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Medicines Management Workstreams

Medicines Management Workstreams. Absar Bajwa Leigh Lord July 2013. Overview. Dermatology guideline update Antibiotic guidelines PPI prescribing – Implementing change Hypertension guidelines Non medical prescribing. Dermatology Update. All practices given a hard copy

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Medicines Management Workstreams

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  1. Medicines Management Workstreams Absar Bajwa Leigh Lord July 2013

  2. Overview • Dermatology guideline update • Antibiotic guidelines • PPI prescribing – Implementing change • Hypertension guidelines • Non medical prescribing

  3. Dermatology Update • All practices given a hard copy • CCG website in progress • Dermatology pathways are being gradually localised on the Map of Medicine. • Electronic copies by request: absar.bajwa@nhs.net Tel: 0161 873 9506

  4. Dermatology Update Acne • Retin A has been discontinued. • Lymecycline dose may be increased to 408mg twice a day (unlicensed dose) for 6/52 after 3 month trial. • Trimethoprim dose increased to 300 mg twice a day (unlicensed dose). This is preferable to Minocycline.

  5. Dermatology Update Atopic eczema • Aqueous cream: Avoid in all eczema px • Adults: Consider tapering prednisolone: in moderate to severe eczema where topical treatments have failed. • Topical trial of 6/52 • Prednisolone 30mg OD reducing by 5mg per week

  6. Equivalent Emollients and Cost

  7. Principles of antibiotic prescribing • Only prescribe where clinical need and evidence of benefit • Empirical treatment is governed by local information about resistance • Alter treatment in response to specific sensitivities • Use narrow spectrum antimicrobials to minimise the selection of organisms such as C difficile and MRSA • Prescribe at the correct dose and for an appropriate duration

  8. Antibiotic Resistance • The main reason for this phenomena is the inappropriate use of antibiotics • World-wide, 20% of medical cases warrant antibiotic treatment however, 80% of cases are prescribed some type of antibiotic • Additionally, many occassions where the prescription is wrong in either recommended dose or length of treatment

  9. Clostridium difficile Infection • C. difficile is a bacterium present in the gut flora in some people. • Antimicrobials disturb the balance of the gut flora. • Symptoms can vary from mild diarrhoea to fatal bowel inflammation. • C. difficile spores are shed in the faeces and can survive for long periods.

  10. Antibiotic association with CDI • Second and third generation cephalosporins: eg., cefaclor, cefuroxime, cefixime and cefpodoxime • Clindamycin • Quinolones: eg., ciprofloxacin, levofloxacin, moxifloxacin, ofloxacin, norfloxacin. • Long courses of amoxicillin, ampicillin, co-amoxiclav or co-fluampicil

  11. Groups at risk of CDI • Elderly • Suffering from severe underlying diseases • Immunocompromised • Environments where individuals are in close contact with one another (e.g. in a care home), particularly if hygiene is lacking.

  12. Other risk factors for CDI • Use of antimicrobials (type and frequency) • Recent gastrointestinal procedures • Presence of a nasogastric tube • The use of proton pump inhibitors (PPIs)

  13. Initial mangement of CDI • Send stool sample for C. difficile toxin • Assess severity. Severe disease indicated by any one of: • White cell count > 15 x109/L • Temperature > 38.5°C • New renal dysfunction (creatinine > 50% above baseline / oliguria) • Evidence of severe colitis (abdominal pain, tenderness, distension, ileus, radiological evidence) • Life threatening disease may be indicated by partial / complete ileus, hypotension, toxic megacolon • REFER

  14. CDI Management • Initiate treatment for C. difficile if diarrhoea is ongoing. • If a strong clinical suspicion of CDI and non-severe, start treatment whilst awaiting results: • Metronidazole 400mg TDS for 10/7 • Monitor daily for clinical deterioration • If symptoms worsen or no response after 4/7 consult micro • Stop / avoid anti-diarrhoeal agents

  15. CDI Management • Review gastric acid suppressive agents / other medications which can cause diarrhoea if possible • Assess fluid balance and ensure adequate hydration • Isolate infected patients in care homes and other places where people are in close contact with one another. • Good hygiene - wash hands with soap and water before and after each contact with a CDI-infected patient. • Alcohol gel is effective against MRSA but not against C. difficile spores.

  16. CDI – Patient case • 84 year old female with infected index finger exuding pus • Prescribed flucloxacillin 250mg QDS • After 3 days - signs of spreading cellulitis. • Antibiotic changed to ciprofloxacin 500mg BD • Shortly after patient had symptoms of diarrohea and took loperamide

  17. CDI – Patient case • Stool sample sent to lab • Loperamide and ciprofloxacin stopped. Metronidazole 400mg TDS 10/7 started. • 6 days later px admitted to TGH with distended abdomen • Diagnosed with toxic megacolon. • Sub total colectomy attempted and px died shortly after.

  18. CDI case – Learning points • Do not prescribe sub therapeutic doses of antibiotic • Formulary takes into account local resistance patterns and commonly associated pathogens. • Ciprofloxacin has little S.aureus activity • Seek advice from microbiology when first line options fail.

  19. Abx guide changes - URTI • Pharyngitis • 85% of cases resolve in one week • Centor criteria – 3 or 4 suggests 40-60% chance of Group A streptococcal infection: • History of fever • Purulent tonsils • Cervical adenopathy • Absence of cough

  20. URTI Pharyngitis cont’d • Abx may be considered in these cases • Penicillin 500mg QDS or 1000mg QDS for 10/7 in severe cases • Delayed prescription if symptoms no better in 3/7 • Symptomatic relief is all that is required in many cases (ibuprofen / paracetamol)

  21. URTI Acute rhinosinusitis: • 80% of cases resolve in 14/7 without abx • Reserve abx for severe/persistent symptoms (>10 days) • Doxycycline 200mg stat then 100mg 7/7 • Amoxicillin for children • Penicillin 500mg QDS 7/7 in pregnancy

  22. URTI Chronic recurrent rhinitis unresponsive to treatment: • Persistence of symptoms for at least 12/52 without resolution: • Clarithromycin 500mg BD up to 12/52 • Doxycycline 200mg stat then 100mg OD 12/52 • Review 4 weekly in secondary care

  23. LRTI Acute bronchitis: • Common bacterial pathogens include S.pneumoniae*, H.influenzaeand atypicals (Legionella and Mycoplasma) • Penicillins and tetracyclines provide good cover • Marginal benefits in healthy adults • Consider abx for those with reduced ability to fight infections

  24. LRTI Acute bronchitis: • Amoxicillin 500mg TDS or 1000mg TDS for 5/7 in severe cases • Doxycycline 200mg stat then 100mg OD for 5/7

  25. LRTI Infected exacerbation of COPD: • Abx not indictated in the absence of purulent sputum • Risk factors for abx resistance: • Co-morbidities • Severe COPD • Frequent exacerbations • Abx in last 3 months

  26. LRTI • Doxycyline 1st line (5/7) • Amoxicillin 500mg TDS or clarithromycin 500mg BD 2nd line (5/7) • If resistance factors significant consider co-amoxiclav 625mg TDS for 5/7 • Long term prophylaxis only on initiation from specialist with regular follow ups

  27. UTIs Urinary tract infections: • More clarity with respect to patient groups: • Uncomplicated UTI in women • Recurrent UTI • UTI in pregnancy – Cephalexin 500mg TDS (7/7) • UTI in men • LUTI in children • UUTI in children • Acute pyelonephritis

  28. Dental Dental abscess: • Co-amoxiclav removed as first line tx • 1st line amoxicillin 500mg TDS for 5/7 Contacts: Infection Control – 0161 975 4710 Microbiology – Dr.Faris 0161 746 2747 Medicines Management – 0161 873 9506

  29. PPI Audit • Audit of over 75’s on long term PPIs • Exclusion criteria: • Barrett’s oesophagus • Oesophageal/Stomach cancer • Current or past history of oesophageal stricture, ulcer or haemorrhage. • Previous bleeding peptic ulcer who remain H.pylori positive after at least two attempts at eradication.

  30. PPI Audit • 523 patients reviewed • 407 found suitable for stop • 156 stopped (31.8%) • 36 now on when required basis (8.8%)

  31. PPI audit learning points • Annual review of px requiring long term management of dyspepsia. • Encourage step down in dose of PPI / H2 antagonist / stop altogether • Return to self treatment with antacid/alginate therapy • Review contributing factors for dyspepsia

  32. PPI audit – Learning points • Medications implicated in dyspepsia: • Calcium antagonists • Nitrates • Theophylline • Bisphosphonates • Corticosteroids • NSAIDs

  33. Any questions?

  34. Hypertension Guidelines • Updated version sent out in May 2013 • Main changes from last update • Measurement of BP to confirm a diagnosis of hypertension • Drug choices of thiazide diuretic to Indapamide from Bendroflumethiazide

  35. Hypertension • Since changes feedback from practices around side effects especially hyponatraemia with Indapamide • Investigated yellow card reports • Query – is it dose related? • Most cost effective product is 2.5mg daily

  36. Hypertension • May be that 1.5mg should be used – less side effects? • Other “highlight” is CVD risk assessment • CVD check LES, however ALL patients need to be risk assessed • Treated accordingly

  37. Future Guidelines • Diabetes – incorporating GLP1s, Gliptins & insulin analogues • H Pylori – diagnosis & treatment • Other ideas welcomed

  38. NMP • Many sound reasons for having a NMP within your practice • Governance • Access to medicines • Free up GPs time • Fits in with integration

  39. NMP (2) • Patients access • Triage • More skilled workforce • Wider range of services?

  40. NMP (3) • New NMP • CCG can assist with accessing courses • Support from MM team & nurse facilitators • Register with NHSBSA (formerly PPA)

  41. NMP (4) • Policy for prescribers • Monitoring prescribing data • Linked to competencies • NMP education

  42. Questions?

  43. Clostridiumspp. Penicillin Clostridium Streptococcus Bacteroides Enterococcus. Haemophilus influenzae Staph aureus Neisseria & Pneumococci Pseudomonas aeruginosa E.coli ('coliforms')

  44. Flucloxacillin Amoxicillin Clostridium Clostridium Streptococcus Streptococci Enterococci Bacteroides Bacteroides . Enterococci Haemophilusinfluenzae Hemophilusinfluenzae Pseudomonas aeruginosa Staph aureus Neisseria spp. Neisseria Pseudomonas aeruginosa Staph aureus E.coli ('coliforms') E.coli ('coliforms')

  45. Ciprofloxacin Claritromycin Clostridium spp. Clostridium Streptococcus Streptococcus Bacteroides. Bacteroides Enterococcus Enterococcus Haemophilusinfluenzae Haemophilusinfluenzae Staphylococcus aureus Staphylococcus aureus Neisseria Neisseria Pseudomonas aeruginosa Pseudomonas aeruginosa E.coli ('coliforms') E.coli ('coliforms')

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