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Antibiotic prescribing – especially quinolones and cephalosporins

Antibiotic prescribing – especially quinolones and cephalosporins . Options for local implementation NPC. Key therapeutic topics – Medicines management options for local implementation. Second update July 2011.

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Antibiotic prescribing – especially quinolones and cephalosporins

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  1. Antibiotic prescribing – especially quinolones and cephalosporins

  2. Options for local implementationNPC. Key therapeutic topics – Medicines management options for local implementation. Second update July 2011 Review and, where appropriate, revise current prescribing practice and use implementation techniques to ensure prescribing is in line with Health Protection Agency (HPA) guidance. Benchmark and review the total volume of antibiotic prescribing against local and national data. Benchmark and review the use of quinolones and cephalosporin prescribing against local and national data.

  3. Key questions Do we need to do something about the volume of antibiotic prescribing? What about quinolones and cephalosporins? What is appropriate antibiotic prescribing? What does national guidance say? What strategies can be used to address over-prescribing? How are we doing?

  4. What this is about? It’s NOT about not prescribing antibiotics!!!!! Antibiotics are life saving in some circumstances and reduce significant morbidity often It’s about the betterTARGETING of antibiotics To people who are inherently more likely to have a serious bacterial infection, or to develop a complication from a less serious infection To people who are not inherently at risk but who have symptoms and signs indicating a more serious infection despite their low risk BUT IT IS VERY IMPORTANT Infectious illness remains a major global threat to health Antibiotic resistance is an alarming threat to modern healthcare We all have a part to play: targeting antibiotics to maximise benefits and minimise harms prudent use of antibiotics to protect their benefits for future generations.

  5. Do we need to do something about the volume of antibiotic prescribing?

  6. Trends in usage of antibacterials in general practice in England © Copyright NHSBSA 2011

  7. High use = high resistanceGoossens H, et al. Lancet 2005; 365: 579–87

  8. Rates of MRSA on downward trend…. Source: HPA: Healthcare-Associated Infections and Antimicrobial Resistance for 2009/10, September 2010

  9. ….and rates of C. difficile look encouraging…. Source: HPA: Healthcare-Associated Infections and Antimicrobial Resistance for 2009/10, September 2010

  10. ….but with an interesting seasonal variation Surveillance of Healthcare Associated Infections Report: Health Protection Agency, July 2008

  11. What about quinolones and cephalosporins?

  12. Trends in usage of quinolones in general practice in England © Copyright NHSBSA 2011

  13. E. coli resistance to ciprofloxacin has increased Antimicrobial Resistance and Prescribing in England, Wales and Northern Ireland, Health Protection Agency, July 2008.

  14. Trends in usage of cephalosporins in general practice in England © Copyright NHSBSA 2011

  15. What is appropriate antibiotic prescribing?What does national guidance say?

  16. Which antibiotic should be prescribed?www.hpa.org.uk/web/HPAwebFile/HPAweb_C/1194947333801 Health Protection Agency – Management of infection guidance for primary care Prescribe an antibiotic only when there is likely to be a clear clinical benefit Consider a no, or delayed, antibiotic strategy for acute self-limiting upper respiratory tract infections A dose and duration of treatment is suggested for common infections seen in primary care Use simple generic antibiotics first whenever possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins)when narrow spectrum antibiotics remain effective, as they increase risk of C. difficile, MRSA and resistant UTIs

  17. Standing Medical Advisory CommitteeThe Path of Least Resistance. Department of Health, 1998 Some key messages: Do not prescribe antibiotics for self-limiting conditions e.g. simple coughs and colds or viral sore throats Limit antibiotic treatment courses to a minimum length e.g. three days for uncomplicated cystitis in otherwise fit women Do not prescribe antibiotics over the telephone other than in exceptional cases Patients expectations/doctors perceptions key Control of use has other benefits - prevents ADRs

  18. Harms of antibioticsalso see common infections respiratory tract elearning materials Antibiotics may benefit some people But we can’t predict who will benefit and who will suffer harm Adverse effects Diarrhoea, vomiting or rash Resistance increases with antibiotic exposure both in the individual and in the population In an individual the benefits must be carefully weighed against the risks

  19. What does NICE say for treating respiratory tract infections (RTIs)? (1)NICE. Respiratory tract infections. CG69. July 2008 An immediate antibiotic prescription and/or further appropriate investigation and/or management should only be offered if the patient: is systemically unwell or has symptoms and signs suggestive of serious illness and/or complications is at high risk of serious complications because of pre-existing comorbidity is older than 65 years with acute cough and two or more of the following criteria, or older than 80 years with acute cough and one or more of the following criteria: hospitalisation in previous year type 1 or type 2 diabetes history of congestive heart failure current use of oral glucocorticoids

  20. Depending on clinical assessment of severity, patients in the following subgroups can also be considered for an immediate antibiotic prescribing strategy bilateral acute otitis media in children younger than 2 years acute otitis media in children with otorrhoea acute sore throat/acute pharyngitis/acute tonsillitis when three or more Centor criteria are present What does NICE say for treating RTIs? (2)NICE. Respiratory tract infections. CG69. July 2008

  21. What strategies can be used to address over-prescribing?

  22. Strategies for targeting volume of antibiotics prescribed for RTIs NICE. Respiratory tract infections. CG69. July 2008 Adults and children over 3 months presenting with the following conditions should be offered a clinical assessment, including a history and, if indicated, an examination to identify relevant clinical signs: acute otitis media acute cough/acute bronchitis acute sore throat acute rhinosinusitis common cold A no antibiotic or a delayed antibiotic prescribing strategy should be agreed for patients with these conditions Patients’ concerns and expectations should be determined and addressed

  23. Do antibiotics prevent complications?Petersen I, et al. BMJ 2007;335:982NPC. MeReC Rapid Review No. 23 Serious complications are rare after upper respiratory tract infections, sore throat and otitis media Primary care prescribers should not base their prescribing for these on a fear of serious complications More than 4000 people would have to be treated to prevent one case of quinsy, mastoiditis or pneumonia However, NNT=39 (95% CI 36 to 42) to prevent one case of pneumonia after chest infection in people 65 years and older

  24. Offer the patient reassurance and a safety net NICE. Respiratory tract infections. CG69. July 2008 If no antibiotics are prescribed, offer: reassurance that antibiotics are not needed immediately because they are likely to make little difference to symptoms and can have side effects a clinical review if the condition worsens or becomes prolonged If a delayed antibiotic strategy is used, offer reassurance and: advice about using the delayed prescription if symptoms are not starting to settle in accordance with the expected course of illness or if a significant worsening of symptoms occurs advice about re-consulting if there is a significant worsening of symptoms despite using the delayed prescription (A delayed prescription with instructions can either be given to the patient or left at an agreed location to be collected at a later date)

  25. Strategies to target those who will most benefit Consider the differential diagnosis What are we really worried about? Is this patient likely to have a bacterial infection? Severe disease or less severe disease? Are antibiotics likely to help? Balancing benefits versus harms of treatment

  26. How are we doing?

  27. Prescribing comparatorAntibacterial items prescribing rate www.nhsbsa.nhs.uk/PrescriptionServices/3334.aspx 0.425 0.203

  28. Prescribing comparatorCephalosporins & quinolones % itemswww.nhsbsa.nhs.uk/PrescriptionServices/3334.aspx 14.05% 2.16%

  29. Key messages Infections are still a major threat to public health Resistance to antibiotics is inevitable but prudent prescribing helps slow down development of resistance Antibiotics are not effective in everyone and cause side effects, so in an individual the benefits must be carefully weighed against the risks Use simple generic antibiotics first whenever possible. Avoid broad spectrum antibiotics (e.g. co-amoxiclav, quinolones and cephalosporins)when narrow spectrum antibiotics remain effective, as they increase risk of Clostridium difficile, MRSA and resistant UTIs Offering a delayed prescription may be one approach to assist in patient negotiation

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