Outline Antimicrobial Resistance Antimicrobial Stewardship What is - PDF document

26/10/2016 Antimicrobial Stewardship and Current Issues in Infection Non-Medical Prescribers Forum 26 th September 2016 Dr Annie Joseph FRCPath Microbiology Registrar Antimicrobial Stewardship Fellow Outline  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 Antimicrobial Resistance 1

26/10/2016 Antimicrobial Resistance Antimicrobial Stewardship “a healthcare system-wide approach to promoting and monitoring judicious use of antimicrobials to preserve their future effectiveness” Antimicrobial Stewardship Patient needing Future patients antibiotics now to unable to be treated treat bacterial due to antimicrobial infection resistance SEPSIS KILLS RESISTANCE KILLS Prescriber Decision “Just to be on the safe side” Diagnostic Support of Patient expectation Education Tests colleagues Precognitive Evidence-based Time Pressure Specialist advice Bias Guidelines 2

26/10/2016 Antimicrobial Stewardship Key Issues in Community Antibiotic Prescribing Respiratory Tract Infections  ~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? http://www.bmj.com/content/340/bmj.c2096.long 3

26/10/2016 Respiratory Tract Infections  Decision-making tools  Clinical e.g. Centor, fever-PAIN  Rapid Diagnostics (POCT) Centor Score for sore throats: Predicts likelihood of Group A Strep: Throat swab may be helpful for intermediate scores No Abx approach Delayed or immediate ABx Respiratory Tract Infections 4

26/10/2016 Urinary Tract Infections 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 E.coli in GP urine samples Jan-Dec 2015 50 45 40 35 IDSA 30 recommended 25 cut-off for use 20 as empirical 15 antibiotic 10 5 0 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 5

26/10/2016 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 Urinary Tract Infections Over-reliance on urine dipstick:  Cheap Over-testing  Quick Mis-interpretation  Easy Over-treatment It is very difficult to ignore a positive result, whether it means something or not! 6

26/10/2016 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 7

26/10/2016 NICE UTI guideline Dipstick Golden Rules: 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 Break  After the break, please sit in professional groups to enable case discussions 8

26/10/2016 Case Discussions: Overview of cases  Health Visitors  Urgent Care Prescribers  Eye infections  UTI in <65yrs  Candida infections  URTI  Community Matrons  District Nurses  UTI in elderly  Skin and soft tissue infection  Antibiotic prophylaxis  Post-op infection Case Discussions: Health Visitors Case Discussions: Health Visitors 9

26/10/2016 Candida and breastfeeding  Controversial area  Lack of evidence  Laboratory testing often unhelpful  Normal flora  Contamination  Topical treatments are low risk  “The Candida Conspiracy”  www.thecandidadiet.com 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. 10

26/10/2016 Case Discussions: Community Matrons 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 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 11

26/10/2016 Case Discussions: District Nurses / Practice Nurses Case Discussions: District Nurses  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 12

26/10/2016 Case Discussions: Urgent Care Prescribers Useful Resources  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 13