F1 Microbiology Session

1. F1 Microbiology Session Matt Rogers Consultant Microbiologist August 2009

2. Session Plan • Brief Induction • Prescribing an antibiotic • Antibiotic Policy • Infection Control Highlights

3. Microbiology Services 1 • Pathology Dept 4th Floor West Wing • Bacteriology • Virology • Parasitology • Mycology • Environmental • See pathology handbook for service details • Lab opening hours 8am-7pm for examination of routine specimens (9am-11.30am Saturday) • Specimens should be at transport collection points no later than 4.30pm Rugby and 5.30pm Walsgrave to be processed that day, 10am on Saturday

4. Microbiology Services 2 • Urgent specimens should be notified to the lab in normal hours and labelled EMERGENCY SPECIMEN, forward ASAP to Path reception UHCW or Specimen Reception Rugby • EMERCENCY SERVICE out of hours • Technical advice/specimen processing • Please contact switchboard and ask to speak to Microbiology Biomedical Scientist on call • Results • CRRS should be used to review results in the first instance • Bacteriology x25428 • Virology x25468

5. Clinical service • Clinical advice • Normal hours • UHCW 25446/x25487 • GE 5325 • SWH 4227 • Ask to speak to a Medic • Out of Hours • Contact duty Medical Microbiologist via switch (24hrs 365 days/year) • Ward rounds • UHCW/SWH/GEH • Conduct daily ward rounds Mon-Fri on GCC/ITU • UHCW includes Cardiothoracic Critical Care, also follow up review requests on other wards

6. Gentamicin • Levels done round the clock by Biochemistry • Dose of Gent in this Trust is 5mg/kg od iv (Lean Body Mass) • 24hrly if CC >61ml/min • 36hrly if CC 41-60 ml/min • 48hrly if CC 21-40 ml/min • Check a random level at 48hr if CC <21 ml/min • Check level before 2nd or 3rd dose should be less than 1mg/l

7. Vancomycin • Levels done round the clock by Biochemistry • Standard adult dose 1g bd iv • If CC normal 1g bd • If CC 50ml/min give 1g 24hrly • If CC 25ml/min give 1g 48hrly • Check pre dose level before 4th or 5th dose • Pre dose levels should be 12-15mg/l

8. Diseases notifiable (to Local Authority Proper Officers) under thePublic Health (Infectious Diseases) Regulations 1988 • Health Protection Agency Unit Contact number 01926 493491 x307 • Outside normal hours please contact switch and ask them to put you through to the Public Health Doctor on call • Do not hesitate to contact either the Public Health Doctor on call, or On call Medical Microbiologist if further advice is required Acute encephalitis Acute poliomyelitis Anthrax Cholera Diphtheria Dysentery Food poisoning Leptospirosis Malaria Measles Meningitis (meningococcal pneumococcal haemophilus Influenzae viral other specifiedunspecified) Meningococcal septicaemia (without meningitis) Mumps Ophthalmia neonatorum Paratyphoid fever Plague Rabies Relapsing fever Rubella Scarlet fever Smallpox Tetanus Tuberculosis Typhoid fever Typhus fever Viral haemorrhagic fever Viral hepatitis Hepatitis A Hepatitis B Hepatitis C other Whooping cough Yellow fever Leprosy is also notifiable, but directly to the HPA, CfI, IM&T Dept

9. TB • Increased burden of TB • Several Cases of TB in Trust have been undiagnosed for a period of time leading to large look back exercises • Suspicion of/or confirmed TB MUST be notified to Health Protection Agency Unit • Please contact Infection Control immediately and isolate the patient • Complete form found on Intranet under Clinical Support>TB data collection

10. Antibiotic Policy

11. Is the antibiotic policy relevant 1 • Yes! • Core policy in The Health Act 2006: Code of practice for the prevention and control of healthcare associated infections • Minimise the use of broad spectrum antibiotics • Longer the hospital stay, greater chance of acquisition of HAI • Ensure only those needing antibiotics receive them and that they get the appropriate duration • Minimise the use of iv antibiotics • Iv/oral switch a central strategy • Certain antibiotics are associated with particular HAIs

12. Is the antibiotic policy relevant 2 • C.difficile • Cefuroxime clearly associated with C.difficile • Trusts that have abolished its use have seen dramatic reduction in rates (Stoke Mandeville) • Other antibiotics such as ciprofloxacin have been associated with Outbreaks • MRSA/ESBLs • Ciprofloxacin usage is related to selection of resistant organisms

13. Evidence of antibiotic prescribing problems within the trust • Antibiotic audit evidence • C.difficile rates need to be reduced • Pharmacy monitoring continues to show use of antibiotics outside of the Hospitals Antibiotic Policy

14. Oral Sev Mild/mod I.V. MAU AuditZoe Campbell F2 SHO • Only those with Severe pneumonia according to CURB criteria should receive IV antibiotics • 18 out of 25 patients received IV antibiotics • 18 patients were classified mild/mod (? Oral antibiotics) • 7 patients were classified severe (? IV antibiotics)

15. Date specified No date specified MAU Audit: IV/Oral Switch • Only 2 out of 25 (8%) patients had an IV to oral switch or a review/stop date specified on initial clerking

16. Current HAI impact • MRSA • Impact on patients quality of life of an acquired infection can be huge • Associated with significant morbidity/mortality • Trust performance managed on MRSA bacteraemia figures • Clostridium difficile • Impact on patients quality of life of an acquired infection can be huge • Associated with significant morbidity/mortality • 40 cases/month at £4500 each can cost Trust up to £180,000/month • Trust now performance managed on C.difficile figures • PCTexpect a 20% reduction in rate in C.difficile

17. New policy • This evidence made it clear that we needed a new fit for purpose policy • Key Principles • Evidence based policy • Improve guidance on diagnosis of infection, specimen collection etc. • Improve guidance on when to use of oral or iv antibiotics • Improve guidance on iv to oral switch • Provide guidance on duration of treatment

18. Key antibiotic changes • Stop use of cefuroxime throughout the Trust • Use lower risk augmentin (but monitor C.difficile rates) • Reduce use of ciprofloxacin (consider penicillin allergy) • Antibiotic policy available under Clinical Guidelines on the intranet • Antibiotic guideline credit cards distributed

23. Antibiotic prescribingWhat’s important? • When • Is there an infection? • How • To diagnose. What specimens? • Why • What is the indication/Likely pathogens? • What • What antibiotic/route/duration

24. When? • Diagnosing infection is a CLINICAL skill • “Hello it’s the SHO here I’ve got this pt, could you tell me if they have an infection” • Basic signs and symptoms of infection • Please remember apart from sterile sites (urine/csf/blood etc) most areas you culture WILL grow bacteria

25. When not to ‘classics’ • CSU-urine cloudy • Chest-we think they’ve got CCF but thought we’d give some cover • Wound with serous exudate • Sloughy Ulcers • Isolated spikes of temp • To treat a high WCC

26. How? • How to diagnose Infection??? • What specimens do you need to take? • What investigations do you need to ask for?

27. Why? • Know your basic Microbiology • The indication (UTI/LRTI etc) • The setting (Pt+environment) • Hospital v Community (feasibility) • Why are we giving Antibiotics • Empirical/Prophylactic/Targeted • The likely pathogens (CRRS)

30. What? • Where, When and Why have been addressed • Now What is the Most appropriate choice of therapy • Pharmacokinetics/Interactions/Allergy/Side effects • What route • What duration • 5-7 days for MOST infections • What outcome expected

31. Also How much? • Unfortunate but Healthcare economics are always a consideration • Particularly with some newer drugs • Antifungals • Antibacterials • Antivirals

32. What must an antibiotic prescription include? • Must be documented with review dates in the patients notes • Length of course or a Review date • (all i/v antibiotics must be reviewed at 48 hours and changed to oral where clinically appropriate) • Indication • All antibiotics must be reviewed daily

34. A few cases

35. Case 1 • Case One • A 65 year old lady admitted 10 days ago with a Community Acquired Pneumonia has had 10 days of IV Amoxicillin 1g tds. • Now presents with cellulitis around venflon site.

38. Case 2 • Case Two • A 72 year old lady presenting to MAU with confusion • Says she has previous history of UTIs

40. Case 3 • Case Three • A 17 year old male University student presenting to GP then the Emergency Department with Meningitis (non-blanching rash / headache /photophobia)

42. Case 4 • Case Four • A 32 year old female IVDU presenting with Groin abscess and new heart murmur

43. Case 5 • Case Five • A year old man treated on W12 for a mild pneumonia with Co-amoxiclav and erythromycin • Develops diarrhoea ?C.difficile

46. Handwashing audit • Conducted by F1/F2s last year • Covert observation of handwashing practices on ward rounds • Noting Hand decontamination procedures between each patient visit

47. The results • Contact and correct HDC

48. Results: Speciality

49. Results: Grade