Coventry and Warwickshire Pathology Antibiotic Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists February 2011.

Coventry and Warwickshire Pathology

Antibiotic Senior Academic Half Day

Matt Rogers & James Clayton

Consultant Microbiologists

February 2011

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

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

A bit of backgroundA potted history of Antibiotics

• The use of antimicrobials in the treatment of infection is one of the triumphs of modern medicine.

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

• Penicillin was not manufactured on a large scale for non-military use until 1949.

Decade Antibiotics

1940s & 1950s

StreptomycinSynthetic penicillinsCephalosporinsChloramphenicolTetracyclines.

1960s Quinolones

2000s Oxazolidinone (Linezolid®)Glycylcycline (Tigecycline®)

2010s ?? Long acting glycopeptides – phase 3 trials

Resistance always developsExamples

Staphylococcus aureus

Penicillin resistance 1950/60sMRSA - Meticillin resistance since 1970sVRSA - Vancomycin resistance in 2001

Enterococci VRE: Vancomycin Resistant Enterococci

Coliforms Quinolone resistanceESBLs: Extended Spectrum Beta-lactamasesMetallo Beta-lactamases (NDM-1)

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

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

Cefuroxime Spend by UHCW NHS Trust

£1,000

£1,500

£2,000

£2,500

£3,000Ap

Diagnostics and Service Division

Medicine and Emergency Division

Rugby St Cross

Specialised Networks Division

Surgery Division

Women and Childrens

TRUST TOTAL

Total Oral Ciprofloxacin spend by UHCW NHS Trust(Includes inpatient, TTO & outpatient issues)

£700Ap

Diagnostics and Service Division

Medicine and Emergency Division

Rugby St Cross

Specialised Networks Division

Surgery Division

Women and Childrens

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

Antibiotic prescribingWhat’s important?

• When– Is there an infection?

• How– To diagnose. What specimens?

• Why– What is the indication/Likely pathogens?

• What– What antibiotic/route/duration

• 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

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

• How to diagnose Infection???

• What specimens do you need to take?

• What investigations do you need to ask for?

• 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)

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

Surgical prophylaxis

• Used to be given for several days

• Evidence now suggests that peri-operative antibiotics adequate for most ‘clean’ operations

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.

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.

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)

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

SIGN: Scottish Intercollegiate

Guidelines Networkwww.sign.ac.uk

www.sign.ac.uk/guidelines/fulltext/104/index.html

• SIGNqrg104.pdf

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

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

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)

Patient factors

• Allergy• Other medications

(interactions)• Can they take PO• Tolerance• Compliance

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

IV or oral

• What are the considerations

• Depends on site of infection

• Oral bioavailability of the antibiotic

• Clear aim/end point (treatment/suppression)

• Licencing

MAU AuditZoe 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)

Mild/Moderate

Severe

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

No date specified

Date specified

Also How much?

• Unfortunate but Healthcare economics are always a consideration

• Particularly with some newer drugs– Antifungals– Antibacterials– Antivirals

‘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

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 Antibiotic Senior Academic Half Day Matt Rogers & James Clayton Consultant Microbiologists February 2011.

warwickshire pathology

optimisation of antibiotic

key antibiotic changes

term antibiotic stewardship

alexander fleming slide

use of ciprofloxacin

use of antimicrobials

s vrsa vancomycin resistance

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