Prescribing dilemmas

1
Prescribing dilemmas

Jonathan Cooke University Hospital of South
Manchester NHS Foundation Trust
2
Dilemmas in Antimicrobial use

• Antimicrobial use leads to resistance
• Antimicrobials are used in
• Non-infections
• Colonisation and contamination
• In the absence of sensitivity tests/inappropriatel
  y
• Too many antimicrobials are used empirically
• Broad spectrum agents are used when narrow
  spectrum agents will do
• Antimicrobials are used for too long
• Antimicrobials are toxic

3
Resistance and antibiotics
4
Quinolone Resistance
E coli
5
(No Transcript)
6
(No Transcript)
7
(No Transcript)
8
(No Transcript)
9
http//www.bsac.org.uk/pyxis/
10
Healthcare CommissionMedicines Management
Indicators

• AHP - 2006
• 21 indicators
• Annual Health Check
• Replaces star ratings
• Number 9 managing antimicrobial prescribing

11
Healthcare Commission Audits 2005/6Medicines
Management Indicator 9Is there good management
of antimicrobials?

• Survey of 173 acute trusts in England
• Score 0 to 5 depending on
• antimicrobial strategy
• clinical guidelines
• surgical guidelines
• 1-3 audit areas covered
• 4-6 audit areas covered

12
Healthcare Commission Acute Hospitals Portfolio -
Medicines Management Progress on Managing
Antimicrobial PrescribingAcute Trusts in England
2005
Good practice
13
IV to Oral Switch

• Appropriate early switching from IV to oral use
• reduce amount and duration of antimicrobials
• reduce duration of stay.
• Known pathogen and sensitivities
• Haemodynamically stable with no signs of fever
• Clinically improving
• Able to take oral medications, have a functional
  GI tract with no malabsorption and there is no
  conflict or interactions with other medications
• Not suffering from certain high-risk infections

14
IV antibiotic point prevalence study UHSM
15
Health Indicators for antimicrobial prescribing

• Process management systems RD, ET
• Clinical Audit process v outcomes
• Clinical Audit qualitative audits
• Clinical Audit quantitative audits
• Outcomes
• Mortality
• Side effects
• Resistance
• Economics

16
Use of Anti-microbials
Acute Hospital trusts in England
17
Oral versus Parenteral
Acute Hospital trusts in England
18
Use of anti-microbials and MRSA
19
Glycopeptides
20
(No Transcript)
21
(No Transcript)
22
(No Transcript)
23
Use of Anti-microbials and C-Diff
Excludes Anti-tuberculous and Anti-leprotic
medicines
24
Use of Anti-microbials and C-Diff
Excludes Anti-tuberculous and Anti-leprotic
medicines
25
Use of Anti-microbials and C-Diff
Excludes Anti-tuberculous and Anti-leprotic
medicines
26
Use of Anti-microbials and C-Diff
Excludes Anti-tuberculous and Anti-leprotic
medicines
27
Use of Anti-microbials and C-Diff
Excludes Anti-tuberculous and Anti-leprotic
medicines
28
(No Transcript)
29
(No Transcript)
30
(No Transcript)
31
(No Transcript)
32
(No Transcript)
33
Health Indicators for antimicrobial prescribing

• High level regional/national
• High level Trust
• Division
• Directorate
• Specialty
• Ward/unit
• Patient

34
Health Indicators for antimicrobial prescribing
easy

• High level regional/national
• High level Trust
• Division
• Directorate
• Specialty
• Ward/unit
• Patient

difficult
35
The Health Act 2006

• Duty to adhere to policies and procedures
• Antimicrobial prescribing

36
DH letter 7th Dec 2006 Healthcare associated
infections, in particular infection caused by
Clostridium difficile

• Antibiotics are only used when indicated by the
  clinical condition of the patient and/or in
  association with the results of microbial
  investigation.
• Avoid empiric overuse to reduce the risk of
  toxicity and resistance Control of the
  prescription of broad-spectrum antibiotics, to
  include specifically extended spectrum
  cephalosporins and fluoroquinolone antibiotics

37
DH letter 7th Dec 2006 Healthcare associated
infections, in particular infection caused by
Clostridium difficile

• Restrict IV antibiotics to a maximum of 48 hours
  in the first instance
• IV to oral administration switch guidance
• Oral antibiotics may be restricted to five days
• Most patients should receive only a single
  prophylactic dose - timing is crucial

38
Thank You Any Questions?