National Changes in Antibiotic Policy

National Changes in Antibiotic National Changes in Antibiotic PolicyPolicy

R. Andrew Seaton

Consultant Physician

Lead doctor Antimicrobial Management Team, NHS GG&C

SAPG Infection Management Workstream

• Developing and applying prudent prescribing principles in hospital and community– Hospital infection management guidelines– Surgical prophylaxis guidelines– Primary care guidelines

• Prescribing indicators to underpin control of HAI

• Unintended consequences of change

0

1000

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1992

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Clostridium difficile and prescribing in Scotland

Adapted from Health Protection Scotland data

Ceftriaxone IV DDD/1000 bed daysJan 2002 to July 2007

DDD=4g

y = 0.0084x - 311.46

0

5

10

15

20

25

Apr-01 Sep-02 Jan-04 May-05 Oct-06 Feb-08 Jul-09

CDI Risk and Antibiotic Treatment

NB. Any Antibiotic. Duration of therapy

CDI Risk and Antibiotic Treatment

NB. Any Antibiotic. Duration of therapy

UPDATE: Quinolone use is strongly

associated with Hyper-virulent, quinolone-

resistant 027 strain of C difficile

UPDATE: Quinolone use is strongly

associated with Hyper-virulent, quinolone-

resistant 027 strain of C difficile

Increased MRSA risk

Reduced MRSA risk

Clostridium difficile NHS Greater Glasgow and

Clyde

• June 2008• 55 CDI / 6 months• 18 either primary

cause or contributing to death

• Infection control issues

• Antibiotic prescribing

AMT response: June 2008

• Urgent review of prescribing, guidance (case mix)

• Stricter restrictions “4 Cs”

CephalosporinsCo-amoxiclavClindamicinCiprofloxacin (Quinolones)

• Promote– Think before you

prescribe– Narrow spectrum

agents/ simplify– Limit duration– Combination with

gentamicin for serious infection

– CDI Rx guidelines

www.glasgowformulary.com

Recommended, Restricted and Alert Antibiotics

Status Oral IV

Recommended Amoxicillin ClarithromycinCo-trimoxazoleDoxycyclineFlucloxacillinMetronidazoleNitrofurantoinTrimethoprimVancomycin

AmoxicillinClarithromycinCo-trimoxazoleFlucloxacillinGentamicinVancomycin

Restricted ClindamycinCo-amoxiclavCiiproflaxacin

ClindamycinCeftriaxoneCo-amoxiclav

“Alert” Linezolid CeftazidimeCiprofloxacinDaptomycinErtapenemLinezolidMeropenemPiperacillin-TazobactamTeicoplaninTigecycline

National Response

• Independent review (Vale of Leven Hospital)– “Prudent antimicrobial prescribing

implemented and monitored both in the Acute and Community sectors”

• Scottish Government: CEL 30, July 2008– AMT for Primary care and secondary

care in all HBs

AMTEducation &Communication

Audit of Practice

Surveillance ofUsage

Antimicrobial PracticeGuidance

And Protocols

AntimicrobialResistanceand CDAD

Alert Restricted Agents

SAPG

AMTs

SAPG, Nov 08

GGC hospitals DDD/1000 bed days 4C antibiotics (total)

0

50

100

150

200

250

300

350

400

450

Co-amoxiclav

Quinolones

Cephalosporins

Clindamycin

Total

Restrictive guidance

IV+ Oral Amoxicillin ddd/1000 bed days All GG&C hospitals, excluding Mental Health and Yorkhill

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50

100

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450

200702 200703 200704 200801 200802 200803 200804 200901 200902 200903 200904

ddd/1000 bed days

1 DDD amoxicillin IV = 1g1 DDD amoxicillin oral = 1g

New policy introductionRestrictive guidance

Clostridium difficile cases per month GG&C

y = -0.0131x + 627.63R2 = 0.0303

y = -0.0989x + 3988R2 = 0.6392

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120

140

160

Oct-06 Apr-07 Nov-07 Jun-08 Dec-08 Jul-09 Jan-10 Aug-10

pre

post new policy

Linear (pre)

Linear (post new policy)

Restrictive guidance

HPS data C. difficile cases >65 years / 1000 total / acute OCBD

0

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

Q4 2007 Q1 2008 Q2 2008 Q3 2008 Q4 2008 Q1 2009 Q2 2009

Scotland (average rate)

GG&C

HEAT target to reduce CDI rate in ≥ 65 yrs by ≥ 30% by March 2011: Prescribing

indicators: Hospital

Improvement Action Plan for NHS Greater Glasgow and Clyde Southern General Hospital Inspection Date: Monday 8 and Tuesday 9 March 2010

“It is recommended that NHS Greater Glasgow and Clyde implements auditing of 20 patient records each month in all receiving wards”

Unintended consequences

• Toxicity– Renal– Oto-vestibular

• Treatment failure– ICU admission– Death

• Prescribing adaptation

• Resistance

Gentamicin DDD/1000 bed days all GG&C hospitals excluding Yorkhill and Mental Health

0

10

20

30

40

50

60

200702 200703 200704 200801 200802 200803 200804 200901 200902 200903 200904

DDD/1000 bed days

1 DDD gentamicin = 240mg

New Policy Introduction

Meropenem spend excluding Gartnavel + western

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2007 Q1 2007 Q2 2007 Q3 2007 Q4 2008 Q1 2008 Q2 2008 Q3 2008 Q4 2009 Q1 2009 Q2 2009 Q3 2009 Q4

royal

clyde

south

total

SAPG Vancomycin and Gentamicin prescribing Guidelines, Sept 09

• National consensus to adopt single national Vancomycin guideline

• Agreed that boards would adopt either Hartford (7mg/kg) or NHS GGC (5mg/kg) regimens– Caution beyond 72 hours

• On line calculators for dosage

A. Helps et al, 2009

2008-092007-08

100

0

-100

year

1st g

enta

mic

in u

ntil

RR

T (

days

)

Pre Post

Dialysis 196 182

Gentamicin 41% 35%

Impact of Gentamicin on Renal Replacement Therapy

Impact of Gentamicin on VIII nerve toxicity

• Discussions with Scottish ENT society– Concern over potential for toxicity– No routine surveillance in place

• Retrospective review in NHS GGC– >1,200 patients Rx with gentamicin– No evidence of increase in ENT presentations

to date

• Prospective review / enhanced surveillance underway

Challenges ahead• Unintended consequences

– Including resistance, morbidity and mortality– Changing prescribing pathways

• Vigilance with adherence to guidelines– Education– Information– Pharma

• Prescribing targets• Organisation, sustainability and collaboration