Download - New Antibiotic guidelines April 2013
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New Antibiotic guidelinesApril 2013
Dr Fiona Donald
Consultant Microbiologist
Nottingham
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Outline of talk
New antibiotic guidelines, summary of changes
Update on antimicrobial resistance A bit about Microbiology
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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
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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
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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
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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
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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
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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)
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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)
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Local resistance patterns
Community urine E coli isolates Amoxicillin resistant
0%
10%
20%
30%
40%
50%
Jul-Dec07
Jan-Dec08
Jan-Dec09
Jan-Dec10
Jan-Dec11
Jan-Dec12
% r
esis
tan
ce
Amoxicillin
But remember sampling bias
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Local resistance patterns
Community urine E coli isolates Nitrofurantoin resistance
0%
10%
20%
30%
40%
50%
Jul-Dec07
Jan-Dec 08
Jan-Dec 09
Jan-Dec 10
Jan-Dec 11
Jan-Dec 12
% r
esis
tan
ce
Nitrofurantoin
Bur remember sampling bias
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Local resistance patterns
Community urine E coli isolates Trimethoprim resistance
0%
10%
20%
30%
40%
50%
Jul-Dec07
Jan-Dec 08
Jan-Dec 09
Jan-Dec 10
Jan-Dec 11
Jan-Dec 12
% r
esis
tan
ce
Trimethoprim
But remember sampling bias
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Local resistance patterns
Community S.aureus Bacteraemias Fucidin Resistant
0%
10%
20%
30%
40%
50%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Date range
%re
sist
ance
Fucidin R
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Local resistance patterns
Community S.aureus Bacteraemias Flucloxacillin Resistant (MRSA)
0%
10%
20%
30%
40%
50%
2004 2005 2006 2007 2008 2009 2010 2011 2012
Date range
%re
sist
ance
Flucloxacillin R
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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
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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
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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
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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
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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
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Culture – chromogenic agar
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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
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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
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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
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TOTAL MRSA screens
0
2000
4000
6000
8000
10000
12000
14000
Sep
-07
Nov
-07
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
Jul-1
1
Sep
-11
Nov
-11
Jan-
12
Mar
-12
May
-12
Jul-1
2
Sep
-12
Nov
-12
Jan-
13
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TOTAL Positive MRSA screening swabs
150
200
250
300
350
400
450
500Ju
l-07
Sep
-07
Nov
-07
Jan-
08
Mar
-08
May
-08
Jul-0
8
Sep
-08
Nov
-08
Jan-
09
Mar
-09
May
-09
Jul-0
9
Sep
-09
Nov
-09
Jan-
10
Mar
-10
May
-10
Jul-1
0
Sep
-10
Nov
-10
Jan-
11
Mar
-11
May
-11
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Gram-stain
Gram-positive cocci
Gram-positive bacilli
Gram-negative cocci
Gram-negative bacilli
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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
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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
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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