Antibiotic Prescribing in Primary care Alastair Monk Medicines

Antibiotic Prescribing in Primary care Alastair Monk Medicines Optimisation Team NHS North of England Commissioning Support Patient Safety Conference Wednesday 1 st April 2016 Partners in improving local health

What are the issues (patient safety) ? § Antimicrobial Resistance § Clostridium difficile infection (and other “Super bugs”) § Drug side effects Partners in improving local health

Antibiotic prescribing in the North East and Cumbria The Guardian 11 Jun 2013 UK map shows areas where GPs are most, or least, likely to prescribe antibiotics to patients. ESPAUR report Highlighting the North East as high prescribers of antibiotics. Partners in improving local health

The Area Teams compared Partners in improving local health

Antimicrobial Resistance § The emergence, selection and spread of resistant bacteria is a major patient safety and public health issue. § Infections with antibiotic-resistant bacteria can result in: • • increased patient morbidity Increased mortality increased hospital length of stay Increased cost of care. Partners in improving local health

UK 5 year AMR strategy Key elements for primary care § Antibiotic guideline, and audit § Public/professional awareness campaign § Educational resources Partners in improving local health

The interventions? – a collection of multifaceted interventions for individual prescribers, practices and CCGs Regional prescribing guidelines Education and training Awareness campaign Guideline document e. Learning Posters and postcards Smartphone app Face to face workshops ‘Non-prescriptions’ Partners in improving local health

Clostridium difficile infection § It’s not just C diff § § § Enterococcus faecium Staph. aureus (MRSA/VRSA) C. difficile Acinetobacter baumanii Pseudomonas aeruginosa Enterobacteriaceae Partners in improving local health

C diff (contd) § People at risk: § Those who have been treated with broad spectrum antibiotics § People with serious underlying illnesses § The elderly are at greatest risk – over 80% of Clostridium difficile infections reported are in people aged over 65 years (they are 10 x more at risk) § Prev. C. diff infection Partners in improving local health

C diff (contd) § Infection can lead to: § Mild to severe diarrhoea – watery and odorous § Pseudomembranous colitis § Toxic megacolon Partners in improving local health

How the Area Teams Compare Partners in improving local health

ESBL’s § Extended spectrum β-lactamase producers § Mainly in E. coli and Klebsiella sp § Resistant to ALL penicillins, cephalosporins and many other antibiotics § The only oral options available may be: § Nitrofurantoin § Pivmecillinam § Fosfomycin § Seen increasingly mainly in urine specimens of the elderly population Partners in improving local health

Possible Adverse Effects of Antibiotics § § Allergy Side effect of antibiotic Interaction with other medication Effect on normal bacterial flora resulting in: § antibiotic associated diarrhoea § oral and vaginal candidiasis § colonisation or infection by resistant bacteria (MRSA, ESBL producing Gram negatives, etc) § Partners in improving local health

Penicillin allergy § In suspected penicillin allergy, a careful history of the nature of the reaction should be taken: § Vague/minor (e. g. gastrointestinal disturbance) → if appropriate, treatment with a penicillin is justified § non-urticarial rash with penicillin (without angio-oedema or anaphylaxis) → cephalosporins, could still be used with caution if appropriate § urticarial rash/angio-oedema/anaphylaxis → all beta-lactams are contraindicated Could lead to the use of “other” less appropriate antibiotics Partners in improving local health

Resources § TARGET antibiotics toolkit: http: //www. rcgp. org. uk/targetantibiotics/ OR http: //www. rcgp. org. uk/clinical-and-research/target-antibioticstoolkit. aspx § ‘Stemming the Tide of Antibiotic Resistance’ educational programme (STAR): http: //www. stemmingthetide. org/ § http: //bsac. org. uk/ § http: //antibiotic-action. com/ § NICE Guidance: § CG 69 Antibiotic Prescribing for Respiratory Infections § NECS MO Website http: //medicines. necsu. nhs. uk/ § www. antibiotic-action. com § Department of Health website § European Antibiotic Awareness Day Partners in improving local health

§ Thank you § Any questions? Partners in improving local health