Antibiotic Prescribing in Primary Care - Addressing Patient Safety Issues

1. Antibiotic Prescribing in Primary care Alastair Monk Medicines Optimisation Team NHS North of England Commissioning Support Patient Safety Conference Wednesday 1st April 2016

2. What are the issues (patient safety) ? • Antimicrobial Resistance • Clostridium difficile infection (and other “Super bugs”) • Drug side effects

3. Antibiotic prescribing in the North East and Cumbria The Guardian 11 Jun 2013 UK map shows areas where GPs are most, or least, likely to prescribe antibiotics to patients. ESPAUR report Highlighting the North East as high prescribers of antibiotics.

4. The Area Teams compared

6. Antimicrobial Resistance • The emergence, selection and spread of resistant bacteria is a major patient safety and public health issue. • Infections with antibiotic-resistant bacteria can result in: • increased patient morbidity • Increased mortality • increased hospital length of stay • Increased cost of care.

7. UK 5 year AMR strategy Key elements for primary care • Antibiotic guideline, and audit • Public/professional awareness campaign • Educational resources

8. The interventions? – a collection of multifaceted interventions for individual prescribers, practices and CCGs Education and training Awareness campaign Regional prescribing guidelines Guideline document eLearning Posters and postcards Smartphone app Face to face workshops ‘Non-prescriptions’

9. Clostridium difficile infection • It’s not just C diff • Enterococcus faecium • Staph.aureus (MRSA/VRSA) • C.difficile • Acinetobacter baumanii • Pseudomonas aeruginosa • Enterobacteriaceae

10. C diff (contd) • People at risk: • Those who have been treated with broad spectrum antibiotics • People with serious underlying illnesses • The elderly are at greatest risk – over 80% of Clostridium difficile infections reported are in people aged over 65 years (they are 10x more at risk) • Prev. C.diff infection

11. C diff (contd) • Infection can lead to: • Mild to severe diarrhoea – watery and odorous • Pseudomembranous colitis • Toxic megacolon

12. How the Area Teams Compare

13. ESBL’s • Extended spectrum β-lactamase producers • Mainly in E.coli and Klebsiella sp • Resistant to ALL penicillins, cephalosporins and many other antibiotics • The only oral options available may be: • Nitrofurantoin • Pivmecillinam • Fosfomycin • Seen increasingly mainly in urine specimens of the elderly population

14. Possible Adverse Effects of Antibiotics • Allergy • Side effect of antibiotic • Interaction with other medication • Effect on normal bacterial flora resulting in: • antibiotic associated diarrhoea • oral and vaginal candidiasis • colonisation or infection by resistant bacteria (MRSA, ESBL producing Gram negatives, etc)

15. Penicillin allergy • In suspected penicillin allergy, a careful history of the nature of the reaction should be taken: • Vague/minor(e.g. gastrointestinal disturbance) → if appropriate, treatment with a penicillin is justified • non-urticarial rash with penicillin (without angio-oedema or anaphylaxis) → cephalosporins, could still be used with caution if appropriate • urticarial rash/angio-oedema/anaphylaxis → all beta-lactams are contraindicated Could lead to the use of “other” less appropriate antibiotics

16. Resources • TARGET antibiotics toolkit: http://www.rcgp.org.uk/targetantibiotics/ OR http://www.rcgp.org.uk/clinical-and-research/target-antibiotics-toolkit.aspx • ‘Stemming the Tide of Antibiotic Resistance’ educational programme (STAR): http://www.stemmingthetide.org/ • http://bsac.org.uk/ • http://antibiotic-action.com/ • NICE Guidance: • CG 69 Antibiotic Prescribing for Respiratory Infections • NECS MO Website http://medicines.necsu.nhs.uk/ • www.antibiotic-action.com • Department of Health website • European Antibiotic Awareness Day

17. Thank you • Any questions?