Antibiotic Resistance

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Antibiotic Resistance Healthcare Associated
InfectionsPrescribing Issues

• Richard Morris
• Prescribing Adviser

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Aims objectives

• Aim
• To raise awareness of the association between
  unnecessary or inappropriate antibiotic
  prescribing and the incidence of bacterial
  resistance and health care associated infections.
• Objectives
• To explain the drivers for controlling antibiotic
  prescribing in primary care
• To illustrate current antibiotic prescribing
  rates across Middlesbrough and Redcar Cleveland
  PCTs
• To cascade the key messages of recent NICE
  guidance on the management of respiratory tract
  infections
• To discuss the evidence for strategies that may
  be employed in general practice to reduce
  antibiotic prescribing rates

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Question 1

• Antibiotic resistance is a major threat to public
  health
• AGREE

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Antibiotic resistance
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Question 2

• High antibiotic prescribing will result in high
  antibiotic resistance
• AGREE

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• HOWEVER..

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PCT Prescribing RatesApril-August 2008 (c.f.
2007)
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Question 3

• Ciprofloxacin resistance in Neisseria gonorrhoea
  has doubled in the last 5 years
• DISAGREE

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Question 4

• How much more likely is it that a patient will
  acquire MRSA if they have taken ciprofloxacin in
  the last 4 months
• Less likely
• No more likely
• Twice as likely
• 3 times as likely

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Quinolone prescribing audit

• Audit of prescribing in June 2008
• 8 practices 4 in each PCT area
• Total list size 58,730
• Mean 7,341 (3,081 13,512)
• Standards
• prescribing in line with PCT Community Infection
  Guidance (January 2008)
• prescribing in line with HPA Management of
  Infection Guidance (June 2008)
• prescribing in response to ve CS result

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Results

• 107 prescriptions identified (in 104 patients)
• 105 for ciprofloxacin
• 2 for ofloxacin
• Practice prescribing rates (items/1000pts)
• Highest 3.46
• Lowest 0.48
• Mean 1.82

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Bottom line

• Quinolones increase the risk of C.diff, MRSA
  multi-drug resistant infections
• Avoid quinolones when narrower spectrum
  antibiotics are likely to be effective
• Reserve quinolones for
• Indications for which they are recommended in
  local or national prescribing guidance
• Proven bacterial infections where cultures have
  demonstrated sensitivity to a quinolone
  antibiotic only

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Question 5

• Using antibiotics in throat infections
  significantly reduces complications
• DISAGREE

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Complications from sore throatMeReC Bulletin
2006 17(3) 12-14

• Cochrane review demonstrated reduced
  complications
• However.
• No consideration of adverse effects or patient
  harms
• Incidence of rheumatic fever has fallen
  significantly over time
• Complication rates are low, therefore absolute
  benefit is small
• NNT (otitis media) 71 NNT (quinsy) 50

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Questions 6 7

• 80 of children presenting with otitis media
  resolve without antibiotic treatment
• AGREE
• Using antibiotics in otitis media prevents glue
  ear
• DISAGREE

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Antibiotics for AOMONeill et al. Clinical
Evidence 2006

• Without antibiotics..
• 60 symptomatic improvement within 24 hours
• 80 resolve in about 3 days
• Serious complications are rare in otherwise
  healthy children (0.12)
• Paracetamol (NNT6) and ibuprofen (NNT5) are
  effective at relieving earache after 2 days

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Antibiotics for AOMGlasziou PP et al. Cochrane
Review 2006

• With antibiotics
• 7 extra patients will gain pain relief at 2-7
  days (no effect at 24 hours)
• BUT
• 6 extra patients will suffer harm (diarrhoea,
  vomiting, rash)
• Cannot predict which individuals will benefit
• lt2 year olds may benefit more

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Question 8

• There is good evidence that patient information
  leaflets reduce further consultation rates for
  acute cough
• AGREE

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PILs for acute coughMacfarlane J et al. BMJ
1997 315 1206-10

• Fewer patients who received a PIL returned to
  surgery (NNT 15), regardless of whether an
  antibiotic was prescribed
• PCT can provide PILs on management of chesty
  coughs, sore throat ear infections

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Question 9

• Using a delayed prescription tactic may
  effectively reduce antibiotic prescribing in a
  population
• AGREE

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• NICE Clinical Guideline 69

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NICE CG69 recommendations (1)

• No antibiotic or delayed Rx for
• Otitis media
• Acute sore throat / pharyngitis / tonsillitis
• Common cold
• Acute rhinosinusitis
• Acute cough / bronchitis
• No antibiotic, delayed Rx or immediate Rx
  depending on severity for
• Children lt2 years with bilateral AOM
• Children with otorrhoea associated with AOM
• Acute sore throat / pharyngitis / tonsillitis and
  3 Centor criteria

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NICE CG69 recommendations (2)

• Immediate Rx or further investigation if
• Systemically unwell
• Symptoms signs of serious illness or
  complications
• High risk of serious complications due to
  pre-existing morbidity
• Over 65 with acute cough and 2, or over 80 and
  1, of the following
• Hospitalisation in previous year
• Diabetes mellitus (type 1 or 2)
• History of congestive heart failure
• Current use of oral glucocorticoids
• Offer all patients advice re. natural history
  average length of illness

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Take home messages (and gifts)

• Quinolones increase the risk of C.diff, MRSA
  multi-drug resistant infections
• Most RTIs are self-limiting and do not require
  antibiotic treatment
• Delayed prescription stamps
• PILs
• Sticky pads, good bugs

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• Thank you!Any questions??
• Richard.morris_at_middlesbroughpct.nhs.uk
• Richard.morris2_at_nhs.net
• 01642 352839