New Antibiotic guidelinesApril 2013

Dr Fiona Donald

Consultant Microbiologist

Nottingham

Outline of talk

New antibiotic guidelines, summary of changes

Update on antimicrobial resistance A bit about Microbiology

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

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

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

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

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

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)

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)

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

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

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

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

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

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

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

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

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

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

Culture – chromogenic agar

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

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

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

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

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

Gram-stain

Gram-positive cocci

Gram-positive bacilli

Gram-negative cocci

Gram-negative bacilli

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

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

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