Transcript UHCW NHS Trust Clostridium difficile rates 2002

Antibiotic Senior Academic Half Day
Matt Rogers & James Clayton
Consultant Microbiologists
February 2011
Coventry and Warwickshire Pathology
Objectives of the session
• By the end of the session you will be able to:
• Describe the factors that need to considered when making the
choice to prescribe an antibiotic
• Develop an understanding of key pathogens and their susceptibility
to antibiotics. You will be able to relate this to the antibiotic policy
within your Trust
• Define what is meant by the term Antibiotic stewardship
• Be aware of key DOH guidelines (Clostridium difficile) that direct the
development of antibiotic policies
• Name the antibiotics associated with Clostridium difficile
• State the minimum requirements of how to prescribe an antibiotic
• Name the key issues around route and duration of antibiotics and
how this affects patients
Coventry and Warwickshire Pathology
Antibiotic stewardship
• Ensures the optimisation
of antibiotic use
–
–
–
–
Only use when necessary
Control who uses what
Control route and duration
Respond to changing
needs
– Respond to changing
Evidence/Policies
– Robust policing, review and
stop strategies
– E prescribing
Coventry and Warwickshire Pathology
A bit of background
A potted history of Antibiotics
• The use of antimicrobials in the treatment
of infection is one of the triumphs of
modern medicine.
Coventry and Warwickshire Pathology
History of Antibiotics
• Before the discovery of the sulphur drugs in 1932,
treatment of infectious disease was limited to
mercury, arsenic, and quinine.
• Penicillin was discovered in 1929.
Alexander Fleming
Coventry and Warwickshire Pathology
History of Antibiotics
• Penicillin was not manufactured on a large scale for nonmilitary use until 1949.
Coventry and Warwickshire Pathology
History of Antibiotics
Decade
Antibiotics
1940s &
1950s
Streptomycin
Synthetic penicillins
Cephalosporins
Chloramphenicol
Tetracyclines.
1960s
Quinolones
2000s
Oxazolidinone (Linezolid®)
Glycylcycline (Tigecycline®)
2010s ??
Long acting glycopeptides – phase 3 trials
Coventry and Warwickshire Pathology
Resistance always develops
Examples
Staphylococcus
aureus
Penicillin resistance 1950/60s
MRSA - Meticillin resistance since 1970s
VRSA - Vancomycin resistance in 2001
Enterococci
VRE: Vancomycin Resistant Enterococci
Coliforms
Quinolone resistance
ESBLs: Extended Spectrum Beta-lactamases
Metallo Beta-lactamases (NDM-1)
Coventry and Warwickshire Pathology
Antimicrobial resistance
• Multiple resistance genes
• Plasmids
• Spread
• Factors leading to  resistance:
– Inappropriate clinical use of ABx
– Poor infection control
– Excessive ABx use in non clinical settings:
• animal husbandry
• shipping
Coventry and Warwickshire Pathology
Coventry and Warwickshire Pathology
Coventry and Warwickshire Pathology
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
Coventry and Warwickshire Pathology
Apr-07
Coventry and Warwickshire Pathology
Mar-11
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
£2,000
May-10
£2,500
Apr-10
£3,000
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
Feb-09
Jan-09
Dec-08
Nov-08
Oct-08
Sep-08
Aug-08
Jul-08
Jun-08
May-08
Apr-08
Mar-08
Feb-08
Jan-08
Dec-07
Nov-07
Oct-07
Sep-07
Aug-07
Jul-07
Jun-07
May-07
Expenditure
Cefuroxime Spend by UHCW NHS Trust
Diagnostics and Service Division
Medicine and Emergency Division
Rugby St Cross
Specialised Networks Division
Surgery Division
Women and Childrens
TRUST TOTAL
£1,500
£1,000
£500
£0
Total Oral Ciprofloxacin spend by UHCW NHS Trust
(Includes inpatient, TTO & outpatient issues)
£700
Diagnostics and Service Division
Medicine and Emergency Division
Rugby St Cross
£600
Specialised Networks Division
Surgery Division
£500
Women and Childrens
£400
£300
£200
£100
Coventry and Warwickshire Pathology
Mar-11
Jan-11
Feb-11
Dec-10
Oct-10
Nov-10
Sep-10
Jul-10
Aug-10
Jun-10
Apr-10
May-10
Mar-10
Jan-10
Feb-10
Dec-09
Oct-09
Nov-09
Sep-09
Jul-09
Aug-09
Jun-09
Apr-09
May-09
Mar-09
Jan-09
Feb-09
Dec-08
Oct-08
Nov-08
Sep-08
Jul-08
Aug-08
Jun-08
Apr-08
May-08
Mar-08
Jan-08
Feb-08
Dec-07
Oct-07
Nov-07
Sep-07
Jul-07
Aug-07
Jun-07
Apr-07
£0
May-07
Expenditure
TRUST TOTAL
Antibiotic stewardship
• Ensures the optimisation
of antibiotic use
–
–
–
–
Only use when necessary
Control who uses what
Control route and duration
Respond to changing
needs
– Respond to changing
Evidence/Policies
– Robust policing, review and
stop strategies
– E prescribing
Coventry and Warwickshire Pathology
Antibiotic prescribing
What’s important?
• When
– Is there an infection?
• How
– To diagnose. What specimens?
• Why
– What is the indication/Likely pathogens?
• What
– What antibiotic/route/duration
Coventry and Warwickshire Pathology
When?
• Diagnosing infection
is a CLINICAL skill
• Basic signs and
symptoms of infection
• Please remember
apart from sterile sites
(urine/csf/blood etc)
most areas you
culture WILL grow
bacteria
Coventry and Warwickshire Pathology
When not to
• CSU-urine cloudy
• ?Chest infection with
no evidence on CXR
• Wound with serous
exudate
• Sloughy Ulcers
• Isolated spikes of
temp
• To treat a high WCC
Coventry and Warwickshire Pathology
How?
• How to diagnose Infection???
• What specimens do you need to take?
• What investigations do you need to ask
for?
Coventry and Warwickshire Pathology
Why?
• Why are we giving Antibiotics
– Empirical/Prophylactic/Targeted
• Know your basic Microbiology
• The indication (UTI/LRTI etc)
• The setting (Pt+environment)
– Hospital v Community (feasibility)
• The likely pathogens (CRRS)
Coventry and Warwickshire Pathology
Prophylaxis
• Therapy given to prevent an infection
• Often given around surgery
• Given to patients prone to particular
infections
– Contacts of Neisseria meningitidis meningitis
• Given to patients who are specifically
immunocompromised
– Splenectomy
– PCP prophylaxis in HIV
Coventry and Warwickshire Pathology
Surgical prophylaxis
• Used to be given for several days
• Evidence now suggests that peri-operative
antibiotics adequate for most ‘clean’
operations
Coventry and Warwickshire Pathology
Principles of antibiotic prophylaxis
• The use of antibiotic prophylaxis involves a
dilemma; it is highly effective in preventing
infection, but can promote resistance.
• Limit to those individuals in whom the risk of
infection is high.
Coventry and Warwickshire Pathology
Principles of antibiotic prophylaxis
• Which antibiotics?
– should be targeted to the most likely pathogens.
• When?
– administration as near the time of incision as possible.
– Intravenous antibiotics should be given during the induction of
anaesthesia with repeat doses for longer procedures.
• Duration:
– keep to a minimum (often even to a single-dose) to reduce the
chance of resistance developing.
– The benefits of post-operative prophylaxis lasting more
than 12 h have not been proven.
Coventry and Warwickshire Pathology
Indications for antibiotic prophylaxis
• Contaminated or dirty operations
– presence of bowel contents, pus, or infected foreign material
• Insertion of graft or prosthesis where development of infection would
be serious.
• Immunocompromised patients
• Patients with cardiovascular abnormalities, may require specific
antibiotic prophylaxis to reduce the risk of endocarditis
– (NICE guidelines, BSAC guidelines)
Coventry and Warwickshire Pathology
Risk Factors for
Surgical Site Infection
• Patient:
–
–
–
–
–
–
Extremes of age
Poor nutritional state
Obesity
Diabetes mellitus
Smoking
Co-existing infections at other
sites
– Bacterial colonisation (e.g.
MRSA)
– Immunosuppression
– Prolonged postoperative stay
• Operation
–
–
–
–
–
–
–
–
–
–
–
Length of surgical scrub
Skin antisepsis
Preoperative shaving
Preoperative skin prep
Length of operation
Antimicrobial prophylaxis
Operating theatre ventilation
Inadequate instrument sterilisation
Foreign material in surgical site
Surgical drains
Surgical technique including
haemostasis, poor closure, tissue
trauma
– Postoperative hypothermia
Coventry and Warwickshire Pathology
SIGN:
Scottish Intercollegiate
Guidelines Network
www.sign.ac.uk
www.sign.ac.uk/guidelines/fulltext/104/i
ndex.html
• SIGNqrg104.pdf
Coventry and Warwickshire Pathology
Empirical therapy
• Therapy given without knowing the
causative organism
• Choice based on practical experience and
evidence based medicine
• ‘Best guess therapy’, unlikely to cover all
possibilities
Coventry and Warwickshire Pathology
Targeted therapy
• Therapy given when the infection and
causative organism is known
• This is the best way of effective treatment
• We should know the actual sensitivity of
the offending pathogen
Coventry and Warwickshire Pathology
What - Considerations in therapy
• Choice of agent includes:
•
•
•
•
Recent DOH guidance (Clostridium difficile) – Has altered policies
Range of pathogens (Why?)
Infection site/drug penetration
Patient factors (allergy)
• The above should be covered by your antibiotic policy
•
•
•
•
•
Combination therapy (synergy/antagonism)
Dose/Frequency
Route – IV/oral
IV/oral switch
Duration (5-7 days for most infection)
Coventry and Warwickshire Pathology
Patient factors
• Allergy
• Other medications
(interactions)
• Can they take PO
• Tolerance
• Compliance
Coventry and Warwickshire Pathology
Infection site
• Drug penetration e.g.
• Antibiotics aren’t always
the answer
– Infection prostheses SURGERY
• Bone/Soft tissue
infections
– Some drugs like the
aminoglycosides do not
penetrate well
• Meningitis
– Many drugs will not
penetrate CSF well
Coventry and Warwickshire Pathology
IV or oral
•
•
•
•
What are the considerations
Depends on site of infection
Oral bioavailability of the antibiotic
Clear aim/end point
(treatment/suppression)
• Licencing
Coventry and Warwickshire Pathology
MAU Audit
Zoe 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)
Oral
I.V.
Severe
Coventry and Warwickshire Pathology
Mild/
Moderate
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
Date specified
No date specified
Coventry and Warwickshire Pathology
Also How much?
• Unfortunate but Healthcare economics are
always a consideration
• Particularly with some newer drugs
– Antifungals
– Antibacterials
– Antivirals
Coventry and Warwickshire Pathology
‘No antibiotic’ option
• Our antibiotic options are running out.
– Increasing resistance
– Paucity of new drugs
• Avoid unnecessarily antibiotics
– Often there to make us feel better rather than the
patient!
– Unnecessary risk to patients
• Look for >1 marker of infection
• Stop antibiotics as soon as possible
– Plan stop dates / review dates
Coventry and Warwickshire Pathology
Coventry and Warwickshire Pathology
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
Coventry and Warwickshire Pathology