Transcript www.rcgp.org.uk

TARGET Antibiotics
“There are few public health issues of potentially
greater importance for society than antibiotic
resistance”
2013 CMO Prof Dame Sally Davies
AIMS
● Why we need responsible prescribing
– provide evidence showing the link between
prescribing and resistance in GP patients
● How we can improve responsible prescribing
– Suggest strategies and sharing materials
Presentation Outline
● The evidence
– Linking prescribing to resistance
● UK Prescribing
● The Patient Perspective
● Possible answers
Evidence
Antibiotic resistance is clinically relevant
Does antibiotic resistance make a change to clinical outcome?
Prospective study of 497 women (18–70 years) with ≥ 2 UTI
symptoms in English general practice
Patients with
Resistant
UTI
Susceptible
UTI
p-value
7 days
3 days
0.0002
28%
68%
0.0002
Re-consultation in first week or less
17 / 39%
17 / 6%
<0.0001
Re-consultation in first month
20 / 45%
41 / 15%
<0.0001
Significant bacteriuria at one month
8 / 42%
23 / 20%
0.04
Median time to symptom resolution
Symptom resolution at 5 days
McNulty et al. J. Antimicrob. Chemother. (2006) 58 (5): 1000-1008
Evidence
Resistance is increasing
Trimethoprin resistance by age group (Welsh data)
42
40
38
Resistance (%)
36
34
32
30
28
26
24
22
20
2005
2006
2007
2008
2009
2010
2011
Year
<2
2-15
16-29
30-49
50-64
60-79
Routine laboratory data generated by the Welsh Antimicrobial
Resistance Programme, Public Health Wales
80+
Evidence
Your prescribing influences resistance
Effect of antibiotic prescribing on resistance
A meta analysis of English Primary Care
Odds ratio risk for resistance
Antibiotic <2m
Antibiotic <12m
UTI
5 studies: n = 14,348
2.5
1.33
RTI
7 studies: n = 2,605
2.4
2.4
Longer duration and multiple courses associated with greater resistance
Costello et al. BMJ. (2010) 340:c2096.
Evidence
Antibiotics increase the risk of C. difficile
2000 diarrhoeal faecal samples submitted from Primary Care
2.1% of samples cytotoxin positive
Urban setting Rural setting
29/100,000
20/100,000
Multiple antibiotic agents
p<0.001
Aminopenicillins (ampicillin, amoxicillin and
bacampicillin)
p<0.05
Oral cephalosprins
p<0.05
Hospitalisation <6mths
p=0.02
Significant association between exposure to antibiotics in the past 4
weeks and the incidence of Clostridium difficle
Wilcox and Freeman. N Engl J Med (2006) 354 :1199-1203
QUESTION: Will reducing antibiotic prescribing
reduce antibiotic resistance?
Effect of prescribing reductions on community antibiotic resistance
20
8 years
3 years
2 years
8 years
7 months
Iceland
Sweden
UK
Israel
0
Finland
% Change
-20
Pneumo
Penicillin
E.coli
Quinolone
-40
-60
GpA BHS
Macrolides
Prescribing Reduction
-80
-100
Change in Resistance
E.coli
Trimethoprim
E.coli
Sulphonamide
Enne VI. JAC ,2010; 65: 179 – 182.
QUESTION: Why does reducing prescribing work
for some organisms and not others?
Antibiotic
Pressure
Mechanism
of Resistance
Fitness cost
of Resistance
Clonal e.g. S.pyogenes
Less-fit resistant bacteria
Association with other resistance
displaced by
Plasmid borne, often co-resistant
More-fit susceptible bacteria
Chromosomal
Enne VI. JAC ,2010; 65: 179 – 182.
EVIDENCE
Reflection
In general practice
● Antibiotic resistance is clinically relevant
● Antibiotic resistance is increasing
● Antibiotic use increases antibiotic resistance
● Your prescribing influences resistance
● Antibiotic use also increases Clostridium difficile
Presentation Outline
● The evidence
● UK Prescribing
– How are we doing?
● The Patient Perspective
● Possible answers
Antibiotic prescribing is related to
consultation rates
– Consultation rate for RTI varies:125–1100 per 1000 patients
– Antibiotics prescribed in 45% to 98% of patients with RTI
– Consultation rates related to prescribing
– Practices who reduced prescribing experienced a reduced
consultation rate
Thus patients can be retrained not to expect antibiotics
Ashworth. BJGP . 2005. 55(517): 603–608
EU Community Antibiotic Consumption
DDD per 1000 inhabitants per day (2010)
40
Other JO1 classes
Sulphonamides and trimethoprim (JO1E)
Quinolones (JO1M)
Macrolides, lincosamides and streptogramins (JO1F)
Tetracyclines (JO1A)
Cephalosporins and other beta-lactams (JO1D)
Penicillins (JO1C)
35
30
25
20
15
10
5
© ECDC
Latvia
Estonia
Netherlands
Lithuania
Sweden
Germany
Slovenia
Austria
Hungary
Norway
Denmark
Czech
Republic
Bulgaria
Finland
United Kingdom
Spain
Ireland
Poland
Malta
Portugal
Iceland
Italy
France
Beelgium
Luxembourg
Greece
0
What is happening to Primary Care
prescribing in England?
Trends in prescribing antibacterials in General Practice in England
800
12% INCREASE
700
Items per 1000 patients
600
500
400
300
10% increase in
Penicillins
200
100
0
Apr 98 – Apr 99 – Apr 00 – Apr 01 – Apr 02– Apr 03 – Apr 04 – Apr 05 – Apr 06 – Apr 07– Apr 08 – Apr 09– Apr 10 – Apr 11 – Apr 12 –
Mar 99 Mar 00 Mar 01 Mar 02 Mar 03 Mar 04 Mar 05 Mar 06 Mar 07 Mar 08 Mar 09 Mar 10 Mar 11 Mar 12 Mar 13
Penicillins
Cephalasporins
Metronidazeole & Tinidazole
Tetracyclines
Sulphonamides & Trimethoprim
All other bacterial drugs
© NHSBSA 2012
Macrolides
Quinolines
UK PRESCRIBING
What is happening to GP prescribing?
Trends in prescribing of antibacterial items (excluding penicillins) in
English General Practices
100
Changes since 2007/08
Macrolides 23%
90
80
Items per 1000 Patients
Tetracyclines
70
52%
Sulphonamides &Trimethoprim
60
50
Co-Amoxiclav
40
21%
Nitrofurantoin
178%
Cephalosporins
128%
30
20
Quinolones
10
53%
Metronidazole & Tinidazole
0
Years (Apr – Mar)
© NHSBSA 2012
23%
0
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UK PRESCRIBING
Local Data
All Antimicrobials per 1000 patients (Apr 12 – Mar13)
900
800
700
Amoxicillin
Cephalosporins
Macrolides
Penicillin resistant
Quinolones
Tetracyclines
Ampiciliin
Co-amoxiclav
Metronidazole
Penicillin V
Sulphonamides & Trimethoprim
600
Your Surgery
500
400
300
200
100
1400
0
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UK PRESCRIBING
Local Data
Abx by STAR PU Qtr4 2010-Qtr3 2011
1800
1600
Your Practice
1200
1000
800
600
400
200
Time
3rd Quarter '10 - '11
2nd Quarter '10 - '11
1st Quarter '10 - '11
4th Quarter '09 - '10
3rd Quarter '09 - '10
2nd Quarter '09 - '10
1st Quarter '09 - '10
4th Quarter '08 - '09
3rd Quarter '08 - '09
2nd Quarter '08 - '09
1st Quarter '08 - '09
4th Quarter '07 - '08
3rd Quarter '07 - '08
2nd Quarter '07 - '08
1st Quarter '07 - '08
4th Quarter '06 - '07
3rd Quarter '06 - '07
2nd Quarter '06 - '07
1st Quarter '06 - '07
Antibiotic items in General Practice
UK Prescribing
Local Data
Total Items, Accumulated BNFs
120,000
100,000
80,000
60,000
40,000
20,000
0
UK PRESCRIBING
Reflection
● Overall GP antibiotic prescribing has increased
nationally
● There has been a decrease in cepahalosporin
and quinolone prescribing
● Your local data shows…
Aims of this Presentation
● The evidence
● UK Prescribing
● The patient perspective
– Why do they visit
– Expectation for antibiotics
– Is delayed prescribing a worthwhile option?
● Possible Answers
The Patient Perspective
What did they do?
1,767 ≥15y in England
58% had RTI in last 6 months
What did they do?
60%
37%
took OTC(50%) or alternative medicine(21%) for symptoms
took extra rest
20%
Contacted or visited GP surgery
6%
1.4%
0.4%
0%
asked pharmacy for advice
used NHS direct
took left-over antibiotics
visited NHS walk in centre
McNulty, Nichols, French et al. BJGP . (2012)
The Patient Perspective
Why they visited their GP with an RTI?
51%
Symptoms severe
47%
Symptoms not improved after several days
14%
family or friends suggestion
11%
Other health problem
9%
I usually visit GP with these symptoms
5%
Worried will infect others who may get very ill
What did they expect?
53·1% Expected antibiotics
24% Advice about self-care
22% Other treatment for symptoms
12% Rule out more serious illness
7% Information about illness duration
6% A sick/fit note for work
3% For referral to hospital/specialist
3% For Tamiflu
POSSIBLE ANSWERS
Improving patients confidence to self-care
Eurobarometer findings:
– 53% with good knowledge vs 21% with poor knowledge
remember receiving information about NOT taking
antibiotics
– 28% UK respondents remembered information from
their doctor or TV, 20% from a poster
– 90% UK respondents said they would use GP as a
trustworthy source of antibiotic information
It’s worth talking about antibiotics in consultations
Eurobarometer: Nov Dec 2009
The Patient Perspective
What did they do?
IPSOS Mori Survey
1,767 random sample >16 yrs, England
26% asked GP for antibiotics for any
condition in last year
96.5% Given antibiotic
3.5% Refused
antibiotic by GP
• 74% after discussion
• 23% immediately
McNulty et al. BMJ . (2012)
The Patient Perspective
Delayed prescribing
Can it reduce antibiotic use and patient expectations?
English RCT comparing three treatment strategies for sore throat (n=582)
100
90
80
70
%
60
50
40
30
20
10
0
Better by day 3
Satisfied patients
Given 10 days antibiotic treatment
Think antibiotics are
effective
Given NO antibiotics
Little et al. BMJ . (1997) 314:722
Would visit GP again for
similar symptoms
Given DELAYED antibiotics
The Patient Perspective
Delayed Prescribing: What patients do
IPSOS Mori Survey
1,767 random sample >16 yrs, England
14% Offered delayed prescribing
in past year
58% actually collect
from surgery
68% actually collect
from pharmacy
97% actually take
the medication
McNulty et al. BMJ . (2012)
Aims of this Presentation
● The evidence
● UK Prescribing
● The patient perspective
● Possible Answers
– Available resources for Primary Care
POSSIBLE ANSWERS
How can we fit together this evidence and
change behaviour during consultation with our
patients to improve antibiotic prescribing?
Practice
GP
Evidence
Patient
The TARGET antibiotic toolkit
This toolkit is here to help clinicians and commissioners to use
antibiotics responsibility and meet CQC requirements
www.rcgp.org.uk/TARGETantibiotics
TARGET:
Self Assessment Checklist
www.rcgp.org.uk/TARGETantibiotics
TARGET:
Self Assessment Checklist
www.rcgp.org.uk/TARGETantibiotics
TARGET:
Antibiotic Management Guidance
Management of Infection Guidance for Primary Care for consultation and
local adaption
UTI in
pregnancy
HPA QRG
CKS
Send MSU for culture and
start antibiotics 1A
Short-term use of
nitrofurantoin in pregnancy is
unlikely to cause problems to
the foetus 2C
Avoid trimethoprim if low
folate status 3 or on folate
antagonist (eg antiepileptic or
proguanil)2
First line:
nitrofurantoin
if susceptible,
amoxicillin
Second line:
trimethoprim
Give folate if 1st
trimester
Third line:
cefalexin 4C, 5B-
www.rcgp.org.uk/TARGETantibiotics
100 mg m/r BD
500 mg TDS
200 mg BD (offlabel)
500 mg BD
All for 7
days 6C
TARGET:
Antibiotic and diagnostic Guides
Acute
Sore
Throat
Venous
Leg
Ulcers
Vaginal
discharge
Fungal
skin and
nail
infections
Antibiotic
Management
Guidance
UTI
Infectious
diarrhoea
H. pylori
MRSA
PVL S. aureus
TARGET:
Patient Information Leaflets
Antibiotic Information Leaflet
www.rcgp.org.uk/TARGETantibiotics
TARGET:
Audits
Antibiotic Information Leaflet
Audit Materials
● Sore Throat Audit
● UTI Audit
TARGET:
Information for patients
Available resources
DH and RTI
Leaflets
Antibiotic Information Leaflet
www.rcgp.org.uk/TARGETantibiotics
Links to relevant websites
TARGET:
Resources for clinicians to use in practice
Antibiotic Information Leaflet
Posters for Display
Videos for patient waiting areas
Life Channel videos
ECDC European Antibiotic Day videos
www.rcgp.org.uk/TARGETantibiotics
TARGET:
Training Resources
STAR
Managing
Acute
Respiratory
Tract
Infections
MARTI
Managing
Urinary
Tract
InfectionS
www.rcgp.org.uk/TARGETantibiotics
MUTS
Stemming the
Tide of
Antimicrobial
Resistance
In summary
Makes a
difference to
resistance in
your patients
Helps to
reduce future
consultations
Reducing
prescribing
in your
practice
Helps to slow
future
antimicrobial
resistance
ACTIONS
What can and will you do?
REFERENCES
1. Simpson et al. J. Antimicrob. Chemother. (2007) 59 (2): 292-296
2. McNulty et al. J. Antimicrob. Chemother. (2006) 58 (5): 1000-1008
3. Goossens et al. Lancet. (2005) 51: 365 (9459): 579-587.
4. Costello et al. BMJ. (2010) 340:c2096.
5. Wilcox and Freeman. N Engl J Med (2006) 354 :1199-1203
6. Enne VI. JAC ,2010; 65: 179 – 182.
7. Ashworth. BJGP . 2005. 55(517): 603–608
8. McNulty et al. BMJ . (2012)
9. Eurobarometer Survey.
http://ec.europa.eu/health/antimicrobial_resistance/docs/ebs_338_
en.pdf
10. McNulty, Nichols, French et al. BJGP . (2012)
Sore throat
17 year old girl.
4/7 days sore throat, fever, tiredness, cough.
Difficulty swallowing.
Temp 37.5°C.
Slough on swollen tonsils, palatal petechiae.
Cervical and axillary lymphadenopathy.
‘Antibiotics helped’ for tonsils last year.
Otitis media
5 year old boy screaming with pain in left ear.
No history of fever, temp 37.4°C.
Not vomiting.
Paracetamol helps but pain returns before next
dose due.
Had AOM this time last year.
Left ear drum bulging and red.
Had antibiotics last time and mother very keen to
have antibiotics again.
Acute cough
45 year old smoker with cough 1/52, green sputum.
Temp 37.8°C.
Gets bronchitis every year, and antibiotics ‘always
help’.
PEFR normal.
Course creps and wheeze, vesicular breath sounds,
no fine crepitations.
What do GPs think?
UK research suggests
– GPs recognise the wider importance of resistance
– Not a problem in their practice
– Blame hospitals/other prescribers e.g. vets
BUT
80% of antibiotics are prescribed in primary care
Simpson et al. J. Antimicrob. Chemother. (2007) 59 (2): 292-296
Evidence
Antibiotic Use and Resistance are linked
High use = High Resistance
Penicillin-resistant S. pneumoniae (%)
50
FR
40
ES
UK
30
PT
HU
20
SI
HR
PL BE
IE
LU
CZ
IT
FL
10
NL
0
0
2
4
DE
SW
AT
6
DK
8
10
12
14
16
18
Consumption of Penicillin (J01C) in DID, AC 2000
Correlation between penicillin use and prevalence of penicillin resistant S. pneumoniae
Goossens et al. Lancet. (2005) 51: 365 (9459): 579-587.
Examples of Campaigns
Poster campaigns used alone have not changed the publics
attitudes to antibiotics or expectations
Cliodna McNulty, T Nichols, M P Boyle, Woodhead, P Davey