Richard BellamyInfectious Diseases Physician, JCUH

Antibiotic prescribing

For GPs

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

3Trends in antibiotic resistance (invasive infections), 2002-2008. Source: European Antimicrobial Resistance Surveillance System (EARSS), 2009.

What is misuse of antibiotics?

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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

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 pre-1940

• 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

6Trends 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

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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.

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/Antibioticresistance/in

dex.htm

– http://antibiotic.ecdc.europa.eu

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