3 rd May 2012 Antimicrobial use and guidance

3 rd May 2012 Antimicrobial use and guidance: Where are we in Wales? Lorna Macfarlane

• Antimicrobial formularies • Antimicrobial prescribing guidance in primary care • Antimicrobial prescribing guidance for respiratory infections in secondary care Antimicrobials and guidance

Antimicrobial formularies • Ax formularies from 5/7 Health Boards • All merged primary and secondary care • Mixture of electronic BNF type and documents Antimicrobials and guidance

• Variation in defining availability of antimicrobials • Variation in defining prescribing restrictions • Interpretation of findings has to take account of: - patient groups served specialist units presence of protocols “custom and practice” • There are broad areas of agreement but………. . Antimicrobials and guidance

amoxycillin ampicillin inj co-amoxiclav vs amoxycillin (1 st) ampicillin (2 nd, micro adv/paeds) co-amoxiclav (2 nd) vs amoxycillin ampicillin co-amoxiclav co-fluampicil Antimicrobials and guidance

piperacillin with tazobactam (H) vs piperacillin with tazobactam ticarcillin with clav acid Antimicrobials and guidance

imipenem (H) meropenem (H) ertapenem (H) vs imipenem meropenem doripenem ertapenem Antimicrobials and guidance

cefalexin (1 st) cefuroxime inj (H) cefotaxime (H) ceftriaxone (micro adv/paeds) cefixime (1 st) ceftazidime (H) vs cefalexin (1 st) cefradine (po/iv) (1 st) cefaclor (1 st) cefuroxime inj (1 st) cefotaxime (1 st) ceftriaxone (1 st) cefixime (1 st), ceftazidime (1 st) Antimicrobials and guidance

doxycycline (1 st) lymecycline (2 nd) oxytetracycline (1 st) tigecycline (H; micro adv) vs doxycycline lymecycline minocycline oxytetracycline tigecycline (micro adv) Antimicrobials and guidance

ciprofloxacin (1 st) levofloxacin (H) ofloxacin (1 st; GUM only) vs ciprofloxacin (PO) ciprofloxacin (IV) levofloxacin moxifloxacin nalidixic acid ofloxacin (oral Rx of PID when tetra not appropriate) Antimicrobials and guidance

Antimicrobial use in primary care mapped to formularies Antimicrobials and guidance

Antimicrobial prescribing guidance in primary care • Primary care guidelines from 6/7 Health Boards • 1 covered primary care and A&E • 4 use HPA format and content is broadly similar to HPA • 1 Health Board – 3 unmerged • Total 8 primary care guidelines Antimicrobials and guidance

How does the content of primary care guidelines compare across the Health Boards? Antimicrobials and guidance

• Antibiotic choices • Doses • Duration of treatment • Clinical commentary Antimicrobials and guidance

Acute otitis media • Amoxicillin 1 st line • Macrolide 2 nd line • 5 days duration • erythromycin vs clarithromycin vs azithromycin • some give second line agent (co-amoxiclav) • commentaries differ slightly Antimicrobials and guidance

UTI in men and women (uncomplicated) • comments differ, some include symptoms • some differentiate female and male UTI • not all state trimethoprim or nitrofutantoin as first line, some just offer trimethoprim • nitrofurantoin m/r vs ordinary nitofurantoin • dose of ordinary nitrofurantoin? 50 mg vs 50100 mg Antimicrobials and guidance

• approach to defining 2 nd line Ax choices differs: - one suggest co-amoxiclav or cefalexin if failure of 1 st line and need to treat pending msu result -one gives more extensive choice for second line -Some suggest awaiting msu result - Some highlight the issue of multiplyresistant E. coli Antimicrobials and guidance

UTI in pregnancy • four give cefalexin as first choice • cefalexin doses differ (500 mg BD or TDS or QDS) • 4 suggest 1 st nitrofurantoin (or amoxycillin if susceptible), 2 nd trimethoprim • two specifically say avoid trimethoprim in 1 st trimester, and avoid nitro in 3 rd trimester/near term • one gives more extensive advice about trimethoprim and nitrofurantoin in pregnancy Antimicrobials and guidance

Cellulitis • most advise flucloxacillin as first line, but two advise penicillin v plus flucloxacillin • clarithromycin vs erythromycin • comments differ slightly • the option of clindamycin not mentioned in several • not all mention facial cellulitis • one doesn’t mention prolonging treatment beyond 7 days Antimicrobials and guidance

Pelvic Inflammatory disease • one doesn’t mention PID • antibiotic regimens differ slightly • doses of cetriaxone vary (250 mg or 500 mg) • one advises admitting pregnant women for iv treatment Antimicrobials and guidance

Antimicrobial prescribing guidance for respiratory infections in secondary care • Guidelines from 5/6 Health Boards • 4 merged guidance • 1 unmerged • Total of 7 guidance documents Antimicrobials and guidance

Exacerbation of COPD/ acute bronchitis Health Board A First line: amoxycillin 500 mg po TDS If penicillin allergic: doxycycline 200 mg po day 1, then 100 mg OD Antimicrobials and guidance

From 2011 point prevalence survey for this HB ……. . • • • Amoxicillin Clarithromycin Co-amoxiclav Doxycycline Amoxicillin, Clarithromycin, Co-amoxiclav Clarithromycin, Levofloxacin Amikacin, Azithromycin, Imipenem Ethambutol, Isoniazid, Pyrazinamide, Rifamipicin 13 3 15 2 1 1 1 (38%) Antimicrobials and guidance

Health Board B • • • Amoxicillin Cefotaxime Ciprofloxacin Clarithromycin, Co-trimoxazole, Pip. Tazo Co-amoxiclav Doxycycline Levofloxacin, Metronidazole Pip. Tazo 3 1 1 1 8 5 4 1 1 (32%) Antimicrobials and guidance

Health Board C Mild/moderate: Amoxycillin 500 mg TDS or doxycycline 200 mg po day 1, then 100 mg OD or clarithromycin 500 mg po BD Severe: Co-amoxiclav 1. 2 g iv TDS +/- clarithromycin 500 mg iv BD Oral switch Co-amoxiclav 625 mg po TDS plus/minus clarithromycin 500 mg po BD (Non severe penicillin allergy) Cefuroxime 1. 5 g iv TDS +/- clarithromycin 500 mg iv BD Oral switch doxycycline 200 mg po day 1, then 100 mg OD Antimicrobials and guidance

• • • Amoxicillin, Clarithromycin, Co-amoxiclav Amoxicillin, Co-amoxiclav Ceftazidime, Gentamicin Clarithromycin, Co-amoxiclav Clarithromycin, Pip. Tazo Co-amoxiclav Doxycycline Metronidazole, Pip. Tazo 10 2 1 1 1 3 3 2 13 1 1 (89%) Antimicrobials and guidance

BTS Guidelines for the management of community acquired pneumonia in adults: updates 2009 Low severity Preferred treatment: amoxycillin 500 mg po TDS Alternatives: doxycycline 200 mg po day 1, then 100 mg OD or clarithromycin 500 mg po BD 7 days Antimicrobials and guidance

Low severity Preferred 1 amoxycillin clarithromycin, doxycycline 2 doxycycline amoxycillin 3 amoxycillin 4 (BTS plus) Alternative clarithromycin, doxycycline 5 amoxycillin 6 amoxycillin, clarithromycin, doxycycline 7 amoxycillin Antimicrobials and guidance clarithromycin doxycycline

Moderate severity Preferred treatment: Amoxycillin 500 mg-1 g po TDS plus clarithromycin 500 mg po BD If iv required: Amoxycillin 500 mg iv TDS or benzylpenicillin 1. 2 g TDS plus clarithromycin 500 mg iv BD Alternatives: doxycycline 200 mg po day 1, then 100 mg OD or levofloxacin 500 mg po OD or (moxifloxacin 400 mg po OD) 7 days Antimicrobials and guidance

Mod severity. Preferred Alternative 1 amoxy +/- clarith doxycycline 2 amoxy + doxy amoxy + eryth (levo) 3 amoxy + clarith or doxy (iv cxm + clarith; levo) 4 (BTS plus) amoxy + doxy 5 amoxy+ clarith levo 6 amoxy+ clarith levo 7 amoxy+ clarith Antimicrobials and guidance clarith

High severity Preferred treatment: Co-amoxiclav 1. 2 g iv TDS plus clarithromycin 500 mg iv BD Alternatives: benzylpenicillin 1. 2 g TDS plus levofloxacin 500 mg iv BD or ciprofloxacin 400 mg iv BD cefuroxime 1. 5 g iv TDS or cefotaxime 1 g iv TDS or ceftriaxone 2 g iv OD plus clarithromycin 500 mg iv BD 7 -10 days, but may need to be extended Antimicrobials and guidance

High severity Preferred Alternative 1 co-amox + clarith cxm +clarith 2 co-amox + clarith levo 3 co-amox + clarith contact micro co-amox + doxy cxm + doxy 5 amoxy+ clarith levo 6 cxm+ clarith levo + clarith 4 7 (BTS plus) co-amox + clarith Antimicrobials and guidance cefotax + clarith

A B C D E F G H J K L M N P R S T AMO COA TET 28. 1 28. 7 28. 3 20. 6 19. 5 22. 3 22. 4 19. 8 27. 0 22. 9 33. 3 25. 7 25. 6 22. 4 30. 1 24. 4 38. 1 19. 3 3. 8 16. 0 5. 3 8. 9 5. 5 6. 9 1. 1 3. 9 7. 5 10. 1 3. 9 4. 7 5. 2 4. 3 8. 1 21. 4 0. 0 1. 3 1. 6 0. 0 1. 0 0. 0 1. 6 0. 2 1. 3 0. 5 0. 7 2. 6 0. 0 0. 9 2. 4 H. influenzae

A B C D E F G H J K L M N P R S ERY 3. 8 8. 8 15. 1 6. 8 5. 5 8. 2 3. 4 4. 1 9. 2 3. 9 10. 5 2. 0 8. 7 5. 7 7. 8 PEN 3. 8 1. 0 2. 3 1. 5 0. 0 5. 9 0. 0 1. 3 2. 5 3. 2 0. 8 2. 6 0. 0 5. 8 0. 0 4. 1 TET 1. 3 1. 1 13. 3 5. 8 5. 4 3. 3 5. 3 2. 8 7. 9 3. 3 5. 9 0. 0 S. pneumoniae

Things are very similar or very different – depending on your point of view ! Antimicrobials and guidance