Transcript Document 7268562

Steve McCormick
Lead Antimicrobial Pharmacist
NHS Lanarkshire
Antimicrobial use is a National priority
• Scottish Antimicrobial Prescribing Group
• Local Antimicrobial Management Team
• Healthcare Environment Inspectorate
Definition of antimicrobial stewardship
• “Prudent prescribing is not to prescribe as few antibiotics
as possible but to identify that small group of patients
who really need antibiotic treatment and then explain,
reassure and educate the large group of patients who
don’t.
British Journal of General Practice 2009, 50:567
Stewardship: Prudent Prescribing
• Is an antibiotic required?
– Only use when clearly indicated, not self limiting (viral) infections
• Select appropriate agent from local antimicrobial policy
– Minimise collateral damage/risk to patient
• Prescribe optimal dosage for shortest duration
– Maximise effect but minimise selective pressure
• Ask specialist/micro for advice if suspect resistance
– Access unedited antibiogram/C+S results
Antimicrobial Prescribing Policies
• New empirical Antimicrobial policies for hospitals and
primary care in place in all NHS Boards
• Evidence based guidance on empirical treatment of
common infections now with HAI focus
• Promote use of narrow spectrum agents and restrict
agents associated with Clostridium difficile.
Risk of C. difficile infection
High Risk
Medium Risk
Low Risk
Fluoroquinolones
Ampicillin/Amoxicillin
Aminoglycosides
Cephalosporins
Co-trimoxazole
Metronidazole
Co-amoxiclav
Clindamycin
Macrolides
Tetracyclines
Trimethoprim
Rifampicin
Tazocin
Vancomycin
Formulary First line Antibiotics
• Amoxicillin
• Tetracyclines
• Flucloxacillin
•
• Metronidazole
• Phenoxymethylpenicillin
• Nitrofurantoin
• Macrolides
• Trimethoprim
HPS 2013
0
Infection
Number of consultations by infection
Number of consultations
Otitis externa
Pyelonephritis
Impetigo
UTI male
Community
acquired
pneumonia
COPD
Otitis media
Cellulitis
Rhinosinusitis,
acute
Other
UTI female
Pharyngitis/sore
throat/tonsillitis
Acute
cough/bronchitis
Number of consultations
600
500
80%
400
70%
60%
300
50%
200
40%
30%
100
Cumulative total
Audit of management of commonly
encountered infection in primary care
100%
90%
20%
10%
0%
Cumulative %
Path of least resistance VT
• Dr Gail Haddock, GP NHS Highland
• http://youtu.be/m5N3dcPmxW0
SAPG homepage
www.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribing_Gr
Primary Care Antimicrobial Guidelines
All NHS boards follow
management of infection
template from Health Protection
Agency
Guidance for acute sore throat
Avoid antibiotics as 90% resolve
in 7 days without, and pain only
reduced by 16 hours 2A+
If Centor score 3 or 4:
(Lymphadenopathy; No Cough;
Fever; Tonsillar Exudate) 3Aconsider 2 or 3-day delayed or
immediate antibiotics 1,A+ or rapid
antigen test.
RCT in <18yr olds shows 10d had
lower relapse8
Antibiotics to prevent Quinsy NNT
>4000 4BAntibiotics to prevent Otitis media
NNT 2002A+
phenoxymethylpenicillin5B-
500 mg 10
QDS
days
1G BD 8A6A+
(QDS
when
severe
7D)
Penicillin Allergy:
Clarithromycin
2505
500mg days
9A+
BD
Public Awareness Campaigns
Patient Expectations+++
Booklet shared with parents in UK general practice
Francis et al BMJ 2010
Effect of the intervention on patient outcomes
Intervention
%
Control
%
OR (95% CI)
Reconsultation
12.9
16.2
0.75 (0.41 to 1.38)
Antibiotic
prescription
19.5
40.8
0.29 (0.14 to 0.60)
Intention to
consult
55.3
76.4
0.34 (0.20 to 0.57)
multi-level modelling
Francis et al BMJ 2010
Delayed Scripts
• Delay for 48 hours prescription
• “Leave behind reception if no better in 2 days”
• Evidence to say – do work
Role of the AMT – Primary care
• Link in with Primary Care Prescribing Advisers who monitor
prescribing using PRISMS
• Engage individual prescribers by feeding back meaningful
data to promote reflection & discussion in order to influence
future prescribing and promote compliance with policy
• Improve quality and reduce quantity of antimicrobial
prescribing
Role of Individual Prescribers
• Awareness of local antimicrobial prescribing policy
• Minimise use of non-policy antibiotics and inappropriate
dosage or duration
• Patient education re self management of self limiting
infections to avoid unnecessary use of antibiotics
• Especially vigilant on antibiotic use in high risk groups
e.g. Elderly, Nursing Homes