New Antibiotic guidelines April 2013

1. New Antibiotic guidelinesApril 2013 Dr Fiona Donald Consultant Microbiologist Nottingham

2. Outline of talk • New antibiotic guidelines, summary of changes • Update on antimicrobial resistance • A bit about Microbiology

3. Antimicrobial guidelines – Why? • Simple, informed decision approach to prescribing • Evidence based and using knowledge of local resistance rates and target organisms • Saves money? • Rational use of antibiotics leads to less antibiotic resistance and fewer side effects • Educational tool • Fewer phone calls to Microbiology

4. Changes to guidelines - overview • Updates to national guidance eg from HPA, CKS, SIGN and NICE • Aim to reduce use of agents which will induce C difficile disease ie cephalosporins and quinolones • Shorter courses are now recommended for some conditions • Trying to stay ahead of resistant organisms

5. Changes to guidelines 2013 • New sections on: • Dental abscess • Diverticulitis • Additional antibiotics for multi-resistant UTIs • Linezolid added as amber 2 agent • Mastitis and breast abscess • Gonorrhoea

6. Changes to guidelines 2013 • Updates on: • Community acquired pneumonia – add clarithromycin to amoxicillin • Whooping cough • Pelvic inflammatory disease/gonorrhoea – IM ceftriaxone, not cefixime • MRSA treatment and decolonisation • Meningococcal prophylaxis, ciprofloxacin now recommended • Shingles age to consider treatment now 50 yrs

7. Use of antibiotics • Antibiotics are essential to modern medicine but their abuse leads to resistance. • A single course of antibiotics in primary care leads to bacterial resistance to that antibiotic (BMJ 18th May 2010). • All staff who prescribe have a responsibility to their patients and for public health to prescribe optimally

8. Antibiotic side effects • Many • Skin, GI, CNS, drug interactions • Clostridium difficile infection • Cephalosporins, penicillins, quinolones, macrolides • Colonisation/infection with resistant bugs • MRSA • ESBL coliforms (NDM) • Candida (thrush)

9. Antibiotic Resistance • Has been called one of the worlds most pressing public health problems • In the US the annual cost of treating infections caused by just 6 types of multi-resistant bacteria exceeded the yearly cost of treating influenza • November 2009 EU/USA summit announced a task force to deal with the problem (BMJ 22nd May 2010) • Goal of developing 10 new antibiotics by 2020 (10 x 20 initiative, IDSA)

10. Local resistance patterns But remember sampling bias

11. Local resistance patterns Bur remember sampling bias

12. Local resistance patterns But remember sampling bias

13. Local resistance patterns

14. Local resistance patterns

15. What can be done? • Rationalisation of prescribing of antibiotics in hospital and the community, use of guidelines • Good infection control practices • Education of the public • Rationalisation of the veterinary usage of antimicrobials, banning of antimicrobial growth promoters • Prevention of disease e.g. vaccination • Development of new antimicrobials or other drugs to beat bacteria

16. Antibiotic Resistant Superbugs • ESBL producing coliforms • Most often seen in community urine samples • Cause of UTI and sepsis • Only one reliable antibiotic available to treat infections, IV meropenem • Hardly any oral options • New strain NDM-1even more resistant

17. ESBL E.coli laboratory data • 2008/09: • 551 urines positive with ESBL E coli • 257 NUH • 294 GP/community • 49 blood cultures (vs 469 non- ESBL E coli) • Currently around 9% of community acquired E coli bacteraemias are multi-resistant

18. New UTI antibiotics • Fosfomycin and • Pivmecillinam (a type of penicillin) • Classified as Amber 2 agents • May be prescribed on the advice of a Medical Microbiologist • Used for oral treatment of multi-resistant UTI when no other oral option available

19. Diagnosis of UTI • Uncomplicated UTI in community – no need to send sample. • Send sample if no response to short course of first line treatment • If complicated UTI (eg pregnancy, loin pain, fever, catheter) send sample before treatment

20. Culture – chromogenic agar

21. Urine culture in men and women >65 years • Asymptomatic bacteriuria is common – one third of >65 yrs • Do not send for culture on the basis of a positive urine dip unless symptomatic • Do not treat asymptomatic bacteriuria, it does not reduce symptomatic episodes or mortality but does increase side effects and resistance rates

22. Urine culture in people with long-term catheters • Urine dipsticks are NOT useful, as catheters will normally become colonised with bacteria • Do not send urine for culture unless there are symptoms of infection • Do not treat asymptomatic bacteriuria in the presence of a catheter • Do not routinely give antibiotic prophylaxis for catheter changes

23. Clinical microbiology service • Based at QMC A floor West Block • All samples come here approx 800,000 per year • One third from GPs, two thirds from acute trusts • Sample processing and reporting carried out by biomedical scientists • Medical microbiologists provide the clinical leadership and interaction with clinicians

26. Gram-stain Gram-positive cocci Gram-negative cocci Gram-positive bacilli Gram-negative bacilli

27. Role of Clinical Microbiology • Diagnose infections • From samples sent to us • By clinical discussion and seeing patients • Provide results on specimens • Electronically reported • Selected results are telephoned • Generate a discussion about a patient

28. Role of Clinical Microbiology • Surveillance • Data provided to local infection prevention and control teams • Locally to HPU and CCDC - particularly notifiable diseases • Nationally to HPA, CDSC, DH • Advice on diagnosis and treatment of infections

29. Further information • Full guideline available at www.nottsapc.nhs.uk • Microbiology website at NUH www.nuh.nhs.uk/healthcare-professionals/microbiology/ • NUH antibiotic guidelines www.nuh.nhs.uk/nch/antibiotics/ • Health Protection Agency/ (now Public Health England) website www.hpa.org.uk