibiotic prophylaxis involves a dilemma; it is highly effective in preventing infection, but can promote resistance. • Limit to those individuals in whom the risk of infection is high. Coventry and Warwickshire Pathology Principles of antibiotic prophylaxis • Which antibiotics? – should be targeted to the most likely pathogens. • When? – administration as near the time of incision as possible. – Intravenous antibiotics should be given during the induction of anaesthesia with repeat doses for longer procedures. • Duration: – keep to a minimum (often even to a single-dose) to reduce the chance of resistance developing. – The benefits of post-operative prophylaxis lasting more than 12 h have not been proven. Coventry and Warwickshire Pathology Indications for antibiotic prophylaxis • Contaminated or dirty operations – presence of bowel contents, pus, or infected foreign material • Insertion of graft or prosthesis where development of infection would be serious. • Immunocompromised patients • Patients with cardiovascular abnormalities, may require specific antibiotic prophylaxis to reduce the risk of endocarditis – (NICE guidelines, BSAC guidelines) Coventry and Warwickshire Pathology Risk Factors for Surgical Site Infection • Patient: – – – – – – Extremes of age Poor nutritional state Obesity Diabetes mellitus Smoking Co-existing infections at other sites – Bacterial colonisation (e.g. MRSA) – Immunosuppression – Prolonged postoperative stay • Operation – – – – – – – – – – – Length of surgical scrub Skin antisepsis Preoperative shaving Preoperative skin prep Length of operation Antimicrobial prophylaxis Operating theatre ventilation Inadequate instrument sterilisation Foreign material in surgical site Surgical drains Surgical technique including haemostasis, poor closure, tissue trauma – Postoperative hypothermia Coventry and Warwickshire Pathology SIGN: Scottish Intercollegiate Guidelines Network www.sign.ac.uk www.sign.ac.uk/guidelines/fulltext/104/i ndex.html • SIGNqrg104.pdf Coventry and Warwickshire Pathology Empirical therapy • Therapy given without knowing the causative organism • Choice based on practical experience and evidence based medicine • ‘Best guess therapy’, unlikely to cover all possibilities Coventry and Warwickshire Pathology Targeted therapy • Therapy given when the infection and causative organism is known • This is the best way of effective treatment • We should know the actual sensitivity of the offending pathogen Coventry and Warwickshire Pathology What - Considerations in therapy • Choice of agent includes: • • • • Recent DOH guidance (Clostridium difficile) – Has altered policies Range of pathogens (Why?) Infection site/drug penetration Patient factors (allergy) • The above should be covered by your antibiotic policy • • • • • Combination therapy (synergy/antagonism) Dose/Frequency Route – IV/oral IV/oral switch Duration (5-7 days for most infection) Coventry and Warwickshire Pathology Patient factors • Allergy • Other medications (interactions) • Can they take PO • Tolerance • Compliance Coventry and Warwickshire Pathology Infection site • Drug penetration e.g. • Antibiotics aren’t always the answer – Infection prostheses SURGERY • Bone/Soft tissue infections – Some drugs like the aminoglycosides do not penetrate well • Meningitis – Many drugs will not penetrate CSF well Coventry and Warwickshire Pathology IV or oral • • • • What are the considerations Depends on site of infection Oral bioavailability of the antibiotic Clear aim/end point (treatment/suppression) • Licencing Coventry and Warwickshire Pathology MAU Audit Zoe Campbell F2 SHO • Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics • 18 out of 25 patients received IV antibiotics • 18 patients were classified mild/mod (? Oral antibiotics) • 7 patients were classified severe (? IV antibiotics) Oral I.V. Severe Coventry and Warwickshire Pathology Mild/ Moderate MAU Audit: IV/Oral Switch • Only 2 out of 25 (8%) patients had an IV to oral switch or a review/stop date specified on initial clerking Date specified No date specified Coventry and Warwickshire Pathology Also How much? • Unfortunate but Healthcare economics are always a consideration • Particularly with some newer drugs – Antifungals – Antibacterials – Antivirals Coventry and Warwickshire Pathology ‘No antibiotic’ option • Our antibiotic options are running out. – Increasing resistance – Paucity of new drugs • Avoid unnecessarily antibiotics – Often there to make us feel better rather than the patient! – Unnecessary risk to patients • Look for >1 marker of infection • Stop antibiotics as soon as possible – Plan stop dates / review dates Coventry and Warwickshire Pathology Coventry and Warwickshire Pathology What must an antibiotic prescription include? • Must be documented with review dates in the patients notes • Length of course or a Review date • (all i/v antibiotics must be reviewed at 48 hours and changed to oral where clinically appropriate) • Indication • All antibiotics must be reviewed daily Coventry and Warwickshire Pathology