Antibiotic prescribing

1
Antibiotic prescribing

• For GPs

Richard Bellamy Infectious Diseases Physician,
JCUH
2
Contents of this presentation

• What is inappropriate prescribing
• Consequences of antibiotic resistance -Emerging
  resistant strains-
• GP dillemas- what you can do differently

3
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

Trends in antibiotic resistance (invasive
infections), 2002-2008. Source European
Antimicrobial Resistance Surveillance System
(EARSS), 2009.
3
4
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

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
Nov30(5)724-7.
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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

6
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

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

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 4136(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 Oct53(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 Sep24(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
May59(5)990-5.
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Multifaceted strategies can address and decrease
antibiotic resistance

• Antibiotic prescribing practices and decreasing
  antibiotic resistance can be addressed through
  multifaceted strategies (Antimicrobial
  Stewardship) including29-31
• 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 Sep24(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 Jul29(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!

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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.

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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.

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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.

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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.

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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.

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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.

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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.

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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 doesnt 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.

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THANK YOU!

• For more information on data sources and
  references, please visit
• http//www.dh.gov.uk/en/Publichealth/Antibioticres
  istance/index.htm
• http//antibiotic.ecdc.europa.eu