Training on use of antimicrobials in clinical practice

1. Training on use of antimicrobials in clinical practice 1

2. Contents • Section One - Policy context: National and local strategic approaches 3 • Section Two - Diagnosis of infection and clinical decision making 12 • Section Three - Prudent antimicrobial prescribing 19 • Section Four - Antimicrobial use in hospital 29 • Section Five - Antimicrobial use in primary care 41 • Section Six - Nurses' role in antimicrobial management 52 You can copy or reproduce the information in this training pack for use within NHSScotland and for educational purposes. You must not make a profit using information in this training pack. Commercial organisations must get our written permission before reproducing this training pack. Training on use of antimicrobials in clinical practice 2

3. Section One Policy context: National and local strategic approaches 3

4. ScotMARAP • Scottish Management of Antimicrobial Resistance Action Plan (ScotMARAP) issued in 2008 • Made recommendations for NHS Boards to address the growing problem of antimicrobial resistance • UK Antimicrobial Resistance Strategy for 2013-18 published in September 2013 and ScotMARAP refreshed in line with new UK objectives SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 4

5. SAPG • The Scottish Antimicrobial Prescribing Group (SAPG) was set up to ensure national delivery of ScotMARAP • Members include representatives from regional NHS Boards and national NHS stakeholders • (HPS, ISD, NES, HIS) and Scottish Government SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 5

6. Antimicrobials and HAI • Healthcare Associated Infection (HAI) is currently a priority area for all NHS Boards • The Healthcare Environment Inspectorate was set up in 2009 to ensure Boards complied • with Infection Control Standards • Antimicrobial prescribing is included within the standards SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 6

7. Antimicrobial Management Teams (AMT) Core activities: • Develop and implement local antimicrobial policies for hospital and primary care • Monitor antimicrobial use at local level– antibiotic usage data and compliance with antimicrobial policy • Ensure clinical staff educated and trained in use of antimicrobials • Feed back data on antimicrobial use and surveillance to prescribers SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 7

8. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 8

9. NHS your name AMT • Lead doctor – • Consultant Microbiologist – • Antimicrobial Pharmacist – • Prevention and Control of Infection representative – • Primary Care representative - SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 9

10. Antimicrobial policies • Separate policies for hospital and primary care • Evidence-based guidance on empirical treatment of common infections • Alternative choices for penicillin-allergic patients • Antibiotic name, dose, frequency, route and duration • Hospital – guidance on IV to oral switch therapy (IVOST) • Must be reviewed by AMT regularly (usually every 2 years). SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 10

11. NHS your name Antimicrobial Policies • Details of access – booklets, intranet, posters • Hospital policy – key features of presentation of information SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section One Policy context: National and local strategic approaches 11

12. Section Two Diagnosis of infection and clinical decision making 12

13. Diagnosis of infection • Definition of sepsis and infection severity indicators • Sepsis: Clinical symptoms of infection (pyrexia, sweats, chills, rigors) • Plus – 2 or more of the SIRS* criteria: Temperature < 36 or > 38 °C • Heart rate > 90 bpm • Respiratory rate > 20/minute • WCC < 4 or > 12 x 109/L • Severe sepsis: Sepsis + organ dysfunction/hypoperfusion (oliguria, confusion, acidosis, hypotension) • Note: The above features may be masked in specific situations e.g. immunosuppression, • The elderly and in patients on certain medications (β-blockers, corticosteroids, etc.) • *SIRS = Systematic Inflammatory Response Syndrome SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making 13

14. Microbiology samples • Will a sample aid diagnosis and management of the suspected infection? • What sample(s) are required? – blood culture, urine, sputum, wound swab? • Take sample before starting empirical treatment (except suspected meningitis) • In severe infections empirical treatment should be started without waiting for the microbiology results SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making 14

15. Interpreting Microbiology reports • Is the microbiology report relevant? • Does the patient need antibiotics? • Which antibiotics should be used? • Do I need to discuss this case with a microbiologist? SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making 15

16. Factors affecting choice of antibiotic • Likely organism and site of infection • Culture and sensitivity results • Patient characteristics e.g. diseases, allergies, medication, renal/hepatic function, pregnancy, breastfeeding • Infection/severity indicators • Spectrum of antimicrobial activity • Formulations available • Relevant cautions/contra-indications/side effects • Risk of C. difficile SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Two Diagnosis of infection and clinical decision making 16

17. Section Three Prudent antimicrobial prescribing 17

18. Some facts about antibiotics • 1/3 of hospital inpatients receive antibiotics • 1/3 to 1/2 are inappropriate • Up to 30% of all surgical prophylaxis is inappropriate • Antimicrobials account for 30% of hospital pharmacy budgets • Inappropriate use leads to resistance, C. difficile, increased morbidity & mortality, increased cost and litigation SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 18

19. Using antibiotics prudently • Is an antibiotic required? • What is optimum choice and duration? • Minimise risk to patient – HAI, drug toxicity • Document decision making • Ask for advice if unsure SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 19

20. Requirements for medical notes • Document indication for antibiotic treatment and antibiotic(s) prescribed • Document duration or review date - unnecessarily long courses of antibiotics put patients at risk of HAI and antimicrobial resistance • Document any advice received from microbiology or pharmacy. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 20

21. Requirements for antibiotic prescriptions • Correct choice of drug – as per local policy • Correct dose – inadequate dosage results in ineffective treatment and selects for resistance • Correct frequency – essential for effective treatment • Correct duration – as per local policy SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 21

22. Duration of antibiotic treatment • Duration depends on site of infection and infecting organism • Antimicrobial policies always state recommended duration • Most common infections do not require treatment for longer than 7 days • Some exceptions are atypical pneumonias, endocarditis, UTIs in males, meningitis SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 22

23. Common problems with antibiotic prescribing and administration • Wrong antibiotic – drug, dose, frequency, route, duration • Penicillin-allergic patients prescribed a penicillin • Empirical antibiotics not reviewed when microbiology results available • Missed doses – can have serious consequences. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 23

24. Problems caused by inappropriate use of antibiotics Patient: • Drug toxicity or ineffective treatment • Allergic and adverse reactions • Healthcare associated infection – MRSA or C. difficile infection (CDI) Population (society): • Emerging antimicrobial resistance SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 24

25. Concordance • Concordance with antibiotic treatment is important in reducing resistance • Patients need information about antibiotics - course length, when to take, potential adverse effects, interactions with food or other medicines SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 25

26. Information on use of antimicrobials • Local antimicrobial policy – intranet link • Microbiology – names /phone & bleep numbers • Antimicrobial pharmacist – name /phone & bleep number • Infectious Diseases consultant – name /phone & bleep number SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Three Prudent antimicrobial prescribing 26

27. Section Four Antimicrobial use in hospital 27

28. Indications for IV antibiotics • Sepsis, severe sepsis or deteriorating clinical condition • Febrile with neutropenia/immunosuppression • Deep-seated/specific infections: bone/joint, moderate to severe cellulitis, deep abscess, endocarditis, meningitis • Oral route compromised: vomiting, nil by mouth, severe diarrhoea, swallowing disorder, unconscious, malabsorption SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 28

29. IV to oral switch therapy (IVOST) policy • Review patient daily • If answer to all of following questions is NO, switch to oral route • - Oral route compromised? • - Continuing sepsis or deteriorating condition? • - Special indication for IV therapy? • - Antimicrobial only available in an IV formulation? SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 29

30. Gentamicin • Indicated for treatment of gram negative infections and in surgical prophylaxis • High or prolonged dosage can lead to renal or ototoxicity • Dosage based on weight and renal function - on-line calculator should be used where possible. See local policy for details. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 30

31. Gentamicin monitoring • Blood sample should be taken 6-14 hours after first dose • Level interpreted using a nomogram (Glasgow or Hartford) – see local policy for details • Subsequent doses given every 24, 36 or 48 hours • Seek advice from microbiology or Infectious Diseases before continuing treatment beyond 72 hours SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 31

32. Vancomycin • First line agent for MRSA infections and may be used for surgical prophylaxis in patients at risk of MRSA • Loading dose given based on body weight then subsequent doses based on renal function • Must be administered by slow IV infusion to avoid shock-like syndrome and thrombophlebitis SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 32

33. Vancomycin monitoring • Check level immediately before 3rd or 4th dose • Target level is 10 -20mg/L (15-20mg/L for severe infections) • Seek advice from pharmacy or microbiology on dose adjustment. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 33

34. Surgical prophylaxis • Single dose antibiotic prophylaxis recommended in SIGN 104 • List of procedures where prophylaxis is recommended • Avoid cephalosporins where possible due to C. difficile risk • Consult local policy for details SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 34

35. MRSA colonisation • MRSA screening used to detect MRSA colonisation • MRSA colonises skin and mucous membranes • Colonisation presents risks for patients with open wounds and those undergoing surgical procedures • Hospital patients who are MRSA positive may receive decolonisation therapy – disinfection of skin and nasal passages SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 35

36. Managing MRSA infection • At one time up to 40% of Staph. aureus infections in UK were due to MRSA but during the past 5 years this level has decreased to less than 10% • Most common site is skin and soft tissues • MRSA pneumonia, UTI and bacteraemia are less common • First line treatment is IV vancomycin • Alternatives include teicoplanin and linezolid – see local policy SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 36

37. C. difficileInfection (CDI) • Gram positive, spore forming anaerobic bacillus which produces 2 main toxins, A and B • Carried by 2% adults as part of normal large bowel flora and carriage increases with age • C. difficile infection (CDI) is associated with significant morbidity and mortality • Symptoms - diarrhoea with characteristic foul odour, abdominal pain, pyrexia, raised WCC and raised serum creatinine SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 37

38. Risk factors for C. difficile Infection (CDI) • > 65 years of age • Antibiotic exposure, especially ‘4C’ (clindamycin, cephalosporins, co-amoxiclav, ciprofloxacin) • Prescription of proton pump inhibitors e.g. omeprazole, lansoprazole • Serious underlying disease / surgery • Prolonged hospital stay • Inadequate cleaning of ward facilities and equipment • Poor Hand Hygiene by patients and staff SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 38

39. Managing Clostridium difficile Infection (CDI) • Isolation with transmission based precautions • Assess severity factors then prescribe either • - Metronidazole 400mg TDS PO 10-14/7 • (can be given IV if patient is NBM) • or • - Vancomycin 125mg QDS PO 10-14/7 • (can only be given orally) SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 39

40. Useful Websites • Scottish Antimicrobial Prescribing Group (SAPG): • www.scottishmedicines.org.uk/SAPG/Scottish_Antimicrobial_Prescribig_Group_SAPG • NHS Education for Scotland, HAI Programme • www.nes-hai.info/ • Pause: • www.pause-online.org.uk/ SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Four Antimicrobial use in hospital 40

41. Section Five Antimicrobial use in primary care 41

42. Antimicrobials in primary care • 80% of total antimicrobial use in humans is in primary care • 60% of that is for respiratory infections • Antibiotics are often prescribed for self-limiting viral infections SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 42

43. Upper respiratory tract infections (URTI) • Most URTI are self-limiting and do not require antibiotics • 92% of patients with acute rhino sinusitis are still prescribed antibiotics in primary care despite evidence that antibiotic therapy does not offer clinically significant benefit • Antibiotics should be reserved for patients with severe or prolonged symptoms and evidence based criteria should be used to identify patients who are likely to benefit from treatment • Doctors over-estimate patient demand for antibiotics • Immediate prescriptions for conditions such as sore throats increase future consultations. SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 43

44. Strategies to reduce antibiotic use for URTIs • Take detailed history, carry out full examination and ask directly about patient’s expectation for antibiotics. Do not prescribe antibiotics via telephone consultation. • • Reassure patients that antibiotics are not needed because they will make little difference to the symptoms and may have side-effects. Use a patient information leaflet to back up this advice. • • Consider using a delayed prescription if symptoms are not settling within a recognised time frame and give symptom management advice. • • Advise patients on the likely timescale for the illness: • Acute otitis media – 4 DAYS • Acute sore throat – 1 WEEK • Acute rhino sinusitis – 2 ½ WEEKS • Acute bronchitis – 3 WEEKS SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 44

45. Healthcare Associated Infections • Healthcare associated infections (HAI) present in mainly in hospital and may also occur in the community in Care Homes and other long term care facilities • Prescribing of antibiotics within primary care can influence development of HAI • The development of C. difficile infection (CDI) can be driven by antibiotic use in the preceding 12 weeks, which is often in primary care • Antibiotics associated with a high risk of C. difficile infection(CDI) are cephalosporins, quinolones, clindamycin and co-amoxiclav • Prescribers should follow the local antibiotic policy and where possible avoid the use of high risk antibiotics particularly in those patients over 65 years SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 45

46. Antimicrobial resistance • Antibiotic use causes resistance through selective pressure • Broad spectrum antibiotics select for resistant pathogens by eradicating natural flora • Current problems with resistant organisms include: • MRSA - methicillin resistant Staphylococcus aureus • VRE - vancomycin resistant enterococci • ESBL - extended spectrum betalactamase • CPE – carbapenemase-producing enterobacteriaceae SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 46

47. Common infections: local antimicrobial policy choices • Acute sore throat – • Acute otitis media – • Acute rhino sinusitis – • Acute bronchitis – • Exacerbation of COPD – • Community acquired pneumonia – • Urinary tract infection (women) – • Cellulitis - SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 47

48. National prescribing indicators • In 2009 a set of 41 prescribing indicators for antibacterials were developed within PRISMS • Provide an overview of quantity and quality of antibacterial prescribing at NHS board, CHP and GP Practice level • Can be used to identify outliers in terms of quantity of antibacterials prescribed and use of non-policy agents • Total use of antibiotics is an example of a quantitative quality indicator and a target level for reduction of this measure was set by Scottish Government in 2013 SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 48

49. Your local information on use of antimicrobials • Local antimicrobial policy – intranet link • Microbiology – names /phone & bleep numbers • Antimicrobial pharmacist – name /phone & bleep number • Infectious Diseases consultant – name /phone & bleep number SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 49

50. Useful resources on use of antibiotics in primary care • Health Protection Agency guidance on primary care management of infections • www.hps.org.uk/HPS/Topics/InfectiousDiseases/InfectionsAZ/1197637041219 • Scottish Antimicrobial Prescribing Group – Prudent antimicrobial use • www.scottishmedicines.org.uk/files/sapg/Respiratory.pdf • National Prescribing Centre Information on URTIs www.npci.org.uk/therapeutics/common_infections/respiratory/resources/pda_rti_general.pdf • NHS Education for Scotland – ScRAP programme • http://www.nes.scot.nhs.uk/education-and-training/by-discipline/pharmacy/about-nes-pharmacy/educational-resources/resources-by-topic/infectious-diseases/antibiotics/scottish-reduction-in-antimicrobial-prescribing-(scrap)-programme.aspx SMC and NES accept no liability, as far as the law allows us to exclude such liability, for the accuracy or currency of amendments, additions and/or revisions of any kind  made to the training pack by a territorial board/third party to reflect local policy and information. Section Five Antimicrobial use in primary care 50