ScRAP Scottish Reduction in Antibiotic Prescribing Programme

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ScRAPScottish Reduction in Antibiotic
Prescribing Programme

• Prescriber Learning Event
• Reducing the unnecessary prescribing of
  antibiotics
• Can we ScRAP the unnecessary antibiotic
  prescription?
• October 2013 edition

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Introduction contents

• Aim of ScRAP
• Facilitator led DVD presentation discussion
  session
• What will be covered?
• What are the barriers to decreasing antibiotic
  use?
• Resisting resistance Presenting the evidence
• Local prescribing data
• Patient expectations Examining a typical
  patient consultation
• Managing complications Targeted use of
  antibiotics
• Myth busters
• Alternative strategies delayed
  prescriptions
• Event closure

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What are the barriers to decreasing antibiotic
use?
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• http//www.youtube.com/watch?vm5N3dcPmxW0

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Introduction contents

• Aim of ScRAP
• Facilitator led DVD presentation discussion
  session
• What will be covered
• What are the barriers to decreasing antibiotic
  use?
• Resisting resistance Presenting the evidence
• Local prescribing data
• Patient expectations Examining a typical
  patient consultation
• Managing complications Targeted use of
  antibiotics
• Myth busters
• Alternative strategies delayed
  prescriptions
• Event closure

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What are the barriers to reducing antibiotic
prescribing?

• Understanding reality of antimicrobial
  resistance?
• Concern of unintended harm as a result of not
  prescribing an antibiotic?
• Demands, expectations and previous experience of
  patients and their representatives?

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Resisting resistance presenting the evidence
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Antibiotic usage at a European population level
ESAC data 2003 Surveillance of antimicrobial
consumption in Europe, 2003
ESAC data 2010 Surveillance of antimicrobial
consumption in Europe, 2010
United Kingdom
United Kingdom
United Kingdom
Sweden
Sweden
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Antibiotic resistance at a European population
level
Goossens et al. Lancet 2005 365
579-587 Outpatient antibiotic use in Europe and
association with resistance a cross-national
database study
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Antibiotic resistance at practice population level
Butler et al. Br J Gen Pract 2007 57,
785 Containing antibiotic resistance decreased
antibiotic-resistant coliform urinary tract
infections with reduction in antibiotic
prescribing by general practices.
Reduction () in resistance to ampicillin
trimethoprim over a 7-year period, by quartile of
reductions in total antibiotic prescribing
Quartile 1 Quartile 2 Quartile 3 Quartile 4 Overall
Ampicillin
Year 1 58.7 50.6 49.2 50.0 51.3
Year 7 53.5 51.0 51.6 49.7 51.2
Reduction (95 CI) 5.2(2.9 to 7.4) -0.4 (-2.3 to 1.5) -2.4 (-4.1 to -0.7) 0.3 (-1.4 to 2.0) 0.0 (-0.9 to 1.0)
Trimethoprim
Year 1 29.1 26.6 26.5 25.5 25.5
Year 7 25.7 24.9 25.0 24.7 25.0
Reduction (95 CI) 3.4 (1.3 to 5.4) 1.7 (0.1 to 3.3) 1.5 (0.0 to 2.9) 0.8 (-0.7 to 2.3) 0.4 (-0.8 to 1.7)
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Antibiotic resistance at patient level
Costelloe et al. BMJ 2010340 c2090 Effect of
antibiotic prescribing in primary care on
antimicrobial resistance in individual patients
systematic review and meta-analysis

• Individuals prescribed an antibiotic in primary
  care for a respiratory or urinary infection
  develop bacterial resistance to that antibiotic
• The effect is greatest in the month immediately
  after treatment but may persist for up to 12
  months
• This effect not only increases the population
  carriage of organisms resistant to first line
  antibiotics, but also creates the conditions for
  increased use of second line antibiotics in the
  community

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Facilitator lead discussion

• What information did you already know?
• What information was new?
• What has the information added to your
  understanding of antimicrobial resistance?
• How do you think this might affect how you
  interact with patients in the future?

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Resisting resistance local prescribing data
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Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish
Antimicrobial Prescribing Group. Report on
Antimicrobial Use and Resistance in Humans in
2011
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Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish
Antimicrobial Prescribing Group. Report on
Antimicrobial Use and Resistance in Humans in
2011
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Antibiotic usage at a national level
Scottish Medicines Consortium / Scottish
Antimicrobial Prescribing Group. Report on
Antimicrobial Use and Resistance in Humans in
2011
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Facilitator lead discussion

• Antibiotic use at local level
• How does your antibiotic usage compare with other
  local practices in your health board?
• Was your antibiotic use higher or lower than you
  expected?
• How has your antibiotic usage changed over time?
• Was the change in your antibiotic usage more or
  less than you expected?
• Key points from local guidelines

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Patient expectations examining a typical
patient consultation
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Expectations but whose are they really?
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Expectations but whose are they really?
V Duijn et al. Br J Gen Pract. 2007 July 1
57(540) 561568. Illness behaviour and
antibiotic prescription in patients with
respiratory tract symptoms

• Health care professionals over-estimate patient
  demand for antibiotics
• In patients with bronchitis, antibiotic
  prescribing had no effect on patient satisfaction
  scores
• Whereas careful physical examination did

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Patient consultation video
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Facilitator lead discussion

• ICE approach
• (Matthys et al. Patients' ideas, concerns, and
  expectations (ICE) in general practice impact on
  prescribing Br J Gen Pract. 2009 January 1
  59(558) 2936)
• Examination and its role in patient satisfaction
• Treating concerns not desires
• Explanation not a battle of wills
• Explanation natural history of infection
• Safety net option
• Any changes to consultation technique?

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Managing complications targeted use of
antibiotics
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Targeted use of antibiotics
Van Duijn et al. Br J Gen Pract. 2007
Jul57(540)561-8. Illness behaviour and
antibiotic prescription in patients with
respiratory tract symptoms

• The antibiotic revolution should be more
  focused...
• Our mission is not to prescribe as few
  antibiotics as possible, but to identify that
  small group of patients who really need
  antibiotic treatment and to explain, reassure and
  educate the large group of patients who dont.

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Targeted use of antibiotics
National Institute for Health and Clinical
Excellence. Respiratory tract infections
Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and
children in primary care. 2008. (Clinical
Guideline 69)

• The following subgroups of patients in whom an
  immediate antibiotic strategy should be
  considered depending on clinical assessment of
  severity
• Bilateral acute otitis media in children
  younger than two years
• Acute otitis media in children with otorrhoea
• Acute sore throat / acute pharyngitis / acute
  tonsillitis where three or more Centor
  Criteria are present
• A delayed prescription or no prescription
  strategy may also be considered

• Centor criteria
• Tonsillar exudate
• Tender anterior cervical lymphadenopathy
• History of fever
• Absence of cough

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Targeted use of antibiotics
National Institute for Health and Clinical
Excellence. Respiratory tract infections
Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and
children in primary care. 2008. (Clinical
Guideline 69)

• An immediate antibiotic prescription and/or
  further appropriate investigation and management
  should only be offered to patients (both adults
  and children) in the following situations
• Systemically very unwell
• Symptoms and signs suggestive of serious
  illness and/or complications (particularly
  pneumonia, mastoiditis, peritonsillar abscess,
  peritonsillar cellulitis, intraorbital and
  intracranial complications)
• High risk of serious complications because of
  pre-existing comorbidity eg significant heart,
  lung, renal, liver or neuromuscular disease,
  immunosuppression, cystic fibrosis, and young
  children who were born prematurely

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Targeted use of antibiotics
National Institute for Health and Clinical
Excellence. Respiratory tract infections
Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and
children in primary care. 2008. (Clinical
Guideline 69)

• If patient is older than 65 years with acute
  cough and two or more of the following criteria,
  or older than 80 years with acute cough and one
  or more of the following criteria
• Hospitalisation in previous year
• Type 1 or type 2 diabetes
• History of congestive heart failure
• Current use of oral glucocorticoids
• For these patients, the no antibiotic prescribing
  strategy and the delayed antibiotic prescribing
  strategy should not be considered

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Facilitator lead discussion

• Does this information help you understand more
  clearly the place in therapy of antibiotics in
  respiratory tract infections?
• Are there instances where you have treated
  patients out with these criteria?
• Do you feel more confident in not prescribing an
  antibiotic out with the criteria?

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Managing complications myth busters
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Myth busters value of antibiotics in RTI
Acute sore throat Spinks et al. Antibiotics for
sore throat. Cochrane database for systematic
review issue 4 2006

• Without antibiotics 40 will resolve after 3 days
  and 90 after 7 days
• The NNT (Number Needed to Treat) was 6 to half
  pain at day 3

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Myth busters value of antibiotics in RTI
Acute Rhinosinusitis Ahovuo-Saloranta et al.
Antibiotics for acute maxillary sinusitis.
Cochrane database for systematic reviews issue 2
2008

• 80 resolve in 14 days with no antibiotics
• Antibiotics have a small benefit after 7 days of
  illness (NNT 15)
• There was no additional benefit of antibiotics in
  older patients, more severe pain or longer
  duration of symptoms

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Myth busters value of antibiotics in RTI
Acute Rhinosinusitis Ahovuo-Saloranta et al.
Antibiotics for acute maxillary sinusitis.
Cochrane database for systematic reviews issue 2
2008

• 66 of children are better within 24 hours and
  antibiotics have no effect on symptoms
• 90 of children are better in 2 to 7 days and
  antibiotics have only a small effect on reducing
  pain by 16 hours (NNT 15)

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Myth busters value of antibiotics in RTI
Acute Cough / Bronchitis Fahey et al.
Antibiotics for acute bronchitis. Cochrane
database for systematic reviews issue 4 2004

• Antibiotics reduced symptoms by only one day in
  an illness lasting up to 3 weeks

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Myth busters value of antibiotics in RTI
Acute Otitis Media Sanders et al. Antibiotics
for acute otitis media in children. Cochrane
database for systematic reviews issue 1 2004

• 66 of children are better within 24 hours and
  antibiotics have no effect on symptoms
• 90 of children are better in 2 to 7 days and
  antibiotics have only a small effect on reducing
  pain by 16 hours (NNT 15)

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Myth busters preventative value ofantibiotics
in RTI
Sore throat and quinsy Peterson et al.
Protective Effects of antibiotics.BMJ
2007335982-984 Centor et al. The diagnosis of
Strep throat in adults in the emergency room. Med
Decision Making 19811239-46

• Overall NNT gt 4000 to prevent one case of quinsy
• Centor score of 3 or 4 160 chance of
  quinsy
• Centor criteria
• Tonsillar exudate
• Tender anterior cervical lymphadenopathy
• History of fever
• Absence of cough

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Myth busters preventative value ofantibiotics
in RTI
Rheumatic Fever Howie et al. Antibiotics, sore
throat and rheumatic fever. BJGP 1985 35
223-224

• It would take 12 working life times of a GP to
  see one case of Rheumatic Fever
• Treating sore throats with antibiotics has no
  effect on risk of developing Rheumatic Fever

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Myth busters preventative value ofantibiotics
in RTI
Glomerulonephritis Taylor et al. Antibiotics,
sore throat and acute nephritis. BJGP 1983 33
783-786

• Glomerulonephritis is a rare condition (2.1 per
  100,000 children) and is not prevented by
  treating sore throats with antibiotics

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Myth busters giving an antibiotic does no harm?
The harm of antibiotics British National
Formulary 201364

• The benefits of antibiotics have to be carefully
  balanced against their harm
• Most antibiotics can cause gastrointestinal
  effects such as nausea, vomiting and
  diarrhoea in some patients
• In addition, a number can cause serious rashes
  and skin reactions

The harm of antibiotics Glasziou PP, et al.
Antibiotics for acute otitis media in children.
Cochrane Review. 2004

• Reviews of antibiotics in people with respiratory
  tract infections have found that, for every 16
  people treated with antibiotics, rather than
  placebo, 1 person will suffer an adverse event

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Facilitator lead discussion

• Does this information help you understand more
  clearly the place in therapy of antibiotics in
  respiratory tract infections?
• Are their instances where you have treated
  patients with an antibiotic in these clinical
  situations?
• Do you feel more confident in not prescribing an
  antibiotic in these clinical situations as a
  result of the evidence?

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Managing complications- alternative strategies
delayed prescriptions
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Delayed prescriptions
Spurling et al. Cochrane Database of Systematic
Reviews 2007, Issue 3.Cochrane 2007 Delayed
antibiotics for respiratory infections.

• Delayed prescriptions substantially reduce
  antibiotic use but might slightly worsen some
  symptoms compared with immediate prescriptions
• Delayed prescriptions might also reduce
  re-consultation rates
• For mild upper respiratory tract infections
  delayed prescriptions are not associated with
  important negative consequences

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Delayed prescriptions
Spurling et al. Cochrane Database of Systematic
Reviews, Issue 4.Cochrane 2013 Delayed
antibiotics for respiratory infections. Update
of 2007

• Most clinical outcomes show no difference between
  strategies
• Delay slightly reduces patient satisfaction
  compared to immediate antibiotics (87 versus
  92) but not compared to none (87 versus 83)
• In patients with respiratory infections where
  clinicians feel it is safe not to prescribe
  antibiotics immediately, no antibiotics with
  advice to return if symptoms do not resolve is
  likely to result in the least antibiotic use,
  while maintaining similar patient satisfaction
  and clinical outcomes to delayed antibiotics

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Delayed prescriptions
National Institute for Health and Clinical
Excellence. Respiratory tract infections
Prescribing of antibiotics for self-limiting
respiratory tract infections in adults and
children in primary care. 2008. (Clinical
Guideline 69)

• When using delayed antibiotic prescriptions,
  patients should be offered
• Reassurance that antibiotics are not needed
  immediately since likely to make little
  difference to symptoms and may have side effects,
  for example, diarrhoea, vomiting and rash
• Advice about using the delayed prescription if
  symptoms are not starting to settle in accordance
  with the expected course of the illness or if a
  significant worsening of symptoms occurs
• Advice about re-consulting if there is a
  significant worsening of symptoms despite using
  the delayed prescription.
• A delayed prescription with instructions -
  either given to patient or left at an agreed
  location to be collected at a later date.

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Facilitator lead discussion

• Any experience of delayed prescriptions?
• How important is patient information in a delayed
  prescription strategy?
• Is a delayed prescription strategy worthwhile
  trialling in this practice?

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Event closure
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Facilitator lead discussion

• Next steps
• What strategy are we going to take to move
  forward?
• Changes to consultation style and/or delayed
  prescriptions?
• Can we reach a practice consensus?
• How we can measure progress?
• Evaluations (health board specific CPD)