Outline Antimicrobial Resistance Antimicrobial Stewardship What is - - PDF document

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Antimicrobial Stewardship and Current Issues in Infection

Non-Medical Prescribers Forum 26th September 2016 Dr Annie Joseph FRCPath Microbiology Registrar Antimicrobial Stewardship Fellow

 Antimicrobial Resistance  Antimicrobial Stewardship

 What is it and why is it relevant?

 Key issues in community prescribing  Case-based discussions in professional small groups  Feedback and discussion  Resources

Outline Antimicrobial Resistance

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Antimicrobial Resistance

“a healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness”

Antimicrobial Stewardship Antimicrobial Stewardship

Patient needing antibiotics now to treat bacterial infection SEPSIS KILLS Future patients unable to be treated due to antimicrobial resistance RESISTANCE KILLS Prescriber Decision Patient expectation “Just to be on the safe side” Education Precognitive Bias Time Pressure Diagnostic Tests Evidence-based Guidelines Support of colleagues Specialist advice

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Antimicrobial Stewardship

Key Issues in Community Antibiotic Prescribing

 ~60% of antibiotics in Primary Care  NICE Guideline Respiratory Tract Infections

 Assess for severity and co-morbidities  No prescribing?  Delayed prescribing?  Immediate prescribing?

 Benefits?  Risks?

Respiratory Tract Infections

http://www.bmj.com/content/340/bmj.c2096.long

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Respiratory Tract Infections

 Decision-making tools

 Clinical e.g. Centor, fever-PAIN  Rapid Diagnostics (POCT)

Predicts likelihood of Group A Strep:

Centor Score for sore throats:

No Abx approach Delayed or immediate ABx Throat swab may be helpful for intermediate scores

Respiratory Tract Infections

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Main Issues:  Rising resistance to trimethoprim and beta-lactams

 Nottingham: Trimethoprim resistance in GP samples = 33%  Highest in elderly (>40%)

 Over-reliance on urine dipstick  Over-treatment of asymptomatic bacteriuria (incl catheters)  Over-use of antibiotic prophylaxis

Urinary Tract Infections Urinary Tract Infections

5 10 15 20 25 30 35 40 45 50

E.coli in GP urine samples Jan-Dec 2015 IDSA recommended cut-off for use as empirical antibiotic

Asymptomatic Bacteriuria

Asymptomatic Bacteriuria: “presence of bacteria in the urine, in the absence of symptoms”  Should not be treated (unless pregnant or prior to urological

surgery):

 Does not prevent UTI or pyelonephritis  Does cause resistance and side-effects  Number needed to harm is only 3

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Asymptomatic Bacteriuria Urinary Tract Infections

Over-use of antibiotic prophylaxis:  Strong evidence in women <65yrs (Cochrane Review)  Lack of evidence in elderly  12% nursing residents on antibiotics for UTI prophylaxis  Risks?  Benefits?  Once started, often not reviewed  Local guideline in development Over-reliance on urine dipstick:

 Cheap  Quick  Easy

Urinary Tract Infections

Over-testing Mis-interpretation Over-treatment

It is very difficult to ignore a positive result, whether it means something or not!

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To dip or not to dip? To dip or not to dip?

SIGN guideline 88:  Very little evidence in the elderly  False positives due to:

 Contamination  ASB

 Advise not to use dipsticks in the elderly for diagnosis of UTI NICE UTI guideline:  Use with caution in the elderly

To dip or not to dip?

SIGN: Suspected UTI in Older People In elderly, send sample for MC&S

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NICE UTI guideline

In the elderly: A negative urine dipstick may be helpful in ruling out a UTI A positive urine dipstick is not helpful in ruling in a UTI Urine dipsticks should never be done on catheter samples for ?UTI If starting antibiotics for UTI, send a urine sample for culture

Dipstick Golden Rules:

 After the break, please sit in professional groups to enable case discussions

Break

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 Health Visitors

 Eye infections  Candida infections

 Community Matrons

 UTI in elderly  Antibiotic prophylaxis

Case Discussions: Overview of cases

 Urgent Care Prescribers

 UTI in <65yrs  URTI

 District Nurses

 Skin and soft tissue infection  Post-op infection

Case Discussions: Health Visitors Case Discussions: Health Visitors

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 Controversial area  Lack of evidence  Laboratory testing often unhelpful  Normal flora  Contamination  Topical treatments are low risk  “The Candida Conspiracy”

 www.thecandidadiet.com

Candida and breastfeeding

Case Discussions: Community Matrons Case Discussions: Community Matrons

 Admitted for ?urosepsis, started Iv piptazobactam.  24h:  Signs of organ failure  Escalated to ITU and meropenem  Reviewed by Microbiology  Confusion  Multiple organ dysfunction  Recent course of steroids for COPD  Started on high-dose IV aciclovir  CSF – Herpes Simplex Virus positive by PCR  Neurologically deteriorated, care withdrawn d4.

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An 87 year old woman in a nursing home has been on prophylactic trimethoprim for 6 years. She has had 3 recent symptomatic UTIs, this is the report from the latest culture sent. What actions would you take?

Case Discussions: District Nurses / Practice Nurses

 Chronic venous skin changes  Likely to be colonised with organisms  S.aureus, beta-haemolytic Streptococci, anaerobes  Signs of active infection:

 Spreading redness, warmth, demarcated edges  New pus or pain +++, systemically unwell

 “Penicillin allergic” patient

Case Discussions: District Nurses / Practice Nurses

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 At risk of sepsis  Sepsis criteria, as per NICE Sepsis Guideline:

 Moderate – High Risk

 Beware in the elderly:

 Hypo or normothermia  Tachycardia masked by drugs  Pre-existing cognitive impairment

Case Discussions: Urgent Care Prescribers

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 Stewardship:  https://youtu.be/PkYQJettZVo  DoH UK 5yr Antimicrobial Resistance Strategy  PHE Antimicrobial Stewardship Competencies for prescribers  NICE Antimicrobial Stewardship  Management:  NICE UTI  NICE Sepsis  NICE Respiratory tract infections antibiotic prescribing  SIGN UTI guideline and algorithm for elderly  Notts APC Antibiotic Guidelines www.nottsapc.nhs.uk  Microbiology – Community Infection Control Doctor:  Dr Vivienne Weston - vivienne.weston@nuh.nhs.uk  Dr Annie Joseph - amelia.joseph@nuh.nhs.uk

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